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In vitro fertilization outcomes in Hispanics versus non-Hispanic whites

2011; Elsevier BV; Volume: 95; Issue: 8 Linguagem: Inglês

10.1016/j.fertnstert.2011.04.031

1556-5653

Anna Shuler, Allison K. Rodgers, Nicole M. Budrys, Alan E.C. Holden, Robert S. Schenken, Robert G. Brzyski,

Reproductive Biology and Fertility

The in vitro fertilization (IVF) outcomes, including clinical intrauterine gestation rate and live birth rate, between Hispanic and non-Hispanic white women were compared, and there were no differences. Hispanics were more likely to have a diagnosis of tubal factor infertility, whereas non-Hispanic white women were more likely to have endometriosis as their infertility diagnosis. The in vitro fertilization (IVF) outcomes, including clinical intrauterine gestation rate and live birth rate, between Hispanic and non-Hispanic white women were compared, and there were no differences. Hispanics were more likely to have a diagnosis of tubal factor infertility, whereas non-Hispanic white women were more likely to have endometriosis as their infertility diagnosis. According to data from the National Survey of Family Growth in 2002, an estimated 12%, or 7.3 million American women aged 15–44 years had impaired fecundity, defined as having experienced difficulties conceiving or bringing a pregnancy to term during their lifetime. This prevalence represented an increase of two percentage points compared with data from 1995 (1Chandra A. Martinez G.M. Mosher W.D. Abma J.C. Jones J. Fertility, family planning, and reproductive health of U.S. women: data from the 2002 National Survey of Family Growth.Vital Health Stat. 2005; 23: 1-160Google Scholar). In vitro fertilization (IVF) is widely accepted as the most successful treatment for infertile couples, and currently more than 1% of all children born in the United States were conceived by assisted reproductive technologies (ART) (2CDC, American Society for Reproductive Medicine, Society for Assisted Reproductive Technology2007 Assisted Reproductive Technology Success Rates. US Department of Health and Human Services, CDC, Atlanta, GA2009Google Scholar). Poor prognostic factors for IVF have been identified such advanced age of the woman, nulliparity, and diminished ovarian reserve. The relevance of race and ethnicity as a prognostic factor for IVF outcomes have been controversial. Most articles on race and ethnicity has compared African-American women to white women, whereas very few reports have addressed Hispanic women and their prognosis for success with ART.When African-American minorities have been compared with white women, several studies have reported racial disparities in the success rates of IVF with conflicting overall results. Sharara and McClamrock (3Sharara F.I. McClamrock H.D. Differences in in vitro fertilization (IVF) outcome between white and black women in an inner-city, university-based IVF program.Fertil Steril. 2000; 73: 1170-1173Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar) found white women had higher implantation rates, clinical pregnancies, and ongoing/delivered pregnancy rates (PR) compared with African-American women. Seifer et al. (4Seifer D.B. Frazier L.M. Grainger D.A. Disparity in assisted reproductive technologies outcomes in black women with white women.Fertil Steril. 2008; 90: 1701-1710Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar, 5Seifer D.B. Zackula R. Grainger D.A. Trends of racial disparities in assisted reproductive technology outcomes in black women compared with white women: Society for Assisted Reproductive Technology 1999 and 2000 vs. 2004–2006.Fertil Steril. 2010; 93: 626-635Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar) analyzed Society for Assisted Reproductive Technology (SART) data from 1999–2000 and 2004–2006 consistently showing decreased PRs in African-American women than their white counterparts. Dayal et al. (6Dayal M.B. Gindoff P. Dubey A. Spitzer T.L.B. Bergin A. Peak D. et al.Does ethnicity influence in vitro fertilization (IVF) birth outcomes?.Fertil Steril. 2009; 91: 2414-2418Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar) reported lower embryo yield but no difference in pregnancy outcomes in African American when compared to white women. However, when controlling for socioeconomic factors, Feinberg et al. (7Feinberg E.C. Larsen F.W. Catherino W.H. Zhang J. Armstrong A.Y. Comparison of assisted reproductive technology utilization and outcomes between Caucasian and African American patients in an equal-access-to-care setting.Fertil Steril. 2006; 85: 888-894Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar) found no difference in live birth rates between African-American women and white women. Nichols et al. (8Nichols Jr., J.E. Higdon III, H.L. Crane IV, M.M. Boone W.R. Comparison of implantation and pregnancy rates in African American and white women in an assisted reproductive technology practice.Fertil Steril. 2001; 76: 80-84Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar) reported that African-American women had a higher clinical PR than white women.A recent review, which evaluated success rates of minorities undergoing IVF (9Huddleston H. Cedars M. Sohn S. Giudice L. Fujimoto V. Racial and ethnic disparities in reproductive endocrinology and infertility.Am J Obstet Gynecol. 2010; 202: 413-419Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar), found that Hispanic women often made up a low percentage of the total population being studied, making it difficult to assess statistically significant differences. Fujimoto et al. (10Fujimoto V. Luke B. Brown M. Jain T. Armstrong A. Grainger D. et al.Racial and ethnic disparities in assisted reproductive technology outcomes in the United States.Fertil Steril. 2010; 93: 382-390Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar) compared IVF outcomes between non-Hispanic white, African-American, Hispanic, and Asian women, and found lower PRs and live births in all minority groups compared with non-Hispanic white women. Again, this study was limited by the fact that Hispanic women made up only 6.5% of the total study population whereas in the US individuals of Hispanic or Latino ethnicity make up 15.1% of the population (10Fujimoto V. Luke B. Brown M. Jain T. Armstrong A. Grainger D. et al.Racial and ethnic disparities in assisted reproductive technology outcomes in the United States.Fertil Steril. 2010; 93: 382-390Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar, 11U.S. Census Bureau, 2006–2008 American Community Survey. U.S. Census Bureau, 2006–2008 American Community Survey. Available at: www.census.gov. Accessed February 8, 2011.Google Scholar). Conversely, Grainger et al. (12Grainger D. Seifer D. Frazier L. Rall M. Tjaden B. Merrill J. Racial disparity in clinical outcomes from women using advanced reproductive technologies (ART): analysis of 80,196 ART cycles from the SART database 1999–2000.Fertil Steril. 2004; 82: S37-S38Abstract Full Text Full Text PDF Google Scholar) reported no differences in rates of live birth or spontaneous abortions between Hispanics and non-Hispanic women during fresh nondonor cycles. When controlling for socioeconomic status, no differences between Hispanic women and non-Hispanic white women with regard to fertility diagnosis or IVF outcomes were noted (13Feinberg E.C. Larsen F.W. Wah R.M. Alvero R.J. Armstrong A.Y. Economics may not explain Hispanic underutilization of assisted reproductive technology services.Fertil Steril. 2007; 88: 1439-1441Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar). We chose to examine IVF outcomes in Hispanic women compared with non-Hispanic white women in our clinic because Hispanics make up 23% of our IVF patient population.After approval from the Institutional Review Board at the University of Texas Health Science Center at San Antonio, IVF cycle data from patients of the South Texas Fertility Center from January 1998 to January 2008 were extracted from the SART database. Inclusion criteria included patients who self reported as Hispanic or non-Hispanic white. Patients were excluded if they self identified as non-white, non-Hispanic, or of unknown race. Cycles using donor oocytes and frozen embryo cycles were excluded from analysis.Only demographic and cycle outcome information from first fresh nondonor IVF cycles was analyzed. Age, body mass index (BMI), race, gravidity and parity, previous IVF cycles, FSH levels, fertility diagnoses, GnRH agonist/antagonist use, sperm source, cycles cancelled, number of oocytes retrieved, number of fetuses, and pregnancy outcome were analyzed. Retrospective chart review was used to identify race and BMI for patients whose information was incomplete in the SART database.Data were analyzed using SPSS v. 15.0 software (2006 IBM). Outcomes data were analyzed using Student's t-test for parametric data and χ2 and Fisher's exact tests for nonparametric data, as appropriate.One hundred thirty-four (30.8%) Hispanic women and 301 (69.2%) non-Hispanic white women met criteria for the study. Hispanic and non-Hispanic white women had no difference in age or BMI. There were no differences between ethnic groups with respect to gravidity, previous births, or history of spontaneous abortions (SAB). There were no differences in cycle characteristics between the groups including semen source, medication protocol, amount of gonadotropins used, number of cycles cancelled, or oocytes retrieved.A significant difference was noted in infertility diagnosis. Hispanic women were more likely to have a diagnosis of tubal infertility (P<.001), whereas non-Hispanic white women had a higher likelihood of a diagnosis of endometriosis (P=.02). There was no difference in the rate of diagnosis of male factor infertility, ovulatory dysfunction, uterine factor, or diminished ovarian reserve.There were no differences in pregnancy outcomes between groups (Table 1). The pregnancies with a clinical intrauterine gestation were 35 (26.1%) and 80 (26.6%) in Hispanic women and non-Hispanic white women, respectively (P=.6). Hispanic women had an eightfold increase in ectopic pregnancy (EP); 3 (2.2%) compared with non-Hispanic white women 1 (0.03%, P=.09). Live birth rates were not statistically different between groups, 27 (20.1%) and 73 (24.3%) (P=.3), for Hispanic women and non-Hispanic white women, respectively. There were no differences in singleton versus multiple PRs between the groups (P=.6).Table 1Outcomes data for Hispanic and non-Hispanic whites by age.Treatment outcomePregnancy outcomeNot pregnantClinical intrauterine gestationSpontaneous abortionLive bornHispanic total (N = 134)85 (63.4%)35 (26.1%)8 (6.0%)27 (20.1%) 42 y (N = 9)9 (100%)0 (0)0 (0)0 (0)Non-Hispanic whites (N = 301)199 (66.1%)80 (26.6%)6 (2.0%)73 (24.3%) 42 y (N = 22)19 (86.4%)3 (13.6%)0 (0)3 (13.6%)P value.59.27Note: No overall differences were noted between Hispanic and non-Hispanic white patients for IVF treatment outcomes or pregnancy outcomes. Open table in a new tab In conclusion, whereas race has been cited by some investigators as a poor prognostic factor for IVF success, our data suggest that Hispanic ethnicity is not an independent risk factor for poor IVF pregnancy outcome. The finding that Hispanics had a higher rate of EP likely reflects the incidence of tubal factor infertility rather that an effect of ethnicity. Our data also illustrate the disparity in utilization of care, as only 23% of IVF patients in our clinic were Hispanic, whereas according to US census data from 2000, 58% of the population of our community is Hispanic (14U.S. Census Bureau, DP-1 Profile of General Demographic Characteristics, 2000. Available at: http://factfinder.census.gov/servlet/QTTable?_bm=n&_lang=en&qr_name=DEC_2000_SF1_U_DP1&ds_name=DEC_2000_SF1_U&geo_id=05000US48029. Accessed February 8, 2011.Google Scholar).Limitations of this study are that socioeconomic differences between the groups were not controlled for and race and ethnicity were determined by patient's self report. Another limitation is that the data were collected during a 10-year period. With the rapid improvement of IVF success rates, the finding may be different with newer techniques. This also likely accounts for the low overall PRs. Sample size was also a limitation, although limiting the study to our clinic allowed us to examine a relatively homogenous population of Hispanics, namely Hispanics of primarily Mexican origin, which constitute at least 70% of the region's Hispanic population (14U.S. Census Bureau, DP-1 Profile of General Demographic Characteristics, 2000. Available at: http://factfinder.census.gov/servlet/QTTable?_bm=n&_lang=en&qr_name=DEC_2000_SF1_U_DP1&ds_name=DEC_2000_SF1_U&geo_id=05000US48029. Accessed February 8, 2011.Google Scholar). Future investigations should assess the reproducibility of these findings when larger sample sizes are analyzed. Although challenging to undertake, future studies should also consider the origins (e.g., Caribbean, South American) of Hispanic populations in IVF surveys, to determine whether region of origin may influence IVF prognosis for Hispanics. According to data from the National Survey of Family Growth in 2002, an estimated 12%, or 7.3 million American women aged 15–44 years had impaired fecundity, defined as having experienced difficulties conceiving or bringing a pregnancy to term during their lifetime. This prevalence represented an increase of two percentage points compared with data from 1995 (1Chandra A. Martinez G.M. Mosher W.D. Abma J.C. Jones J. Fertility, family planning, and reproductive health of U.S. women: data from the 2002 National Survey of Family Growth.Vital Health Stat. 2005; 23: 1-160Google Scholar). In vitro fertilization (IVF) is widely accepted as the most successful treatment for infertile couples, and currently more than 1% of all children born in the United States were conceived by assisted reproductive technologies (ART) (2CDC, American Society for Reproductive Medicine, Society for Assisted Reproductive Technology2007 Assisted Reproductive Technology Success Rates. US Department of Health and Human Services, CDC, Atlanta, GA2009Google Scholar). Poor prognostic factors for IVF have been identified such advanced age of the woman, nulliparity, and diminished ovarian reserve. The relevance of race and ethnicity as a prognostic factor for IVF outcomes have been controversial. Most articles on race and ethnicity has compared African-American women to white women, whereas very few reports have addressed Hispanic women and their prognosis for success with ART. When African-American minorities have been compared with white women, several studies have reported racial disparities in the success rates of IVF with conflicting overall results. Sharara and McClamrock (3Sharara F.I. McClamrock H.D. Differences in in vitro fertilization (IVF) outcome between white and black women in an inner-city, university-based IVF program.Fertil Steril. 2000; 73: 1170-1173Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar) found white women had higher implantation rates, clinical pregnancies, and ongoing/delivered pregnancy rates (PR) compared with African-American women. Seifer et al. (4Seifer D.B. Frazier L.M. Grainger D.A. Disparity in assisted reproductive technologies outcomes in black women with white women.Fertil Steril. 2008; 90: 1701-1710Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar, 5Seifer D.B. Zackula R. Grainger D.A. Trends of racial disparities in assisted reproductive technology outcomes in black women compared with white women: Society for Assisted Reproductive Technology 1999 and 2000 vs. 2004–2006.Fertil Steril. 2010; 93: 626-635Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar) analyzed Society for Assisted Reproductive Technology (SART) data from 1999–2000 and 2004–2006 consistently showing decreased PRs in African-American women than their white counterparts. Dayal et al. (6Dayal M.B. Gindoff P. Dubey A. Spitzer T.L.B. Bergin A. Peak D. et al.Does ethnicity influence in vitro fertilization (IVF) birth outcomes?.Fertil Steril. 2009; 91: 2414-2418Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar) reported lower embryo yield but no difference in pregnancy outcomes in African American when compared to white women. However, when controlling for socioeconomic factors, Feinberg et al. (7Feinberg E.C. Larsen F.W. Catherino W.H. Zhang J. Armstrong A.Y. Comparison of assisted reproductive technology utilization and outcomes between Caucasian and African American patients in an equal-access-to-care setting.Fertil Steril. 2006; 85: 888-894Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar) found no difference in live birth rates between African-American women and white women. Nichols et al. (8Nichols Jr., J.E. Higdon III, H.L. Crane IV, M.M. Boone W.R. Comparison of implantation and pregnancy rates in African American and white women in an assisted reproductive technology practice.Fertil Steril. 2001; 76: 80-84Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar) reported that African-American women had a higher clinical PR than white women. A recent review, which evaluated success rates of minorities undergoing IVF (9Huddleston H. Cedars M. Sohn S. Giudice L. Fujimoto V. Racial and ethnic disparities in reproductive endocrinology and infertility.Am J Obstet Gynecol. 2010; 202: 413-419Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar), found that Hispanic women often made up a low percentage of the total population being studied, making it difficult to assess statistically significant differences. Fujimoto et al. (10Fujimoto V. Luke B. Brown M. Jain T. Armstrong A. Grainger D. et al.Racial and ethnic disparities in assisted reproductive technology outcomes in the United States.Fertil Steril. 2010; 93: 382-390Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar) compared IVF outcomes between non-Hispanic white, African-American, Hispanic, and Asian women, and found lower PRs and live births in all minority groups compared with non-Hispanic white women. Again, this study was limited by the fact that Hispanic women made up only 6.5% of the total study population whereas in the US individuals of Hispanic or Latino ethnicity make up 15.1% of the population (10Fujimoto V. Luke B. Brown M. Jain T. Armstrong A. Grainger D. et al.Racial and ethnic disparities in assisted reproductive technology outcomes in the United States.Fertil Steril. 2010; 93: 382-390Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar, 11U.S. Census Bureau, 2006–2008 American Community Survey. U.S. Census Bureau, 2006–2008 American Community Survey. Available at: www.census.gov. Accessed February 8, 2011.Google Scholar). Conversely, Grainger et al. (12Grainger D. Seifer D. Frazier L. Rall M. Tjaden B. Merrill J. Racial disparity in clinical outcomes from women using advanced reproductive technologies (ART): analysis of 80,196 ART cycles from the SART database 1999–2000.Fertil Steril. 2004; 82: S37-S38Abstract Full Text Full Text PDF Google Scholar) reported no differences in rates of live birth or spontaneous abortions between Hispanics and non-Hispanic women during fresh nondonor cycles. When controlling for socioeconomic status, no differences between Hispanic women and non-Hispanic white women with regard to fertility diagnosis or IVF outcomes were noted (13Feinberg E.C. Larsen F.W. Wah R.M. Alvero R.J. Armstrong A.Y. Economics may not explain Hispanic underutilization of assisted reproductive technology services.Fertil Steril. 2007; 88: 1439-1441Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar). We chose to examine IVF outcomes in Hispanic women compared with non-Hispanic white women in our clinic because Hispanics make up 23% of our IVF patient population. After approval from the Institutional Review Board at the University of Texas Health Science Center at San Antonio, IVF cycle data from patients of the South Texas Fertility Center from January 1998 to January 2008 were extracted from the SART database. Inclusion criteria included patients who self reported as Hispanic or non-Hispanic white. Patients were excluded if they self identified as non-white, non-Hispanic, or of unknown race. Cycles using donor oocytes and frozen embryo cycles were excluded from analysis. Only demographic and cycle outcome information from first fresh nondonor IVF cycles was analyzed. Age, body mass index (BMI), race, gravidity and parity, previous IVF cycles, FSH levels, fertility diagnoses, GnRH agonist/antagonist use, sperm source, cycles cancelled, number of oocytes retrieved, number of fetuses, and pregnancy outcome were analyzed. Retrospective chart review was used to identify race and BMI for patients whose information was incomplete in the SART database. Data were analyzed using SPSS v. 15.0 software (2006 IBM). Outcomes data were analyzed using Student's t-test for parametric data and χ2 and Fisher's exact tests for nonparametric data, as appropriate. One hundred thirty-four (30.8%) Hispanic women and 301 (69.2%) non-Hispanic white women met criteria for the study. Hispanic and non-Hispanic white women had no difference in age or BMI. There were no differences between ethnic groups with respect to gravidity, previous births, or history of spontaneous abortions (SAB). There were no differences in cycle characteristics between the groups including semen source, medication protocol, amount of gonadotropins used, number of cycles cancelled, or oocytes retrieved. A significant difference was noted in infertility diagnosis. Hispanic women were more likely to have a diagnosis of tubal infertility (P<.001), whereas non-Hispanic white women had a higher likelihood of a diagnosis of endometriosis (P=.02). There was no difference in the rate of diagnosis of male factor infertility, ovulatory dysfunction, uterine factor, or diminished ovarian reserve. There were no differences in pregnancy outcomes between groups (Table 1). The pregnancies with a clinical intrauterine gestation were 35 (26.1%) and 80 (26.6%) in Hispanic women and non-Hispanic white women, respectively (P=.6). Hispanic women had an eightfold increase in ectopic pregnancy (EP); 3 (2.2%) compared with non-Hispanic white women 1 (0.03%, P=.09). Live birth rates were not statistically different between groups, 27 (20.1%) and 73 (24.3%) (P=.3), for Hispanic women and non-Hispanic white women, respectively. There were no differences in singleton versus multiple PRs between the groups (P=.6). Note: No overall differences were noted between Hispanic and non-Hispanic white patients for IVF treatment outcomes or pregnancy outcomes. In conclusion, whereas race has been cited by some investigators as a poor prognostic factor for IVF success, our data suggest that Hispanic ethnicity is not an independent risk factor for poor IVF pregnancy outcome. The finding that Hispanics had a higher rate of EP likely reflects the incidence of tubal factor infertility rather that an effect of ethnicity. Our data also illustrate the disparity in utilization of care, as only 23% of IVF patients in our clinic were Hispanic, whereas according to US census data from 2000, 58% of the population of our community is Hispanic (14U.S. Census Bureau, DP-1 Profile of General Demographic Characteristics, 2000. Available at: http://factfinder.census.gov/servlet/QTTable?_bm=n&_lang=en&qr_name=DEC_2000_SF1_U_DP1&ds_name=DEC_2000_SF1_U&geo_id=05000US48029. Accessed February 8, 2011.Google Scholar). Limitations of this study are that socioeconomic differences between the groups were not controlled for and race and ethnicity were determined by patient's self report. Another limitation is that the data were collected during a 10-year period. With the rapid improvement of IVF success rates, the finding may be different with newer techniques. This also likely accounts for the low overall PRs. Sample size was also a limitation, although limiting the study to our clinic allowed us to examine a relatively homogenous population of Hispanics, namely Hispanics of primarily Mexican origin, which constitute at least 70% of the region's Hispanic population (14U.S. Census Bureau, DP-1 Profile of General Demographic Characteristics, 2000. Available at: http://factfinder.census.gov/servlet/QTTable?_bm=n&_lang=en&qr_name=DEC_2000_SF1_U_DP1&ds_name=DEC_2000_SF1_U&geo_id=05000US48029. Accessed February 8, 2011.Google Scholar). Future investigations should assess the reproducibility of these findings when larger sample sizes are analyzed. Although challenging to undertake, future studies should also consider the origins (e.g., Caribbean, South American) of Hispanic populations in IVF surveys, to determine whether region of origin may influence IVF prognosis for Hispanics.