Asian Americans and infertility: genetic susceptibilities, sociocultural stigma, and access to care
2021; Elsevier BV; Volume: 3; Issue: 2 Linguagem: Inglês
10.1016/j.xfre.2021.12.004
ISSN2666-3341
AutoresMichelle Vu, Anh-Tho Antoinette Nguyen, Snigdha Alur-Gupta,
Tópico(s)Reproductive Biology and Fertility
ResumoInfertility affects over 6 million people in the United States and has been shown to disproportionally affect minority patient populations. Asian American infertility is a particularly understudied area of research. This mini review article explores the current state of published research focusing on Asian American infertility trends as well as their barriers to fertility care. A small number of published studies have found that Asian American patients have decreased success with fertility treatments, including lower rates of pregnancy and live birth. These trends may be attributed to a combination of genetic, environmental, and cultural factors, which will be discussed here in further detail. It is crucial to continue building on Asian American fertility research to provide this diverse patient population with comprehensive, compassionate, and culturally sensitive care. Infertility affects over 6 million people in the United States and has been shown to disproportionally affect minority patient populations. Asian American infertility is a particularly understudied area of research. This mini review article explores the current state of published research focusing on Asian American infertility trends as well as their barriers to fertility care. A small number of published studies have found that Asian American patients have decreased success with fertility treatments, including lower rates of pregnancy and live birth. These trends may be attributed to a combination of genetic, environmental, and cultural factors, which will be discussed here in further detail. It is crucial to continue building on Asian American fertility research to provide this diverse patient population with comprehensive, compassionate, and culturally sensitive care. Discuss: You can discuss this article with its authors and other readers at https://www.fertstertdialog.com/posts/xfre-d-21-00148Essential Points•There are only a few studies investigating Asian American infertility. These studies report that Asian American patients have greater difficulty conceiving, wait longer to seek infertility treatment, and have decreased treatment success rates.•Asian Americans are genetically and environmentally predisposed to infertility; however, cultural factors affect their willingness to seek fertility treatment.•Recommendations for Asian American infertility research include differentiating between Asian racial and ethnic groups and increasing participation in research through the destigmatization of infertility. Discuss: You can discuss this article with its authors and other readers at https://www.fertstertdialog.com/posts/xfre-d-21-00148 •There are only a few studies investigating Asian American infertility. These studies report that Asian American patients have greater difficulty conceiving, wait longer to seek infertility treatment, and have decreased treatment success rates.•Asian Americans are genetically and environmentally predisposed to infertility; however, cultural factors affect their willingness to seek fertility treatment.•Recommendations for Asian American infertility research include differentiating between Asian racial and ethnic groups and increasing participation in research through the destigmatization of infertility. Infertility affects >6 × 106 women in the United States (1Centers for Disease Control and Prevention. Reproductive Health. 2021. Available at: https://www.cdc.gov/reproductivehealth/infertility/index.htm. Accessed July 20, 2021.Google Scholar). In recent years, there has been an increase in publications demonstrating that infertility is more prevalent in minority patients than in White women (2Quinn M. Fujimoto V. Racial and ethnic disparities in assisted reproductive technology access and outcomes.Fertil Steril. 2016; 105: 1119-1123Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar). Despite the increased prevalence, studies have shown that minority women undergoing infertility treatment are less likely to be successful. The odds of pregnancy are reduced for Asians (odds ratio [OR], 0.86; 95% confidence interval [CI], 0.80–0.93), and the odds of live birth are reduced for all minority groups: Asian (OR, 0.90; 95% CI, 0.82–0.97), Black (OR, 0.62; 95% CI, 0.56–0.68), and Hispanic (OR, 0.87; 95% CI, 0.79–0.96) women in comparison to White women (3Missmer S.A. Seifer D.B. Jain T. Cultural factors contributing to health care disparities among patients with infertility in Midwestern United States.Fertil Steril. 2011; 95: 1943-1949Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar, 4Fujimoto V.Y. Luke B. Brown M.B. Jain T. Armstrong A. Grainger D.A. 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 (153) Google Scholar). Asian American infertility and its treatment are particularly understudied areas of research. However, with increasing awareness about the role of ethnic disparities in reproductive outcomes, this subject has come to the forefront. Asian is a race category encompassing a large contingent of people, including those with origins in the Far East, Southeast Asia, and the Indian subcontinent (5United States Census Bureau. About Race. 2020. Available at: https://www.census.gov/topics/population/race/about.html. Accessed July 20, 2021.Google Scholar). According to the 2019 US Census Bureau population estimate, there are 18.9 × 106 Asian Americans, accounting for 5.7% of the nation’s population (6U.S. Department of Health and Human Services Office of Minority Health. Profile: Asian Americans. 2021. Available at: https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=63. Accessed July 23, 2021.Google Scholar). Despite the millions of Asian Americans seeking healthcare in our country, Asian Americans are underrepresented in the infertility literature. In a literature review evaluating infertility in the Asian race within the United States, only 10 studies were found for the past 15 years. Although there is self-reported data among US Black and Hispanic women showing an increase in infertility rates, no data currently exist on the self-reported rates of infertility in the Asian population (7Huddleston H.G. Cedars M.I. Sohn S.H. Giudice L.C. Fujimoto V.Y. Racial and ethnic disparities in reproductive endocrinology and infertility.Am J Obstet Gynecol. 2010; 202: 413-419Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar). Data published in 2019 by the Centers for Disease Control and Prevention did note that Asian women had a lower number of births per 1,000 women of 1,511 than White women of 1,610.5 (8Martin J.A. Hamilton B.E. Osterman M.J. Curtin S.C. Matthews T.J. Births: final data for 2013.Natl Vital Stat Rep. 2015; 64: 1-65PubMed Google Scholar). Asian American patients undergoing fertility treatment differ from their White counterparts in a few key baseline characteristics. The maternal age at which they begin to seek treatment is higher (34.7 ± 4.54 years vs. 33.7 ± 4.52 years for White women, P<.01) (9Purcell K. Schembri M. Frazier L.M. Rall M.J. Shen S. Croughan M. et al.Asian ethnicity is associated with reduced pregnancy outcomes after assisted reproductive technology.Fertil Steril. 2007; 87: 297-302Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar). Asian women are more likely to be nulligravid (58.9% vs. 52.9% for White women, P<.01) or nulliparous (85.2% vs. 78.1% for White women, P<.01). They are also more often given the diagnosis of diminished ovarian reserve (11.4% vs. 7.9% for White women, P<.0001) (4Fujimoto V.Y. Luke B. Brown M.B. Jain T. Armstrong A. Grainger D.A. 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 (153) Google Scholar, 9Purcell K. Schembri M. Frazier L.M. Rall M.J. Shen S. Croughan M. et al.Asian ethnicity is associated with reduced pregnancy outcomes after assisted reproductive technology.Fertil Steril. 2007; 87: 297-302Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar). Not surprisingly, this has translated to poorer outcomes. Asian American patients have decreased clinical pregnancy and live birth rates, even after receiving treatment. In a study conducted by Purcell et al. (9Purcell K. Schembri M. Frazier L.M. Rall M.J. Shen S. Croughan M. et al.Asian ethnicity is associated with reduced pregnancy outcomes after assisted reproductive technology.Fertil Steril. 2007; 87: 297-302Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar), the investigators studied two data sets: the Society for Assisted Reproductive Technology (SART) database from 1999 to 2000 and the data from patients attending the reproductive health clinic at the University of California, San Francisco, from 2001 to 2003. The study sample size included 25,843 White and 1,429 Asian patients from the SART database and 370 Caucasian and 197 Asian patients from the site-specific clinic. In the SART data set, the adjusted odds ratio (aOR) of having a live birth in Asian patients compared with White patients was 0.76 (95% CI, 0.66–0.88), and in the site-specific data set, the aOR was 0.59 (95% CI, 0.37–0.94). Multivariate analysis of this study concluded that Asian ethnicity itself was found to be an independent predictor of poor in vitro fertilization (IVF) outcomes (9Purcell K. Schembri M. Frazier L.M. Rall M.J. Shen S. Croughan M. et al.Asian ethnicity is associated with reduced pregnancy outcomes after assisted reproductive technology.Fertil Steril. 2007; 87: 297-302Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar). A subsequent study using the SART database from 2004 to 2006 published by Fujimoto et al. (4Fujimoto V.Y. Luke B. Brown M.B. Jain T. Armstrong A. Grainger D.A. 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 (153) Google Scholar) echoed these findings. They studied 107,484 White patients and 13,671 Asian patients, reporting a lower OR of pregnancy in Asian patients than in White patients (OR, 0.86; 95% CI, 0.80–0.93) and of live birth (OR, 0.90; 95% CI, 0.82–0.97) (4Fujimoto V.Y. Luke B. Brown M.B. Jain T. Armstrong A. Grainger D.A. 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 (153) Google Scholar). Baker et al. (10Baker V.L. Luke B. Brown M.B. Alvero R. Frattarelli J.L. Usadi R. et al.Multivariate analysis of factors affecting probability of pregnancy and live birth with in vitro fertilization: an analysis of the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System.Fertil Steril. 2010; 94: 1410-1416Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar) also conducted a study using the SART database for the same time period of 2004–2006. The investigators reverberated the findings of the study by Fujimoto et al. (4Fujimoto V.Y. Luke B. Brown M.B. Jain T. Armstrong A. Grainger D.A. 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 (153) Google Scholar); however, they also reported that Asians were more likely to experience stillbirth (0.8 vs. 0.5, P<.0001) and fetal loss (17.8 vs. 15.7, P<.0001) across all gestational ages (10Baker V.L. Luke B. Brown M.B. Alvero R. Frattarelli J.L. Usadi R. et al.Multivariate analysis of factors affecting probability of pregnancy and live birth with in vitro fertilization: an analysis of the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System.Fertil Steril. 2010; 94: 1410-1416Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar). The most recent study using the SART database to examine ethnic disparities in infertility treatment published by Shapiro et al. (11Shapiro A.J. Darmon S.K. Barad D.H. Albertini D.F. Gleicher N. Kushnir V.A. Effect of race and ethnicity on utilization and outcomes of assisted reproductive technology in the USA.Reprod Biol Endocrinol. 2017; 15: 1-11Crossref PubMed Scopus (37) Google Scholar) investigated assisted reproductive technology (ART) cycles, specifically 515,263 cycles in non-Hispanic White patients and 87,845 cycles in Asian patients, performed in the United States between 2004 and 2013. It was reported that Asian patients aged 15–44 years using autologous ART increased >10% over the 9 years, whereas non-Hispanic White women had an increase of <5%. Asian women had lower live birth rates with autologous ART (25.8%) than non-Hispanic White women (31.2%) (11Shapiro A.J. Darmon S.K. Barad D.H. Albertini D.F. Gleicher N. Kushnir V.A. Effect of race and ethnicity on utilization and outcomes of assisted reproductive technology in the USA.Reprod Biol Endocrinol. 2017; 15: 1-11Crossref PubMed Scopus (37) Google Scholar). Three studies conducted at their respective fertility centers also reported decreased clinical pregnancy and live birth rates. Langen et al. (12Langen E.S. Shahine L.K. Lamb J.D. Lathi R.B. Milki A.A. Fujimoto V.Y. et al.Asian ethnicity and poor outcomes after in vitro fertilization blastocyst transfer.Obstet Gynecol. 2010; 115: 591-596Crossref PubMed Scopus (41) Google Scholar) studied 180 fresh blastocyst transfer IVF cycles (112 White and 68 Asian) from January 2005 to December 2006 at Stanford University Medical Center. Both the White and Asian groups were similar in treatment characteristics, the number of oocytes retrieved, fertilization rate, and the number of blastocysts transferred. Despite the similarities, Asian women had a lower implantation rate (28% vs. 45%, P=.01), clinical pregnancy rate (43% vs. 59%, P=.03), and live birth rate (31% vs. 48%, P=.02) (12Langen E.S. Shahine L.K. Lamb J.D. Lathi R.B. Milki A.A. Fujimoto V.Y. et al.Asian ethnicity and poor outcomes after in vitro fertilization blastocyst transfer.Obstet Gynecol. 2010; 115: 591-596Crossref PubMed Scopus (41) Google Scholar). McQueen et al. (13McQueen D.B. Schufreider A. Lee S.M. Feinberg E.C. Uhler M.L. Racial disparities in in vitro fertilization outcomes.Fertil Steril. 2015; 104: 398-402Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar) studied 4,045 women (3,003 White and 541 Asian women) who underwent their first autologous IVF cycle at Fertility Centers of Illinois from January 2010 to December 2012. The aOR of clinical pregnancy was 0.63 (95% CI, 0.44–0.88), and the aOR of live birth was 0.64 (95% CI, 0.51–0.80). However, in this study, the researchers also noted that Asian women required a longer duration of stimulation (10.3 days vs. 9.9 days, P=.00034), had a higher mean peak estradiol level (2,694.0 vs. 2,388.6, P<.0001), had fewer oocytes retrieved (12.1 vs. 13.6, P=.0043), and had fewer surplus blastocysts available for cryopreservation (1.5 vs. 2.0, P=.0004) (13McQueen D.B. Schufreider A. Lee S.M. Feinberg E.C. Uhler M.L. Racial disparities in in vitro fertilization outcomes.Fertil Steril. 2015; 104: 398-402Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar). Shahine et al. (14Shahine L.K. Lamb J.D. Lathi R.B. Milki A.A. Langen E. Westphal L.M. Poor prognosis with in vitro fertilization in Indian women compared to Caucasian women despite similar embryo quality.PLoS One. 2009; 4: 1-5Crossref Scopus (44) Google Scholar) studied 225 patients (145 White and 80 Indian) who had a blastocyst transfer from January 2005 to June 2007 at Stanford University Medical Center. Indian patients had a significantly lower clinical pregnancy rate (36% vs. 52%, P=.02) and live birth rate (24% vs. 41%, P<.01). However, this study was limited by the small sample size and the inclusion of only Indian women (14Shahine L.K. Lamb J.D. Lathi R.B. Milki A.A. Langen E. Westphal L.M. Poor prognosis with in vitro fertilization in Indian women compared to Caucasian women despite similar embryo quality.PLoS One. 2009; 4: 1-5Crossref Scopus (44) Google Scholar). In contrast, studies by Sharara et al. (15Sharara F.I. Seifer D.B. Flaws J.A. Environmental toxicants and female reproduction.Fertil Steril. 1998; 70: 613-622Abstract Full Text Full Text PDF PubMed Scopus (206) Google Scholar) and Gleicher et al. (16Gleicher N. Weghofer A. Lee I.H. Barad D.H. Association of FMR1 genotypes with in vitro fertilization (IVF) outcomes based on ethnicity/race.PLoS One. 2011; 6: 2-7Crossref Scopus (57) Google Scholar) found no difference in IVF outcomes for Asian women. The study by Sharara et al. (15Sharara F.I. Seifer D.B. Flaws J.A. Environmental toxicants and female reproduction.Fertil Steril. 1998; 70: 613-622Abstract Full Text Full Text PDF PubMed Scopus (206) Google Scholar) was limited by its small sample size of Asian women (n = 54), significant differences in baseline characteristics (including younger age and higher polycystic ovary syndrome [PCOS] diagnosis in the Asian cohort), and no documentation of whether these factors were controlled for in analyses. Gleicher et al. (16Gleicher N. Weghofer A. Lee I.H. Barad D.H. Association of FMR1 genotypes with in vitro fertilization (IVF) outcomes based on ethnicity/race.PLoS One. 2011; 6: 2-7Crossref Scopus (57) Google Scholar) conducted a single-center study analyzing 339 consecutive IVF patients for FMR1 genotypes and tested associations among race, FMR1 genotype, autoimmunity, and pregnancy outcomes with IVF. Their Asian sample size was also noted to be small (n = 48) (16Gleicher N. Weghofer A. Lee I.H. Barad D.H. Association of FMR1 genotypes with in vitro fertilization (IVF) outcomes based on ethnicity/race.PLoS One. 2011; 6: 2-7Crossref Scopus (57) Google Scholar). Another study published by Lamb et al. (17Lamb J.D. Huddleston H.G. Purcell K.J. Modan A. Farsani T.T. Dingeldein M.A. et al.Asian ethnicity is associated with decreased pregnancy rates following intrauterine insemination.Reprod Biomed Online. 2009; 19: 252-256Abstract Full Text PDF PubMed Scopus (30) Google Scholar) focused on the difference in intrauterine insemination (IUI) outcomes between Asians and their White counterparts at the University of California, San Francisco. The researchers performed a retrospective analysis of the cohorts of Asian and Caucasian patients treated with IUI between December 2002 and December 2006, including 2,327 IUI cycles among 814 patients. They concluded that the aOR of cumulative pregnancy rates after IUI was 0.68 (95% CI, 0.47–0.98) compared with White women. Of note, they also determined that a greater proportion of Asians (43.9% vs. 24.6%, P<.0001) presented for treatment with >2 years of infertility at the time of initial consultation, thereby suggesting that Asian patients tend to wait longer to seek infertility treatment (17Lamb J.D. Huddleston H.G. Purcell K.J. Modan A. Farsani T.T. Dingeldein M.A. et al.Asian ethnicity is associated with decreased pregnancy rates following intrauterine insemination.Reprod Biomed Online. 2009; 19: 252-256Abstract Full Text PDF PubMed Scopus (30) Google Scholar). Interestingly, a study published by Dieke et al. (18Dieke A.C. Zhang Y. Kissin D.M. Barfield W.D. Boulet S.L. Disparities in assisted reproductive technology utilization by race and ethnicity, United States, 2014: a commentary.J Womens Health (Larchmt). 2017; 26: 605-608Crossref PubMed Scopus (53) Google Scholar) investigated the data from the Centers for Disease Control and Prevention’s National ART Surveillance System to calculate the number of ART procedures per million women of reproductive age for each racial/ethnic category in 2014. It was reported that Asian and Pacific Islander women had the highest number of ART procedures per million women aged 15–44 years (5,883.0), followed by White non-Hispanic women (2,888.4) (18Dieke A.C. Zhang Y. Kissin D.M. Barfield W.D. Boulet S.L. Disparities in assisted reproductive technology utilization by race and ethnicity, United States, 2014: a commentary.J Womens Health (Larchmt). 2017; 26: 605-608Crossref PubMed Scopus (53) Google Scholar). Although Asian Americans have been reported to have worse ART outcomes, this study suggests a trend toward increased ART utilization. The majority of published research on Asian American infertility shows that Asian women have greater difficulty conceiving and lower success rates of infertility treatment. There may be a myriad of explanations for this, including differing genetic susceptibilities, underlying infertility factors, and environmental factors. Each of these is explored further in this article. Several genetic differences between Asian and White women have been suggested to contribute to disparities in ART outcomes. A higher number of FMR1 gene mutations have been found in Asian women with CGG repeats of >34. Typically, most women have 5–44 CGG repeats in their FMR1 genes; however, studies have shown that infertile women with a diminished ovarian reserve are more likely to have ≥35 FMR1 CGG repeats (19Pastore L.M. Young S.L. Baker V.L. Karns L.B. Williams C.D. Silverman L.M. Elevated prevalence of 35-44 FMR1 trinucleotide repeats in women with diminished ovarian reserve.Reprod Sci. 2012; 19: 1226-1231Crossref PubMed Scopus (44) Google Scholar). A high number of FMR1 mutations has been associated with infertility and may thus contribute to these findings in Asian women (11Shapiro A.J. Darmon S.K. Barad D.H. Albertini D.F. Gleicher N. Kushnir V.A. Effect of race and ethnicity on utilization and outcomes of assisted reproductive technology in the USA.Reprod Biol Endocrinol. 2017; 15: 1-11Crossref PubMed Scopus (37) Google Scholar). Although some studies have shown that Asian women have similar mean day 3 follicle-stimulating hormone levels, the number of follicles produced during stimulation, and the total number of oocytes retrieved and transferred (9Purcell K. Schembri M. Frazier L.M. Rall M.J. Shen S. Croughan M. et al.Asian ethnicity is associated with reduced pregnancy outcomes after assisted reproductive technology.Fertil Steril. 2007; 87: 297-302Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar), other studies have shown that there are higher exogenous follicle-stimulating hormone requirements during an IVF cycle in Asian patients who are homozygous for the serine variant in the follicle-stimulating hormone receptor gene (20Tang H. Yan Y. Wang T. Zhang T. Shi W. Fan R. et al.Effect of follicle-stimulating hormone receptor Asn680Ser polymorphism on the outcomes of controlled ovarian hyperstimulation: an updated meta-analysis of 16 cohort studies.J Assist Reprod Genet. 2015; 32: 1801-1810Crossref PubMed Scopus (33) Google Scholar). This may be due to the fact that homozygosity for the serine variant is associated with poor ovarian response and lower numbers of oocytes retrieved. Asian patients have also been shown to have allelic polymorphism frequencies in the CYP19 receptor genes compared with White patients. These polymorphisms are believed to affect estradiol synthesis and metabolism and thus contribute to different clinical outcomes (21Simoni M. Nieschlag E. Gromoll J. Isoforms and single nucleotide polymorphisms of the FSH receptor gene: implications for human reproduction.Hum Reprod Update. 2002; 8: 413-421Crossref PubMed Scopus (182) Google Scholar, 22Miyoshi Y. Noguchi S. Polymorphisms of estrogen synthesizing and metabolizing genes and breast cancer risk in Japanese women.Biomed Pharmacother. 2003; 57: 471-481Crossref PubMed Scopus (64) Google Scholar). A study conducted at a private reproductive medicine clinic in Australia of 2,594 patients (2,072 White and 522 Asian) undergoing IVF noted that despite requiring higher doses of gonadotropin, Asian patients achieved fewer oocytes and had resultant fewer embryos for transfer and cryopreservation (23Kan A. Leung P. Luo K. Fay L. Tan C.L. Do Asian women do as well as their Caucasian counterparts in IVF treatment: cohort study.J Obstet Gynaecol Res. 2015; 41: 946-951Crossref PubMed Scopus (9) Google Scholar). Figure 1 lists the genetic susceptibilities related to infertility in Asian American women. Some common underlying etiologies of infertility in couples include endometriosis, ovulatory dysfunction, and male factor infertility. Studies have shown that there is a difference in the prevalence of these causative factors between Asian Americans and their White counterparts. Endometriosis is present in 9%–50% of infertile women (24Taylor H.S. Pal L. Seli E. Speroff’s clinical gynecologic endocrinology and infertility.9th ed. Lippincott Williams & Wilkins, Philadelphia2020Google Scholar). Asian Americans have significantly higher rates of endometriosis (15.7% vs. 5.8% for White patients, P<.05) (25Yamamoto A. Johnstone E.B. Bloom M.S. Huddleston H.G. Fujimoto V.Y. A higher prevalence of endometriosis among Asian women does not contribute to poorer IVF outcomes.J Assist Reprod Genet. 2017; 34: 765-774Crossref PubMed Scopus (43) Google Scholar). A prospective registry study in a Canadian tertiary referral center evaluating for endometriosis and pelvic pain found that, of the 1,594 women included, East and Southeast Asian patients (n = 145) were 8.3 times more likely than White patients (n = 1,214) to have a previous diagnosis of stage III/IV endometriosis before referral (95% CI, 3.74–18.57). A retrospective chart review of 717 patients undergoing their first round of IVF between 2008 and 2009 at the University of California, San Francisco, found that although Asian Americans have poorer ART outcomes, including clinical pregnancy rates, the discrepancy was conditionally independent on the presence of endometriosis (25Yamamoto A. Johnstone E.B. Bloom M.S. Huddleston H.G. Fujimoto V.Y. A higher prevalence of endometriosis among Asian women does not contribute to poorer IVF outcomes.J Assist Reprod Genet. 2017; 34: 765-774Crossref PubMed Scopus (43) Google Scholar). Ovulatory dysfunction accounts for 15% of couples infertility (24Taylor H.S. Pal L. Seli E. Speroff’s clinical gynecologic endocrinology and infertility.9th ed. Lippincott Williams & Wilkins, Philadelphia2020Google Scholar). Polycystic ovary syndrome is one of the most common causes of ovulatory dysfunction, affecting approximately 8%–13% of reproductive-aged women (26Teede H.J. Misso M.L. Costello M.F. Dokras A. Laven J. Moran L. et al.Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome.Hum Reprod. 2018; 33: 1602-1618Crossref PubMed Scopus (874) Google Scholar). The prevalence of PCOS in Asian patients compared to White patients is limited and focused on specific ethnicities. The prevalence is 5.6% in Chinese patients and 5.7% in Thai patients based on the Rotterdam criteria vs. 4.9% in Korean patients based on the National Institute of Health criteria (27Huang Z. Yong E.L. Ethnic differences: is there an Asian phenotype for polycystic ovarian syndrome?.Best Pract Res Clin Obstet Gynaecol. 2016; 37: 46-55Crossref PubMed Scopus (37) Google Scholar). Although White patients have been found to have a higher prevalence of PCOS, there is an increasing evidence that Asian women present with different phenotypic presentations and may have different fertility outcomes (28Zhao Y. Qiao J. Ethnic differences in the phenotypic expression of polycystic ovary syndrome.Steroids. 2013; 78: 755-760Crossref PubMed Scopus (104) Google Scholar). For instance, South Asian women (typically defined as Indian or Asian-other) with PCOS have higher total mean Ferriman-Gallwey scores for hirsutism (29Chahal N. Quinn M. Jaswa E.A. Kao C.N. Cedars M.I. Huddleston H.G. Comparison of metabolic syndrome elements in White and Asian women with polycystic ovary syndrome: results of a regional, American cross-sectional study.F S Rep. 2020; 1: 305-313Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar). East Asian women (typically defined as Chinese, Japanese, Korean, Filipino, Vietnamese, Thai, Nepalese, Cambodian, or Indonesian) with PCOS have increased central obesity (29Chahal N. Quinn M. Jaswa E.A. Kao C.N. Cedars M.I. Huddleston H.G. Comparison of metabolic syndrome elements in White and Asian women with polycystic ovary syndrome: results of a regional, American cross-sectional study.F S Rep. 2020; 1: 305-313Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar). A study conducted in the United Kingdom comparing 324 IVF/intracytoplasmic sperm injection cycles between White (n = 220) and Asian (n = 104) patients diagnosed with PCOS found that White patients had a higher fertilization rate and a 2.5 times (95% CI, 1.25–5) higher chance of ongoing clinical pregnancy than their Asian counterparts (30Palep-Singh M. Picton H.M. Vrotsou K. Maruthini D. Balen A.H. South Asian women with polycystic ovary syndrome exhibit greater sensitivity to gonadotropin stimulation with reduced fertilization and ongoing pregnancy rates than their Caucasian counterparts.Eur J Obstet Gynecol Reprod Biol. 2007; 134: 202-207Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar). Male factors account for 35% of couples infertility (24Taylor H.S. Pal L. Seli E. Speroff’s clinical gynecologic endocrinology and infertility.9th ed. Lippincott Williams & Wilkins, Philadelphia2020Google Scholar). There have been mixed findings regarding the semen quality of Asian patients compared with White patients. A study at Stanford University of 1,230 men presenting for semen analysis concluded that White patients had higher semen volumes than Asians (2.9 mL vs. 2.6 mL, P<.01); however, Asians had higher sperm concentrations (60.9 × 106/mL vs. 51.3 × 106/mL, P<.0001) (31Kh
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