We know that about 1 in 7 couples worldwide experience infertility which is defined as a failure to conceive after 12 months of unprotected sexual intercourse for a heterosexual couple. Over the last two decades there has been a growing awareness that women in high income countries who are of certain racial backgrounds such as Black or Asian have a reduced chance of having a child through fertility treatments.
The latest data comes from a report published in March 2021 by the Human Fertilisation and Embryology Authority (HFEA) suggesting that Black women in the UK are treated with IVF on average 18 months later than their white counterparts. For those between the ages of 30-34 years, they also have a success rate of 23% compared to 30% for white women. Asian women also had a lower success rate compared with white women. The HFEA database does record ethnicity of patients and this data is from almost 59,000 cycles from 2014 to 2018. This indicates that there are disparities in fertility treatment related to ethnicity in amongst Black and Asian communities.
What are the reasons for this?
We can try to explain some of these differences in terms of the medical model where we examine some conditions which are known to be more common in certain ethnic groups. However we know that a much more complex narrative exists as to why women from minority groups may struggle to get timely fertility investigation and treatment, leading to a poorer outcome.
The major factor for the reduced rates is that the women are older and have tried longer before having IVF. Higher age and longer duration of infertility are the very factors disproportionately affecting women from Black and Minority Ethnic (BAME) communities in the UK.
Economic factors are one of the major reasons for the differences in outcome as assisted conception treatment is self-funded for the majority of couples. In the UK where most patients have access to a primary care physician the initial investigation is free through the National Health Service but we find that many couples delay seeking advice possibly because they have poor fertility knowledge in addition to cultural and societal beliefs. Some people believe it is better to conceive naturally and indeed may have mistrust of the healthcare profession due to past experiences or perceived racism. We need more research about these factors to allow earlier access to treatments.
Women from BAME groups have a greater proportion with higher BMI.
It is known that a higher body mass index (BMI-the relationship between height and weight) is associated with reduced fertility outcomes and this may be a factor for women from minority groups due to economic factors. Health knowledge and self-advocacy may be lower in these groups which affects health behaviours, and often women don’t feel confident to navigate the fertility journey.
We know that fibroids are 3 to 4 times more common in Black populations, whether African, Afro-American or Afro-Caribbean. Fibroids can be small but if in the wrong place, such as distorting the womb ling (submucosal) these can reduce implantation of an embryo in IVF treatment. Fibroids can become very large and not only cause significant menstrual symptoms but can influence fertility, both natural conception and IVF. Surgery may be needed to help conception.
The chances of tubal disease (blocked fallopian tube) is also higher in the Black population, whereas endometriosis has been shown to have a higher prevalence in the white and Asian populations. The classic features of this condition are typically painful periods and painful intercourse, and these can overlap with symptoms of fibroids. This is diagnosed notoriously late for the typical groups mentioned but probably even later for Black women, due to diagnostic bias. However, it is important to point out that many studies to date have had under-representation from the Black and minority communities, and the reasons may be due to possible racism in healthcare research. More representative data is needed before we can truly estimate the incidence of these conditions. It is extremely important to consider each couple as individual and listen to the woman’s story to ensure we diagnose in a timely manner.
Ovulation problems such as polycystic ovary syndrome (PCOS) are more common in the Asian groups. Women who have irregular cycles and come from a South East Asian background have a higher chance of being found to have PCOS , which can be treated with fairly simple measures but a full work-up for the couple is needed to ensure that male factor and tubal factors are also assessed. The BMI often plays a role in this condition.
Egg reserve reflects the number of eggs which a women has at any given time and can be tested with an AMH level; this along with her chronological age can give some estimate of likelihood of IVF success. Some studies have suggested that Asian women have a slightly lower egg reserve with age-matched women, which may affect fertility outcomes.
It is critical to know that any woman concerned about infertility should see a specialist early in the fertility journey to get this tested. This will allow decisions of how quickly to proceed with treatment.
Donor Sperm Issues
Same sex, single women and couples seeking donor gamete treatments from BAME groups were also examined in the HFEA report; there were fewer options for ethnically matched egg and sperm donors within the UK, should that be the desire of the person in need of donor sperm. Often gametes had to be sourced from abroad, but this makes the fertility journey even more difficult.
Health Beliefs and socio-cultural factors
In this short article it is difficult to cover the variety of influences which affect when a person or couple seeks advice from a Fertility specialist about their desire to have a child. However, as stated above, research shows that existing ideas about conceiving naturally and fear or mistrust of the healthcare establishment and myths about fertility treatments can stop people taking even the first step. It is only through building trust and listening to women from the communities who experience lower outcomes that we can begin to address the inequalities
Some women live in a family where infertility for a couple is always assumed to be the woman’s problem and getting engagement from the male partner is problematic and this can delay presentation. It is important for the clinician to understand the dynamics in these relationships as diagnosis of male factor can cause relationship issues; indeed the guilt and blame from diagnosis of an issue for either or both partners is a very sensitive area and counselling should be offered. We need to de-stigmatise fertility issues.
What is Needed
Ultimately policy makers and government need to recognise the real distress of couples who suffer from infertility and allow better access to treatment through equitable funding for a greater range of people. But apart from funding treatment more fairly, we need to better understand why certain groups present later and also improve fertility education in these groups to reduce barriers to accessing fertility care. Healthcare professionals are also working to improve how care is delivered such that all people feel included and not marginalized throughout the process. Through wider research, we need more inclusive data on relevant medical factors so that we can tailor treatments for patients from a BAME background.
Finally for women who do or don’t belong to the groups mentioned above, arm yourselves with knowledge from reliable sources, seek expert advice early and remember that wanting to have a family is a natural instinct and a reproductive choice and there is a whole world of support if you look for it. We wish you success in your fertility journey.