Objective
To investigate barriers in accessing care for infertility in Mexico, because little is known about this issue for low and middle-income countries, which comprise 80% of the world’s population.
Design
Cross-sectional analysis.
Setting
Mexcian Teachers’ Cohort.
Patient(s)
A total of 115,315 female public school teachers from 12 states in Mexico.
Intervention(s)
None.
Main Outcome Measure(s)
The participants were asked detailed questions about their demographics, lifestyle characteristics, access to the health care system, and infertility history via a self-reported questionnaire. Log-binomial models, adjusted a priori for potential confounding factors, were used to estimate the prevalence ratios (PRs) and 95% confidence intervals ( CIs) of accessing medical care for infertility among women reporting a history of infertility.
Result(s)
A total of 19,580 (17%) participants reported a history of infertility. Of those who experienced infertility, 12,470 (63.7%) reported seeking medical care for infertility, among whom 8,467 (67.9%) reported undergoing fertility treatments. Among women who reported a history of infertility, women who taught in a rural school (PR, 0.95; 95% CI, 0.92–0.97), spoke an indigenous language (PR, 0.88; 95% CI, 0.84–0.92), or had less than a university degree (PR, 0.93; 95% CI, 0.90–0.97) were less likely to access medical care for fertility. Women who had ever had a mammogram (PR, 1.07; 95% CI, 1.05–1.10), had a pap smear in the past year (PR, 1.08; 95% CI, 1.06–1.10), or who had used private health care regularly or in times of illness were more likely to access medical care for fertility.
Conclusion(s)
The usage of infertility care varied by demographic, lifestyle, and access characteristics, including speaking an indigenous language, teaching in a rural school, and having a private health care provider.
Infertility affects approximately 50–80 million people worldwide; however, the true global burden is difficult to estimate, given different definitions of infertility and a lack of available surveillance data in many settings (
1- Mascarenhas M.N.
- Flaxman S.R.
- Boerma T.
- Vanderpoel S.
- Stevens G.A.
National, regional, and global trends in infertility prevalence since 1990: a systematic analysis of 277 health surveys.
,
2- World Health Organization. Programme of M.
- Child H.
Family Planning U. Infertility: a tabulation of available data on prevalence of primary and secondary infertility.
,
3Infertility around the globe: new thinking on gender, reproductive technologies and global movements in the 21st century.
). Among couples who experience infertility, there are many barriers that prevent them from accessing appropriate fertility care. Differences in access have been documented by race, age, socioeconomic status, and health-related factors (
4- Farland L.V.
- Collier A.Y.
- Correia K.F.
- Grodstein F.
- Chavarro J.E.
- Rich-Edwards J.
- et al.
Who receives a medical evaluation for infertility in the United States?.
,
5- Chandra A.
- Copen C.E.
- Stephen E.H.
Infertility service use in the United States: data from the National Survey of Family Growth, 1982-2010.
,
6- Ordovensky Staniec J.F.
- Webb N.J.
Utilization of infertility services: how much does money matter?.
,
7Use of infertility services in the United States.
,
8Health disparities and infertility: impacts of state-level insurance mandates.
,
9- Greil A.L.
- McQuillan J.
- Shreffler K.M.
- Johnson K.M.
- Slauson-Blevins K.S.
Race-ethnicity and medical services for infertility: stratified reproduction in a population-based sample of U.S. women.
,
10- White L.
- McQuillan J.
- Greil A.L.
Explaining disparities in treatment seeking: the case of infertility.
,
11Socioeconomic and racial disparities among infertility patients seeking care.
,
12Disparities in access to infertility services in a state with mandated insurance coverage.
,
13Introduction: access to fertility care.
). Prior research on barriers to accessing fertility care has focused predominantly on the influence of markers of financial access (e.g., household income, insurance, and education) and racial disparities in accessing care, with little information on how other cultural or lifestyle factors (eg, physical activity and health history) may influence accessing fertility care (
4- Farland L.V.
- Collier A.Y.
- Correia K.F.
- Grodstein F.
- Chavarro J.E.
- Rich-Edwards J.
- et al.
Who receives a medical evaluation for infertility in the United States?.
,
14- Missmer S.A.
- Seifer D.B.
- Jain T.
Cultural factors contributing to health care disparities among patients with infertility in Midwestern United States.
). Moreover, most of the research on barriers to accessing fertility care has been conducted within the United States and has focused on non-Hispanic white women (
15A review of disparities in access to infertility care and treatment outcomes among Hispanic women.
).
Results
Among the 115,307 participants, 19,580 (17%) reported infertility. Participants who reported having accessed medical care for infertility were, on average, 43.2 years old (standard deviation [SD] = 7.0) at baseline and 28.0 (5.3) at the first experience of infertility, whereas participants who did not access care for infertility were 44.2 (7.3) years old at baseline and 26.1 (5.6) at reported infertility. Among women who experienced infertility, 63.7% (n = 12,470) reported accessing medical care for infertility (
Table 1). Among women who did access care, the most common infertility diagnoses were ovulatory disorders (other than PCOS) (18.7%), tubal-factor infertility (16.2%), and PCOS (13.0%); 21.5% reported an unknown or idiopathic cause of their infertility and 11% reported cause attributed to their male partner. Most participants with infertility reported having used fertility treatment (67.9%). The most common type of treatment used was ovulation induction (62.3%), with fewer women reporting IUI (4.3%) and IVF (1.3%). When asked about specific fertility drugs used, most women reported using “other” (47.5%), followed by clomiphene (34.5%), and gonadotropin injections (14.6%).
TABLE 1Accessing medical care for infertility among participants with self-reported infertility in the Mexican Teacher’s Cohort at baseline in 2008.
Note: Values are mean ± standard deviation or percentages and are standardized to the age distribution of the study population
Values of polytomous variables may not sum to 100% because of rounding
BMI = body mass index; IMSS = Instituto Mexicano del Seguro Social; ISSSTE = Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado; IUI = intrauterine insemination; IVF = in vitro fertilization.
When investigating the relationship between demographic characteristics and the probability of fertility care, several associations emerged (
Table 2). Women who taught in a rural school (PR, 0.95; 95% CI, 0.92–0.97) or who spoke an indigenous language (PR, 0.88; 95% CI, 0.84–0.92) were less likely to access fertility care. Compared with women with a university degree, women with a graduate degree were more likely to access medical care for infertility (PR, 1.06; 95% CI, 1.03–1.09), whereas women with less than a university degree were less likely to access care (PR, 0.93; 95% CI, 0.90–0.97). Compared with women who lived in Mexico City, women who lived in central states (Guanajuato, Hidalgo, Jalisco, and México) were also less likely to access fertility care (PR: 0.96; 95% CI, 0.93–0.99).
TABLE 2The association between demographic characteristics and accessing medical care for infertility in the Mexican teacher’s cohort among women reporting a history of infertility.
Central: Guanajuato, Hidalgo, Jalisco, México;
South: Chiapas, Yucatán, Veracruz
When investigating the role of health care systems access (
Table 3), we found that women who had ever had a mammogram (PR, 1.07; 95% CI, 1.05–1.10) or who had undergone a pap smear in the past year (PR, 1.08; 95% CI, 1.06–1.10) were more likely to access fertility care than women who had not (
Table 3). Compared with women who used private health care providers as their primary provider, women who used IMSS (PR, 0.88; 95% CI, 0.86 -0.91) or ISSSTE (PR, 0.88; 95% CI, 0.84–0.92) as their primary health care provider were less likely to seek medical care for fertility, as were women with other public insurance (PR, 0.83; 95% CI, 0.72–0.95) and other insurance (PR, 0.94; 95% CI, 0.91–0.97). Specifically, during a time of illness, women who used IMSS (PR, 0.94; 95% CI, 0.92–0.97) or ISSSTE (PR, 0.95; 95% CI, 0.95–0.99) were less likely to seek out fertility care compared with women who used private health care providers during times of illness.
TABLE 3The association between health care systems access and accessing medical diagnosis of infertility in the Mexican teacher’s cohort among women reporting a history of infertility.
When investigating the role of reproductive and lifestyle characteristics, women who had a history of using HCs were less likely to access care (PR, 0.91; 95% CI, 0.89–0.93) (
Table 4). Compared with nulliparous women, women who were parous were also less likely to access fertility care, with women who had three or more children the least likely to access care (PR, 0.74; 95% CI, 0.72–0.76). We observed a statistically significant inverse linear relationship between increasing age at menarche and the likelihood of accessing medical care for infertility (
P<.001 for linear trend). Women who reported >3 hours of vigorous physical activity per week at the age of 18 years were more likely to access fertility care (PR, 1.04; 95% CI, 1.01–1.06). There was no difference between women seeking care for infertility by the history of smoking, alcohol consumption, type 2 diabetes diagnosis, BMI at the age of 18 years or baseline, or body size in adolescence or adulthood.
TABLE 4The association between reproductive and lifestyle characteristics and accessing medical care for infertility in the Mexican teacher’s cohort among women reporting a history of infertility.
Discussion
Among our sample of female teachers across 12 regions in Mexico, 17% of women reported infertility. Of these women, the majority (63.7%) reported seeking access to fertility care. The most common diagnoses of infertility were an ovulatory, tubal factor, and unknown. The fertility care use in Mexico varied by demographic, lifestyle, and access characteristics. Women were less likely to seek access to infertility care if they were single, used HCs, taught in a rural area, spoke an indigenous language, or had less than a university degree. Women were also less likely to access medical care for infertility if they had previously had a child. Conversely, women were more likely to seek medical care for infertility if they had ever had a mammogram or pap smear in the past year or if they had used private health care providers.
Our study found that approximately 17% of women in our sample reported a history of infertility. This finding is slightly higher than estimates in the United States that have ranged from 6.0% (
19- Chandra A.
- Copen C.E.
- Stephen E.H.
Infertility and impaired fecundity in the United States, 1982–2010: data from the National Survey of Family Growth.
)–15.5% (
20- Thoma M.E.
- McLain A.C.
- Louis J.F.
- King R.B.
- Trumble A.C.
- Sundaram R.
- et al.
Prevalence of infertility in the United States as estimated by the current duration approach and a traditional constructed approach.
). Estimates of infertility prevalence across 25 population surveys from low, middle, and high-income countries observed that infertility ranged from 3.5%–16.7%, with an overall median prevalence among less developed countries of 9% (
21- Boivin J.
- Bunting L.
- Collins J.A.
- Nygren K.G.
International estimates of infertility prevalence and AU: potential need and demand for infertility medical care.
). Most women who experienced infertility in our sample accessed medical care for their infertility (63.7%). Our estimate of fertility care access is similar to previous findings from 25 international studies, which found that 56% of couples reported access to medical care for infertility globally (range, 42%–76%), with slightly fewer couples seeking care in less developed countries (mean = 51.2%; range, 27–74%) (
21- Boivin J.
- Bunting L.
- Collins J.A.
- Nygren K.G.
International estimates of infertility prevalence and AU: potential need and demand for infertility medical care.
). This is similar to findings from the Nurses’ Health Study II in the United States (65%) (
4- Farland L.V.
- Collier A.Y.
- Correia K.F.
- Grodstein F.
- Chavarro J.E.
- Rich-Edwards J.
- et al.
Who receives a medical evaluation for infertility in the United States?.
,
22- Farland L.V.
- Missmer S.A.
- Rich-Edwards J.
- Chavarro J.E.
- Barbieri R.L.
- Grodstein F.
Use of fertility treatment modalities in a large United States cohort of professional women.
) but greater than estimates from the National Survey for Family Growth in the United States (36%) (
19- Chandra A.
- Copen C.E.
- Stephen E.H.
Infertility and impaired fecundity in the United States, 1982–2010: data from the National Survey of Family Growth.
). This may reflect the fact that Mexican citizens who are government employees or in the formal private sector have access to universal health care coverage and, therefore, are more likely to access medical care than couples in the United States. Among women who accessed medical care for infertility, the most common diagnoses were ovarian infertility, PCOS, blockage of the fallopian tube, and unknown. Our findings are consistent with prior research on infertility in Mexico that suggested that the most common causes for infertility were asymptomatic infection and anovulation, possibly indicative of PCOS (
16- Leke R.J.
- Oduma J.A.
- Bassol-Mayagoitia S.
- Bacha A.M.
- Grigor K.M.
Regional and geographical variations in infertility: effects of environmental, cultural, and socioeconomic factors.
). Only 11% of women indicated that their infertility is because of the male partner, which is lower than previous estimates among infertile couples in Mexico (
23- Salgado Jacobo M.I.
- Tovar Rodríguez J.M.
- Hernández Marín I.
- Ayala Ruiz A.R.
Frequency of altered male factor in an infertility clinic. Article in Spanish.
). Consistent with findings in the United States (
4- Farland L.V.
- Collier A.Y.
- Correia K.F.
- Grodstein F.
- Chavarro J.E.
- Rich-Edwards J.
- et al.
Who receives a medical evaluation for infertility in the United States?.
), the cause of infertility for many women is unknown.
Of those women who accessed medical care for fertility, the majority underwent ovulation induction (62.3%); the most common drug used was clomiphene (34.5%). A large percentage of women (47.5%) reported using “other” types of infertility drugs. This may reflect differences in drug name provided on the survey (eg, “Clomifeno”) and the more commonly known brand names for clomiphene which was not included on the questionnaire (eg, Omifin). Of all the women who received treatment, only 1.3% underwent IVF, and 4.3% underwent IUI. We hypothesize that this low use is partially influenced by economic, geographic, and time barriers in accessing treatment. In the country of México, there are few public hospitals with IVF programs. These public hospitals perform IVF services according to the government budget, so the number of cycles and patients can fluctuate. The public hospital with the largest IVF program is the Instituto Nacional de Perinatologίa, which offers approximately 200 IVF cycles per year and has an approximately 1-year waiting list to enroll in their IVF program. The cost of an IVF cycle at a public hospital is limited to the medication cost, which can range from $500–2,100 USD, based on socioeconomic status. As of 2019, there were approximately 40 private fertility clinics in Mexico that reported their outcomes to the Latin American Registry of Assisted Reproduction. The cost of IVF at private clinics can range from $1,500–10,500 USD per cycle, and many are located in major metropolitan centers. Therefore, women may need to wait to access fertility care at a public hospital or pay higher costs with private clinics, which may explain the low use of IUI and IVF.
Among women who experience infertility, not all are able to access medical care for treatment. Issues related to accessing medical care for fertility are complex. In the United States, there are established differences in accessing fertility care by race, age, causes of infertility, and socioeconomic factors that influence who receives medical care (
4- Farland L.V.
- Collier A.Y.
- Correia K.F.
- Grodstein F.
- Chavarro J.E.
- Rich-Edwards J.
- et al.
Who receives a medical evaluation for infertility in the United States?.
,
8Health disparities and infertility: impacts of state-level insurance mandates.
). Indeed, research from the National Survey of Fertility Barriers found that Black and Hispanic women were less likely to receive infertility services than white women and that this relationship was driven, but not fully accounted for, by income, insurance status, and level of education (
9- Greil A.L.
- McQuillan J.
- Shreffler K.M.
- Johnson K.M.
- Slauson-Blevins K.S.
Race-ethnicity and medical services for infertility: stratified reproduction in a population-based sample of U.S. women.
). Research from the National Survey of Family Growth found that among women who reported infertility, whether a woman sought out fertility treatment varied by income, insurance coverage, age, and parity (
6- Ordovensky Staniec J.F.
- Webb N.J.
Utilization of infertility services: how much does money matter?.
). In addition to socioeconomic factors, other demographic, lifestyle, and environmental factors may also explain potential differences between women who accessed care and those who did not; however, this relationship has not been adequately studied. Prior research in the Nurses’ Health Study II found that in addition to the traditional relationships, a pattern of “healthy lifestyle behavior” was associated with accessing infertility care. Women were less likely to seek medical care related to infertility if they were older, parous, current smokers, or had a higher BMI than their counterparts who did seek medical care (
4- Farland L.V.
- Collier A.Y.
- Correia K.F.
- Grodstein F.
- Chavarro J.E.
- Rich-Edwards J.
- et al.
Who receives a medical evaluation for infertility in the United States?.
). Those who did seek fertility care were also more likely to take multivitamins, exercise, and have had a recent physical examination.
We observed that women who reported speaking an indigenous language were less likely to access medical care for infertility. Prior research has suggested that indigenous people in Mexico have a higher prevalence of health problems and lower rates of using primary health care (
24- Leyva-Flores R.
- Servan-Mori E.
- Infante-Xibille C.
- Pelcastre-Villafuerte B.E.
- Gonzalez T.
Primary health care utilization by the Mexican indigenous population: the role of the Seguro popular in socially inequitable contexts.
). Additionally, we found that women with graduate-level education were more likely to access care, whereas women with less than a university degree were less likely to access fertility care. Our findings support other studies that have found higher levels of education were associated with increased access to fertility care (
12Disparities in access to infertility services in a state with mandated insurance coverage.
). This gradient demonstrates the role education plays in gaining financial resources that may help access care but may also be reflective of self-advocacy skills learned from gaining a higher education.
We observed that reproductive history and some lifestyle factors were associated with access to infertility care. Women who reported ever using HCs, were parous, and started menarche at an older age were less likely to access fertility care. We found no association between type 2 diabetes history, BMI at the age of 18 years, BMI at questionnaire baseline, or body size in adolescence and adulthood and accessing fertility care. Women who participated in ≥3 hours of vigorous physical activity at the age of 18 years were more likely to access fertility care. This finding is consistent with other research from the Nurses’ Health Study II that found an association between “healthy lifestyle behaviors” and accessing fertility care. Specifically, they found that women who exercised regularly were more likely to access fertility care (
4- Farland L.V.
- Collier A.Y.
- Correia K.F.
- Grodstein F.
- Chavarro J.E.
- Rich-Edwards J.
- et al.
Who receives a medical evaluation for infertility in the United States?.
).
Most women in our research reported using ISSSTE, which covers health care for federal government employees, for regular health care needs, and for major illness or intervention; our findings demonstrated that those who were able to supplement their public or government insurance (ISSSTE, IMSS, or other public) with private health care coverage were more likely to access fertility care. We also found that women who taught in rural areas were less likely to access fertility care, indicating that women who live and teach in rural areas may be presented with additional geographic barriers to seeking care. Geographic barriers to accessing fertility care have been documented in the United States as well (
25- Abusief M.E.
- Missmer S.A.
- Barbieri R.L.
- Jain T.
- Hornstein M.D.
Geographic distribution of reproductive endocrinology and infertility (REI) fellowships in the United States.
); because quality fertility services tend to be clustered in urban regions, women who live further away from these centers need to travel a greater distance to access this care. We found that women who had a mammogram or pap smear in the past year were more likely to access infertility care, suggesting that women who are more connected with the medical system (i.e., undergoing screening services) may be more likely to access fertility care. When stratified by region, women in the north, central, and south regions were less likely to report seeking access to infertility care than women in Mexico City.
Our study, among a sample of Mexican women, confirmed similar patterns of access as have been found in other populations; women who are single, had lower income, had lower education levels, or who taught in rural areas were less likely to access medical care for infertility, whereas women who were well connected to the health care system as estimated by having private health care insurance, having undergone mammography, or having a pap smear in the past year were more likely to receive medical care. We found some unique patterns related to accessing fertility care among women in Mexico; women who spoke an indigenous language and who lived in regions outside of Mexico City were less likely to access care. Our findings add to the existing body of literature, which can inform future policy recommendations by examining how lifestyle and demographic factors influence who receives care and provide insight into how these factors are related to accessing care. Future research should continue to investigate policies focused on improving access to fertility care for women who speak an indigenous language or who live in rural areas.
A strength of our study was the use of the MTC, a well-established, large cohort study with detailed information from across 12 states in Mexico (
17- Lajous M.
- Ortiz-Panozo E.
- Monge A.
- Santoyo-Vistrain R.
- Garcia-Anaya A.
- Yunes-Diaz E.
- et al.
Cohort profile: the Mexican Teachers' Cohort (MTC).
). However, there also are important limitations of our findings. Our analysis uses self-reported measures that may be prone to misclassification. However, we would expect that any misclassification would be nondifferential and, thus, attenuate our reported relationships. Additionally, given the cross-sectional nature of the baseline survey collection, there is the possibility of recall bias; however, we would expect this bias to be minimal. Additionally, the findings of the study may not be generalizable to other populations inside and outside of Mexico, because this sample was comprised of women employed as teachers. Thus, these findings may be most appropriately generalized to women with similar occupational and educational backgrounds within Mexico with access to health care. However, our population has geographic variability as we were able to study women from 12 states and several geographic regions across Mexico. Lastly, our data source lacked detailed information on the use of gynecologic surgery to treat infertility, and therefore, we are not able to comment on the prevalence of these procedures.
Acknowledgments
The authors acknowledge the participants in the Mexican Teachers Cohort study and the National Institute of Public Health of Mexico’s research support staff for their time and commitment to advancing the health care of women in Mexico. They thank the Servicio Profesional Docente at the Mexican Ministry of Education, with special thanks to Victor Sastré, Director of Promotion in Service. They also thank all the staff that has participated in questionnaire distribution from the State Ministries of Education of Baja California, Chiapas, Ciudad de México, Durango, Guanajuato, Hidalgo, Jalisco, Estado de México, Nuevo Léon, Sonora, Veracruz, and Yucatan. Finally, they would like to acknowledge ISSSTE, IMSS, ISSSTECali, ISSTELeon, ISSSTESon, ISSTECH, ISSEG, and ISSTEY for their continued support of the project.
Article info
Publication history
Published online: November 23, 2022
Accepted:
November 21,
2022
Received in revised form:
November 18,
2022
Received:
March 23,
2022
Publication stage
In Press Corrected ProofFootnotes
L.V.F. reports funding from the National Institutes of Health, Centers for Disease Control, and Federal Emergency Management Agency outside the submitted work. J.E.Ch. reports funding from the National Institutes of Health and on Food and Drug Administration; royalties from Harvard Health Publications; honoraria from Johns Hopkins University School of Medicine, National Institutes of Health, Northwestern University Feinberg School of Medicine, Carolinas Medical Center, American Society for Reproductive Medicine, British Dietetic Association, and Pacific Coast Reproductive Society; travel support from Johns Hopkins University School of Medicine, Pacific Coast Reproductive Society, European Society of Human Reproduction and Embryology, Health Sciences University School of Medicine (Colombia), Institut Hospital del Mar d’Investigacions Mediques (Spain), Japanese Society for Reproductive Medicine (Japan), Zhejiang University School of Medicine (China), Lund University Faculty of Medicine (Sweden), Medical University of Vienna (Austria) outside the submitted work. S.A.M. reports funding from AbbVie, NIH, and Marriot Family Foundation; honoraria from University British Columbia, WERF, and Huilun Shanghai; travel support ESHRE 2019 (and 2020 virtual), International Association for the Study of Pain (IASP) 4th World Congress on Abdominal and Pelvic Pain (WCAPP) 2019, National Endometriosis Network UK Meeting 2019, Society for Reproductive Investigation–69th Annual Scientific Meeting (2022), ESHRE 2022, FWGBD 2022, University of Michigan, Massachusetts Institute of Technology; advisory board AbbVie and Roche, field chief editor Frontiers in Reproductive Health, Roundtable participation–Abbott; unpaid leadership roles SWHR, WERF, WES, ASRM, and ESHRE outside the submitted work. S.M.K. has nothing to disclose. D.S. has nothing to disclose. R.L-R. has nothing to disclose. A.C-K. has nothing to disclose. A.P.S-S. has nothing to disclose. M.S.R. is currently an employee of Sanofi and may hold stock/stock options in the company. M.L. reports funding from the National Institutes of Health, the American Institute for Cancer Research, and hte Mexican Council for Science and Technology
Copyright
© 2022 The Authors. Published by Elsevier Inc. on behalf of American Society for Reproductive Medicine.