ASRM Today: Equity, Access, and Innovation, Episode Two: Access

ASRM Today tackles equity, access, and innovation in reproductive medicine. Hear personal stories and expert insights on overcoming barriers to fertility care, especially for women of color and LGBTQIA+ individuals.

Are you ready to be at the forefront of family building and reproductive health? Join us for ASRM 2024 in Denver, Colorado, October 19th through the 23rd. This year's event features expanded meeting spaces, more seating, and a new global health track as part of a comprehensive program that goes beyond infertility to cover all aspects of reproductive health. We welcome members, trainees, and colleagues from every corner of the globe.

Join us for an unforgettable experience at the ASRM 2024 Scientific Congress and Expo. For more information and to register, visit asrmcongress.org. The word access raises many questions for me in reproductive medicine. Today on the show, part two of our series on equity, access, and innovation, and what that means to reproductive medicine.

I am Jeffrey Hayes and this is ASRM Today. Welcome to ASRM Today, a podcast that takes a deeper dive into the current topics in reproductive medicine. Part two, access.

What we learned about equity in our last episode raised some direct questions in my readings and research, namely, how can we have equity and fairness in reproductive medicine if there are impediments to accessing treatment? I decided to start by focusing on access as it relates to the patient's experience. Ilana Frank, CEO and founder of the Jewish Fertility Foundation, from my conversation with her about her infertility journey from 2023. My journey started probably, oh my gosh, I'm married almost 14 years next week.

So what happens when a nice Jewish gal gets married to a nice Jewish guy? You get married, you have lots of babies and it didn't go exactly as planned for us. About 15 plus years ago, we found each other finally and we decided to move to Israel and we were going to have our million babies there and it just did not go as planned. So after just a few months of really trying, I was able to work up the courage and go visit a doctor.

And this is in a country with socialized medicine, so things are a little bit different, just navigating which doctor, how to do it. And they asked me, the first question that the gynecologist asked was, well, how long have you been married? Not how long have you been trying? And so I said, it's already been over a year, no birth control. And she's like, okay, no problem.

Here's some clomid. No checking of my body, nothing really invasive. I was going to get pregnant, nothing, nothing, nothing, month after month.

Things are starting to get a little hard with my husband. He just wants to figure out how to make me happy. Sex was exhausting and I was already really getting frustrated.

I finally confided in my aunt in Israel who works in the medical system and her first question to me was, do you know how to have sex? And I was like, I think so. And then she's like, just go relax, take a vacation. But I do know this doctor, you should go to him.

So we started going to this well-known doctor's house in the evening, private medicine, writing a check for him to do IUI treatments on me. And he never checks me once. My husband was doing his business in the bathroom.

We did this for months and we weren't talking about it. And like 14, 15 years ago, it was different on the worldwide web, what was available in terms of access for information. And so we just did it.

After a while, we're like, this is weird. And we got a second opinion. And this is after well over a year of doing these things.

Finally, somebody checked me and guess what? My tubes are blocked. So I am not going to get pregnant naturally or from an IUI. Eventually I was able to have IVF for free because of socialized medicine.

And I was very lucky enough to retrieve a ton of embryos and ultimately have two children via IVF in Israel. When I came back to America, my journey wasn't over. For five years, I was trying to adopt.

My husband and I didn't want to go through the IVF journey again in Israel. I was like using my extra embryos in Israel. I was going back and forth to Israel to use up all my embryos.

Nothing was working. Tried to adopt. We failed at that.

We tried to adopt from the foster care system. Failed that way. And ultimately, a woman reached out to me to try to donate her embryos.

And I had started Jewish Fertility Foundation by this time. And I wasn't really thinking about that for myself. But I sometimes was able to make matches through embryo donation.

And eventually, after another failure around adoption, I said, what about me? And so next week, my four-year-old from a donor embryo is, well, he's turning four next week was the point of the story. So that's kind of my journey. What I got from Alana's story is that access to services is crucial because they directly impact a person's ability to make informed decisions about their reproductive health in their future.

For example, infertility can be a deeply distressing condition and access to treatments like IVF can make a significant difference in a person's life. Similarly, access to contraception allows individuals to plan their families and futures on their own terms. However, access to these services can vary dramatically depending on where you live, your socioeconomic status, race or ethnicity, or lack of acknowledgement of culturally competent gender-affirming care.

Dr. Gloria Richard-Davis from our conversation in 2024 on equity and access regarding women of color. Now, what I do know is that there are more of the large practices that are really looking at their database and drilling down to look at the outcomes with women of color who enter care from their perspective. How many of them discontinue care? How many of them actually, when they enter care, continue and convert to active cycles, right? Because the things that we know from the current literature is that there is one, there's a delay in entering care, the access is not equitable, even in the states where we have mandated care, and that women of color tend to leave here, right? Much of it is linked to the experience that they have with fertility centers, the perhaps cultural stigma and lack of support that occurs.

And so, you know, really addressing those issues at multiple levels becomes very critical. What I take from Dr. Richard-Davis' conversation with me is that there are several significant barriers regarding access. One of the biggest is cost.

Many reproductive health services, especially advanced fertility treatments like IVF, are expensive and often not covered by insurance. This makes them inaccessible to many people. Geographic location is another barrier.

In rural areas, there might not be any reproductive health specialists nearby. Additionally, there are systemic issues like racial and socioeconomic disparities that mean people of color and those with lower incomes often receive lower quality care or face discrimination within the healthcare system. Next, I went back to a conversation I had with Dr. Quinton Katler.

I would say from a big picture point of view, there's several issues that come to mind. One, and it's interesting that we started this conversation by identifying LGBTQ+, or IA+, as an umbrella term. Clinics and providers can fall into this habit of grouping all LGBTQIA plus patients under this homogenous group title.

I always like to remind myself and remind my colleagues that each of those letters within that acronym has its own barriers, their own journeys, their own challenges, and really important considerations for family building and reproductive care. Second is that of all the patients that are seeking out assisted reproductive technology, especially those patients of ours that are seeking out reproduction using third party reproduction, so donor sperm or donor egg, all of these patients face significant barriers to care. They have uncertainty about their biologic connectedness to that child.

They face challenges regarding disclosure to their child. I would argue that LGBTQIA plus patients, they face these barriers, plus they face really longer lasting and historically derived barriers. So they have issues relating to self-identity, issues relating to internal feelings of questioning their ability to be a parent as a queer person.

They struggle with feelings of internalized homophobia, societal homophobia. They also struggle with restrictions in terms of access to care with providers that have cultural competency. And I also would argue that LGBTQIA plus patients also have unique choices to make when it comes to the path to parenthood, of which a lot of the ethical implications can't and shouldn't be ignored, such as who's going to carry the child, which partner is going to go first, who's sperm to use, who's egg to use.

These are emotional considerations that can play a deeply challenging role in this person or this couple's path to parenthood. What I take from Dr. Katler's conversation is that providers need to recognize the emotional barriers to access to care that can be problematic for patients. Today's episode on the word access has illuminated much for me, and it urges me to continue to investigate what it means for reproductive medicine.

Tooling through ASRM's Practice and Ethics Committee documents on access to care has been helpful, but it is just the start, as I know that conversations with providers and patients such as we have had on the program today will continue to help clarify these issues in access. Join me next time as we dive into the topic of innovation in reproductive medicine. Until then, I'm Jeffrey Hayes, and this is ASRM Today.

This concludes this episode of ASRM Today. For show notes, author information, and discussions, go to asrmtoday.org. This material is copyrighted by the American Society for Reproductive Medicine and may not be reproduced or used without express consent from ASRM. ASRM Today series podcasts are supported in part by the ASRM Corporate Member Council.

The information and opinions expressed in this podcast do not necessarily reflect those of ASRM and its affiliates. These are provided as a source of general information and are not a substitute for consultation with a physician.