Disparities remain as fertility patient age continues to rise

The Human Fertilisation and Embryology Authority (HFEA)'s Fertility Trends 2022: Preliminary Trends and Figures Report provides an update on fertility treatment and outcomes in the UK from 1991 to 2022, providing preliminary statistics for IVF and donor insemination treatment, gamete and embryo storage and donation.

A key finding of this year's report was that the average age of patients starting fertility treatment has reached 35 for the first time (see BioNews 1248). This is an important milestone as success rates decline rapidly with age, which could impact on patients' chances of having successful treatment.

Shining a spotlight on ethnic disparities

Although this is the first time the average age of all patients starting fertility treatment has passed 35, this was already the case for black patients, whose average age at first treatment was over 35 years old in 2015. By 2021, the average age had increased to 36, which was the largest increase in age at first treatment for this group.

Asian patients started treatment at a younger age when compared to other groups, although the average age increased from below 34 years in 2008 to nearly 35 years in 2021. HFEA data also shows that within this group, Chinese patients were older at 37 years while patients from Bangladesh and Pakistan were 33.4 years or younger when starting treatment.

Recent HFEA reports have continued to show disparities between ethnic groups. The Ethnic diversity in fertility treatment report found that, from 2017-2021, single black and Asian patients started treatment at an older age (38-39) on average, compared to an average of 36.2 for single white patients (see BioNews 1220).

The same report found that patients in female same-sex partnerships started their first treatment at a younger age on average (32.7) compared to patients in heterosexual relationships, ranging from 32.5 for patients with a mixed background and 32.7 for white patients to 35.8 years for Asian patients. There may be a number of reasons why female same-sex couples start treatment sooner than heterosexual couples such as varied funding criteria, costs and longer waiting lists for donors of matching ethnicity.

Patient experiences when speaking to a GP also vary by ethnicity, with black patients being more likely to experience delays in speaking with a GP than patients of other ethnicities. The reasons for these disparities are complex and not fully understood. However, there could be many reasons why black patients experience delays when seeking treatment and wider concerns about discrimination from healthcare staff faced by black people in the UK must be considered, especially when survey findings show this is highest for black people aged 18-34.

Given the importance of seeking advice as soon as possible was highlighted in the HFEA's Fertility Trends 2022 report, more needs to be done to investigate the various forms of discrimination and inequalities that black and ethnic minority patients are experiencing in medical settings, to try and minimise delays and ensure patients feel able to approach healthcare professionals without anxiety.

Barriers to treatment

NHS-funded fertility treatment cycles have declined across the UK in recent years, however HFEA data shows that they have declined the most among black patients, from 60 percent of all cycles undertaken by this group in 2019 to 41 percent in 2021. Geographically, NHS-funded treatments decreased the most in London, from 23 percent in 2019 to 17 percent in 2021, where almost 50 percent of the black population in England and Wales lived in 2021. In the same year, the proportion of IVF cycles funded through the NHS was 49 percent for Asian patients.

The differences in the number of patients accessing NHS-funded fertility treatment may be due to regional funding availability and eligibility criteria set by governments in Scotland, Wales and Northern Ireland and Integrated Care Boards (ICBs) in England. The availability of IVF funding can range from no funding to three funded cycles depending on location and eligibility restrictions such as body mass index (BMI).

While having a healthy BMI is one of the key NHS eligibility criteria, there has been an ongoing conversation in recent years as to whether the measurement which infers adiposity from weight is an appropriate determinant of risk, particularly for black people, and therefore represents a further barrier to access to NHS-funded treatment.

Given that there are some health conditions that are more prevalent in the black community such as tubal damage and fibroids, decision makers should look into gynaecological disorders and the impact they may have on the treatment outcomes of black and ethnic minority patients.

General health may also have a part to play in the differences of birth rates. Obesity is associated with not only an increased risk of infertility but also impairs ovarian response to stimulation drugs and decreases implantation and live birth rates following IVF. However, developing a full understanding of the disparities that exist is complex as they may be influenced by existing social and economic inequalities, pre-existing diseases and other societal factors.

A call to action

In order to understand why patient age when starting treatment continues to vary by ethnicity, more work needs to be done to understand the variations that exist and how they impact black patients’ experiences of fertility treatment. As well as understanding the variations, the long-standing disparities need to be tackled in order to create long-lasting change.

The HFEA's ongoing call to action with the Royal College of Obstetricians and Gynaecologists, the British Fertility Society, the Royal College of General Practitioners and Fertility Network UK, calls for improvements to be made in development of clinical policy, information and awareness, NHS commissioning, and research to tackle the ethnic disparities in fertility treatment.

There is no room for the health inequalities that exist within fertility treatment and we will continue to raise awareness of these disparities and work together to achieve meaningful change for all patients.