Beyond the diagnosis: a call for equity in PCOS fertility care across racial and socioeconomic lines

Existing literature has identified various factors
contributing to disparities in access to fertility care across racial groups,
including societal, economic, and geographic variables, which can result in
delays in care for affected patients. Compared with White women, African
American and Hispanic women face greater challenges in securing appointments,
missing work for treatments, and covering costs. Moreover, African American and
Hispanic women are more likely to be self-referred or referred by friends or
family and are more likely to experience longer duration of infertility before
receiving fertility care than White women. An investigation by Dongarwar et al.
highlighted similar concerns and showed that compared with non-Hispanic White
women, non-Hispanic Asian women had a 7% lower likelihood and non-Hispanic
Black and Hispanic women had a 70% lower likelihood of receiving any
infertility treatment. Although these studies have provided valuable insights,
there has been limited investigation into how these factors specifically impact
patients with PCOS.

To investigate the factors at play for those with PCOS,
Applebaum et al. explored the critical question: where do disparities in
fertility treatment lie for those with PCOS across racial and socioeconomic lines?
Their comprehensive analysis delved into both patient and physician factors
that could contribute to inequities.

By focusing on the use of clomiphene citrate, letrozole, and
injectable gonadotropins, the study revealed that Black patients, those with
household incomes below the federal poverty line, and those with public
insurance were significantly less likely to be prescribed these fertility
medications compared with White patients, those with household incomes above
the national median, and those with commercial insurance. These findings add to
the existing literature, underscoring the urgent need to address the
disparities that continue to undermine the quality of care for patients with
PCOS.

The study also sheds light on disparities in the provision
of treatment on the basis of the type of healthcare provider. Patients were
less likely to be prescribed these fertility medications from general
obstetrician-gynecologists and family medicine and internal medicine physicians
compared with those from reproductive endocrinologists. This finding highlights
the need for proactive measures within the field of reproductive medicine. For
many patients with PCOS, the first point of contact is their primary care
provider or general obstetrician-gynecologist. Enhancing collaboration between
these providers and reproductive endocrinologists, coupled with robust support
and education initiatives, is essential to ensure that patients have access to
the comprehensive and equitable care they deserve.

Only five patients in the study were uninsured, and <3%
had incomes below the federal poverty line. This limited representation of some
of the most vulnerable populations underscores two important points. First, the
study’s findings may only begin to reveal the full extent of inequity affecting
these groups. Second, the low percentage of such patients may reflect existing
barriers to healthcare access, emphasizing the need for expanded access through
improved insurance coverage and care availability. To better understand and
address these disparities, future research should prioritize the inclusion of
low-income and uninsured individuals to further assess the barriers to care
faced by this population.

The findings of Applebaum et al. highlight the need for
targeted interventions to bridge the gap in fertility care across racial and
socioeconomic groups affected by PCOS. Establishing these interventions will
require a multifaceted approach involving policy changes, community outreach,
and the development of culturally competent care models that address the unique
needs of this population.

Source: Stephanie Hallisey, M.D. Lawrence Engmann, M.D.;FertSert;
VOL. 122 NO. 5 / NOVEMBER 2024

https://doi.org/10.1016/j.fertnstert.2024.08.341