People who study the fertility business have been concerned for years over the fact that racial minorities utilize fertility treatments at a lower rate than whites. One easy explanation is the distribution of wealth in the U.S. Fertility care is expensive and often not covered by insurance, and some people in racial minority groups do not seek care because they are priced out of the market. But, this explanation is incomplete because even in states where insurance covers fertility treatments, African American and Hispanic women are underrepresented among those seeking fertility treatments.
Another concerning possibility is that some sort of conscious or unconscious racist norms operate within the business. As law professor Dorothy Roberts pointed out in an important essay over 15 years ago, however, the problem is that "[e]vidence is hard to come by." Last summer, several research assistants and I tried to uncover some evidence by looking at virtually every U.S. fertility clinics' website to see what these websites say about the cultural norms present in the fertility industry. Despite going into the project knowing about the concerns of other scholars, I was surprised by what we found.
The first thing we looked at was the race of the babies in the pictures that are prominently featured on most clinics' websites. Looking just at first page that pops up when we typed in the website address, we recorded the races of the babies we saw. Of the 294 websites that presented images of babies, 62.93 percent presented pictures of only white babies. Contrast that number with the number of websites that had pictures exclusively of another race: 1.02 percent of websites presented images of only a black baby; 0.34 percent had an image of only a Latino baby; and 1.02 percent had a picture of only an Asian baby. Some websites had pictures of babies from multiple races, and if you count those, 97.28 percent of websites with pictures of babies have pictures of white babies.
The number of reproductive endocrinologists in the U.S. who are racial minorities mirrors the pictures of babies, suggesting racial minorities are underrepresented in the field. Of the 1,124 reproductive endocrinologists' races we recorded on clinics' websites, 79.89 percent were white, 2.14 percent were black, 4.27 percent were Latino, 8.27 percent were Asian, and 5.43 percent were of other races.
So what do these numbers tell us about why members of racial minority groups do not use ART as often as whites? Part of the answer is that racial minorities might not see fertility care as welcoming to minorities or as a treatment to which they have access. Social psychologists tell us that we often make decisions based on what we see other people doing. It is called the social proof principle -- think of laughing at an inane sitcom when you hear the laugh track run. And, we are most likely to follow the behavior of people who are most similar to us. It is possible that pictures of white babies and pictures of white doctors give social proof to white individuals considering fertility care but not to people who are of other races, driving up the number of white patients and driving down the number of patients from other races.
Here is where the law or self-regulation in the fertility industry could help. For instance, fertility clinics or the trade association to which these clinics belong could make a conscience effort to include more pictures of babies of different races in their marketing efforts. It is also possible lawmakers could intervene. The Fair Housing Act, as an analogy, allows courts to order rental businesses who have engaged in discrimination to integrate different races into their advertising, and similar provisions could be enacted here to ensure that clinics' pictures represent the entire US population.
But, until someone steps up to fix this problem, we are left with a deeply troubling reality -- the picture of fertility care in our country is predominantly a picture of white parents using treatments to have white babies with the help of white doctors.
The full results of my paper and the methodology can be downloaded for free here.
<strong>1. Your fertility is mostly determined by genetics, which influences how many eggs you are born with. </strong> Doctors believe that the number of eggs you have at birth determines the length of time you will remain fertile. At birth, women have about two million eggs in their ovaries. For every egg ovulated during your reproductive life, about 1,000 eggs undergo programmed cell death. Other things, such as smoking cigarettes and certain types of chemotherapy, can accelerate egg cell death and promote an earlier menopause.
<strong>2. Regular menstrual cycles are a sign of regular ovulation.</strong> Most women have regular cycles lasting between 24 and 35 days. This is usually a sign of regular, predictable ovulation. Women who do not ovulate regularly have irregular menstrual cycles. Those who do not ovulate at all may have a genetic condition called polycystic ovarian syndrome (PCOS).
<strong>3. Basal temperature charting does not predict ovulation.</strong> An older method of tracking ovulation involves taking your oral body temperature each morning before getting out of bed. This is called basal body temperature. This method is used to spot a rise in basal temperature, which is a sign that progesterone is being produced. The main problem with using this method is that your temperature rises after ovulation has already occurred. This makes it more difficult to time intercourse at an optimal time for conception. A better method is to use over-the-counter urine ovulation predictor test kits such as Clearblue Easy. These kits test for the hormone that prompts ovulation, which is called luteinizing hormone (LH).
<strong>4. Most women with blocked fallopian tubes are completely unaware they may have had a prior pelvic infection.</strong> About 10 percent of infertility cases are due to tubal disease, either complete blockage or pelvic scarring causing tubal malfunction. One major cause of tubal disease is a prior pelvic infection from a sexually transmitted disease such as chlamydia. These infections can cause so few symptoms that you may be completely unaware your tubes are affected. This is why fertility physicians will order a dye test of the tubes, called a hysterosalpingogram (HSG), if you have been trying and failing to conceive for 6 months or longer.
<strong>5. In most cases, stress does not cause infertility.</strong> Except in rare cases of extreme physical or emotional distress, women will keep ovulating regularly. Conceiving while on vacation is likely less about relaxation than about coincidence and good timing of sex.
<strong>6. By age 44, most women are infertile, even if they are still ovulating regularly.</strong> Even with significant fertility treatment, rates of conception are very low after age 43. Most women who conceive in their mid-40's with fertility treatment are using donated eggs from younger women.
<strong>7. Having fathered a pregnancy in the past does not guarantee fertility.</strong> Sperm counts can change quite a bit with time, so never assume that a prior pregnancy guarantees fertile sperm. Obtaining a semen analysis is the only way to be sure the sperm are still healthy!
<strong>8. For the most part, diet has little or nothing to do with fertility.</strong> Despite popular press, there is little scientific data showing that a particular diet or food promotes fertility. One limited study did suggest a Mediterranean diet with olive oil, fish and legumes may help promote fertility.
<strong>9. Vitamin D may improve results of fertility treatments.</strong> A recent study from the University of Southern California suggested that women who were undergoing fertility treatments, but had low vitamin D levels, might have lower rates of conception. This vitamin is also essential during pregnancy. At Pacific Fertility Center, we recommend our patients take 2,000-4,000 IU per day.
<strong>10. Being either underweight or overweight is clearly linked with lowered levels of fertility.</strong> The evidence in recent years is that obesity is clearly linked with a longer time to conception. Having a body mass index less than 18 or over 32 is associated with problems ovulating and conceiving, as well as problems during pregnancy.