Distribution of male infertility specialists in relation to the male population and assisted reproductive technology centers in the United States

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1 Distribution of male infertility in relation to the male and assisted reproductive technology s in the United s Ajay K. Nangia, M.B.B.S., a Donald S. Likosky, Ph.D., b,c and Dongmei Wang c a Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon; b Department of Surgery, Dartmouth Medical School, Hanover; and c The Dartmouth Institute for Health Policy and Clinical Practice, and Community and Family Medicine, Dartmouth Medical School, Hanover, New Hampshire Objective: To describe the spatial distribution of assisted reproductive technology () s and male infertility by location, driving distance from, and potential male in need of these resources. Design: Cross-sectional study. Setting: Male in the reproductive years (20 49 years old) based on U.S. Census Bureau data in Urology male infertility as defined by 2005 specialty society membership directories. s registered with the Society for Assisted Reproductive Technology in Main Outcome Measure(s): Male and male infertility within the service area served by in-state and -state s, as defined by a 60-minute travel time. Result(s): One hundred ninety-seven male infertility and 390 s were identified. On a state level, the highest male in the reproductive years was seen in California, Texas, and Florida. The highest male s per male specialist were found in Oregon, Tennessee, and Oklahoma. The highest number of s per male specialist was found in Tennessee. The highest proximities of male within the 60-minute driving service area of different s were found in the North East and Southern California. The Midwest to Northwest had the least. Conclusion(s): A disparity of urology male infertility exists in the United s, with large areas of the country being underserved and overserved based on the location of s. (Fertil Steril Ò 2010;94: Ó2010 by American Society for Reproductive Medicine.) Key Words: Male infertility, s, service areas, urology Approximately 12% 15% of sexually active couples are infertile (1 3). The etiology of infertility is likely multifactorial. Previous work has estimated that 50% of infertility is attributed to the female, 30% to the male, and 20% to both the male and female (4, 5). Received January 24, 2009; revised February 4, 2009; accepted February 5, 2009; published online April 9, A.K.N. has nothing to disclose. D.S.L. has nothing to disclose. D.W. has nothing to disclose. Supported by an academic grant from the Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire. Reprint requests: Ajay K. Nangia, M.B.B.S., Department of Urology, MS3016, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS (TEL: ; FAX: ; anangia@kumc.edu). Urology care of male partners in couples with infertility is becoming more specialized with genetic, endocrine/medical, obstructive causes that need to be investigated and treated with advanced testing, interpretation and microsurgical techniques. Proximity of male to assisted reproductive technology () s is important for the care of the infertile couple. This is related to access to andrology facilities, cryopreservation services, joint procedures, and interaction between urology and. Lack of male investigation or limited urologic services can lead to potentially reversible, life-threatening, and/or genetic conditions being missed. Management of men with obstructive or nonobstructive etiologies that request or require sperm retrieval techniques also needs to be coordinated. The distribution of this joint care and the distribution of men in the reproductive years are unknown and have not been studied previously. The objective of the study was to describe the variation in allocation of resources for male infertility involving or requiring, especially as it relates to males in their reproductive years of life. Our hypothesis is that male infertility in the United s are underrepresented in relation to s and the distribution of the male in the reproductive years. MATERIALS AND METHODS Databases The 2000 U.S. Census Bureau estimates of male in the reproductive years (ages 20 49) are calculated from block groups and county levels (aggregated from census block groups). Assisted reproductive technology s registered with the Society for Assisted Reproductive Technology (S) in 2005 were retrieved from the website /$36.00 Fertility and Sterility â Vol. 94, No. 2, July doi: /j.fertnstert Copyright ª2010 American Society for Reproductive Medicine, Published by Elsevier Inc.

2 Street network and speed limit data from the Environmental System Research Institute (ESRI)/Geographic Data Technologies (now TeleAtlas, Redlands, CA) were used. We did not include any satellite clinics of listed s, unless they were listed separately by the S. Data on urology male infertility in the United s were obtained from the 2005 membership directories of the Society for the Study of Male Reproduction (SSMR), a society within the American Urological Association, and the Society for Male Reproduction and Urology (SMRU), a society within the American Society for Reproductive Medicine. Candidate members/trainees and members outside the United s were excluded. Analytic Tools Geographic Information System (GIS) software (ArcGIS 9.2 and Network Analyst Extension of ArcGIS 9.1) by ESRI was used to map s. Sixty-minute travel distances from s were calculated using United s highways and major roads ESRI/TeleAtlas ( Microsoft (Redmond, WA) Access and Excel were used to compile the data tables. Analysis Methods All of the s included in the 2005 S database were located geographically based on their full street addresses. Driving distance within 60-minutes from each was calculated exclusive of the three s located in Puerto Rico, because of inadequate road mapping. All of the road segments reached from one were then generalized into an area, which defined an service area. The methodology used for this has been described previously by our group (6). Male were located by their practice addresses in a similar method to the s. The male in the reproductive years and the total male state (all ages) were calculated from the 2000 census data and tabulated for each state (Table 1). The ratios of male to s and vice versa on a state level were calculated (Table 1). Assisted reproductive technology service areas and the locations of male were plotted in relation to the census county block groups of men in the reproductive years (Fig. 1). The male within the service areas was calculated and aggregated for each state, thereby determining the total male in the reproductive years served by s within a state (Table 2). In addition, the proportion of a state s male served by in-state and out-ofstate s was determined (Table 2). The number of service areas served by a single male specialist (i.e., the number of service areas in which a single male specialist practiced) was also calculated and plotted in relation to the study male (Fig. 2). The average number of male within a single service area was also plotted (Fig. 3). s with partial or complete mandated insurance coverage for services in 2005 were identified versus states without these mandates (Fig. 3). Mandated state insurance coverage for services was correlated with the male and male. RESULTS Service areas for 387 of 390 s were calculated. The three s located in Puerto Rico were excluded because of inadequate road mapping. There were 197 urologic in male infertility identified in the United s, excluding Puerto Rico. Montana and Alaska had neither resource (i.e., no male specialist or ). Wyoming was the only other state that had no. Thirteen states had no male (Table 1). Distribution of Male in the Reproductive Years and Male Specialists On a state level, the highest male s in the reproductive ages of years were seen in California (7,864,781), Texas (4,774,475), and Florida (3,296,219) (Table 1). The lowest s were seen in Vermont (130,533), the District of Columbia (136,125), Alaska (153,883), and Montana (189,643) (Table 1). Analysis of the male on a county level per square mile shows the highest distribution of men in the reproductive years in the North West, California, Florida, and the North East (Fig. 1). Across states, nearly half of the total male was in their reproductive years (Table 1). The states with the lowest percentage of men in the reproductive years were Florida and Montana with 42%. Assisted reproductive technology s and male per state are listed in Table 1. There was variability in the number of male across states. In absolute terms, the highest number of male was found in New York (n ¼ 27) and then California (n ¼ 20). Thirteen states had no male. Oregon, Tennessee, and Oklahoma had the highest number of males in their reproductive years per male specialist (among states that had a specialist), whereas the lowest ratios were found in Wyoming and Louisiana (Table 1). Most states had 200, ,000 men in their reproductive years per male specialist (Table 1). The distribution of male per male specialist was generally independent of a state s mandated coverage for (Figure 3 and data not shown). Distribution of Centers and Male Infertility Specialists s with the highest number of s in 2005 were California (n ¼ 49), New York (n ¼ 34), and Texas (n ¼ 30). There were no s in Wyoming, Montana and Alaska. On an overall state level (with the proximity of to male specialist not being considered) the highest number of s served per male specialist was found in Tennessee (n ¼ 7), followed by Connecticut (n ¼ 6), Indiana (n ¼ 5) and Kansas (n ¼ 5) (Table 1). Location of 600 Nangia et al. Male infertility in the United s Vol. 94, No. 2, July 2010

3 Fertility and Sterility â 601 TABLE 1 Demographic and male specialist resource allocation by state. abbreviation No. of men aged y Total state male (all ages) age of total state male in the reproductive years (%) s in the reproductive years (20 49) per male specialist No. of s per Arkansas AR 555,248 1,304, Alabama AL 937,785 2,146, , Alaska AK 153, , Arizona AZ 1,130,287 2,561, , California CA 7,864,781 16,874, , Colorado CO 1,049,701 2,165, , Connecticut CT 726,917 1,649, , Delaware DE 168, , District of DC 136, , , Columbia Florida FL 3,296,219 7,797, , Georgia GA 1,912,062 4,027, , Hawaii HI 275, , , Idaho ID 279, , Illinois IL 2,764,631 6,080, , Indiana IN 1,331,850 2,982, , Iowa IA 618,712 1,435, , Kansas KS 584,283 1,328, , Kentucky KY 891,638 1,975, , Louisiana LA 946,934 2,162, , Maine ME 266, , Maryland MD 1,154,126 2,557, , Massachusetts MA 1,401,892 3,058, , Michigan MI 2,163,591 4,873, , Minnesota MN 1,103,790 2,435, , Mississippi MS 592,734 1,373, Missouri MO 1,185,486 2,720, , Montana MT 189, , Nebraska NE 369, , , Nevada NV 467,146 1,018, New Hampshire NH 272, , , New Jersey NJ 1,842,668 4,082, , New Mexico NM 380, , , New York NY 4,137,459 9,146, , North Carolina NC 1,835,102 3,942, , Nangia. Male infertility in the United s. Fertil Steril No. of s per male specialist

4 602 Nangia et al. Male infertility in the United s Vol. 94, No. 2, July 2010 TABLE 1 Continued. abbreviation No. of men aged y Total state male (all ages) age of total state male in the reproductive years (%) s in the reproductive years (20 49) per male specialist No. of s per North Dakota ND 140, , Ohio OH 2,421,965 5,512, , Oklahoma OK 737,066 1,695, , Oregon OR 759,284 1,696, , Pennsylvania PA 2,559,608 5,929, , Rhode Island RI 224, , , South Carolina SC 866,922 1,948, South Dakota SD 159, , Tennessee TN 1,248,146 2,770, ,248, Texas TX 4,774,475 10,352, , Utah UT 499,659 1,119, , Vermont VT 130, , Virginia VA 1,621,455 3,471, , Washington WA 1,346,822 2,934, , West Virginia WV 378, , Wisconsin WI 1,180,505 2,649, , Wyoming WY 108, , , Nangia. Male infertility in the United s. Fertil Steril No. of s per male specialist

5 FIGURE 1 Distribution of male in the reproductive years, urology male infertility, and s with service areas within the United s. Nangia. Male infertility in the United s. Fertil Steril s and male were generally well located in relation to high density of male in the reproductive years (Figure 1). Service Areas The highest percentage of the male in the reproductive years within the 60-minute driving distance of any was found in the North East (Rhode Island, Connecticut, Massachusetts New Jersey, and New York), the District of Columbia, and California, with the lowest in Montana, Wyoming, and West Virginia (Table 2). The North East also had the highest percentage of the male study within 60-minute access to their own state s s. Men living in Rhode Island, Connecticut, Delaware, and the District of Columbia had the greatest access to states s (Table 2). New Jersey, New York, Connecticut, and California had the highest number of male within the 60-minute driving distance to s located in their own state, whereas states in the Midwest to North West had the least (Table 2 and Figure 3). The access to service areas from the perspective of male was analyzed. The calculation of the number of service areas served by a single male specialist showed the highest density in the North East and Southern California (Figure 2). The majority of the country showed that the male were in proximity to one to five service areas (Table 2 and Fig. 2). Seven male were not within an service area (Fig. 2). DISCUSSION We found wide variability in the allocation of urology male infertility in the United s. Male and s were located in regions with dense male Fertility and Sterility â 603

6 604 Nangia et al. Male infertility in the United s Vol. 94, No. 2, July 2010 TABLE 2 Male in the reproductive years and male in and out of state service areas. No. of men living within 60 minutes of an s Total living within 60 minutes of an CENTER (%) covered by own state s covered by own state s Men y old state s state s Center in state jointly state and states jointly state and states from and states within 60 minutes of state s Alabama 426, , , , , Alaska 0 153, Arizona 931,591 1,130, , Arkansas 204, , , , California 7,077,549 7,864, ,066, , Colorado 877,822 1,049, , Connecticut 726, , , , Delaware 131, , , , District of Columbia 136, , , , Florida 3,013,224 3,296, ,013, , , Georgia 1,385,161 1,912, ,304, , , Hawaii 204, , , Idaho 143, , , , Illinois 2,270,778 2,764, ,127, , , Indiana 1,020,788 1,331, , , , Iowa 324, , , , Kansas 357, , , , , Kentucky 409, , , , , Louisiana 683, , , Maine 144, , , , , Maryland 1,062,003 1,154, ,036, ,019, Massachusetts 1,366,219 1,401, ,355, ,058, Michigan 1,734,027 2,163, ,729, , , Minnesota 825,340 1,103, , , Mississippi 242, , , , Missouri 776,717 1,185, , , , Montana 0 189, Nebraska 221, , , Nevada 429, , , New Hampshire 214, , , , , New Jersey 1,828,463 1,842, ,828, ,789, New Mexico 222, , , , New York 3,780,411 4,137, ,761, ,719, North Carolina 1,294,377 1,835, ,233, , , Nangia. Male infertility in the United s. Fertil Steril 2010.

7 Fertility and Sterility â 605 TABLE 2 Continued. No. of men living within 60 minutes of an s Total living within 60 minutes of an CENTER (%) covered by own state s covered by own state s Men y old state s state s Center in state jointly state and states jointly state and states from and states within 60 minutes of state s North Dakota 39, , , Ohio 2,129,865 2,421, ,107, , , Oklahoma 484, , , Oregon 457, , , , Pennsylvania 2,134,861 2,559, ,086, ,403, Rhode Island 223, , , , , South Carolina 667, , , , , South Dakota 56, , , Tennessee 1,022,622 1,248, ,022, Texas 3,393,874 4,774, ,367, , Utah 412, , , Vermont 104, , , , , Virginia 1,258,250 1,621, ,234, , Washington 1,084,794 1,346, , , , West Virginia 96, , , , Wisconsin 861,797 1,180, , , , Wyoming 18, , , Median Nangia. Male infertility in the United s. Fertil Steril 2010.

8 FIGURE 2 Number of s served by a single male specialist based on service areas. Nangia. Male infertility in the United s. Fertil Steril s in their reproductive years. Variability existed in the spatial distribution of male to the location of s, with most male within 60 minutes of an. However, many service areas still remain underserved (i.e., there are no male ). The North East has the highest number of male within service areas. The distribution of male per male specialist was independent of a state s mandated insurance status for services. The gender distribution of infertility is commonly quoted in the literature as being 50% caused by a female factor, 20% joint male and female factor, and 30% male factor alone (4). The methodologic science underlying these statistics is unclear, with epidemiologic data on male factor infertility being limited and poorly studied (5). Nonetheless, a recent Centers for Disease Control and Prevention (CDC) study analyzed data from the 2002 National Survey for Family Growth (NSFG) from a male perspective and found that a total of 7.5% of all sexually experienced men reported a visit for help with having a child at some time during their lifetime (equating to million men) (7). More visits were reported by the oldest men (aged years) in the sample (11.1%). Socioeconomic factors such as a college education, a family income above 300% of the poverty level, and having private health insurance resulted in a higher number of men seeking help (7). Of men who sought help, 18.1% were received a diagnosis of a male-related infertility problem, including sperm or semen problems (13.7%) and varicocele (5.9%) (7). The care for male infertility is mostly limited to physician office visits, outpatient surgical settings, and often fee-for-service, which results in limited use data being available. Data from the National Survey for Ambulatory Surgery showed that in the cumulative rate of ambulatory surgery visits from male infertility was 61 per 100,000 for a total of 55,441 visits nationally. Stratification 606 Nangia et al. Male infertility in the United s Vol. 94, No. 2, July 2010

9 FIGURE 3 Number of male within 60-minutes driving distance of a single. Nangia. Male infertility in the United s. Fertil Steril for age showed the highest use for men years old (126/100,000), then men years old (83/100, 000), and finally men years old (20/100,000) (8 10). Data for men aged years was insufficient to produce estimates. Geographically, the most surgeries for male infertility were performed in the North East, followed by the Midwest, and the South, with the fewest in the West (8 10). The reason for this regional variation was unclear and may have been related to regional variations in insurance coverage for infertility versus socioeconomic distribution and the ability to pay for a traditionally uninsured problem. Data from the Center for Health Care Policy from on physician office visits for male infertility have shown the highest use among men years old followed by men years old (11). Geographically, this usage was higher in the North East than in anywhere else in the country. Correlation with the rate of physician visits for women with the primary diagnosis of infertility from the National Ambulatory Care Survey database (with the same limitations of reporting methodology) showed a higher use in the North East than the Midwest or West (12). This is most likely due to the highest concentration of clinics in the North East (6). A study of a defined health care system in the United s, the Veterans Affairs (VA) Health System, has shown that from the users of male infertility services were mostly men aged years (13). The same VA study also showed that the highest usage of male infertility services was in the South and not in the North East, as in the private sector. This finding suggests that access to care or insurance coverage issues changes the reporting of male infertility (13). In 2005, 59% of couples with infertility seen at s in the United s were specifically treated with in vitro fertilization intracytoplasmic sperm injection (IVF-ICSI) (14). Thirty five percent of IVF cycles were reported because of male infertility, with more than 85% of male factor issues being seen at s involving IVF-ICSI (14). The proximity of male to s is important Fertility and Sterility â 607

10 for the overall care of the couple with male factor infertility. This is related to the common understanding and interaction between urology and regarding joint management or procedures for the couple. Lack of this joint care can potentially lead to significant biases, incomplete evaluation, and poorly informed discussion about treatment choices. Sophisticated procedures to assist in complicated cases of male infertility, ranging from microsurgical reconstruction to microdissection of the testes for sperm retrieval, may not be offered or being performed by urologists not specializing in male infertility or s without access to a male infertility specialist. The relationship between the availability of these services and s likely to require these services has broad implications for the treatment of this condition. Location of Male Specialists in Relation to Potential Male s and Centers Although the highest male and male per service area (own state and access to state services) was seen in the North East, we are unable to determine whether the number of male is a function of the background or s. We suggest that this is most likely a function of the former. Association with service areas being more secondary and possibly partly independent, unless s with practices actively recruited specialized male infertility, such as in many university programs. Assisted reproductive technology s are located as a result of the demand, but also possibly by state mandated insurance coverage (for female only) (6). The number of s per male specialist or male per s did not show a trend on a state level, but did so more closely based on service areas, especially in the North East. This study showed that many service areas around the country were underserved, based on the number of service areas with no male specialist within the 60-minute travel time (Fig. 3). However, in areas where male are present, they are within service areas (Fig. 2). This proximity is again most likely a function of density and that there are more s than urology. A possible need for more male may be inferred for some locations. The number of men per male was independent of a state s mandated insurance status for services (data not shown). In addition, we have shown previously that the supply of services itself appears to be insensitive to mandated coverage and thus dictated by some other factor (6). Limitations and Rational for Methodology The male was calculated from 2000 census data and compared with and specialist urology services from Extrapolation data on census numbers for 2005 did not show a significant deviation from The arbitrary allocation of male age distribution was based partly on the range used by the NSFG on data showing that the highest first-child birth rate (64%) was for men aged years. Men older than 30 years accounted for 21% of births (1, 7). We opted not to start at age 15 because services are generally not provided to this age group. Although we are aware that men older than 49 years are fertile and also seek infertility services, genetic risk, especially aneuploidy of sperm, has been shown to double at the age of 50 years, although effect on fecundity success is far from clear (15). The age group chosen may underestimate the number of men within the services areas in potential need of services estimated to be 7% 8% of the male by the NSFG for men (7). We opted to use the S database because of the strict criteria required to report services (i.e., identification, and outcome results from IVF). In 2005, S was responsible for reporting 94% of cycles in the United s to the CDC. This choice afforded us the ability to determine access to s providing full embryology and andrology services and not just outpatient office settings. We did not include any satellite clinics of listed s, unless listed separately by S. We did not use the male infertility databases as outlined previously because they are limited by source and volume of data as well as inherent biases (e.g., use of services by socioeconomic factors and not need alone). The VA data show a different distribution of need, but are limited by a different access to care (13). We felt that a broader study would serve as a more useful reflection of potential need and highlight catchment area discrepancies. Our study does show a higher distribution of male and services in the North East, similar to databases based on male infertility usage already quoted. density suggests an increase in services and an increase in the number of patients diagnosed, or vice versa. Although male infertility specialty society directories may underestimate infertility services provided by local community urologists, the directories identify providers who have expressed more interest in the field of male infertility or who have undergone additional training in the field of andrology with advanced medical and microsurgical options. These providers often have close understanding of andrology as it relates to requirements, and many community urologists refer patients to these. This was a bias of the study. Some male infertility services are provided by nonurologists (e.g., endocrinologists and gynecologists), and these were not considered. This bias was deliberate because surgical intervention for male infertility by nonurologists is rare and is often performed out of necessity for the lack of urology services. Limited surgical services provided by nonspecialty urologists fulfill the need in some communities, but the degree of this service cannot be gauged accurately. As a result, the number of services areas underserved may be overestimated, with some services provided by other providers and the male per male specialist may be less. Similarly, the geographic distribution may be different. The definition used to determine an service area was chosen to represent a practical situation for access to care for 608 Nangia et al. Male infertility in the United s Vol. 94, No. 2, July 2010

11 patients. Patients undergoing these services are often required to travel to their for a variety of monitoring studies. They will also have to travel to the for egg retrieval and embryology services. This proximity is also important for male infertility services provided by urologists for s from patient evaluation to sperm retrieval procedures. Assisted reproductive technology s often provide andrology laboratory and cryobank services. Joint care of the male and female partners is also better facilitated if are in close proximity. CONCLUSION We have shown in this study that a close spatial distribution is present between male infertility and male potentially needing those services. Male, when present, are generally in close proximity to s. Many service areas in the United s still remain underserved regarding specialized urology male infertility services. REFERENCES 1. Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility, family planning and reproductive health of U.S. Women: data from the 2002 National Survey of Family Growth. Vital Health Stat 2005;23: Simmons FA. Human infertility. N Engl J Med 1956;255: Mosher WE. Reproductive impairments in the United s, Demography 1985;22: MacLeod J. Human male infertility. Obstet Gynecol Surv 1971;26: Tielemans E, Burdorf A, tevelde E, Weber R, van Kooij R, Heederik D. Sources of bias in studies among infertility clients. Am J Epidemiol 2002;156: Nangia AK, Likosky DS, Wang D. Access to Centers in the USA. Fertil Steril Published online December 10, 2008 [Epub ahead of print] 7. Anderson JE, Farr SL, Jamieson DJ, Warner L, Macaluso M. Infertility services reported by men in the United s: national survey data. Fertil Steril. Published online December 10, 2008 [Epub ahead of print]. 8. Kozak LJ, Hall MJ, Pokras R, Lawrence L. Ambulatory surgery in the United s, Advance data from Vital and Health Statistics no Hyattsville, Maryland: National Center for Health Statistics, Hall MJ, Lawrence L. Ambulatory Surgery in the United s, Advance Data from Vital and Health Statistics no Hyattsville, MD: National Center for Health Statistics, Hall MJ, Lawrence L. Ambulatory surgery in the United s, Advance data from Vital and Health Statistics no Hyattsville, MD: National Center for Health Statistics, Center for Health Care Policy and Evaluation Niederberger C, Joyce GF, Wise M, Meachem RB. Male Infertility. Urologic Diseases in America. US Department of Health and Human Services, Public Health Services, National Institute of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington DC, 2007: NIH publication No National Ambulatory Medical Care Survey 1992, 1994, 1996, 1998, 2000 ( 13. Meacham RB, Joyce GF, Wise M, Kparker A, Niederberger C. Urologic Diseases in America Project. Male infertility. J Urol 2007;177: Centers for Disease Control and Prevention, American Society for Reproductive Medicine, Society for Assisted Reproductive Technology Assisted reproductive technology success rates: National summary and fertility clinic reports. Atlanta, GA: Centers for Disease Control and Prevention, Sloter E, Nath J, Eskenazi B, Wyrobek AJ. Effects of male age on the frequencies of germinal and heritable chromosomal abnormalities in humans and rodents. Fertil Steril 2004;81: Fertility and Sterility â 609