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 2000. Urology male infertility as defined by 2005 specialty society membership directories. s registered with the Society for Assisted Reproductive Technology in 2005. 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;94:599 609. 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, 2009. 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 66160 (TEL: 913-588-0799; FAX: 913-588-7625; E-mail: 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 http://www.sart.org. 0015-0282/$36.00 Fertility and Sterility â Vol. 94, No. 2, July 2010 599 doi:10.1016/j.fertnstert.2009.02.012 Copyright ª2010 American Society for Reproductive Medicine, Published by Elsevier Inc.
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 (http://www.teleatlas.com). 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 20 49 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 200,000 500,000 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
Fertility and Sterility â 601 TABLE 1 Demographic and male specialist resource allocation by state. abbreviation No. of men aged 20 49 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 1,304,693 43 0 1 0 Alabama AL 937,785 2,146,504 44 2 468,893 5 0 3 Alaska AK 153,803 324,112 47 0 0 Arizona AZ 1,130,287 2,561,057 44 5 226,057 10 1 2 California CA 7,864,781 16,874,892 47 20 393,239 49 0 2 Colorado CO 1,049,701 2,165,983 48 2 524,851 7 0 4 Connecticut CT 726,917 1,649,319 44 1 726,917 6 0 6 Delaware DE 168,670 380,541 44 0 1 0 District of DC 136,125 269,366 51 1 136,125 4 0 4 Columbia Florida FL 3,296,219 7,797,715 42 13 253,555 25 1 2 Georgia GA 1,912,062 4,027,113 47 8 239,008 7 1 1 Hawaii HI 275,823 608,671 45 1 275,823 4 0 4 Idaho ID 279,541 648,660 43 0 1 0 Illinois IL 2,764,631 6,080,336 45 9 307,181 22 0 2 Indiana IN 1,331,850 2,982,474 45 2 665,925 10 0 5 Iowa IA 618,712 1,435,515 43 2 309,356 2 1 1 Kansas KS 584,283 1,328,474 44 1 584,283 5 0 5 Kentucky KY 891,638 1,975,368 45 2 445,819 1 2 1 Louisiana LA 946,934 2,162,903 44 7 135,276 5 1 1 Maine ME 266,520 620,309 43 0 1 0 Maryland MD 1,154,126 2,557,794 45 4 288,532 7 1 2 Massachusetts MA 1,401,892 3,058,816 46 7 200,270 8 1 1 Michigan MI 2,163,591 4,873,095 44 6 360,599 13 0 2 Minnesota MN 1,103,790 2,435,631 45 5 220,758 5 1 1 Mississippi MS 592,734 1,373,554 43 0 1 0 Missouri MO 1,185,486 2,720,177 44 5 237,097 7 1 1 Montana MT 189,643 449,480 42 0 0 Nebraska NE 369,017 843,351 44 2 184,509 2 1 1 Nevada NV 467,146 1,018,051 46 0 4 0 New Hampshire NH 272,337 607,687 45 1 272,337 1 1 1 New Jersey NJ 1,842,668 4,082,813 45 12 153,556 19 1 2 New Mexico NM 380,720 894,317 43 1 380,720 1 1 1 New York NY 4,137,459 9,146,748 45 27 153,239 34 1 1 North Carolina NC 1,835,102 3,942,695 47 5 367,020 9 1 2 Nangia. Male infertility in the United s. Fertil Steril 2010. No. of s per male specialist
602 Nangia et al. Male infertility in the United s Vol. 94, No. 2, July 2010 TABLE 1 Continued. abbreviation No. of men aged 20 49 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 140,229 320,524 44 0 1 0 Ohio OH 2,421,965 5,512,262 44 8 302,746 12 1 2 Oklahoma OK 737,066 1,695,895 43 1 737,066 3 0 3 Oregon OR 759,284 1,696,550 45 1 759,284 3 0 3 Pennsylvania PA 2,559,608 5,929,663 43 8 319,951 17 0 2 Rhode Island RI 224,174 503,635 45 1 224,174 1 1 1 South Carolina SC 866,922 1,948,929 44 0 4 0 South Dakota SD 159,063 374,558 42 0 1 0 Tennessee TN 1,248,146 2,770,275 45 1 1,248,146 7 0 7 Texas TX 4,774,475 10,352,910 46 11 434,043 30 0 3 Utah UT 499,659 1,119,031 45 1 499,659 2 1 2 Vermont VT 130,533 298,337 44 0 1 0 Virginia VA 1,621,455 3,471,895 47 3 540,485 12 0 4 Washington WA 1,346,822 2,934,300 46 4 336,706 8 1 2 West Virginia WV 378,753 879,170 43 0 1 0 Wisconsin WI 1,180,505 2,649,041 45 6 196,751 7 1 1 Wyoming WY 108,206 248,374 44 1 108,206 0 0 197 387 Nangia. Male infertility in the United s. Fertil Steril 2010. No. of s per male specialist
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 2010. 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
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 20 49 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 426,224 937,785 45 415,179 44 61,051 7 50,006 5 1 2 Alaska 0 153,803 0 0 0 0 0 0 0 0 0 Arizona 931,591 1,130,287 82 931,315 82 276 0 0 0 5 5 Arkansas 204,088 555,248 37 185,590 33 18,498 3 0 0 0 0 California 7,077,549 7,864,781 90 7,066,966 90 11,207 0 624 0 20 20 Colorado 877,822 1,049,701 84 877,822 84 0 0 0 0 2 2 Connecticut 726,354 726,917 100 715,575 98 704,466 97 693687 95 28 1 Delaware 131,310 168,670 78 131,310 78 116,411 69 116411 69 10 0 District of Columbia 136,125 136,125 100 136,125 100 136,125 100 136125 100 5 1 Florida 3,013,224 3,296,219 91 3,013,224 91 47,989 1 47,989 1 13 13 Georgia 1,385,161 1,912,062 72 1,304,210 68 98,032 5 17,081 1 7 8 Hawaii 204,808 275,823 74 204,808 74 0 0 0 0 1 1 Idaho 143,638 279,541 51 119,073 43 24,565 9 0 0 0 0 Illinois 2,270,778 2,764,631 82 2,127,401 77 281,137 10 137,760 5 12 9 Indiana 1,020,788 1,331,850 77 761,227 57 269,158 20 9,597 1 2 2 Iowa 324,517 618,712 52 292,460 47 32,247 5 190 0 2 2 Kansas 357,688 584,283 61 357,688 61 194,415 33 194,415 33 1 1 Kentucky 409,383 891,638 46 252,207 28 161,783 18 4,607 1 2 2 Louisiana 683,584 946,934 72 683,336 72 248 0 0 0 6 7 Maine 144,108 266,520 54 144,108 54 6,745 3 6,745 3 0 0 Maryland 1,062,003 1,154,126 92 1,036,195 90 1,019,592 88 993784 86 5 4 Massachusetts 1,366,219 1,401,892 97 1,355,936 97 1,058,751 76 1048468 75 8 7 Michigan 1,734,027 2,163,591 80 1,729,514 80 415,014 19 410,501 19 7 6 Minnesota 825,340 1,103,790 75 801,469 73 23,871 2 0 0 5 5 Mississippi 242,973 592,734 41 137,188 23 105,785 18 0 0 0 0 Missouri 776,717 1,185,486 66 769,303 65 261,547 22 254,133 21 5 5 Montana 0 189,643 0 0 0 0 0 0 0 0 0 Nebraska 221,238 369,017 60 221,238 60 0 0 0 0 2 2 Nevada 429,628 467,146 92 429,628 92 0 0 0 0 0 0 New Hampshire 214,690 272,337 79 43,678 16 181,724 67 10,712 4 1 1 New Jersey 1,828,463 1,842,668 99 1,828,064 99 1,789,783 97 1789384 97 41 12 New Mexico 222,165 380,720 58 185,759 49 36,406 10 0 0 1 1 New York 3,780,411 4,137,459 91 3,761,820 91 2,719,352 66 2700761 65 37 27 North Carolina 1,294,377 1,835,102 71 1,233,511 67 64,008 3 3,142 0 5 5 Nangia. Male infertility in the United s. Fertil Steril 2010.
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 20 49 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 39,150 140,229 28 39,150 28 0 0 0 0 0 0 Ohio 2,129,865 2,421,965 88 2,107,466 87 154,958 6 132,559 5 10 8 Oklahoma 484,002 737,066 66 483,493 66 509 0 0 0 1 1 Oregon 457,049 759,284 60 450,396 59 6,653 1 0 0 1 1 Pennsylvania 2,134,861 2,559,608 83 2,086,904 82 1,403,384 55 1355427 53 12 8 Rhode Island 223,961 224,174 100 223,961 100 178,468 80 178,468 80 7 1 South Carolina 667,028 866,922 77 600,892 69 120,733 14 54,597 6 0 0 South Dakota 56,407 159,063 35 56,407 35 0 0 0 0 0 0 Tennessee 1,022,622 1,248,146 82 1,022,622 82 0 0 0 0 1 1 Texas 3,393,874 4,774,475 71 3,367,529 71 26,345 1 0 0 10 11 Utah 412,831 499,659 83 412,831 83 0 0 0 0 1 1 Vermont 104,412 130,533 80 74,308 57 35,877 27 5,773 4 0 0 Virginia 1,258,250 1,621,455 78 1,234,670 76 531,398 33 507818 31 8 3 Washington 1,084,794 1,346,822 81 989,982 74 96,722 7 1,910 0 4 4 West Virginia 96,561 378,753 25 62,625 17 33,936 9 0 0 0 0 Wisconsin 861,797 1,180,505 73 828,132 70 388,757 33 355,092 30 5 6 Wyoming 18,805 108,206 17 0 0 18,805 17 0 0 0 1 Median 73 67 10 Nangia. Male infertility in the United s. Fertil Steril 2010.
FIGURE 2 Number of s served by a single male specialist based on service areas. Nangia. Male infertility in the United s. Fertil Steril 2010. 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 3.3 4.7 million men) (7). More visits were reported by the oldest men (aged 35 44 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 1994 1996 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
FIGURE 3 Number of male within 60-minutes driving distance of a single. Nangia. Male infertility in the United s. Fertil Steril 2010. for age showed the highest use for men 25 34 years old (126/100,000), then men 35 44 years old (83/100, 000), and finally men 45 54 years old (20/100,000) (8 10). Data for men aged 18 24 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 1994 2002 on physician office visits for male infertility have shown the highest use among men 25 34 years old followed by men 35 44 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 1998 2003 the users of male infertility services were mostly men aged 25 34 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
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 2005. Extrapolation data on census numbers for 2005 did not show a significant deviation from 2000. 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 20 29 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
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;23:1 160. 2. Simmons FA. Human infertility. N Engl J Med 1956;255:1140 92. 3. Mosher WE. Reproductive impairments in the United s, 1965 1982. Demography 1985;22:415 30. 4. MacLeod J. Human male infertility. Obstet Gynecol Surv 1971;26: 325 51. 5. 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;156:86 92. 6. 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, 1994. Advance data from Vital and Health Statistics no. 283. Hyattsville, Maryland: National Center for Health Statistics, 1997. 9. Hall MJ, Lawrence L. Ambulatory Surgery in the United s, 1995. Advance Data from Vital and Health Statistics no. 296. Hyattsville, MD: National Center for Health Statistics, 1997. 10. Hall MJ, Lawrence L. Ambulatory surgery in the United s, 1996. Advance data from Vital and Health Statistics no. 300. Hyattsville, MD: National Center for Health Statistics, 1997. 11. Center for Health Care Policy and Evaluation 1994 2002. 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. 07-5512. 12. National Ambulatory Medical Care Survey 1992, 1994, 1996, 1998, 2000 (www.cdc.gov). 13. Meacham RB, Joyce GF, Wise M, Kparker A, Niederberger C. Urologic Diseases in America Project. Male infertility. J Urol 2007;177:2058 66. 14. Centers for Disease Control and Prevention, American Society for Reproductive Medicine, Society for Assisted Reproductive Technology. 2005 Assisted reproductive technology success rates: National summary and fertility clinic reports. Atlanta, GA: Centers for Disease Control and Prevention, 2007. 15. 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;81:925 43. Fertility and Sterility â 609