Infertility services reported by men in the United States: national survey data

MALE FACTOR Infertility services reported by men in the United States: national survey data John E. Anderson, Ph.D., Sherry L. Farr, Ph.D., M.S.P.H., Denise J. Jamieson, M.D., M.P.H., Lee Warner, Ph.D., M.P.H., and Maurizio Macaluso, M.D., Dr.P.H. Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia Objective: To describe the extent to which men report they or their partners had made use of infertility services, what services and conditions were reported, and what factors were associated with their use of services. Design: Analysis of the male sample of the 2002 National Survey of Family Growth, a nationally-representative household survey of men 15-44. Analysis involved estimation of percentages, chi-squared tests of difference, and multivariate logistic regression analysis. Setting: The 2002 National Survey of Family Growth, Cycle 6. Patient(s): A total of 4109 sexually experienced men aged 15 44 years in the 2002 National Survey of Family Growth who had received infertility services. Intervention(s): None. Main Outcome Measure(s): Percentage of men reporting that they had sought help with having a baby. Result(s): A total of 7.5% of all sexually experienced men reported a visit for help with having a child; 2.2% reported a visit in the past year, equivalent to 3.3 4.7 million men reporting a lifetime visit and 787,000 1.5 million a past-year visit. Visits were reported more frequently by older men, those currently or previously married, and the more highly educated. Male-related infertility conditions were reported by 18.1% of those who sought help, the most frequent being sperm or semen problems and varicocele. Conclusion(s): Previous estimates of infertility help-seeking were based on data from women. Men report a percentage seeking help that appears to be somewhat lower than reported by women. About 1 in 5 of those seeking help reported male-related infertility conditions. (Fertil Steril Ò 2009;91:2466 70. Ó2009 by American Society for Reproductive Medicine.) Although seeking help to become pregnant generally involves a couple, most of what is known on infertility care-seeking behavior has been based on information collected from women. Previous studies have found, for example, that among women the prevalence of seeking help becoming pregnant is higher for certain population groups: older women, those in higher socioeconomic categories, and currently married women (1). Surveys over time have documented an increasing number of women seeking infertility services (1 3). What has been lacking is nationally representative information from men s perspective measuring whether they or their partners had sought infertility care. Data are now available from a national sample of men aged 15-44 years on the prevalence Received December 10, 2007; revised and accepted March 10, 2008; published online April 25, 2008. J.A. has nothing to disclose. S.F. has nothing to disclose. D.J. has nothing to disclose. L.W. has nothing to disclose. M.M. has nothing to disclose. The findings and conclusions in this paper are those of the authors and do not necessarily represent the views of the U.S. Centers for Disease Control and Prevention. Reprint requests: Dr. John Anderson, Women s Health and Fertility Branch, Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Mail-stop K-34, 4770 Buford Highway NE, Atlanta, GA 30341 (FAX: 770-488-6450; E-mail: jea1@cdc.gov). of self-reported help-seeking for infertility, factors associated with help-seeking, and prevalence of diagnosed conditions and services received. METHODS The data reported here are from the male sample of the 2002 National Survey of Family Growth (NSFG). The NSFG consisted of independent probability samples of 4,928 men and 7,643 women representing the population of the United States living in households. Interviews were conducted by trained interviewers in selected respondents homes between March 2002 and February 2003. The men s and women s surveys are nationally representative multistage probability samples and are designed to produce unbiased estimates representative of the national population (4). One person was selected for interview in each sample household. Teenagers and black and Hispanic adults were sampled at higher rates than others to provide greater sample size for analysis. The majority of the interview was conducted as an interviewer-administered questionnaire, but the most sensitive information was collected using audio computerassisted self-interview techniques which provide more privacy to the respondent. The overall response rate for men 2466 Fertility and Sterility â Vol. 91, No. 6, June 2009 0015-0282/09/$36.00 Copyright ª2009 American Society for Reproductive Medicine, Published by Elsevier Inc. doi:10.1016/j.fertnstert.2008.03.022

interviewed in cycle 6 of the NSFG was 78% and completed interviews for men in the cycle 6 NSFG averaged 60 min. The NSFG procedures and questionnaires were reviewed and approved by Research Ethics Review Board of the Centers for Disease Control and the National Center for Health Statistics and by a similar board at the contracting organization, the University of Michigan (4). In the interview, all male respondents who had ever had sex with a woman (4,109 of 4,928) were asked whether they or their partner had ever sought help for possible infertility ( Have you or your wife or partner ever been to a doctor or other medical care provider to talk about ways to help you have a baby together? ). Those who answered yes were asked about the dates of their visits, services received, and any conditions diagnosed. In the present report we present the percentage of male respondents reporting visits, the corresponding estimates of the numbers of U.S. men 15-44 who had visits, the differences in help-seeking by characteristics of the men, and the conditions diagnosed and services received. Associations between demographic characteristics and helpseeking were assessed using chi-squared tests and multiple logistic regression models. All estimates are weighted to provide unbiased national estimates and adjusted for the complex sample design. RESULTS 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, including visits made by themselves, by their partner, or by both; 2.2% reported a visit in the year before interview (Table 1). This equates to 3.3-4.7 million men reporting a lifetime visit and 787,000-1.5 million having a visit in the past year. Table 1 indicates that the percentage who reported that they had ever had an infertility-related visit varied by demographic characteristics. For example, visits were reported more frequently by the oldest men in the sample, aged 35-44 years (11.1%) and by those who were currently married (11.3%) or previously married (8.3%). Various socioeconomic measures are associated with a higher percentage who reported seeking help: a college education, a family income above 300% of the poverty level, and having private health insurance. Male respondents were less likely to report seeking help if they reported behaviors possibly associated with some degree of sexual risk, or with not being in a stable marital union: multiple sex partners in the past year, past-year sexually transmitted disease treatment, and binge drinking. By body mass index (BMI) categories, normal-weight men (BMI <25 kg/m 2 ) reported help-seeking the least often (5.4%), whereas men in the obese range (BMI R30 kg/m 2 ) reported help most often (9.2%). Finally, a number of factors shown in Table 1 did not have statistically significant bivariate associations with infertility help-seeking: race/ethnicity, daily drinking of alcoholic beverages, and self-reported health status. In the multiple logistic regression analysis, the model was reduced using stepwise methods so that it includes only statistically significant predictors (Table 2). Significant adjusted odds ratios (aors) were found for only a small number of examined characteristics. Men aged 25-34 years and 35-44 years were more likely to have sought help than those under age 25 years (aor 4.0 and 4.9, respectively). Compared with never married men, married men and previously married men were more likely to have sought help (aor 12.9 and 9.9, respectively); and men who had completed college (aor 4.2) or had attended college without graduating (aor 2.1) were more likely to have sought help than those who had not graduated from high school. None of the other comparisons that were examined in the multiple logistic regression analysis were found to be associated with seeking help with having a child. These results did not differ substantially when we limited the analysis to men who were currently or formerly married. Of men who sought help, 18.1% reported clinician-diagnosed male-related infertility problems, including sperm or semen problems (13.7%) and varicocele (5.9%) (Table 3). In total, an estimated 725,000 men (95% confidence interval [CI] 458,000 991,000) reported clinician-diagnosed male factor infertility. Regarding services received, advice on infertility was obtained by 70.7%, infertility tests of either partner by 49.4%, and treatment for varicocele was reported by 5.9%. Treatments for the female partner were also reported by the male respondents: drugs to improve ovulation (31.7%), surgery to correct blocked tubes (11.4%), and artificial insemination (8.7%). DISCUSSION The percentage of men that reported they or their partner had sought infertility services, 7.5%, can be compared with the percentage of the independent 2002 NSFG sample of women. The comparison is made difficult by differences in the male and female questionnaires for the NSFG. Men were asked a single question on whether they and/or their partner had seen a medical care provider regarding ways to help you have a baby together. Women were asked two separate questions about whether they and/or their partner had consulted with a health care provider to talk about ways to help you become pregnant or to talk about ways to help you prevent miscarriage or pregnancy loss. Among sexually experienced women, 13.4% responded yes to either one of these questions (95% CI 12.3% 14.6%), which is significantly higher than the 7.5% of men who reported seeking help in having a baby. In addition to asking men and women different questions about infertility help, the questions were asked of somewhat different subgroups in the two samples; for purposes of comparison we limited attention to the same subgroup for both male and female samples: all respondents who had ever had sex with someone of the opposite sex. Other differences in the two independent samples could account for the observed differences. For example, the male respondents reported that they were an average of 2 years older than their partners, a factor that could have resulted in differences in reported levels of infertility care-seeking between genders. Also, the female data could contain women in same-gender Fertility and Sterility â 2467

TABLE 1 Percentage and estimated number of men aged 15 44 years who have sought help with their partner s preganancy in the preceding year and ever, by characteristic. Unweighted no. of cases in sample Weighted % 95% CI Estimated no. (1000s) 95% CI A. Sought help in past year 4109 2.2 1.6 2.9 1155 787 1522 B. Ever sought help 4109 7.5 6.4 8.8 4007 3312 4703 Age at interview 15 24 years 1369 0.7 0.3 1.6 90 12 168 25 34 1355 8.4 6.6 10.5 1561 1152 1970 35 44 1385 11.1 8.8 13.8 2357 1818 2896 Marital status at interview Never married 2033 0.6 0.3 1.2 99 29 169 Married 1612 11.3 9.5 13.4 3547 2864 4230 Previously married 464 8.5 5.9 12.1 362 236 488 Race/ethnicity White 2087 8.4 7.0 10.1 2908 2342 3475 Black 830 6.4 4.5 9.0 418 262 575 Hispanic 985 5.2 3.7 7.3 477 312 643 Other 207 6.7 3.0 14.2 203 43 364 Education College graduate or higher 732 16.0 12.4 20.5 1818 1283 2354 Some college 1142 6.3 4.6 8.5 929 627 1231 High school graduate or GED 1360 5.6 4.0 7.7 987 655 1318 Less than high school graduate 875 2.9 1.7 4.9 274 129 418 Family income %149% poverty level 989 4.3 2.5 7.3 503 231 774 150% 299% 1150 4.8 3.3 6.9 724 431 1018 300% 1970 10.6 8.7 12.8 2780 2173 3388 Number of sex partners in past year 0 sex partners 445 2.3 1.1 4.6 108 32 183 1 partner 2400 9.5 8.2 11.1 3566 2914 4217 2 partners 515 3.6 1.9 6.8 167 58 276 3þ partners 709 2.6 1.3 5.0 160 53 268 Sexually transmitted diseases Treated in the past year 157 0.7 0.1 4.9 11 0 32 Not treated in past year 3927 7.7 6.6 9.0 3980 3282 4677 Health insurance status Health insurance None 984 3.2 2.0 5.3 363 175 551 Private insurance 2560 9.2 7.7 11.0 3329 2696 3963 Medicaid 252 2.7 1.2 5.8 65 14 116 Government/military 313 7.3 4.4 11.8 250 117 382 Body mass index category Not overweight 1676 5.4 4.0 7.5 1070 712 1429 Overweight 1564 8.7 6.8 11.0 1841 1353 2329 Obese 826 9.2 7.0 11.9 1084 770 1399 Alcohol consumption in past year 5þ drink/day monthly 1286 4.8 3.6 6.4 733 499 967 Others 2805 8.6 7.1 10.4 3268 2597 3939 Drink alcohol daily 397 8.3 4.8 13.9 408 185 631 Others 3694 7.5 6.3 8.8 3593 2917 4269 Health status Excellent/very good health 2976 8.2 6.8 9.8 3181 2529 3834 Good 888 5.8 4.0 8.4 651 394 907 Fair/poor 232 5.7 2.9 11.1 169 52 286 Fatherhood status Have fathered a child 1746 9.7 7.8 11.9 2777 2185 3369 Never fathered a child 2363 5.0 3.9 6.4 1230 895 1566 Note: All bivariate differences significant at P<.05 (chi-squared) except race/ethnicity, daily drinking, and health status. CI ¼ confidence interval. 2468 Anderson et al. Infertility services reported by men Vol. 91, No. 6, June 2009

TABLE 2 Adjusted odds ratios (aors) for factors predicting ever seeking help getting pregnant. aor 95% CI Age group 15 24 1.0 25 34 4.0 1.6 10.5 35 44 4.9 1.9 12.9 Marital status Never married 1.0 Married 12.9 5.8 28.8 Previously married 9.9 4.1 23.7 Education College graduate or higher 4.2 2.3 7.9 Some college 2.1 1.1 3.7 High school graduate or GED 1.5 0.8 3.0 Less than high school graduate 1.0 Note: CI ¼ confidence interval. relationships, some of whom seek treatment for infertility; however, the data suggest that women in opposite-gender relationships are more likely to seek help than others. As found in studies of women, the data for men indicated that being or having been married, being older, and having TABLE 3 Men (aged 15 44 years) who sought help for infertility with wife/partner by conditions diagnosed and services received. % 95% CI A. Infertility conditions 1. Sperm or semen problems 13.7 8.6 21.3 2. Varicocele 5.9 2.6 13.0 3. Other male problems 2.1 0.8 5.4 4. Any male problem 18.1 12.9 24.8 5. Non-male problems 81.7 75.0 86.9 B. Infertility services 1. Advice 70.7 61.7 78.3 2. Infertility test: either gender 49.4 40.6 58.3 2a. Infertility test: male 40.1 31.1 49.8 2b. Infertility test: female 44.6 36.3 53.2 3. Ovulation drugs 31.7 24.8 39.5 4. Tubal surgery 11.4 6.5 19.3 5. Artificial insemination 8.7 5.2 14.2 6. Varicocele treatment 5.9 2.6 12.8 7. Other help 19.4 12.5 29.0 Note: Unweighted number of cases ¼ 224. CI ¼ confidence interval. higher education status were associated with seeking help having a child (1). In earlier studies of women, income was found to be an important factor in determining whether couples seek assistance with infertility (5, 6), but in the present analysis of male data the bivariate association with income (measured by family income relative to the poverty level) was not maintained when controlling for other factors. The observed association between seeking help having a child and body mass index is of interest because of the earlier finding of greater infertility among overweight and obese men (7). In the present analysis the association did not maintain statistical significance after controlling for other factors in the logistic regression analysis. However, the outcome in this analysis is seeking help for infertility rather than difficulty conceiving. Of men who reported seeking help, 18.1% reported male factor infertility diagnosed by a health care provider. Threefourths of these men reported sperm or semen problems and one-third varicocele, which is considered by some to be the most prevalent male infertility condition (8). Information from other sources on the prevalence of male infertility can provide some context for these results. For example, it has been suggested that male factor infertility, alone or in combination with female infertility, may be involved in as much as two-thirds of cases where couples fail to conceive (9). Among couples making use of assisted reproductive technologies, it is estimated that 37% have been diagnosed with male factor infertility (10). However, these should not be considered direct comparisons with the NSFG estimates, because of differences in methods and persons included. The NSFG data are based on self-reports, and respondents may not know or recall their diagnosis. Analysis of the data is further limited by the small number of men reporting male factor infertility (unweighted n ¼ 40). The data we have examined come from a cross-sectional survey, and therefore we are limited in interpreting the results. The demographic information reported is from date of interview, and not at the time help was sought. We attempted to limit this bias by conducting a sensitivity analysis among men who had sought help in the past year; results were not substantially different among this group of men, although the small numbers reporting recent visits made estimates imprecise. Additionally, the NSFG data do not include other factors associated with male-factor infertility, such as smoking status, and occupational or other exposure to toxins, drugs, and radiation (9). Because the female and male samples are independent, we were unable to link responses between partners. Because of the wording of the single question on infertility help-seeking, men are reporting on help-seeking visits that either they or their partners made. This approach makes sense to the extent that it is the couple that is trying to have a baby. However, use of this type of outcome measure could explain some of the results, such as the lack of association between help-seeking and some covariates that may be directly linked to male-factor infertility. Fertility and Sterility â 2469

These nationally representative estimates indicate the extent of help-seeking for infertility reported by men and the factors associated with help-seeking, but they do not provide direct estimates of the prevalence of infertility in men. Nonetheless, the results fill an information gap for this couple-centered activity and indicate that although men apparently report a lower level of help-seeking there is a general concordance between these estimates for men and those from the womens sample. REFERENCES 1. Stephen EH, Chandra A. Use of infertility services in the United States: 1995. Fam Plan Perspect 2000;32:132 7. 2. 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. National Center for Health Statistics. Vital Health Stat 2005;23(25). 3. Wilcox L, Mosher W. Use of infertility services in the United States. Obstet Gynecol 1993;82:122 7. 4. Martinez GM, Chandra A, Abma JC, Jones J, Mosher WD. Fertility, contraception, and fatherhood: data on men and women from cycle 6 (2002) of the National Survey of Family Growth. National Center for Health Statistics. Vital Health Stat 2006;23(26). 5. Staniec J, Webb N. Utilization of infertility services: how much does money matter? Health Serv Res 2007;42:971 89. 6. Bitler M, Schmidt S. Health disparities and infertility: impacts of statelevel insurance mandates. Fertil Steril 2006;85:858 65. 7. Sallmen M, Sandler D, Hoppin J, Blair A, Baird D. Reduced fertility among overweight and obese men. Epidemiology 2006;17:520 3. 8. Redmon J, Carey P, Pryor J. Varicocele the most common cause of male factor infertility? Human Reproductive Update 2002;8:53 8. 9. Niederberger C, Joyce GF, Wise M, Meacham RB. Male infertility. In: Litwin MS, Saigal CS, eds. Urologic diseases in America. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. NIH Publication no. 07 5512. Washington, DC: US Government Printing Office, 2007:461 81. 10. Division of Reproductive Health, Centers for Disease Control and Prevention and American Society for Reproductive Medicine Society for Assisted Reproductive Technology. 2004 assisted reproductive technology success rates, national summary of Fertility clinic reports. December 2006. Available at: http://www.cdc.gov/art/art2004. Accessed: June 19, 2007. 2470 Anderson et al. Infertility services reported by men Vol. 91, No. 6, June 2009