You are on page 1of 8

INFERTILITY Perceptions of womens infertility: what do physicians see?

Rosario Ceballo, Ph.D.,a Antonia Abbey, Ph.D.,b and Deborah Schooler, Ph.D.a
a

University of Michigan, Ann Arbor; and b Wayne State University, Detroit, Michigan

Objective: To assess physicians awareness of the infertility risk associated with race, age, and education, and to elicit their clinical management recommendations for a hypothetical patient. Design: Cross-sectional survey. Setting: Surveys were mailed to 1,000 randomly selected primary care physicians in the state of Michigan. Patient(s): None. Interventions(s): None. Main Outcome Measure(s): Self-reported questionnaire asking the relative prevalence of infertility among women based on race, education, and age. Physicians were also asked what interventions they would recommend for one of four hypothetical female infertility patients who were either European American or African American and either a working professional or receiving Medicaid. Result(s): Although most physicians did not correctly identify the associations between age, race, and socioeconomic status and womens infertility, their suggested clinical interventions did not vary based on a hypothetical patients race or socioeconomic status. Female physicians, obstetrician/gynecologists, and physicians with more infertility experience or who had seen more infertile patients recommended more components of a model standard of care. Conclusion(s): A questionnaire using a hypothetical patient model suggests that primary care physicians may not be sufciently aware of the infertility risk of African American women and women with lower socioeconomic status to ensure that women in need of services are identied. (Fertil Steril 2010;93:106673. 2010 by American Society for Reproductive Medicine.) Key Words: African American, gender, infertility, physicians, race, social class

To date, the preponderance of medical and psychologic research on infertility has relied on European American samples consisting of couples with middle to high socioeconomic status. Approximately 13% of married women between the ages of 15 and 44 have some form of fecundity impairment, with over 6 million women in the United States affected by infertility (13), the inability to conceive after 1 year of unprotected intercourse. Members of infertile couples typically experience a barrage of stressful psychologic sequelae following the diagnosis of an infertility problem (411). Couples who have participated in research studies tend to be those who can afford highly specialized medical treatments (4). Among infertile women, obtaining some type of medical treatment is positively associated with age, being married, graduating from college, having a high income, and being

Received June 19, 2008; revised November 6, 2008; accepted November 15, 2008; published online January 25, 2009. R.C. has nothing to disclose. A.A. has nothing to disclose. D.S. has nothing to disclose. Reprint requests: Rosario Ceballo, Ph.D., University of Michigan, Department of Psychology, 530 Church Street, Ann Arbor, MI 48109 (FAX: 734-615-0573; E-mail: rosarioc@umich.edu).

non-Hispanic White (12). Even in Massachusetts, a state with mandated comprehensive insurance coverage for infertility, couples accessing medical care for infertility tend to be European American, of upper socioeconomic status, and highly educated (13). For example, among 561 women who attended a large infertility clinic in Massachusetts (at Brigham & Womens Hospital), none of the patients had less than a high school diploma compared with 15% in the state population. Additionally, about half of the patients had advanced degrees compared with 12% in the population (13). The obstacles that poor and racial minority women face in receiving infertility treatment are potentially numerous, including economic disadvantage, lack of referrals, little or no insurance coverage, racial discrimination, and cultural sanctions against infertility treatment (2, 14). When African American women do seek medical care, they tend to have experienced difculty conceiving for a longer period of time before seeking medical attention compared with European American women (2). It is quite likely, therefore, that many women who struggle with infertility never go beyond a single visit or conversation with a general/family practitioner or their gynecologist. In a society that glamorizes highly technical, medical interventions, how then are African American women and women of lower
0015-0282/10/$36.00 doi:10.1016/j.fertnstert.2008.11.019

1066

Fertility and Sterility Vol. 93, No. 4, March 1, 2010 Copyright 2010 American Society for Reproductive Medicine, Published by Elsevier Inc.

income backgrounds likely to be treated when they discuss infertility with a medical practitioner? RACE- AND CLASS-BASED DISPARITIES IN HEALTH CARE In general, lower socioeconomic status is associated with receiving fewer preventative medical services such as papanicolaou tests, mammograms, and immunizations, as well as lower quality hospital care (15). Similarly, in comparison to European Americans, membership in a racial minority group is linked to less preventative care including breast cancer screening, fewer cardiovascular procedures, less surgical treatment for cancers, fewer kidney and bone marrow transplants, and even less receipt of pain medication as part of routine hospital care (1520). Studies evaluating medical care for coronary artery disease consistently report lower quality treatment for African American patients, in comparison to European Americans (2123). Moreover, compared with their European American counterparts, African Americans are more likely to be denied authorization for emergency care by managed care gatekeepers, to encounter greater difculties in accessing their primary care providers, and to rate their visits with physicians as less participatory (2426). Schulman and colleagues (27) designed a computerized survey instrument to experimentally assess physicians treatment recommendations for managing chest pain in hypothetical patient/actors. Participating physicians randomly viewed actors portraying patients in a video recorded interview of a patient with chest pain. The actors relied on scripted interviews about symptoms for three kinds of chest pain. A total of 720 doctors viewed 1 of 144 possible case scenarios that varied by patient race, sex, age, level of coronary risk, type of chest pain, and results of an exercise stress test. The results showed that both women and African Americans were less likely to be referred for cardiac catheterization in comparison to men and European Americans, respectively. Further, patients race and gender interacted so that African American women, in particular, were less likely to be referred for catheterization in comparison to European American men. The compelling nature of this study rests in the use of a randomized design, with actors sharing identical demographic characteristics, insurance, clinical symptoms, and clinical presentations. Infertility: including race and social class Regrettably, the research on infertility has virtually ignored racial minorities and couples of lower socioeconomic classes, relying instead on the sample of people who appear for treatment at medical clinics. Hence, glaring limitations exist in our understanding of the impact of infertility on racially and socioeconomically diverse groups of people (4, 5, 28). By the same token, virtually nothing is known about the many people who experience infertility but do not seek medical treatment, estimated to be almost half of all infertile couples (4). In 1988, for example, only 43% of all women with infertility reported having ever obtained any medical infertility service (29). Further, many infertility clinics can selectively provide services to married, heterosexual couples
Fertility and Sterility

who can afford private fee-for-service health care (14). Ironically, couples who are most likely to be infertile in the United States do not match the demographic prole of couples who are most likely to seek medical treatment and to participate in research investigations. In contrast to popularly held perceptions, it is African American, less well-educated, and low-income couples who are most likely to struggle with infertility in the United States (1, 2, 4, 13, 28, 3033). Scholars have proposed several possible explanations for the racial disparity in infertility rates, such as inadequate access to treatment for sexually transmitted diseases and occupational hazards (34). African American women also experience high rates of reproductive problems, such as pelvic inammatory disease and ectopic pregnancies, which can cause infertility (28). For example, among 561 women who sought medical care for infertility, a greater proportion of African American and Hispanic women received a diagnosis of tubal factor infertility compared with European American women (2). Likewise, women with less than a high school education also have higher rates of infertility than do women with more education (1). Age is also associated with infertility, such that women over the age of 35 are much more likely to experience infertility than are younger women. Thus, there is a startling mismatch between the demographic prole of women who seek medical care for infertility and women who are most likely to suffer with infertility. The present study surveys physicians about their knowledge of infertility among different demographic groups of women and examines how patient and physician characteristics may inuence physicians treatment responses to hypothetical infertile patients. MATERIALS AND METHODS Participants and procedure All of the research undertaken in this study received approval from the institutional review board at the rst investigators university. A three-page survey was mailed to 1,000 physicians randomly selected from 6,000 physicians in the state of Michigan. The survey was both anonymous and condential, and thus, returning the survey represented a physicians informed consent to participate in this study. The cover letter explained that we were surveying general and family practitioners, obstetricians, gynecologists, and internists because we were interested in the initial interactions that women have with medical professionals before some decide to consult with a fertility specialist. We estimated that it would take doctors, on average, about 15 minutes to complete the short questionnaire. For our mailing, we randomly selected physicians who met all of the following four criteria: [1] members of the American Medical Association, [2] involved in patient care, [3] nished with their medical training (residents and fellows were excluded), and [4] afliated with one of four specialties (general practice, family practice, internal medicine, or obstetrics/gynecology). A total of 205 surveys were returned for a nal response rate of 20%. No followup mailings were possible.
1067

Measures Knowledge about the prevalence of infertility among different groups of women Physicians were asked three questions about the prevalence of infertility among women in the United States. First, they were asked which racial group had the highest prevalence of infertility: European American, African American, Hispanic, or Asian American. Second, they were asked which age group of women had the highest prevalence of infertility: women under 25 years, 25 to 30 years, 31 to 35 years, or over 35 years. Third, they were asked which educational group of women had the highest prevalence of infertility: women without a high school degree, women with a high school degree, women with a college degree, or women with a professional degree. Different educational groups were used to reect social class differences among women. Physicians characteristics and experiences Physicians were asked to identify their area of medical specialty, how many years they had been in practice, and the number of infertile patients that they had seen in the past year. We constructed a scale assessing physicians infertility experience by summing their afrmative responses to ve dichotomous (yes/no) questions. These questions regarded whether or not they had ever made a referral to an infertility specialist, ever discussed adoption with a patient, ever discussed a child-free lifestyle with a patient, ever discussed the costs of fertility treatments with a patient, and ever referred a patient with infertility to a support group. Recommended treatment for hypothetical patient Physicians were asked how they would treat a ctional female patient, 32 years of age, who had been trying to get pregnant for 14 months without success, thereby clearly meeting the medical standard for a diagnosis of infertility. The patients race and social class varied across the surveys that were mailed in a 2 2 design, resulting in four possible patient proles: [1] a European American professional woman, [2] a European American woman on Medicaid, [3] an African American professional woman, and [4] an African American woman on Medicaid. Each survey presented a physician with only one of the possible patient proles for consideration, and surveys with different patient proles were randomly distributed throughout the mailing. Response rates were generally equivalent across the patient prole types. Physicians were asked what interventions they would typically make if presented with the hypothetical infertile patient briey described in their survey. Intervention choices included a list of possible medical tests (e.g., basal body temperature charts, endometrial biopsy, postcoital test, laparoscopy, assessment of thyroid functioning, hyspterosalpingogram, and semen analysis). Intervention choices also incorporated engaging in nonmedical interventions (e.g., provide assurance that there is no need to worry yet, suggest educational reading, recommend counseling services, discuss options of adoption or child-free lifestyle) and making referrals to infertility specialists. Physicians were instructed to
1068 Ceballo et al. Perceptions of womens infertility

check as many or as few of the interventions that they would typically conduct with such a patient. To assess the adequacy of a physicians treatment plan, standards developed by the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine were used (35, 36). Following a fertility history and physical examination, these experts recommend that the basic workup include four components: a semen analysis, documentation of ovulation, a postcoital test, and evaluation of tubal patency. Three methods may be used to assess ovulation: basal body temperature, serum progesterone, or endometrial biopsy and two methods, a hysterosalpingogram or a laparoscopy, may be performed to evaluate tubal patency. Based on this information, an acceptable medical standard of care score was created by summing participating physicians responses to the appropriate items. Scores ranged from 0 to 4 (mean 1.9, SD 1.4), and physicians acquired one point for each component of the workup by checking off any one of the acceptable methods. In other words, a physician who checked solely basal body temperature and a physician who checked basal body temperature and endometrial biopsy would both receive one point for assessing ovulation on the standard of care scale. Doctors could endorse either of the two interventions, provide educational information about basal body temperature charts (if the patient has not done this already) or perform an endometrial biopsy to receive credit for checking the patients ovulation. A scale of acceptable nonmedical interventions included two items: suggest educational reading, and suggest psychologic or counseling services. We excluded the option of assuring the patient that there is no need to worry as an acceptable response. The American College of Obstetricians and Gynecologists technical bulletin specically advises physicians against giving couples nonspecic reassurance or admonitions to relax. Most couples interpret the recommendation to relax as hurtful, because it implies that their worries and anxiety may cause their infertility. We also omitted the item about suggesting adoption or a child-free lifestyle because these options seem premature before any medical tests are completed or the cause of the infertility understood. A sum of the two nonmedical interventions, with possible scores ranging from 0 to 2 (mean .35, SD .58) was used as a scale of acceptable nonmedical interventions. Finally, an index of specialized referral care included two items about providing referrals to infertility specialists [1] in hospital settings or [2] in private practice. Because some patients in Michigan may wish to avoid physician ofces or infertility clinics located in urban hospitals, we specied the setting of specialist referrals to capture all types of referrals. Immediate referral to a specialist is not usually recommended (unless there are special circumstances) without rst completing standard tests; thus, we did not consider making referrals to be part of a medical standard of care. The scores on these items were summed, with possible scores ranging from 0 to 2 (mean .70, SD .70).
Vol. 93, No. 4, March 1, 2010

RESULTS Physician characteristics Sixty-eight percent of the responding physicians were male; 32% were female. Physicians ages ranged from 25 to 73, with an average age of 46 years (SD 11.3). The majority, 90%, of the responding sample identied themselves as European American. All four specialties were represented in the responding sample, with some physicians having multiple afliations. Forty-two percent of the physicians were in family practice, 23% were in general practice, 23% were internists, and 17% identied as obstetricians or gynecologists. Including their residency years, participating physicians had been in practice for an average of 19 years (SD 17.5). Out of these 205 physicians, the mean number of infertile patients seen in the past year was 12 (SD 22.78) and the median number of infertile patients seen was 5.00. In addition, 186 (91%) reported that they had at some time made a referral to a fertility specialist for a patient, and 136 (66%) had made at least one such referral in the past year.

Treatment recommendations and patient characteristics Table 2 provides information on the percentages of physicians who endorsed specic types of interventions for a hypothetical infertile patient. The extent to which physicians recommended the medical standard of care was not signicantly different for the African American female patients (mean 1.93, SD 1.44) compared with the European American patients (mean 1.93, SD 1.30), t (203) .01, ns, and only marginally signicant between professional patients (mean 2.09, SD 1.34) and patients using Medicaid (mean 1.74, SD 1.38), t (193) 1.82, P.07. Analysis of variances (ANOVAs) were conducted to test for possible interaction effects between patients race and socioeconomic status; however, no signicant interaction effects were found. We examined whether the extent to which physicians would make nonmedical interventions (suggest educational reading and counseling services) and refer to specialists varied by the patients race and socioeconomic class. The socioeconomic class and race of the hypothetical patient were not signicantly related to the nonmedical interventions proposed. Likewise, suggesting referrals to specialists did not vary by the patients race. However, physicians were signicantly more likely to refer the professional female patient (mean .81, SD .68) to an infertility specialist compared with the patient using Medicaid (mean .56, SD .65), t (203) 2.71, P<.01. Once again, no interaction effects between patients race and socioeconomic status were found.

Physicians knowledge about the prevalence of infertility among different groups Out of our total sample of 205 doctors, 155 responded to the question about which racial group of women has the highest prevalence of infertility. As illustrated in Table 1, only 16% of the responding physicians correctly identied African Americans as the racial group most at risk for infertility. Eightytwo percent of the participating physicians reported that European Americans were most likely to experience infertility. Of the 24 doctors who correctly identied African American women as being most at risk for infertility, 19 were male and only one was an obstetrician/gynecologist. Compared with the rest of the sample, these 24 physicians infertility experience score and mean number of infertile patients seen in the last year were equivalent to those of the rest of the sample. Similarly, only 13% of those who responded to the question (N 150) identied women without a high school degree as being most at risk for infertility. Thirty-one percent identied women with college degrees and 40% identied women with professional degrees as most likely to be infertile. Among the 19 doctors who correctly identied women without a high school degree as being most at risk for infertility, 15 were male and 17 were not specialists in obstetrics or gynecology. Once again, these doctors did not report having more experience with infertility patients than the rest of the sample. There were 12 doctors who accurately identied both African American women and women without high school degrees as most likely to experience infertility. Finally, a larger number of physicians, 43%, correctly identied people over the age of 35 as being most vulnerable to infertility. It is worth noting that only two physicians, a 44-yearold female general practitioner and a 47-year-old male family practitioner, were accurate on all three questions, and 44% of the 135 physicians who answered all three questions did not provide an accurate response on any of the questions.
Fertility and Sterility

Treatment recommendations and physician characteristics Only 16% of the physicians indicated that they would provide the full standard of care, performing medical tests to assess all four components for the patient. Compared with the medical standard of care, physicians were more likely to endorse other types of interventions. For example, 28% of the doctors reported that they would recommend educational reading for the patient. Twenty-ve percent of the physicians would refer the hypothetical patient to a specialist in private practice, 20% would refer to a specialist at a hospital, and 12% indicated that they would refer the patient to specialists in both settings. We used independent samples t tests and correlational analyses to determine whether physicians characteristics were associated with the standard of care provided to the hypothetical female patient. The variables tested included doctors age, sex, medical specialty, years in practice, number of infertile patients seen in the past year, and experience with infertility issues. We found that female physicians (mean 2.29, SD 1.26) provided more components of the medical standard of care for an infertility evaluation than did male physicians (mean 1.79, SD 1.38) t (201) 2.48, P<.05. A dichotomous medical specialty variable was created where 1 represented an Ob/Gyn specialty and 0 represented all other specialties. Physicians with a specialty in obstetrics and
1069

TABLE 1
Response frequencies: infertility prevalence among different demographic groups of women. Race (n [ 155), % European American African Americana Hispanic American Asian American
a

Education (n [ 150), % 82 16 1 1 Professional degree College degree High school degree No high school degreea 40 30 17 13

Age (n [ 164), y (%) >35 (43)a 3135 (38) 2530 (15) <25 (4)

Within the categories of race, education, and age, this is the demographic group most at risk for infertility.

Ceballo. Perceptions of womens infertility. Fertil Steril 2010.

gynecology (mean 2.86, SD 1.40) also provided the hypothetical patient with more elements of the standard of care compared with the other respondents (mean 1.75, SD 1.28) t (202) 4.58, P<.001. Similarly, physicians who had seen more infertile patients in the past year (r .37, P<.001) and who had greater experience with infertility issues (r .41, P<.001) provided more components of the standard of care. Physicians age and number of years in practice were not related to the medical standard of care score. Physicians sex and infertility experience were signicantly related to the endorsement of nonmedical interventions. Female physicians (mean .55, SD .71), in comparison to male physicians (mean .26, SD .49), endorsed more nonmedical interventions for the hypothetical patient presented to them, t (201) 3.01, P<.01. Physicians with more infertility experience (r .28, P<.001) and physicians who had seen more infertile patients in the past year (r .15, P<.05) endorsed more nonmedical recommendations for the infertile patient presented to them in the survey.

5.00 were given a value of 1 and all those equal to or <5.00 were assigned a value of 0. All variables were entered into the regression simultaneously. The results of the regression analyses are presented in Table 3. Neither race nor socioeconomic status of the patient was a signicant predictor of the medical standard of care.

TABLE 2
Physicians treatment recommendations for the hypothetical patient. Intervention recommended Medical standard of care Semen analysis Basal body temperature Endometrial biopsy Postcoital test Hyspterosalpingogram Laparoscopy Nonmedical interventions Suggest educational reading Suggest psychological or counseling services Provide referral to infertility specialist Specialist in a hospital Specialist in private practice Specialists in both settings Other interventions Assure no reason to worry yet Make no referrals Raise option of adoption in future Raise option of child-free lifestyle in future
Ceballo. Perceptions of womens infertility. Fertil Steril 2010.

Percentage of physicians endorsed (%) 65 72 26 25 34 15 28 7

Multivariate predictors of physicians treatment recommendations A standard multiple regression analysis was performed to assess the simultaneous contributions of patient and physician characteristics in predicting the extent to which the medical standard of care was endorsed for the patient. A dummy variable was created for patients race, coding African American patients as 0 and European American patients as 1. A dummy variable was also created for patients socioeconomic status, coding Medicaid patients as 0 and patients with professional occupations as 1. Only those physician characteristics that were signicantly associated with the standard of care in bivariate analyses were included in the regression analysis. Physician characteristics used as predictors included physicians sex, specialty, number of infertile patients seen in the past year, and infertility experience. A dummy variable for the number of infertile patients seen in the past year was created to handle this variables skewed distribution. We based this variable on a median split, such that all numbers above
1070 Ceballo et al. Perceptions of womens infertility

20 25 12 18 5 19 7

Vol. 93, No. 4, March 1, 2010

TABLE 3
Multiple regression analyses predicting standard of care and nonmedical interventions. Medical standard of care Predictor variables Characteristics of physicians Sexa Ob/Gyn specialtyb Number of infertile patients in past yearc Infertility experience Characteristics of patients Patients raced Patients social classe 2 R F df
a

Nonmedical interventions b .20** .00 .03 .27*** .04 .03 .12 4.54*** 6, 192 SE B .09 .11 .09 .03 .08 .08

Referral to specialists b .07 .06 .21** .06 .02 .19** .09 3.30*** 6, 192 SE B .10 .13 .11 .04 .09 .09

b .15* .21*** .30*** .25*** .01 .08 .33

SE B .18 .23 .18 .06 .16 .16 15.77*** 6, 192

1 female; 0 male; b 1 Ob/Gyn; 0 not Ob/Gyn specialist; c 1 more than ve patients; 0 ve patients or less; d 1 European American; 0 African American; e 1 professional degree; 0 Medicaid use. * P%.05; ** P%.01; *** P%.001.

Ceballo. Perceptions of womens infertility. Fertil Steril 2010.

However, all four physician characteristics remained signicant. Female physicians, Ob/Gyn specialists, physicians who had seen more infertile patients, and physicians who had greater experience with infertility recommended more components of the medical standard of care. These four physician characteristics explained 33% of the variance in making recommendations along an acceptable medical standard of care. Parallel multiple regression analyses were conducted to examine the predictors for providing nonmedical interventions and referrals to infertility specialists. As shown in the middle column of Table 3, the patients race and social class were not signicant predictors of nonmedical interventions; however, physicians sex and infertility experience were signicant. Female physicians and physicians with greater infertility patient experience reported that they would provide more nonmedical interventions. The patients social class was a signicant factor in the specialist referrals recommended by the doctors. Physicians were more likely to endorse referrals to infertility specialists when the hypothetical patient had a professional career compared with the patient who relied upon Medicaid. Finally, physicians who had seen fewer infertile patients in the past year were more likely to refer the hypothetical patient to a specialist. DISCUSSION This studys ndings suggest that many physicians are unaware of demographic risk factors associated with infertility. When asked about education, only 13% identied women without a high school degree as being at highest risk. When
Fertility and Sterility

asked about ethnicity, only 16% identied African American women as being at highest risk. When asked about age, only 43% identied women age 35 and older as being at highest risk. It is not surprising that many physicians are unaware of the most common risk prole for infertility given societal portrayals of infertile women as hard driving professionals in their 30s. European American women with high incomes and educational levels are also most likely to seek treatment for infertility (4, 30); thus, it is easy to understand why many physicians assume that these women are at greatest risk. Even some African American women who are struggling with infertility believe that infertility is a White thing; a White womans problem [(37), p. 12] and may internalize stereotypes about African American womens fecundity (38). These ndings demonstrate the importance of providing more information to physicians who are not infertility specialists about the characteristics of women with infertility and the unfortunate discontinuity between those who are most likely to seek treatment and those who are most likely to be experiencing a problem becoming pregnant. It is particularly important for physicians with general practices such as family practioners, internists, and gynecologists to be aware of the high rates of infertility among ethnic minority women, less educated women, and low income women to ensure that they identify women in need of services. Women of childbearing age should routinely be asked if they have been trying to become pregnant, and if so, for how long. This will facilitate identication of individuals who might be having a fertility problem but who do not request treatment. Some of these women might assume that nothing can be done for them or that they cannot afford treatment, so they do not mention
1071

the problem. However, there may be options available that a well-informed physician can recommend. Both because European American, professional women are more likely to seek medical treatment for infertility and because they have been the focus of most infertility research, we expected that the medical interventions suggested for the hypothetical European American professional patient would be most complete. Instead, we found that physicians suggested medical treatments did not vary based on hypothetical patients race or socioeconomic status. This suggests that once physicians know that infertility is a problem, they are likely to recommend comparable treatments for patients regardless of race or socioeconomic status. This lack of bias is admirable, particularly when one considers the preponderance of research which documents racial and class-based inequalities in health care (15, 17, 21, 25, 39). For example, van Ryn and Burke (40) found that physicians perceived African American and poor patients more negatively than European American patients on a number of dimensions. Even more recently, Green and colleagues (23) reported that it was not explicit racial biases, but rather implicit stereotypes of African Americans that accounted for racially discrepant treatment of patients with coronary artery disease. Although the hypothetical patients race and social class were not related to medical interventions or nonmedical recommendations in our study, the hypothetical patients social class did emerge as a factor in predicting physicians referrals to infertility specialists. Physicians were less likely to provide referrals to specialists when they were told that the hypothetical patient relied upon Medicaid. Physicians reluctance to refer Medicaid patients to infertility specialists is understandable given the great expense of specialized infertility services and the lack of Medicaid insurance coverage for such services. Nonmedical recommendations for the hypothetical patient included suggesting educational reading and suggesting that seeking psychological services might be helpful. Although van Ryn and Burke (40) found that physicians offer less information (e.g., educational reading) to racial minorities and low-income patients compared with their European American and more nancially advantaged counterparts, these recommendations did not vary by the patients race or socioeconomic status in our survey. Providing patients with informational reading seems quite appropriate regardless of a patients race or social class background. In a practical sense, reading about infertility offers patients a low-cost, informative strategy for coping with their infertility. Although data certainly exists that suggest that race and class can affect physicians treatment of their patients, we did not nd evidence for that conclusion using this particular survey instrument. Several of the physicians characteristics were related to both the medical standard of care and the nonmedical interventions endorsed for the hypothetical patient. Results from our multivariate analyses revealed that all of the physician characteristics studied contributed to recommendations
1072 Ceballo et al. Perceptions of womens infertility

toward meeting a medical standard of care. Female physicians and Ob/Gyn specialists recommended more of the medical tests incorporated in the medical standard of care. Additionally, physicians who had seen more infertile patients in the past year and those with more infertility patient experience also recommended more interventions meeting the standard of care. Female physicians and doctors with more infertility experience were more likely to endorse nonmedical interventions as well. It is not surprising that physicians with greater infertility experience and specialization in a related area would provide more comprehensive medical care during an initial patient evaluation stage. It is also logical that those with more infertility patient experience would feel more adept at suggesting nonmedical resources (e.g., informational reading and counseling services). We found that female physicians reported that they would provide a hypothetical infertility patient with more medical tests as well as nonmedical recommendations compared with their corresponding male physicians. As there is evidence that female physicians engage in more discussion with patients, talk more about psychological issues, and provide more counseling than their male colleagues (4143), we conjecture that female physicians may feel greater empathy and afnity toward a hypothetical female patient, allowing female doctors to provide a more comprehensive evaluation in an abstract scenario. These results highlight the importance of attending to the demographic characteristics among all people involved in medical exchanges. In the complex and dynamic encounters between patients and physicians, we cannot ignore the demographic characteristics of the physicians themselves. An important direction for future research includes replicating our ndings with data from actual rather than hypothetical patients. As with all studies, several other limitations must be acknowledged. Our study used a nonrandomized, selfselected sample of physicians, thereby limiting the generalizability of our results. Additionally, the physicians surveyed in this study may share certain biases because of the fact that they all practice medicine in the state of Michigan, and they are all members of the American Medical Association.
Acknowledgment: The authors wish to acknowledge the invaluable support, feedback, and assistance provided by Professor Abigail Stewart at every stage of this research project.

REFERENCES
1. Chandra A, Stephen EH. Impaired fecundity in the United States: 1982 1995. Fam Plann Perspect 1998;30:3442. 2. Jain T. Socioeconomic and racial disparities among infertility patients seeking care. Fertil Steril 2006;85:87681. 3. Mosher WD, Pratt WF. Fecundity and infertility in the United States, 196588. Vol. 192. Hyattsville, MD: National Center for Health Statistics: Vital and Health Statistics: Advance Data Reports, 1990:19. 4. Greil AL. Infertility and psychological distress: a critical review of the literature. Soc Sci Med 1997;45:1679704. 5. Abbey A. Adjusting to infertility. In: Harvey JH, Miller ED, eds. Loss and trauma: general and close relationship perspectives. Philadelphia, PA: Brunner-Routledge, 2000:33144.

Vol. 93, No. 4, March 1, 2010

6. Abbey A, Andrews FM, Halman LJ. Genders role in responses to infertility. Psychol Women Q 1991;15:295316. 7. Abbey A, Halman L, Andrews FM. Psychosocial, treatment, and demographic predictors of the stress associated with infertility. Fertil Steril 1992;57:1228. 8. Berg BJ, Wilson JF. Psychiatric morbidity in the infertile population: a reconceptualization. Fertil Steril 1990;53:65461. 9. Cousineau TM, Domar AD. Psychological impact of infertility. Best Pract Res Clin Obstet Gynecol 2007;21:293308. 10. Domar AD, Broome A, Zuttermeister PC, Seibel M, Friedman R. The prevalence and predictability of depression in infertile women. Fertil Steril 1992;58:115863. 11. Mahlstedt PP. The psychological component of infertility. Fertil Steril 1985;43:33546. 12. Stephen EH, Chandra A. Use of infertility services in the United States: 1995. Fam Plann Perspect 2000;32:1327. 13. Jain T, Hornstein MD. Disparities in access to infertility services in a state with mandated insurance coverage. Fertil Steril 2005;84:2213. 14. Inhorn MC, Fakih MH. Arab Americans, African Americans, and infertility: barriers to reproduction and medical care. Fertil Steril 2006;85: 84452. 15. Fiscella K, Franks P, Gold MR, Clancy CM. Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA 2000;283:257984. 16. Becker ER, Rahimi A. Disparities in race/ethnicity and gender in in-hospital mortality rates for coronary artery bypass surgery patients. J Natl Med Assoc 2006;98:172938. 17. Geiger HJ. Racial stereotyping and medicine: the need for cultural competence. CMAJ 2001;164:1699700. 18. Schneider EC, Zaslavsky AM, Epstein AM. Racial disparities in the quality of care for enrollees in Medicare managed care. JAMA 2002;287:128894. 19. van Ryn M, Fu SS. Paved with good intentions: do public health and human service providers contribute to racial/ethnic disparities in health? Am J Public Health 2003;93:24855. 20. Epstein AM, Ayanian JZ. Racial disparities in medical care. N Engl J Med 2001;344:14713. 21. Canto JG, Allison JJ, Kiefe CI, Fincher C, Farmer R, Sekar P, et al. Relation of race and sex to the use of reperfusion therapy in Medicare beneciaries with acute myocardial infarction. N Engl J Med 2000;342: 1094100. 22. Chen J, Rathore SS, Radford MJ, Wang Y, Krumholz HM. Racial differences in the use of cardiac catheterization after acute myocardial infarction. N Engl J Med 2001;344:14439. 23. Green AR, Carney DR, Pallin DJ, Ngo LH, Raymond KL, Iezzoni LI, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for Black and White patients. J Gen Intern Med 2007;22:12318. 24. Cooper-Patrick L, Gallo JJ, Gonzales JJ, Vu HT, Powe NR, Nelson C, et al. Race, gender, and partnership in the patientphysician relationship. JAMA 1999;282:5839. 25. Lowe RA, Chhaya S, Nasci K, Gavin LJ, Shaw K, Zwanger ML, et al. Effect of ethnicity on denial of authorization for emergency depart-

26. 27.

28.

29. 30. 31. 32.

33.

34.

35.

36.

37.

38. 39. 40.

41. 42. 43.

ment care by managed care gatekeepers. Acad Emerg Med 2001;8: 25966. Shi L. Experience of primary care by racial and ethnic groups in the United States. Med Care 1999;37:106877. Schulman KA, Berlin JA, Harless W, Kerner JF, Sistrunk S, Gersh BJ, et al. The effect of race and sex on physicians recommendations for cardiac catheterization. N Engl J Med 1999;340:61826. Molock SD. Racial, cultural, and religious issues in infertility counseling. In: Burns LH, Covington SN, eds. Infertility counseling: a comprehensive handbook for clinicians. New York: The Parthenon Publishing Group, 1999:24965. Wilcox LS, Mosher WD. Use of infertility services in the United States. Obstet Gynecol 1993;82:1227. Aral SO, Cates W. The increasing concern with infertility: why now? JAMA 1983;250:232731. Meyer CS. Family focus or career focus: controlling for infertility. Soc Sci Med 1999;49:161522. Phipps SAA. African-American couples lived experience of infertility. In: McCubbin HI, Thompson EA, Thompson AI, Futrell JA, eds. Resiliency in African-American families. Thousand Oaks, CA: Sage Publications, 1998:24558. Scritcheld SA. The social construction of infertility: from private matter to social concern. In: Best J, ed. Images of issues: typifying contemporary social problems. 2nd ed. Hawthorne, NY: Aldine de Gruyter, 1995:13146. Harris L. Challenging conception: a clinical and cultural history of in vitro fertilization in the United States. Unpublished doctoral dissertation. Ann Arbor, MI: University of Michigan, 2006. American College of Obstetricians and Gynecologists (ACOG). Infertility. Technical Bulletin No. 125. Washington, DC: American College of Obstetricians and Gynecologists, 1989. Guzick DS, Sullivan MW, Adamson GD, Cedars MI, Falk RJ, Peterson EP, et al. Efcacy of treatment for unexplained infertility. Fertil Steril 1998;70:20713. Ceballo R. The only Black woman walking the face of the earth who cannot have a baby: two womens stories. In: Romero M, Stewart AJ, eds. Womens untold stories: breaking silence, talking back, voicing complexity. New York: Routledge, 1999:319. Roberts D. Killing the Black body: race, reproduction, and the meaning of liberty. New York: Vintage Books, 1997. Bach PB, Cramer LD, Warren JL, Begg CB. Racial differences in the treatment of early-stage lung cancer. N Engl J Med 1999;341:1198205. van Ryn M, Burke J. The effect of patient race and socio-economic status on physicians perceptions of patients. Soc Sci Med 2000;50: 81328. Henderson JT, Weisman CS. Physician gender effects on preventive screening and counseling. Med Care 2001;39:128192. Meeuwesen L, Schaap C, Van Der Staak C. Verbal analysis of doctor patient communication. Soc Sci Med 1991;32:114350. Roter D, Lipkin M, Korsgaard A. Sex differences in patients and physicians communication during primary care medical visits. Med Care 1991;29:108393.

Fertility and Sterility

1073