(98) Substance Use Disorders and Fertility Care: Disparities in Evaluation and Treatment

Background & Introduction: Reproductive-age individuals capable of pregnancy with substance use disorders (SUDs) experience stigma and structural barriers that limit access to pregnancy planning and fertility evaluation and treatment.1,2 Prior research has focused primarily on contraception access for this population, with less attention to these broader reproductive health needs.3 As fertility care is increasingly delivered through specialized services with variable access,4 these gaps may be particularly consequential for people with SUDs who may experience substance-related menstrual irregularities that heighten perceived infertility risk.5 To our knowledge, no studies have examined fertility care access among individuals with SUDs seeking pregnancy and subsequently evaluated for infertility.

Methods: We conducted a retrospective cohort study using Merative MarketScan Commercial and Multi-State Medicaid claims databases (2016-2023). Our cohort included all individuals capable of pregnancy with an infertility diagnosis identified via established ICD codes. The primary predictor was SUD diagnosis (operationalized via ICD codes), with covariates including mood and anxiety disorders, Post-Traumatic Stress Disorder (PTSD), Attention-deficit/hyperactivity disorder (ADHD), pain-related disorders, recurrent pregnancy loss, spontaneous abortion, obesity, Polycystic Ovary Syndrome (PCOS), diabetes, endometriosis, and uterine fibroids. Outcome variables included fertility workup, defined as imaging and laboratory testing, and treatment (oral medications including clomiphene and letrozole, intrauterine insemination [IUI], and assisted reproductive technology [ART]). We estimated adjusted modified Poisson regression models with robust standard errors to assess the association between SUD and receipt of fertility workup and treatment.

Results: The sample consisted of 247,604 individuals with infertility diagnoses (mean age=33 years), including 223,249 (90.2%) with commercial insurance and 24,355 (9.8%) with Medicaid. Among the cohort, 20.7% had SUD, 42.1% had any mood disorder, and 51.0% had anxiety disorders. Compared to individuals without SUD, those with SUD were significantly less likely to receive fertility workup in unadjusted models (RR=0.58 [95% CI, 0.55-0.60]). After adjusting for insurance type and baseline comorbidities, people with SUD remained 15% less likely to receive fertility workup than peers without SUD (RR=0.85 [0.81-0.88). While depression (RR=0.95) and bipolar disorder (RR=0.93) were also associated with decreased workup likelihood, the magnitude of disparity for SUD was approximately three times greater. In contrast, ADHD (RR=1.05) and anxiety disorders (RR=1.06) were associated with slightly increased likelihood of workup. Analyses evaluating receipt of fertility treatment were limited to commercially insured individuals due to the small sample size among those with Medicaid. Among commercially insured individuals receiving fertility treatments, those with SUD had decreased likelihood of receiving clomiphene (RR=0.74 [0.65-0.84]), letrozole (RR=0.76 [0.66-0.87]), IUI (RR=0.69 [0.59-0.80]), and ART (RR=0.78, [0.69-0.89]) compared to peers without SUD.

Conclusion & Discussion: Significant disparities exist in fertility evaluation for women with SUD capable of pregnancy, even after controlling for insurance type and co-occurring mental health conditions. While our findings highlight the disparity in receipt of fertility treatment among commercially insured individuals in the sample, we were unable to evaluate treatment receipt among patients with Medicaid coverage due to small sample size. Another limitation is that administrative claims data do not allow us to determine the type or cause of infertility, and we cannot link partners in couples seeking fertility care. In addition, whether observed disparities reflect patient preferences, provider recommendations, cost barriers, or discriminatory practices cannot be determined in this analysis. Finally, while we cannot assess clinical appropriateness of specific fertility treatments for individual patients, we would expect most individuals diagnosed with infertility to be candidates for fertility workup (imaging and laboratory testing), making disparities in these outcomes particularly concerning. Despite these limitations, this study represents an important initial step in characterizing the unexplored area of infertility access and treatment among people capable of pregnancy with SUD. Further research is needed to elucidate factors (i.e., insurance barriers, state-level policies) contributing to differences in fertility care access among individuals with SUDs.

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