The fertility cascade: infertility prevalence, access to treatment, and successful live birth

Abstract

BACKGROUND:

Access to fertility care in the United States is limited by availability of services, inadequate insurance coverage, restrictive legislation, and social determinants of health. Despite increasing demand for fertility services, national estimates of fertility care utilization and outcomes–particularly across sociodemographic groups–remain poorly characterized.

OBJECTIVE:

To quantify infertility awareness, treatment access, and live birth using a cascade of care framework, overall and by sociodemographic characteristics.

STUDY DESIGN:

We used a cascade of care framework to estimate infertility awareness, treatment access, and live birth outcomes. We used data from 3 sources: lifetime infertility prevalence from the World Health Organization (1991–2021), self-reported infertility and treatment access from the National Health and Nutrition Examination Survey (2013–2020), and live births conceived with fertility treatment from US birth certificates (2016–2021). Disparities were examined by race, ethnicity, education, insurance, and age.

RESULTS:

Among US women aged 20 to 44 years in the National Health and Nutrition Examination Survey, 12% (95% confidence interval, 11–13) reported infertility. Among those, mean age was 34 years; 13.1% self-identified as Black and 19.7% as Hispanic. While infertility awareness was high (70%; 95% confidence interval, 60–74), access to fertility treatment (39%; 95% confidence interval, 33–45) and live births resulting from fertility treatment (10%; 95% confidence interval, 8%, 12%) were low. Live births were highest among Asian (17%; 95% confidence interval, 10–27) and White (13%; 95% confidence interval, 10–18) women and lowest among Hispanic (4%; 95% confidence interval, 2–6) and Black (3%; 95% confidence interval, 2–5) women. Higher education and private insurance were associated with increased treatment access and live birth.

CONCLUSION:

Fewer than half of US women with infertility report accessing treatment, and only 1 in 10 achieve a live birth, with striking disparities across the fertility care cascade. Black, Hispanic, and socioeconomically disadvantaged women face the greatest barriers to successful outcomes. These inequities may worsen as more restrictive fertility legislation emerges, highlighting the need for health systems and policymakers to prioritize equitable access to fertility care.

Introduction

Infertility represents a substantial public health burden, affecting approximately 1 in 6 women globally.¹ Despite the high prevalence of infertility, substantial disparities are present in access to fertility treatments in the United States based on race, ethnicity, education, income, and geography.^2–4 Compared to the demographic composition of the United States, individuals with lower household income, lesser educational attainment, and those of Black race and Hispanic ethnicity are under-represented among those receiving fertility services.^5,6 Moreover, evidence suggests that among those who do access care, Black and Hispanic women experience lower rates of implantation and higher rates of miscarriages after in vitro fertilization (IVF).^7,8 However, much of the prior research has been geographically limited or based on single data sources, leaving gaps in understanding population-level patterns across the continuum of fertility care.

The cascade-of-care framework offers a useful approach for quantifying burden and identifying critical points of attrition in health services delivery and has been widely applied to chronic conditions such as HIV, diabetes, and hypertension.^9–11 Care cascades can also be stratified based on specific population characteristics to identify groups in need of more intensive programs and interventions. To date, no national fertility care cascade has been developed to characterize the stages of infertility from recognition to treatment and outcomes in the United States. Such a framework is increasingly relevant and may provide an important tool for clinicians and public health practitioners, as recent state and federal regulations may exacerbate existing racial, ethnic, and socioeconomic disparities in access to fertility treatment and outcomes.¹² This is particularly concerning given the advancing maternal age due to delayed childbearing and the increased use of fertility treatments in the United States, demonstrating that more women than ever will need these treatments to start a family.^13,14

Thus, our objective was to generate a fertility care cascade to provide contemporary national estimates of infertility awareness, access to treatment, and live birth outcomes among US women with infertility. We also examined disparities across racial, ethnic, educational, and insurance groups to identify key gaps in care and opportunities to advance reproductive health equity.

Methods

Data sources

We synthesized data from 3 independent sources (Figure 1 and Supplemental Table 1).

FIGURE 1. Fertility care cascade and data sources.

Lifetime prevalence of infertility was ascertained by data from the World Health Organization for high-income countries, infertility awareness by data from the National Health and Nutrition Examination Survey (NHANES), and accessed a medical professional by data from NHANES and prevalence of live birth using fertility treatment from US birth certificate data from US National Vital Statistics.

World Health Organization

The World Health Organization (WHO) pooled lifetime infertility prevalence from high-income countries was estimated as 17.8% (95% confidence interval [CI], 15.3–20.7) from 1991 to 2021.^1,15 This pooled estimate is generated from a meta-analysis that incorporates 30 different studies including 11 from the United States.

The National Health and Nutrition Examination Survey

We calculated infertility prevalence and access to treatment among women aged 20 to 44 years using data from the 2013–March 2020 National Health and Nutrition Examination Survey (NHANES).

NHANES is an in-person, population-based survey that is designed to be representative of the noninstitutionalized, civilian population of the United States. The survey is implemented using a stratified, clustered 4-stage sampling design and is released in 2-year cycles. The 2019 to 2020 cycle was combined with 2017 to 2018 to produce pre-COVID-19 pandemic estimates.¹⁶

Information on infertility was collected on the reproductive health questionnaire administered through a computer-assisted personal interview. The presence of infertility was determined by the following question: “Have you ever attempted to become pregnant over a period of at least a year without becoming pregnant?” This is consistent with the recommendation from the American Society of Reproductive Medicine and the WHO.¹⁷ Infertility treatment was defined as a positive response to the survey question: “Have you ever been to a doctor or other medical provider because you have been unable to become pregnant?”

Birth certificates

We identified live births resulting from fertility treatment using US birth certificate data from the National Vital Statistics System (2016–2021), restricted to women aged 20 to 44 years¹⁸ National Vital Statistics natality files include nearly all live births within the United States. Fertility treatment use is recorded on birth certificates based on information provided by medical personnel attending the delivery, supplemented by maternal self-report and documentation from prenatal and delivery records. To avoid duplicated maternal information from multiple gestations, we separated the dataset into singleton and nonsingleton births and used the ‘unique’ function in R to remove duplicate maternal records for nonsingleton deliveries.

Statistical analyses

We performed the following calculations to estimate the proportion of reproductive-aged women with infertility at each step of the cascade that were aware of their infertility, accessed a medical professional, and achieved a live birth using fertility treatment. The data source is indicated in parentheses.

Infertility awareness was estimated by dividing the proportion of US women aged 20 to 44 years self-reporting a history of infertility (NHANES, 2013–2020) by the pooled lifetime infertility prevalence among women in high-income countries (WHO, 1991–2021). Treatment access was calculated by multiplying the proportion of women with self-reported infertility who reported seeking medical care (NHANES, 2013–2020) by the infertility awareness estimate.

To estimate live births following fertility treatment, we divided the proportion of live births conceived using fertility treatment (National Vital Statistics System birth certificate data, 2016–2021) by the product of infertility prevalence and treatment access. This estimate was then multiplied by the access-to-care value to yield the final stage of the cascade: live births among all women with infertility. All final proportions were converted to percentages.

We used nonparametric bootstrapping with 5000 iterations to calculate 95% CIs, resampling individuals with replacement while preserving the NHANES survey design. Full equations are provided in the Supplemental Methods.

We examined differences in the fertility care cascade by self-reported race and ethnicity (Asian, Black, Hispanic, White, and Other), highest education (less than high school, high school, associate’s degree, and college graduate or above), health insurance (private, public, and no insurance), and age (20–29, 30–30, and 40–44 years).

We performed a sensitivity analysis excluding live births from 2021 to assess COVID-related disruptions in reproductive care.

Institutional review board approval was not required as data were publicly available. Analyses were performed using R version 4.2.3, and NHANES complex survey design was accounted for using the ‘survey’ package. ¹⁹

Results

Infertility prevalence and characteristics

The prevalence of infertility among women aged 20 to 44 years (unweighted n=444) was 11.9% (95% CI, 10.6–13.3) and did not differ based on race and ethnicity, educational attainment, health insurance status, or income (Supplemental Table 2). We observed differences in the prevalence of women with access to treatment and live births using fertility treatments (Table 1). While White women comprised 58.5% (95% CI, 51.2–65.7) of those with infertility, they comprised 72.5% (95% CI, 72.3–72.6) of live births conceived using fertility treatments. Among women with infertility, Black and Hispanic women were more likely to have lower educational attainment and public or no health insurance compared to White or Asian women (Supplemental Table 3).

TABLE 1.

Demographic characteristics of women aged 20 to 44 years overall and by infertility prevalence, access to treatment, and live births in the United States

Characteristic	All reproductive-aged women (unweighted n=3760)	Women with self-reported infertility (unweighted n=444)	Women with infertility who accessed medical professional (unweighted n=234)	Women who had a live birth using fertility treatment (n=355,289)
Age, ya	32.0 (25.0, 38.0)	35.0 (29.0, 40.0)	36.0 (32.0, 40.0)	34.0 (31.0, 38.0)
Race and ethnicity
Asian	6.4 (5.0, 7.7)	5.3 (3.5, 7.1)	6.7 (4.2, 9.1)	11.6 (11.3, 11.9)
Black	13.4 (11.0, 15.8)	13.1 (9.9, 16.4)	10.9 (6.6, 15.3)	4.9 (4.6, 5.2)
Hispanic	20.0 (16.8, 23.1)	19.7 (14.5, 24.8)	16.2 (9.3, 23)	9.1 (8.8, 9.4)
White	56.2 (51.9, 60.5)	58.5 (51.2, 65.7)	62.0 (52.4, 71.5)	72.5 (72.3, 72.6)
Otherb	4.1 (3.3, 4.8)	3.5 (1.5, 5.4)	4.3 (1.5, 7.1)	2.0 (1.7, 2.3)
Educational attainment
Less than high school	10.7 (9.2, 12.2)	10.9 (7.8, 14)	7.1 (4.0, 10.3)	0.3 (0, 0.6)
High school	19.5 (17.0, 21.9)	20 (14.9, 25.2)	11.2 (7.1, 15.3)	18.5 (18.2, 18.8)
Associate’s degree	35.0 (33.0, 37.1)	35.5 (30.6, 40.5)	38.1 (31.5, 44.8)	8.2 (7.9, 8.5)
College graduate and above	34.8 (31.2, 38.3)	33.5 (27.7, 39.3)	43.6 (36.0, 51.1)	72.9 (72.7, 73.1)
Insurance status
Private	58.5 (55.7, 61.3)	59.0 (53.2, 64.8)	72.6 (65.9, 79.3)	90.2 (90.1, 90.3)
Public	23.4 (21.0, 25.8)	19.8 (15.8, 23.8)	14.9 (10.0, 19.8)	8.3 (7.9, 8.6)
No insurance	18.1 (16.2, 20.0)	21.2 (16.1, 26.2)	12.5 (7.9, 17.0)	1.6 (1.2, 1.9)

Proportions (%, 95% CIs) are shown. Estimates for overall reproductive-aged women (column a), infertility prevalence (column b), and treatment access (column c) were derived from the National Health and Nutrition Examination Survey (NHANES) 2013 to 2020 and reflect weighted survey estimates. Live birth estimates (column d) are derived from US birth certificate data (2016–2021). Age is reported as median (interquartile range).

^aMedian, IQR

^bOther race and ethnicity includes American Indian and Alaska Native, Native Hawaiian and Other Pacific Islander, and women who self-identified as more than one racial group.

Fertility care cascade

Infertility awareness was high (70%; 95% CI, 60%, 74%). However, few had access to a medical professional for infertility (39%; 95% CI, 33%, 45%) and only 10% (95% CI, 8%, 12%) had a live birth using fertility treatment (Figure 2 and Supplemental Table 4).

FIGURE 2. Fertility care cascade among women with infertility in the United States.

Estimated fertility care cascade among reproductive-aged women (20–44 years) in the United States. Bars represent the weighted percentage of all women with infertility who were aware of their infertility (70%; 95% CI, 60%, 74%), accessed a medical professional (39%; 95% CI, 33%, 45%), and achieved a life birth using infertility treatment (10%; 95% CI, 8%, 12%). Estimates are based on pooled data from the World Health Organization, National Health and Nutrition Examination Survey (2013–2020), and US birth certificates (2016–2021). NHANES estimates are weighted to account for the complex survey design.

CI, confidence interval; NHANES, National Health and Nutrition Examination Survey.

Disparities according to race and ethnicity

Infertility awareness was higher among women who identified as White, Black, or Hispanic compared to Asian women (Figure 3A). However, Black and Hispanic women were far less likely to have accessed fertility treatment. Asian women with infertility had the highest likelihood of live birth using fertility treatment (17%; 95% CI, 10–27) compared to White (13%; 95% CI, 9–−18), Black (3%; 95% CI, 2–5), or Hispanic (4%; 95% CI, 2–6) women (Supplemental Table 4).

FIGURE 3. Fertility care cascade by race and ethnicity, educational attainment, and insurance status.

Fertility care cascade by self-reported race and ethnicity, highest level of educational attainment, and insurance status among reproductive-aged women (20–44 years) in the United States. Bars represent the percentage of women with infertility who were aware of their infertility, accessed a medical professional, and achieved a live birth using infertility treatment. 95% confidence intervals are shown as error bars. Estimates are based on pooled data from the World Health Organization, National Health and Nutrition Examination Survey (2013–2020), and US birth certificates (2016–2021). NHANES estimates are weighted to account for the complex survey design.

NHANES, National Health and Nutrition Examination Survey.

Education attainment

Awareness of infertility was similar across different levels of educational attainment. However, women with an associate’s degree (42%; 95% CI, 32–52) or college graduate or above (49%; 95% CI, 37–61) were much more likely to have accessed a medical professional compared to those with only a high school degree (22%; 95% CI, 13–32). This disparity persisted with 20% (95% CI, 14–28) of women with a college degree or more having a live birth compared to 1% (95% CI, 0.5%, 2%) of women with less than a high school degree (Figure 3B and Supplemental Table 4).

Insurance status

While awareness of infertility was similar across groups defined by insurance status, women with private insurance were more likely to have accessed a medical professional (48%; 95% CI, 39–57) and achieve a live birth using fertility treatment (17%; 95% CI, 13–22) compared to women receiving public health insurance (2%; 95% CI, 1–3) or reporting no insurance (4%; 95% CI, 2–6) (Figure 3C and Supplemental Table 4).

Age stratification

Infertility awareness increased with age, from 42% (95% CI, 33–52) among women aged 20 to 29 years to 93% (95% CI, 74–100) in women aged 40 to 44 years. Access to a medical professional was lowest in the youngest age group (16%; 95% CI, 11–22) and similar among women aged 30 to 39 (54%; 95% CI, 43–66) and 40 to 44 years (56%; 95% CI, 41–72). Live births followed a similar pattern (Supplemental Table 4).

Sensitivity analysis

Our estimates were consistent across race and ethnicity, educational attainment, insurance status, and age after excluding births from 2021 (Supplemental Table 5).

Comment

Principal findings

We provide national estimates of infertility prevalence, awareness, treatment access, and live births among reproductive-aged women in the United States. While approximately 70% of women with infertility were aware of their condition, less than 40% had seen a medical professional, and ultimately only 10% of live births occurred using fertility treatment. This suggests a potential drop-off between the need for fertility care and successful treatment indicating that many women with infertility may not seek care, may be unable to access services, or may not have successful outcomes even when treatment is pursued. There are also stark disparities across the fertility care cascade, with Black and Hispanic women being the least likely to have a successful live birth. We also demonstrate that women with lower educational attainment, public insurance, and younger women are the least likely to have live births.

Results in the context of what is known

Our findings of racial and ethnic disparities in access to fertility treatment and outcomes are consistent with prior epidemiologic studies.^6,20 In our study, Black and Hispanic women with infertility were more likely to have lower educational attainment and lack private health insurance, which may have contributed to the observed disparities. While Black and Hispanic women experience similar to higher rates of infertility, they are considerably less likely to seek or use fertility treatments compared to White women.²¹ These differences are further compounded by delays in care, with Black, Hispanic, and Asian women waiting, on average, 2 years longer to seek treatment.²² Delayed access to care may contribute to diminished ovarian reserve impairing the likelihood of successful treatment outcomes.^23,24

In addition to these sociodemographic disparities, we observed marked variation by age. Consistent with prior research showing infertility diagnosis and treatment use increase with age,¹⁴ infertility awareness and treatment use were lowest among women aged 20 to 29 years and highest in women aged 40 to 44 years, nearly 40% of whom achieved a live birth using fertility treatment.

When examining the driving factors behind fertility disparities, studies have demonstrated that they stem from social, provider-related, and biological influences. Delays in seeking treatment, higher dropout rates following unsuccessful cycles, and financial barriers disproportionately affect Black and Hispanic women.^25,26 Minoritized racial and ethnic groups often face challenges such as insufficient insurance coverage,²⁷ work leave difficulties,²⁸ and geographic barriers.^{29 ,30} Social stigma and cultural beliefs may delay care, with women reporting concerns about privacy, spousal disappointment, and societal judgment. ³¹ Provider factors, including implicit bias and medical mistrust, can impact outcomes, as many women of color experience dismissive attitudes or lack access to culturally competent care.^28,32 Biological factors, such as higher rates of uterine fibroids, tubal factor infertility, and exposure to endocrine-disrupting chemicals, that are not adequately treated due to financial and social barriers, can also play a driving role in poorer outcomes for women of color undergoing fertility treatment.³³

Our findings build upon prior work on the role of insurance in fertility treatment access and live birth outcomes. Since many reproductive rights in the United States are regulated at the state level, state-level variation in insurance mandates largely dictates the degree of coverage for infertility services. According to the Department of Health and Human Services, the cost of a single IVF cycle ranged from $15,000 to $20,000 with multiple cycles often needed to have a live birth.^34,35 While the use of medications, such as fertility-enhancing drugs, is associated with lower out-of-pocket expenses compared to IVF, these costs can still approach $1000.³⁶ Only 21 states mandate third-party coverage for infertility services with considerable variation in the eligibility criteria for these services.^37,38 The lack of insurance coverage for IVF has created an environment where approximately 30% of assisted reproductive technology cycles in the United States occur at private equity affiliated practices.³⁹ Uncertainty remains regarding how this pattern of acquisition and ownership will impact the cost and outcomes of these procedures. Importantly, studies have shown that even in the presence of insurance mandates, racial and education disparities exist in access to infertility treatments.⁴⁰ A comparative study of high-income countries showed that educational disparities in live birth after assisted reproductive technology persisted despite adjusting for socioeconomic factors only in the United States.⁴¹ Taken together, this indicates that third-party insurance mandates are not enough to close the gap in access and outcomes to fertility treatments.

Clinical and research implications

Our study provides a novel approach for monitoring disparities in fertility care access and outcomes over time and across populations. We identified substantial disparities among women who were Black, Hispanic, uninsured, or had lower educational attainment. Given that infertility awareness was relatively high, especially among women aged 30 years and more but access to care dropped off sharply, efforts should focus on improving early identification and referrals, especially in underserved populations. Incorporating routine fertility history and education into well-women visits, especially for those aged 30 years and more or with known risk factors, may help identify individuals earlier in the cascade.

Health systems and insurers should consider mechanisms to improve affordability and continuity of care for fertility services, such as coverage for screening tests and diagnostic services. Closing structural barriers to care including insurance exclusions, lack of culturally competent providers, and the limited geographic distribution of fertility clinics and services will be essential in decreasing the gaps in access and outcomes. The large drop-off in live birth rates among publicly insured and uninsured women in our study underscores the importance of expanding comprehensive fertility coverage in Medicaid and marketplace plans. From a policy perspective, our findings also call attention to the limitations of existing insurance mandates and suggest that broader, more inclusive state and federal policies may be needed to promote equitable access to fertility care.

Importantly, future research is needed to validate this cascade model in other national datasets and to investigate differences across gender identity, sexual orientation, and state of residence. Longitudinal studies could also be used to track how shifts in policy, practice, or insurance coverage impact movement through the fertility care cascade.

Strengths and limitations

Strengths of our study include the integration of multiple nationally representative data sources to construct a comprehensive, population-level fertility care cascade. By combining prevalence estimates from the WHO, survey data from NHANES, and administrative data from US birth certificates, we provide large-scale and contemporary estimates of infertility awareness, access to treatment, and live birth outcomes. Importantly, our analysis is stratified by key sociodemographic characteristics–including race, ethnicity, educational attainment, insurance status, and age–allowing for a nuanced understanding of disparities across each stage of the fertility care continuum. The cascade framework presented here serves as a practical tool for clinicians, public health practitioners, and policymakers to identify points of attrition, allocate resources more equitably, and develop policies that address structural barriers to fertility care.

Limitations of our study reflect limitations of the 3 data sources used. We used the WHO pooled lifetime prevalence of infertility from high-income nations as our baseline estimate, and it is possible that US infertility rates differ from other high-income nations. NHANES data on infertility prevalence and access to care are self-reported and misclassification is possible. NHANES does not collect data on the age at which infertility was first recognized or clinically confirmed limiting our ability to ensure awareness preceded care-seeking. The infertility treatment variable reflects any contact with a medical professional about difficulty becoming pregnant, including consultations that may not have led to diagnostic testing or intervention. The prevalence reported here likely overestimates the proportion of women initiating intensive treatment. However, this measure captures a critical step in the fertility care cascade, and prior research suggests that disparities at this stage can influence subsequent outcomes.^{22 ,25} Future studies using more detailed data sources are needed to better distinguish consultation from active treatment and assess differential reporting.

Also, while birth certificates capture nearly all live births within the United States, there may be high specificity (>99%) but moderate sensitivity (∼40%) for reporting on IVF.⁴² Underascertainment is therefore expected to result in conservative estimates of live birth following treatment, but there is no evidence to suggest systematic differences in reporting by sociodemographic group but may be due to state or regional policies.⁴³ Other factors that may drive disparities such as gender identity, sexual orientation, and state-level variation could not be examined, but these are important considerations for future studies.⁴⁴ Despite these limitations, our study is the first to provide representative, contemporary national estimates of infertility prevalence, access to care, and likelihood of live birth across the continuum of fertility care.

Conclusion

In summary, although infertility awareness among US women is relatively high, far fewer women report accessing treatment, and only a small fraction of live births ultimately are achieved through fertility care. Our findings reveal substantial disparities across the fertility care cascade by race, ethnicity, educational attainment, and insurance status. These inequities may be exacerbated by evolving legal landscapes, as several US states enact increasingly restrictive reproductive health policies. Mapping these care gaps through a cascade framework offers critical insight into where interventions are most needed. By identifying populations disproportionately excluded from fertility services, this work can inform clinical practice, public health efforts, and policy initiatives aimed at promoting equitable access to reproductive care and outcomes.

AJOG at a Glance.

Why was this study conducted?

To quantify what percentage of US women with infertility are aware of their status, have access to fertility treatment, and had a live birth.

Key findings

In this cross-sectional study, awareness of infertility was high, but treatment access and live births were low. Live birth was slightly higher among Asian and White women, those with higher education, and private insurance compared to other groups.

What does this add to what is known?

This is the first study to quantify the US fertility care cascade using 3 data sources. The cascade framework provides nationally representative estimates and identifies critical gaps in access and outcomes across sociodemographic groups.