Association of neighborhood deprivation and live birth after 8155 first, single euploid frozen embryo transfers: the lived patient experience matters

Abstract STUDY QUESTION Is there an association between neighborhood deprivation and frozen embryo transfer outcomes? SUMMARY ANSWER After adjusting for important reproductive characteristics most closely associated with embryo transfer outcomes, residual significant differences in live birth were present with a progressive decline in the probability of live birth as measures of socioeconomic disadvantage increased. WHAT IS KNOWN ALREADY Residence in a socioeconomically disadvantaged neighborhood is associated with adverse reproductive health outcomes, including decreased fecundability, preeclampsia, gestational diabetes, preterm birth, and low birthweight. STUDY DESIGN, SIZE, DURATION Retrospective cohort study including 8155 patients undergoing first, single, euploid, frozen embryo transfer between 2017 and 2022 at a single university-affiliated fertility center. The primary outcome was live birth. Secondary outcomes included any pregnancy loss, mode of delivery, birthweight, and gestational age at delivery. After accounting for all inclusion criteria, only 2.5% of the total cases were excluded due to missing information on BMI, insurance status, or type of transfer protocol. PARTICIPANTS/MATERIALS, SETTING, METHODS A total of 8155 patients met inclusion criteria. The primary exposure of this study was the state decile Area of Deprivation Index (ADI) score, or the composite score that measures overall socioeconomic disadvantage at the Census block level. ADI scores were then divided into four groups: low or least disadvantaged (score 1–2, n = 3138, 38.5%), low-middle (score 3–5, n = 3145, 38.5%), middle-high (score 6–8, n = 1573, 19.3%), and high or most disadvantaged (score 9–10, n = 299, 3.7%). MAIN RESULTS AND THE ROLE OF CHANCE Individuals living in areas with higher neighborhood deprivation (more disadvantaged) had a higher BMI and were more likely to be uninsured than those in areas of lower deprivation (less disadvantaged). Overall, 60.9% (n = 4963) of patients had a live birth with significantly lower rates in those living in neighborhoods with higher levels of socioeconomic disadvantage compared to those in neighborhoods with lower levels of socioeconomic disadvantage (P = 0.002). Compared to couples living in areas with the lowest deprivation index scores census blocks, the probability of live birth was significantly decreased for couples living in areas with low-middle, middle-high, and high scores in multivariable regression analyses after adjustment for maternal age, BMI, duration of time from initial consult to decision for IVF, primary infertility diagnosis, office location, insurance status, FET protocol, endometrial thickness, max estradiol level, and embryo grade (aOR 0.90 (95% CI 0.81–0.99), P = 0.047; aOR 0.87 (95% CI 0.77–0.99), P = 0.047; aOR 0.70 (95% CI 0.54–0.90), P = 0.006; respectively). Additionally, there was a significant dose-response relationship between neighborhood deprivation and probability of live birth (P = 0.003). Compared to couples living in areas of low neighborhood deprivation, the probability of any pregnancy loss was significantly higher for couples living in the highest ADI census blocks in adjusted models (aOR 1.64 (95% CI 1.21–2.24), P = 0.002). There was no difference in mode of delivery, birthweight, or gestational age at delivery. LIMITATIONS, REASONS FOR CAUTION Limitations of this study include its retrospective design, external validity, and variable patient experiences. Additionally, socioeconomic status remains a multifaceted and broad concept that includes factors often difficult to measure. WIDER IMPLICATIONS OF THE FINDINGS This study highlights the significant differences in the probability of live birth among populations residing in neighborhoods of worsening area-based socioeconomic disadvantage after adjusting for important reproductive characteristics most closely associated with IVF outcomes. Our data emphasize that reproductive health providers should not only focus on optimizing clinical and laboratory processes to improve patient outcomes but also extend focus and efforts to understand the broader systemic, economic, and geographic factors that influence overall reproductive health. STUDY FUNDING/COMPETING INTEREST(S) Funding was not utilized for the purposes of this project. The authors declare that they have no conflicts of interest. TRIAL REGISTRATION NUMBER Not applicable