Associations between social and economic determinants of health and receiving infertility care among female Veterans: a cross-sectional study.

Objective: To examine the associations between social and economic determinants of health with receipt of infertility diagnoses and care among Veterans. In the non-Veteran population, socially and economically marginalized individuals are less likely to receive infertility care. Little is known about these associations in the population of United States military Veterans, who may have unique fertility care needs and healthcare access experiences. Design: We analyzed cross-sectional survey data collected from the Impact of Sexual Assault and Combat-Related Trauma on Fertility in Veterans study conducted from 2016 to 2020. Subjects: Our analytic sample includes the subset of Veterans aged 20-45 years who were assigned female sex at birth and experienced infertility, defined as a self-reported history of unprotected sex for 12 or more months without pregnancy. Exposure: Variables of interest included social and economic determinants, including income, Veterans Health Administration (VA) benefits and insurance status, marital status, race and ethnicity, and sexual orientation. Main Outcome Measures: Outcomes included self-reported receipt of an infertility diagnosis and fertility treatment. Associations between social and economic determinants and the outcomes were evaluated using multivariable logistic regression. Age and lifetime diagnoses of mental health conditions were included as potential confounders of these associations. Results: Among the 589 female Veterans with self-reported infertility, 22.8% reported receiving an infertility diagnosis and 19.5% reported receiving fertility treatment. Having a household income of greater than $110,000 (odds ratio [OR] = 5.33, 95% confidence interval [CI], 2.06-13.77) was positively associated with receipt of an infertility diagnosis in adjusted models. Being married or currently living with a partner (OR = 2.32, 95% CI, 1.22-4.41) and having a household income of greater than $110,000 (OR = 3.89, 95% CI, 1.38-10.98) were positively associated with receiving fertility treatment in adjusted models. Neither race nor VA benefits and insurance status were associated with either outcome. Conclusion: Similar to the non-Veteran population, income remains an important economic determinant of care receipt among Veterans. Our finding that only a minority of those with self-reported infertility received a diagnosis or treatment highlights the need for efforts to improve Veterans' access to fertility care and thus their ability to achieve the families they desire.