By Jeannel Miclat
Editor’s Note: Jeannel Miclat was in her last year of medical school when she chose to enroll in the FACTS online elective in fertility awareness and restorative reproductive medicine. As part of the award-winning elective, she summarized an article published by Boltz et al titled, “Fertility Treatment, Use of in Vitro Fertilization, and Time to Live Birth Based on Initial Provider Type.” [1] The study confirmed what most primary care physicians know: most couples with infertility present to a primary care physician first, and the utilization rate of in vitro fertilization (IVF) is lower among these couples compared to those who present to an infertility clinic for their initial assessment.
Introduction
Natural family planning has existed for centuries, with roots in traditional observations of fertility signs and rhythms passed down from generation to generation. In modern times, these approaches have evolved into multiple different fertility awareness-based methods (FABMs) that rely on tracking signs of fertility – cervical mucus, basal body temperature, and urinary hormones. [2] FABMs are supported by scientific research that validates their effectiveness and applicability in diverse clinical and personal contexts. [2] Misinformation surrounding FABMs creates barriers for patients and physicians, making it harder to be informed enough to try these methods and use them effectively. [2][3] Relatively few physicians incorporate FABMs into their practice, and even fewer feel fully comfortable teaching these methods to patients. [3] For many women experiencing fertility concerns, the first medical professional they turn to is their primary care physician; thus, a physician’s knowledge about FABMs is instrumental in the care these patients receive. [1]
“FABMs are supported by scientific research that validates their effectiveness and applicability in diverse clinical and personal contexts … (but) few physicians incorporate FABMs into their practice.”
Methodology
The study by Boltz et al [1] was a retrospective cohort study between 2000 and 2007 focused on women in Utah with a history of primary infertility, defined as twelve months of intercourse without contraception with no resulting conception, and no prior pregnancies. The study analyzed how long it took a woman between the ages of 18 and 35 (n=867) to become pregnant and the different treatments they underwent to achieve pregnancy. [1] The women were divided into two groups: the general population and those seen in specialty fertility clinics. Online questionnaires and phone interviews asked questions such as:
- Did they see a physician or other medical professional specifically for fertility-related issues; if so, what type of medical professional did they see?
- Did they receive any IVF treatments?
- How long did it take for them to have a live birth since their initial encounter?
Results
In the study, 84% of patients seeking fertility-directed care first saw a generalist; 8% of patients saw a fertility specialist first, and 8% did not see a medical professional. [1] All patients were equally likely to achieve a live birth no matter which medical professional they saw first. [1] Yet, even when adjusted for income, age, and length of time trying to conceive, women who were seen by generalists were less likely to receive IVF treatment than those seen at a specialty fertility clinic – a statistically significant finding. [1] Additionally, comparing which medical professional they saw first, there was no statistically significant difference between the median time from pregnancy to live birth versus achieving pregnancy within the first 5 years of attempting. [1]
“All patients were equally likely to achieve a live birth no matter which medical professional they saw first. Yet … women who were seen by generalists were less likely to receive IVF treatment than those seen at a specialty fertility clinic – a statistically significant finding.”
Discussion
Strengths of the study by Boltz et al include its large sample size, good representation of the general population, inclusion of specialty fertility clinics, and time-sensitive data points throughout the pregnancy journey. [1] One of the main limitations of the study was how they defined a “generalist,” since family medicine physicians, OB/Gyn physicians, PAs, and NPs were combined under the umbrella of a generalist. [1] There was no reported breakdown within this group, which should have been considered since the breadth and depth of knowledge and experience between these medical professionals vary greatly. [1] The questionnaires relied on patients to classify their medical professional, which may have led to misclassifications affecting the statistical significance of some findings. [1] Additionally, the state of Utah is not necessarily representative of the entire U.S. population.
Although most patients who saw a generalist first were least likely to undergo IVF treatment, this finding does not imply a causal relationship. [1] Other variables not investigated during this study may be a confounding factor that leads to the association seen. Still, the study highlights the importance of the role of a generalist in fertility-focused care. IVF treatment can be medically invasive and adds to our growing healthcare expenditures nationwide. The comparable birth rates observed in couples with and without IVF treatment suggest IVF may not always be necessary to achieve pregnancy.
“For the healthcare system as a whole, this study highlights that promoting access to a variety of fertility care options could lower costs and reduce reliance on high-tech treatments without compromising success.”
Conclusion
Infertility is stressful and deeply personal. The path to parenthood looks different for every couple. This study helps answer a question many patients face at the start: Does it matter which medical professional I see first? According to the study results, it matters in terms of the types of treatment a patient may undergo, but it does not seem to affect whether a patient is able to become pregnant or how quickly they conceive. For the healthcare system as a whole, this study highlights that promoting access to a variety of fertility care options could lower costs and reduce reliance on high-tech treatments without compromising success.
References
[1] Boltz MW, Sanders JN, Simonsen SE, Stanford JB. Fertility Treatment, Use of in Vitro Fertilization, and Time to Live Birth Based on Initial Provider Type. J Am Board Fam Med. 2017;30(2):230-238. doi:10.3122/jabfm.2017.02.160184
[2] Duane M, Stanford JB, Porucznik CA, Vigil P. Fertility Awareness-Based Methods for Women’s Health and Family Planning. Front Med (Lausanne). 2022;9:858977. Published 2022 May 24. doi:10.3389/fmed.2022.858977
[3] Choi J, Chan S, Wiebe E. Natural family planning: physicians’ knowledge, attitudes, and practice. J Obstet Gynaecol Can. 2010;32(7):673-678. doi:10.1016/s1701-2163(16)34571-6
ABOUT THE AUTHOR
Jeannel Miclat
Jeannel Miclat is a fourth-year medical student at the Philadelphia College of Osteopathic Medicine (PCOM) in Suwanee, GA. She earned a Master of Science in health care delivery from Arizona State University and a Master of Science in biomedical sciences from PCOM. She plans to pursue residency in internal medicine with the goal of becoming a gastroenterologist to improve patients’ quality of life. She enrolled in the FACTS elective to learn more about natural family planning methods and hopes to use this knowledge to better support patients in their health and reproductive decisions.
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