Analyzing patterns in infertility may lead to improved interventions
According to the CDC, infertility rates are rising in the United States.1 Experts believe this trend is due to a number of factors that are making infertility more common. Though research in recent years has improved our understanding of the causes of infertility, up to one-third of all cases are still attributed to unknown causes.2 Identifying risk factors for infertility as early as possible is critical for advising potential treatment options and helping individuals understand what paths to parenthood exist for them.
Digital health solutions can be a means to help people identify infertility risk factors and receive more effective treatment earlier, potentially optimizing their chances of building a family. Digital health technologies recently have grown in number and popularity to support women’s fertility goals – in the U.S., approximately 30% of women now use apps to track their reproductive health.3 Digital health solutions such as Ovia Health (a Labcorp company) work to provide customized support and education for individuals and families throughout the whole spectrum of women’s health, from cycle tracking and preconception to pregnancy, parenting, and into menopause. The broad use of reproductive mobile health solutions like Ovia present a unique opportunity to understand infertility at a larger scale.
Understanding the most common causes of infertility is critical to designing successful interventions that could reduce preventable risks and ultimately ease the financial and emotional burdens of fertility challenges. To learn more, Ovia researchers examined health assessment data from approximately 2.6 million Ovia users who self-reported the goal of “trying to conceive” upon signup with the Ovia app. We spoke with Katie Noddin, a Senior Analytics Engineer at Ovia, to learn more about the details behind this study and what the findings mean for not only our users, but also for employers and health plans looking to support their members along their reproductive journeys.
Can you give us some background on infertility? How is it defined, and what are some well-known risk factors?
The CDC defines infertility as the inability to get pregnant after one year of unprotected sex among heterosexual couples for women under 35. Since infertility increases with age among both sexes, providers often begin evaluating women aged 35 and older who have not been able to get pregnant after six months. Common risk factors that affect men and women alike include smoking, obesity, low body weight, excessive alcohol or drug use, and physical or emotional stress. An important factor contributing to the rise in infertility to know about is age; women in the U.S. are more likely to delay motherhood now than in decades past to prioritize educational attainment, build careers, and secure financial footing. The average age of all first-time mothers in 2021 was 27.3 years, the highest in America’s history, and this trend persists across most races and ethnicities.1 This trend increases the proportion of people seeking to build a family in their 30’s and 40’s, when both female and male fertility declines.2 Among women aged 15-49, 13.4% had impaired fecundity, which means they are unable to get pregnant on their own or carry a pregnancy to full term, and almost 8% were infertile. Importantly, infertility and subfertility are not solely a women’s health issue; a third of infertility causes are due to male-factor infertility, and between 2015-2019, over 11% of men aged 15-49, reported some form of infertility.1,2 It’s important to note that though the definition of infertility uses an age cut-off for women under or over 35, the root cause of infertility is not always associated with female factors; in fact, the causes of infertility are evenly split between male factor, female factor, and unknown causes. The age cut-off is simply an indicator for a further fertility work-up.
Can you speak more about the difference between male and female infertility? Are there key differences to be aware of?
In women, infertility commonly presents itself with conditions affecting the uterus, fallopian tubes, or ovaries such as endometriosis, uterine fibroids, or polycystic ovarian syndrome (PCOS); in men, it is typically caused by testicular or ejaculatory disorders or hormonal imbalances. In many cases, the cause of infertility is undetermined.
How can digital health apps help us better understand and tackle infertility?
Digital health apps are becoming more popular among people of reproductive age–people who have grown up with technology and feel comfortable using it to inform their health journeys. Growing up, many women are taught to track their period using a pen and a calendar, which may work for folks with regular menstrual cycles; however, this approach doesn’t work for many women who experience irregular menstrual cycles and doesn’t account for other important fertility symptoms. Apps have the ability to capture data at a rate, volume, and detail that is typically unmatched in standard data reporting procedures and research practices. When these apps are designed appropriately through a clinical lens and with careful consideration of the individuals using them, the data collected are rich and robust and can provide deeper insight on risk factors affecting health conditions like infertility on a large scale. Digital health apps should be designed to fit into a user’s everyday life; at Ovia, we feel we’ve achieved that given our users log on average 15-30 sessions per month, translating to users logging in almost daily to log important fertility data. Important female fertility indicators to track include menstrual cycle information, cervical fluid, basal body temperature, ovulation predictor test results, and more. Digital health apps can make tracking these data points easier and can paint a holistic picture of a user’s fertility information while helping users feel aware of their fertility trends.
What was the motivation and background behind conducting this study? What were you hoping to find out through your work?
Our team discussed a few different health issues we wanted to investigate more deeply, and we decided the most pressing and potentially impactful topic would be infertility, given how common it is and that it’s been increasing in recent years. Our Ovia (Fertility) app user base is primarily female identifying, which means that we have a unique opportunity to investigate female-related factors of fertility. We were hoping to see whether our data confirmed what national data suggests, while also uncovering other insights in the process.
How was the investigation conducted? What was the inclusion criteria?
We decided to look at infertility trends in our Ovia (Fertility) app longitudinally while still including key variables from the in-app Health Assessment (a series of optional questions offered throughout the app experience that captures personal and family health history variables relevant to reproductive health and socioeconomic factors). In our study, we included US-based users who signed up for the Ovia app between 2017-2023, indicated they were trying to conceive (TTC) at sign-up, and also completed the Health Assessment. One question in the Health Assessment asks the individual to select whether they currently have or have a history of conditions such as polycystic ovarian syndrome (PCOS), uterine fibroids, endometriosis, or multiple abnormal pap smears, all of which are known risk factors for infertility. We ultimately defined infertility risk as anyone who self-reported having PCOS, uterine fibroids, or endometriosis in the Health Assessment, and we stratified these conditions by users’ race, ethnicity, and age.
What did you find out from the data collected? What were some of the key findings from your research?
Our sample included approximately 2.6 million individuals between 2017 and 2023. We found that infertility risk increased by 14% across the time period, but this varied across racial and age groups. The average age among individuals TTC rose by 8.4%, from 28.5 to 30.9 years, which is older than the average age at first pregnancy in the U.S. (27.3 years, according to the CDC). The fastest growing age group of Ovia users across the time period were users who were 45 years or older. Interestingly, the youngest age group (18-25 years) reported the highest rate increase in reported infertility risk across the time period (4.2%). Asian, Black or African American, and American Indian/Alaska Native users reported the greatest infertility risk rate increases, while white-identifying users reported the lowest. Interestingly, the overall reported rate of diagnosed infertility decreased by 42% over the seven year time period.
What did you find to be the most common risk factors for infertility? What does this mean for Ovia members?
PCOS was the most common risk factor and also increased the most (2.9%) over the time period, followed by endometriosis (1%). Both of these conditions, as well as uterine fibroids, are common and are more prevalent among populations of color. This trend could also be attributed to an increase in awareness in provider diagnostic patterns; some studies indicate it requires seeing more than three providers on average to receive a PCOS diagnosis, and 10-11 years from symptom onset for patients to receive an endometriosis diagnosis.4,5 This temporal delay is even more pronounced for patients who have limited access to healthcare due to structural or socioeconomic barriers. Endometriosis in particular is notoriously difficult to diagnose as it requires surgical confirmation, which can be risky and inaccessible to patients depending on insurance status. Additionally, we noticed our TTC population’s age is increasing, which matches the national trends we’re observing in the U.S. It appears that users of the Ovia app are potentially older than the average person trying to conceive and may be turning to a digital health solution to give them extra support on their reproductive health journey.
Were there any limitations to this study? Are there any areas you hope to explore in future research?
One limitation of this study is that it assesses self-reported risk factors, so these aren’t confirmed by the user’s medical chart or provider. The sample may not be generalizable to all reproductive-aged women in the U.S.; though our sample size is impressive and fertility tracking apps are popular among reproductive-aged women, our users may or may not be similar to other women of reproductive age who don’t use fertility tracking apps. We’re currently pursuing a research project together with an academic research partner to assess this exact research question: how similar are Ovia app users compared to non-Ovia app users in terms of demographics and health backgrounds? More to come on those findings.
What are the impacts from the findings in your research? What does this mean for employers or health plans who are hoping to tackle infertility among their populations?
As women consciously delay childbearing to pursue other personal or professional goals, they are attempting to build their families and achieve pregnancy later in life than ever before. Rarely are adults taught about their fertility until it’s too late. Being properly informed about fertility health, how to optimize fertility through lifestyle behaviors such as diet, sleep, and exercise, and being aware of one’s own fertility and ovulation windows are all critical in assisting as many folks as possible in achieving pregnancy on their own without the need of expensive assisted reproductive technology such as IVF that may lead to high-risk pregnancies. Based upon these findings, it’s likely that members using the Ovia app who indicate that they are “trying to conceive” at sign-up may have more pre-existing risk factors for infertility than the average woman of reproductive age. These members require more support and attention to fulfill their family-building goals. Ovia is able to provide that by helping members log the right types of fertility data, understand their data, receive personalized and evidence-based education, and communicate with the Ovia Care Team about common questions on their reproductive health journey.
1. Osterman MJK, Hamilton BE, Martin JA, Driscoll AK, Valenzuela CP. Births: Final data for 2021. National Vital Statistics Reports; vol 72, no 1. Hyattsville, MD: National Center for Health Statistics. 2023. DOI: https://dx.doi.org/10.15620/cdc:122047.
2. Cleveland Clinic: https://my.clevelandclinic.org/health/diseases/16083-infertility
3. KKF Henry J Kaiser Family Foundation (2019.) Health Apps and Information Survey September 2019. https://files.kff.org/attachment/Topline-Health-Apps-and-Information-Survey-September-2019
4. Gibson-Helm M, Teede H, Dunaif A, Dokras A. Delayed Diagnosis and a Lack of Information Associated With Dissatisfaction in Women With Polycystic Ovary Syndrome. J Clin Endocrinol Metab. 2017;102(2):604-612. doi:10.1210/jc.2016-2963.
5. Yale Medicine: https://www.yalemedicine.org/conditions/endometriosis#:~:text=Also%2C%20a%20definitive%20diagnosis%20requires,and%20diagnosis%20(and%20treatment).