Does your ethnicity influence your fertility success?

Are certain ethnicities more fertile? 

In the UK, baby deaths and stillbirths are twice as likely among Black and Asian mothers as they are among White mothers¹. This fertility gap is found around the world, including other wealthy countries. Global research reveals that¹:  

• Black women consistently have worse pregnancy outcomes than White women worldwide. 

• US Hispanic women (women in the US of Spanish-speaking or Latin American heritage) are three times more likely to experience baby deaths compared with White women.  

• South Asian women have an increased chance of early (premature) births and having a baby with an unexpectedly low weight compared with White women worldwide. 

These disparities can't be explained by biology alone - in other words, no ethnicity is more capable of having babies than the next.  

It's true that your ethnicity might influence your risk of health conditions that affect fertility. For example, Black women are up to three times more likely to develop uterine fibroids², have higher rates of obesity in countries like the US³, and are more likely to have twins (where pregnancy complications are more likely)^4.  

Yet, look closer and you'll begin see that biology is far from a standalone factor - if it's one at all: 

• Black women are more prone to fibroids if they use chemical hair relaxers, a socio-environmental factor.  

• While obesity is likely influenced by differences in genetics, Black women are also susceptible to psycho-social stress, cultural, and environmental factors⁵. 

These examples offer just a glimpse of the full picture - the complex mix of factors that affect healthy pregnancies and births.  

Fertility treatment success

In the UK, a report by the Human Fertilisation and Embryology Authority (HFEA) in December 2023 found that the ethnicity of people using fertility services appeared to influence the age they accessed treatment, and its likelihood of success. 

HFEA report findings⁶: 

• Birth rates - Black and Asian people aged 18-37 had the lowest birth rates - 23% and 24% respectively - compared to 32% White people in 2020-21.  

• IVF success rates - IVF was most used by White people, at 77%, with Black people accounting for 3% of all IVF patients.  

• Multiple births - Are a high risk to parents and babies. Black people had the highest multiple birth rates at 9%, compared to 7% for White people.  

• Age before fertility treatment - Fertility declines with age and starting treatment earlier means higher chances of success. Black heterosexual couples started fertility treatment around a year later than other ethnic groups at age 36. Single Black and Asian people started fertility treatment at 38-39 years, compared to 36 years for White single people in 2017-21. 

Following these findings, the HFEA, Royal College of Obstetricians and Gynaecologists, British Fertility Society, and Fertility Network UK are calling for positive change to ensure that no one is left behind in access to, and experience of, fertility treatment. 

Marta Jansa Perez, director of embryology at Bridge Clinic London, says: "It's known that there are challenges for people of minority ethnic backgrounds accessing care, but I didn't expect the magnitude of these results. Whilst fertility treatment is already an extremely stressful and sometimes greatly expensive process, changes need to be made to ensure equal chances of success regardless of ethnic background."`

Social determinants of health 

The significant differences found in this report, and in wider global fertility and treatment disparities, might be explained by social determinants of health (SDOHs).

These are non-medical factors that can influence your health - in this case your chances of a successful pregnancy. They are underlined by systemic racism and historical attitudes and policies. Here are some SDOHs that may be at work.  

Late diagnosis and referrals 

Women from minority groups are less likely to have their pregnancy or fertility concerns taken seriously, according to the National Institute for Health and Care Research¹. This leads to delays in many seeing fertility specialists, and the older a woman is the less chance there is of her treatment being successful.  

This pattern is true for general fertility problems as well as for certain health conditions that affect your ability to become pregnant.  

Jansa Perez says: "While it comes into play that certain conditions are common in minority group women, it's a much wider, more complex problem that's influenced by socioeconomic factors."

The director of embryology believes that education will help close this access gap: "This means educating healthcare professionals on the importance of early referrals when patients from ethnic minority groups have - or are high risk for - conditions that may reduce fertility chances. It also means educating the public in seeking help as soon as they think there is a problem."

Stigma and stereotypes in communities 

Infertility as a disease has been stigmatised around the world - it's all too common for people struggling to get pregnant to feel shame, withdrawing in silence rather than seeking medical help. This social stigma appears to be heightened in many ethnic minority communities.  

For British Pakistanis, infertility stigma can be exacerbated by traditional cultural views of gender. Here, research has uncovered that British Pakistani women typically take the 'blame' for infertility - no matter the cause - to protect their male partners from what is considered to be inherently 'un-masculine'. These men are more likely to resist healthcare that diagnoses male fertility problems¹¹.  

The taboo around the topic has also created the damaging myth that infertility and IVF is a 'White' problem. In the US, many Black women grow up believing that they're not supposed to struggle with pregnancy. One review found that this stereotype, and other racial, gendered, and religious beliefs, influenced African American women experiencing infertility - damaging their sense of identity and imposing silence and isolation¹².  

Financial factors 

When it comes to getting fertility treatment, money can be a huge barrier for lots of people. Private services are generally costly, and financial income gaps continue to negatively affect some ethnicities more than others in wealthy countries. This can marginalise them in the reproductive choice conversation¹³.  

In the UK, nationally funded treatment is available on the NHS for those who meet the criteria. But waiting lists can be long - an extra stress for women already a way into their reproductive years.

"NHS funding for treatment is also entangled with using fertility treatment at a later age, when your chances of success are decreasing," adds Jansa Perez.  

As an example of this knock-on effect, the HFEA found that funding for IVF cycles decreased in London from 23% to 17% between 2019-2021. This may have disproportionally affected the English/Welsh Black population, with 49% living in London during 2021⁶.  

What needs to change? 

For Jansa Perez, industry wide reform starts with the acknowledgment that these inequalities exist. There are ways to move forward and help close this gap, including:  

• Education awareness - around high-risk factors in ethnic minorities for communities and health professionals. "I believe that all stakeholders need to do work on this, from the regulator to the GPs and those providing the specialist care." 

• Improving referrals - "In the UK, GPs are the gateway to fertility treatment, and therefore they need to be given more information about fertility issues, how they present in certain groups, and the importance of quick referrals."

• Financial support - "Private clinics need to be affordable with their prices so treatment is accessible to as many people as possible."

• Better representation - Using focus groups, the clinical embryologist heard from patient representatives from different ethnic backgrounds who strongly felt they weren't represented in the imagery on fertility clinic websites. "If you look at many websites in this country, it's mostly images of White babies, which has delayed some people from engaging with treatment providers," says Jansa Perez. "It's so important to make imagery and patient communications inclusive and ethnically diverse, so that people can feel welcome and identified."

 Further reading 

1. National Institute for Health and Care Research: Black women around the world have worse pregnancy outcomes.  

2. Eltoukhi et al: The health disparities of uterine fibroids for African American women: a public health issue.  

3. Wise et al: Body size and time-to-pregnancy in black women.  

4. Wang et al: Temporal trends in the rates of singletons, twins and higher-order multiple births over five decades across racial groups in the United States.  

5. Agyemang and Powell-Wiley: Obesity and Black women: special considerations related to genesis and therapeutic approaches.  

6. HFEA: Latest ethnic diversity data highlights disparities in treatment outcomes, UK regulator finds.  

7. Katon et al: Racial disparities in uterine fibroids and endometriosis: a systematic review and application of social, structural, and political context.  

8. Bougie et al: Revisiting the impact of race/ethnicity in endometriosis.   

9. Murji et al: Influence of ethnicity on clinical presentation and quality of life in women with uterine fibroids: results from a prospective observational registry.  

10. Bougie et al: Revisiting the impact of race/ethnicity in endometriosis.  

11. Blell: British Pakistani muslim masculinity, (in)fertility, and the clinical encounter.  

12. Ceballo et al: Silent and infertile: an intersectional analysis of the experiences of socioeconomically diverse African American women with infertility.  

13. Iba et al: Household income and medical help-seeking for fertility problems among a representative population in Japan.