Male Factor Infertility and the Rural-Urban Continuum.

Objective: To examine the association between male factor infertility and the Rural-Urban continuum.

Materials and methods: Single institution retrospective cohort study using the Utah Population Database (UPDB), which combines demographic, medical, and residential data for patients residing in Utah and links to the Subfertility Health Assisted Reproduction and Environment (SHARE) database, which houses fertility data from 1998-2017. The data was divided by metropolitan (metro-) [large, medium, small], and non-metropolitan (non-metro-) [urban, rural] status, based on United States Department of Agriculture (USDA) rural-urban continuum codes (RUCC).

Results: Non-metro urban/rural males were less likely to be a racial/ethnic minority (91.3% non-Hispanic white vs 85.7%), or use assisted reproductive technology (ART) (13.4% vs 18.5%). Multivariate regression controlling for race/ethnicity, age, semen analysis category (oligozoospermic vs normozoospermic), previous successful fertility outcome, and use of ART, demonstrated complete rurality was associated with decreased likelihood of successful fertility outcome (Hazard Ratio [HR] 0.63, 95% CI 0.44-0.91, n=65). Non-metro urban individuals trended towards lower likelihood of successful fertility outcome ([HR] 0.93, 95% CI 0.85-1.01). Complete rurality was associated with longer time for 50% cohort successful fertility outcome (>60 months vs approximately 34 months both metro). All comparisons p<0.001.

Conclusions: Across the rural-urban continuum, residing in a metro area was associated with higher rates of racial/ethnically diversity, fertility treatment utilization, and successful fertility outcomes (live births). Given approximately 18% of the United States resides with a rural community (12% in Utah), these findings can provide more informed infertility care.