Fecundability in Association With Everyday and Lifetime Discrimination.

Importance: There are well-documented racial and socioeconomic disparities in fertility outcomes, yet little is known about the association between discrimination and fecundability.

Objective: To examine the association of self-reported experiences of everyday and lifetime discrimination with fecundability.

Design, Setting, And Participants: This cohort study included data from the Pregnancy Study Online, a web-based prospective preconception cohort study that examines whether lifestyle factors are associated with fertility and pregnancy. Female participants aged 21 to 45 years in the US and Canada who were attempting pregnancy were recruited online from June 2013 to January 2023 and followed up for up to 12 months.

Exposures: Everyday discrimination (eg, disrespect, harassment) and lifetime discrimination (eg, on the job, by police) as measured using adapted versions of Williams' Everyday Discrimination Scale and Major Experiences of Discrimination scale. Summary score variables were created for frequency of everyday discrimination (ranging from 0 to ≥7, with scores of ≥7 indicating very high everyday discrimination) and for the number of lifetime discrimination types (ranging from 0 to ≥3, with ≥3 indicating greater lifetime discrimination). Attributions of and responses to discrimination were also examined.

Main Outcomes And Measures: Fecundability, the per-cycle probability of conception, was measured using bimonthly follow-up questionnaires. Proportional probabilities regression models were used to estimate fecundability ratios (FRs) and 95% CIs across categories of everyday and lifetime discrimination. Adjustments were made for potential confounders and stratified analyses by race and ethnicity.

Results: Among 6578 female participants (mean [SD] age, 30.5 [3.9] years), 1164 (17.7%) reported everyday discrimination scores of 7 or more, and 3144 (47.8%) reported 1 or more experiences of lifetime discrimination. In terms of race and ethnicity, 375 participants (5.7%) identified as Hispanic, 110 (1.7%) as non-Hispanic Black, 5701 (86.7%) as non-Hispanic White, and 392 (6.0%) as non-Hispanic other race (including American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, and multiracial or other race). Everyday discrimination was associated with reduced fecundability (score ≥7 vs 0: FR, 0.82 [95% CI, 0.75-0.90]; especially harassment [few times or more per month] vs none: FR, 0.74 [95% CI, 0.64-0.87]). Any experience (vs none) of lifetime discrimination was associated with decreased fecundability (FR, 0.93 [95% CI, 0.88-0.99]), especially discrimination when receiving medical care (FR, 0.88 [95% CI, 0.81-0.95]) and when on the job (FR, 0.94 [95% CI, 0.88-0.99]) vs no such discrimination. Reduced fecundability was mostly observed among White participants who experienced everyday discrimination (everyday discrimination score ≥7 vs 0: FR, 0.79 [95% CI, 0.71-0.87]) and among racial and ethnic minority individuals who experienced any lifetime discrimination (FR, 0.80 (95% CI, 0.68-0.94]) compared with no such discrimination. Participants who attributed their discrimination to race or ethnicity (lifetime discrimination score of 2 vs 0: FR, 0.66 [95% CI, 0.52-0.83]) or who kept quiet and accepted their experiences (everyday discrimination score ≥7 vs 0: FR, 0.76 [95% CI, 0.63-0.92]) were generally more likely to have reduced fecundability.

Conclusions And Relevance: The findings of this cohort study suggest that everyday and lifetime experiences of discrimination were associated with reduced fecundability. Associations varied by frequency and type of discrimination, highlighting the need for more research on the possible reproductive health effects of unfair treatment.