STUDY QUESTION Is geographic proximity to a fertility clinic associated with the likelihood of women of reproductive age undertaking different forms of medically assisted fertility treatment? SUMMARY ANSWER After adjusting for socioeconomic status (SES) and other confounders including a proxy for the need for infertility treatment, women who lived within 15 km of a fertility clinic were 21% more likely to undergo ART treatment and 68% more likely to undergo IUI treatment than those who lived further than 60 km away. WHAT IS KNOWN ALREADY In most countries, patients living outside of metropolitan areas are more likely to be more socio-economically disadvantaged and to have less equitable access to healthcare. However, how a woman's residential proximity to fertility clinics predicts utilization of high-cost/high-technology treatment (ART) and low-cost/low-technology treatment (IUI) is limited, and whether socio-economic disadvantage explains much of the hypothesized lower utilization is unknown. Australia's universal insurance scheme provides supportive reimbursement for almost all ART and IUI treatment regardless of age or number of cycles, providing a unique setting to investigate disparities in access to infertility treatment. STUDY DESIGN, SIZE, DURATION National population-based observation study of ART and IUI treatment utilization by women across socio-economic gradients and Australian residential locations between August 2015 and December 2017. PARTICIPANTS/MATERIALS, SETTING, METHODS Universal insurance claims information on female patients who underwent ART or IUI were provided by Services Australia, comprising 67 670 female patients who accessed 162 795 ART treatments, and 10 211 female patients who accessed 19 615 IUI treatments over a 29-month period. Incidence rates by SES and proximity to fertility clinics were calculated to describe the number of women undergoing at least one ART or IUI treatment cycle per 1000 women of reproductive age (25-44). Treatment frequencies were calculated to describe the average number of ART or IUI treatment cycles per woman of reproductive age who had undergone at least one ART or IUI treatment during the study period. Poisson regression analyses were used to estimate the independent effect on accessibility to infertility treatment by geographic proximity (based on small area locations) to the closest fertility clinic after adjusting for SES, childbearing delay, remoteness area, and marital status. MAIN RESULTS AND THE ROLE OF CHANCE On average, 19.1 women per 1000 women of reproductive age underwent at least one fresh or frozen ART cycle, with an average 2.3 ART cycles each, while 3.0 women per 1000 women of reproductive age received at least one IUI cycle, with an average of 1.6 IUI cycles each. After adjusting for SES and other confounders including a proxy for the need for infertility treatment, women who lived within 15 km of a fertility clinic were 21% more likely to undergo ART treatment and 68% more likely to undergo IUI than those who lived over 60 km away. Regardless of geographic location, there was a steady and independent gradient in access to ART treatment based on increasing SES, with women residing in the most advantaged residential quartile having a 37% higher rate of receiving ART treatment compared to those in the most disadvantaged quartile. The negative effect of social disadvantage on ART use became more pronounced as distance from a fertility clinic grew, indicating that the barriers to access to ART care caused by distance were further compounded by the level of socioeconomic advantage of the women's residential location. In contrast, socioeconomic status did not modify the likelihood of using IUI over and above the distance from a fertility clinic. In relation to IUI treatment, differences in utilization by SES disappeared after adjusting for geographic proximity to a fertility clinic, childbearing delay, remoteness area, and marital status. LIMITATIONS, REASONS FOR CAUTION Information is aggregated by small geographic areas and it therefore may not reflect individual characteristics. Australia provides partial but comparably supportive reimbursement for both ART and IUI through its universal healthcare system and thus the results may not be fully generalizable to other settings. WIDER IMPLICATIONS OF THE FINDINGS Residential proximity to a fertility clinic is a persistent barrier to accessing ART and IUI treatment, regardless of SES, even in countries characterized by supportive public funding, such as Australia. SES is less of a barrier to accessing IUI than ART, presumably driven by the lower cost and fewer clinic visits required with IUI treatment. Safe and effective fertility treatment should be available to all women regardless of where they live. STUDY FUNDING/COMPETING INTEREST(S) This work was supported by the Australian National University Research scholarship and by the Higher Degree Research Fee Merit Scholarship. The authors have no conflict of interest. TRIAL REGISTRATION NUMBER N/A.

中文翻译：

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居住地靠近生育诊所与女性接受 ART 和 IUI 治疗的可能性独立相关。

研究问题 生育诊所的地理位置是否与育龄妇女接受不同形式的医学辅助生育治疗的可能性有关？答案总结 在调整了社会经济地位 (SES) 和其他混杂因素（包括不孕症治疗需求的替代因素）后，居住在生育诊所 15 公里范围内的女性接受 ART 治疗的可能性增加 21%，接受 IUI 的可能性增加 68%治疗比居住在 60 公里以外的那些人。已知情况 在大多数国家/地区，居住在大都市地区以外的患者更有可能在社会经济上处于更不利的地位，并且获得医疗保健的机会更不公平。然而，一个女人如何 s 住宅靠近生育诊所预测高成本/高科技治疗 (ART) 和低成本/低技术治疗 (IUI) 的利用是有限的，社会经济劣势是否解释了假设的较低利用的大部分原因尚不清楚. 澳大利亚的全民保险计划为几乎所有 ART 和 IUI 治疗提供支持性报销，无论年龄或周期数如何，为调查获得不孕症治疗方面的差异提供了独特的环境。研究设计、规模、持续时间 2015 年 8 月至 2017 年 12 月期间，跨社会经济梯度和澳大利亚居住地的女性对 ART 和 IUI 治疗利用的全国人口观察研究。参与者/材料、环境、方法 接受 ART 或 IUI 的女性患者的全民保险理赔信息由 Services Australia 提供，其中包括在 29 个月期间接受 162 795 次 ART 治疗的 67 670 名女性患者和接受 19 615 次 IUI 治疗的 10 211 名女性患者。计算 SES 的发生率和与生育诊所的距离，以描述每 1000 名育龄妇女 (25-44) 中接受至少一个 ART 或 IUI 治疗周期的妇女人数。计算治疗频率以描述在研究期间至少接受过一次 ART 或 IUI 治疗的每位育龄妇女的 ART 或 IUI 治疗周期的平均数。在调整 SES、生育延迟、偏远地区和婚姻状况后，使用泊松回归分析来估计与最近的生育诊所的地理接近度（基于小区域位置）对不孕症治疗可及性的独立影响。主要结果和机会的作用 平均每 1000 名育龄妇女中有 19.1 名妇女接受了至少一个新鲜或冷冻的 ART 周期，每个平均 2.3 个 ART 周期，而每 1000 名育龄妇女中有 3.0 名妇女至少接受了一次 IUI周期，每个平均 1.6 个 IUI 周期。在针对 SES 和其他混杂因素进行调整后，包括不孕症治疗需求的代理因素，居住在生育诊所 15 公里以内的女性接受 ART 治疗的可能性比居住在 60 公里以外的女性高 21%，接受 IUI 的可能性高 68%。无论地理位置如何，基于 SES 的增加，在获得 ART 治疗方面存在稳定且独立的梯度，居住在最有利住宅四分位数的女性与最弱势四分位数的女性相比，接受 ART 治疗的比率高 37%。随着与生育诊所距离的增加，社会劣势对 ART 使用的负面影响变得更加明显，这表明距离造成的获得 ART 护理的障碍因妇女居住地的社会经济优势水平而进一步加剧。相比之下，社会经济地位并没有改变在远离生育诊所的距离之外使用 IUI 的可能性。关于 IUI 治疗，在调整与生育诊所的地理距离、生育延迟、偏远地区和婚姻状况后，SES 的利用差异消失了。局限性、谨慎的理由 信息按小地理区域汇总，因此可能无法反映个人特征。澳大利亚通过其全民医疗保健系统为 ART 和 IUI 提供部分但相对支持的报销，因此结果可能无法完全推广到其他环境。研究结果的更广泛意义 无论 SES，居住地靠​​近生育诊所是获得 ART 和 IUI 治疗的持续障碍 即使在以支持性公共资金为特征的国家，例如澳大利亚。与 ART 相比，SES 对获得 IUI 的障碍较小，这可能是由于 IUI 治疗所需的成本较低且门诊次数较少。所有女性，无论她们住在哪里，都应该获得安全有效的生育治疗。研究资金/竞争兴趣 这项工作得到了澳大利亚国立大学研究奖学金和更高学位研究费优异奖学金的支持。作者没有利益冲突。试用注册号 N/A。研究资金/竞争兴趣 这项工作得到了澳大利亚国立大学研究奖学金和更高学位研究费优异奖学金的支持。作者没有利益冲突。试用注册号 N/A。研究资金/竞争兴趣 这项工作得到了澳大利亚国立大学研究奖学金和更高学位研究费优异奖学金的支持。作者没有利益冲突。试用注册号 N/A。