Clinical and Sociodemographic Profile of Patients Accessing Assisted Reproductive Techniques in a Public Unit: Equity in Access and the Exploratory Role of Uterine Factor

1. Introduction

Infertility is currently defined as a disease of the reproductive system characterized by the inability to achieve a clinical pregnancy after twelve months or more of regular unprotected sexual intercourse. According to the most recent international terminology, infertility also encompasses the need for medical intervention to achieve pregnancy in individuals or couples whose reproductive circumstances prevent conception without assistance, including specific family models requiring donor gametes [1].

Over recent decades, its prevalence has increased markedly in Western societies, affecting approximately 15% of couples of reproductive age [2]. This phenomenon represents not only a medical challenge but also a substantial psychosocial and economic burden, consolidating infertility as a major public health issue that has driven the development and refinement of assisted reproductive techniques (ART).

In female infertility, the uterine factor plays a central role. The uterus is essential for embryo implantation and pregnancy progression; therefore, congenital anomalies (Müllerian malformations) and acquired conditions (leiomyomas, endometrial polyps, intrauterine adhesions, adenomyosis) may be associated with implantation failure, recurrent miscarriage, and obstetric complications, with an estimated involvement in up to 50% of reproductive failure cases [3]. The clinical impact depends on the type, size, and location of the lesion, as well as the degree of distortion of the endometrial cavity, meaning that not all uterine abnormalities exert the same effect on fertility nor require identical therapeutic approaches [4].

These pathologies alter uterine cavity anatomy and endometrial receptivity. Therefore, accurate diagnostic evaluation—ranging from transvaginal ultrasound to advanced techniques such as hysteroscopy or magnetic resonance imaging—is essential to establish prognosis and select the most appropriate therapeutic strategy.

However, the success of ART does not depend solely on correcting anatomical or functional factors. The sociodemographic profile of patients—including age, educational level, employment status, and family model—significantly influences access to and outcomes of these treatments [5,6]. In Spain, access to reproductive medicine through the National Health System aims to guarantee equity; nonetheless, it remains necessary to investigate whether inequalities persist based on non-clinical factors.

This perspective is particularly relevant in the current context, characterized by delayed childbearing, increasing diversity in family structures, and a sustained rise in demand for care in human reproduction units [7,8].

Based on this premise, the main objective of the present study is to analyze the clinical and sociodemographic profile of patients who accessed ART in a tertiary-level public hospital in Andalusia, evaluating the association between these variables and the techniques employed, with the aim of identifying potential patterns of utilization and ensuring that access to motherhood is primarily governed by clinical need.

2. Materials and Methods

Study Design and Clinical Setting

A retrospective, observational, descriptive–analytical study was conducted in the Assisted Reproduction Unit of the Maternal and Child Hospital, part of the Regional University Hospital of Málaga (Spain). The study period extended from January to June 2025. The STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines were followed to ensure transparent and rigorous scientific reporting [9,12].

Study Population and Eligibility Criteria

The study population included all patients who initiated or underwent assisted reproductive techniques (ART) at the center during the study period, resulting in a final sample of 222 patients. Data were obtained through a systematic review of electronic medical records, ensuring anonymity and confidentiality in accordance with the Spanish Organic Law on Personal Data Protection and Digital Rights.

All patients meeting the inclusion criteria during the study period were consecutively enrolled to minimize the selection bias inherent to retrospective designs.

The sample size corresponded to the total number of patients initiating ART during the study period (consecutive convenience sampling). Given the descriptive–exploratory nature of the study, no a priori sample size calculation was performed; statistical power for the main associations is reflected through the 95% confidence intervals of the estimates.

The study protocol was reviewed and approved by the Research Ethics Committee (CEIm) of the Province of Málaga (study code: TFGLIMRC2025), which issued a favorable opinion in session number 1, held on 29 January 2026.

Variables and Data Collection

Two categories of variables were defined to characterize the patient profile:

• Sociodemographic variables: age at treatment initiation; marital status (categorized as heterosexual couple, female couple, and single mother by choice—SMC); educational level (primary, secondary, or higher education); employment status; and area of residence (urban or rural).
• Clinical and reproductive variables: BMI, smoking status, obstetric history, etiological diagnosis of infertility, duration of infertility, and type of ART performed. The category of structural uterine pathology included leiomyomas, endometrial polyps, adenomyosis, Müllerian malformations, and intrauterine adhesions.

Statistical Analysis

Statistical analyses were performed using JASP software (version 0.18.3; JASP Team, 2024; available at https://jasp-stats.org/). An initial descriptive analysis was conducted using frequencies and percentages for qualitative variables, and means with standard deviations for quantitative variables.

Normality of quantitative variables was assessed using the Shapiro–Wilk test. For bivariate analyses, Pearson’s chi-square test (or Fisher’s exact test when appropriate) was used for qualitative variables, and Student’s t-test for comparisons of means between two groups. Finally, a multivariate analysis was performed using binary logistic regression, with statistical significance set at p < 0.05.

3. Results

Sociodemographic Characteristics of the Sample

A total of 222 patients were included in the study. The mean age was 34.70 years (SD not specified), with the highest concentration in the 35–39-year group. Regarding family model, 76.40% were heterosexual couples, 16.70% were single mothers by choice (SMC), and 6.90% were female couples. Most patients were employed (88.68%), and urban residence predominated (63.35%). The cohort showed a notable representation of new family models (23.6%). Table 1

This age distribution is clinically relevant, as the predominance of women aged 35–39 years coincides with the period of most pronounced decline in ovarian reserve, which may influence the indication for higher-complexity techniques. The distribution of marital status reflects a substantial proportion of non-heteronormative family models and SMC, reinforcing the need for inclusive care pathways and eligibility criteria centered on clinical need.

Clinical Profile and Reproductive History

The predominant clinical profile was that of a woman with a normal BMI and non-smoking status. Most patients were nulligravid. The most frequent infertility-related diagnoses were structural uterine pathology and diminished ovarian reserve, with a mean time attempting pregnancy between 2 and 5 years. High-complexity techniques (IVF/ICSI) were the most commonly used.

Structural uterine pathology accounted for 23.02% of valid gynecological histories, followed by diminished ovarian reserve (17.27%), endometriosis (13.67%), polycystic ovary syndrome (16.55%), and pelvic inflammatory disease (7.19%). A substantial proportion of missing data (37.39%) corresponded mainly to patients belonging to new family models without documented reproductive pathology or with incomplete diagnostic evaluation. Table 2

Factors Associated with the Type of Assisted Reproductive Technique

Statistical analysis showed that access to different ART modalities was significantly influenced by clinical factors and marital status, whereas other sociodemographic variables such as educational level or employment status did not show a determining influence on technique selection. Table 3, Table 4 and Table 5.

Infertility Diagnosis and Duration

Among patients with a documented infertility diagnosis, the most frequent etiologies were male factor (35.00% of valid cases) and unexplained infertility (36.43%). The duration of infertility was most commonly between 1 and 2 years (48.57% of valid cases). Missing data (36.94%) were predominantly associated with new family models without prior infertility evaluation. Table 3

Type of Assisted Reproductive Technique

High-complexity techniques (IVF, ICSI, IVF/ICSI combined, oocyte donation, PGT-M) represented the majority of treatments. Low-complexity techniques (IAC, IAD) were more frequent among SMC and female couples, consistent with the absence of underlying reproductive pathology and the need for donor gametes. Table 4

The missing data observed in Table 3 and Table 4 (36.94%) predominantly correspond to patients entering emerging family models who, at the time of analysis, did not have a documented diagnosis of reproductive pathology or had an incomplete diagnostic workup. This situation reflects the clinical reality of populations accessing assisted reproductive services without a formally established prior diagnosis, which is particularly relevant in the context of evolving family diversity.

Multivariate Model

The multivariate logistic regression model identified:

• Marital status as a strong predictor of technique type (p < 0.001). Female couples and SMC showed markedly higher odds of undergoing low-complexity techniques (adjusted OR 21.79 and 18.45, respectively).
• Infertility diagnosis was also significantly associated with technique selection (p < 0.001). Female, male, and mixed infertility factors were associated with lower odds of low-complexity techniques compared with patients without a diagnosis.
• Educational level, BMI, age, residence, and smoking status did not reach statistical significance.
• Structural uterine pathology showed a non-significant trend toward increased use of high-complexity techniques (adjusted OR 1.16; 95% CI: 0.48–2.77; p = 0.742), likely influenced by limited statistical power and the high proportion of missing data.

Table 6. Bivariate Analysis of Factors Associated with Assisted Reproductive Techniques.

Variable	Category	Low-complexity technique (%)	High-complexity technique (%)	OR (95% CI)	p-value
Age	Continuous	37.71	62.29	1.02 (0.98–1.06)	0.359
BMI	Continuous	37.50	62.50	0.97 (0.91–1.04)	0.719
Educational level	Basic (ref.)	12.14	26.01	1.00	—
	Higher / Superior	17.92	21.39	1.79 (0.89–3.58)	0.103
Marital status	Male partner (ref.)	22.96	77.04	1.00	<0.001
	Female partner	86.67	13.33	21.79 (8.5–55.6)	<0.001
	Single mother	84.62	15.39	18.45 (7.2–47.1)	<0.001
Infertility diagnosis	No diagnosis (ref.)	6.77	3.76	1.00	<0.001
	Female	7.52	24.81	0.17 (0.05–0.58)	0.007
	Male	5.26	21.81	0.13 (0.04–0.46)	0.004
	Mixed	3.01	27.07	0.06 (0.01–0.28)	<0.001
Gynecological history	No (ref.)	15.34	19.89	1.00	0.447

Table 6. Bivariate Analysis of Factors Associated with Assisted Reproductive Techniques.

Variable	Category	Low-complexity technique (%)	High-complexity technique (%)	OR (95% CI)	p-value
Age	Continuous	37.71	62.29	1.02 (0.98–1.06)	0.359
BMI	Continuous	37.50	62.50	0.97 (0.91–1.04)	0.719
Educational level	Basic (ref.)	12.14	26.01	1.00	—
	Higher / Superior	17.92	21.39	1.79 (0.89–3.58)	0.103
Marital status	Male partner (ref.)	22.96	77.04	1.00	<0.001
	Female partner	86.67	13.33	21.79 (8.5–55.6)	<0.001
	Single mother	84.62	15.39	18.45 (7.2–47.1)	<0.001
Infertility diagnosis	No diagnosis (ref.)	6.77	3.76	1.00	<0.001
	Female	7.52	24.81	0.17 (0.05–0.58)	0.007
	Male	5.26	21.81	0.13 (0.04–0.46)	0.004
	Mixed	3.01	27.07	0.06 (0.01–0.28)	<0.001
Gynecological history	No (ref.)	15.34	19.89	1.00	0.447

4. Discussion

The findings of this study provide a contemporary overview of the profile of ART users within the public healthcare system. The main result indicates that access to these techniques in our center is primarily determined by clinical criteria and family model rather than socioeconomic factors. This equity in access represents a positive indicator of the role of the public system in reducing gaps in reproductive healthcare. However, these results must be interpreted within the context of a single-center study and the variables included in the analytical model, which do not allow the exclusion of potential influences from other unmeasured social determinants.

The mean age of patients (34.70 years) aligns with the current sociological trend of delayed motherhood in developed countries [7]. From a biological perspective, ovarian reserve declines more rapidly after age 35, accompanied by an increase in aneuploidy rates [9]. This pattern accounts for the high frequency of diminished ovarian reserve observed in our sample. Although low ovarian reserve is not, in itself, an indication for high-complexity techniques, the subsequent referral to such techniques is nevertheless often increased.

A relevant aspect of our cohort is the high prevalence of structural uterine pathology. Available evidence underscores the decisive role of the uterus in implantation and the association of uterine anomalies with implantation failure and recurrent miscarriage [3,4,5]. In our series, structural uterine pathology was among the most frequent diagnoses and showed a non-significant trend toward increased use of high-complexity techniques.

In line with the existing literature, congenital and acquired uterine anomalies (leiomyomas, polyps) may compromise both endometrial receptivity and the structural integrity of the uterine cavity, potentially affecting implantation and early embryonic development. Available evidence indicates that correction of selected abnormalities can improve reproductive outcomes in appropriately chosen patients; however, the magnitude of benefit is heterogeneous and depends on the type of lesion, its location, and the degree of endometrial cavity distortion [4,8,13,14].

Within this context, our findings are consistent with the hypothesis that, when correction of the uterine factor is not feasible or is not considered clinically indicated, the use of high-complexity techniques tends to increase in routine practice. This pattern may reflect the need to optimize the likelihood of success in anatomically unfavorable scenarios, even when the uterine anomaly itself does not constitute a direct indication for such techniques. Nevertheless, it is important to emphasize that the study design does not allow causal inferences, and these observations should therefore be interpreted with caution.

Regarding family models, the fact that nearly one-quarter of the sample consisted of SMC and female couples highlights a social transformation that the public healthcare system has successfully integrated. The significant association between these profiles and the use of low-complexity techniques is expected, as these patients do not present underlying reproductive pathology but rather require access to donor gametes. Nevertheless, it would be advisable to ensure that screening protocols for uterine pathology and ovarian reserve are equally rigorous in this group to avoid repeated failure of low-complexity techniques.

Finally, the bimodal distribution of educational level (primary and higher education) suggests that the tertiary-level hospital functions as a universal access point. This observation contrasts with studies conducted in private healthcare systems, where educational level and purchasing power are direct predictors of access to ART [3,10,11,14]. However, the absence of a statistical association between educational level and technique type does not imply the absence of social inequalities in overall access, as variables such as income, administrative status, or geographic accessibility were not analyzed.

Limitations and Strengths

This study presents the inherent limitations of a retrospective, single-center design, including potential information loss; a high proportion of missing data, mainly corresponding to patients belonging to new family models without documented reproductive pathology; and a study period restricted to six months. It should also be noted that the applied protocols correspond to those established within the public healthcare system, which may entail differences in clinical practice compared with other settings. Among its strengths, the study benefits from the contemporaneity of the data (first semester of 2025), the simultaneous inclusion of clinical and sociodemographic variables, and adherence to STROBE guidelines. Future multicenter and prospective studies incorporating outcome variables (implantation rates, clinical pregnancy, and live birth) will allow validation of these findings and a more precise assessment of the influence of the uterine factor on therapeutic strategy and reproductive prognosis.

5. Conclusions

• The profile of patients accessing ART in the public healthcare system has evolved, reflecting a delay in the search for a first pregnancy (mean age 34.7 years) and a diversification of family models (23.6% without a male partner). These findings are consistent with the demographic changes observed in the Spanish population over recent decades. The proportion of women aged 35–39 years (46.85%) reinforces that public assisted reproduction currently serves a population in which age already significantly conditions prognosis.
• Access to ART in the public healthcare system of Málaga demonstrates a high degree of socioeconomic equity for the variables analyzed: educational level and employment status did not determine the type of treatment received. This conclusion must be interpreted within the specific healthcare setting evaluated and the variables included in the model. The absence of an association with educational level does not exclude more subtle inequities, particularly if unmeasured barriers related to income, waiting times, or geographic accessibility persist.
• The choice of technique is based on clinical need. Medical infertility diagnoses (male, female, or mixed factor) and marital status were significantly associated with the type of technique (p < 0.001). Structural uterine pathology was one of the most frequent diagnoses and showed a trend toward the use of high-complexity techniques that did not reach statistical significance in the multivariate model (p > 0.05), thus requiring confirmation in studies with greater statistical power.
• The precise identification and management of structural uterine pathology are essential for tailoring treatment, always according to the type of lesion, its clinical impact, and the available evidence. The present study provides information on its frequency in clinical practice but does not allow the establishment of a causal relationship between this pathology and the indication of advanced techniques.
• It is necessary to continue monitoring these profiles to adapt care protocols to the changing sociodemographic reality. Future prospective and multicenter studies incorporating outcome variables will allow a more precise determination of the influence of clinical and sociodemographic factors on reproductive outcomes.