Fertility experiences in women reporting endometriosis: findings from the Understanding Fertility Management in Contemporary Australia survey

Purpose: To examine the fertility experiences of women reporting and not reporting endometriosis in a population-based survey.

A cross-sectional survey among a community sample of 1543 women in Australia. Data were analysed to compare fertility management between women who did and did not report endometriosis. Factors associated with unintended pregnancy, infertility diagnosis, time to conception and live birth were identified through multivariable analyses.

While individual contraceptive use did not differ by endometriosis status, avoiding pregnancy was less important to women reporting endometriosis (50.5%) than to others (68.7%; p<0.001). Women reporting endometriosis were approximately 3 times more likely to report an infertility diagnosis— the majority (39.7%) of which were ‘unexplained female or male infertility’ (p<0.001)—and 6 times more likely to report taking longer than 12 months to conceive than those who did not report endometriosis (p<0.001). However, there were no endometriosis-associated differences in women’s reports of unintended pregnancy, abortion, having been pregnant, or having had a live birth.

Our findings counter the common assertion that women with endometriosis are unlikely to conceive and support the need for healthcare and information that addresses all aspects of fertility management (not just infertility) for women with endometriosis.

endometriosis; fertility; infertility; unintended pregnancy; abortion; surveys and questionnaires Endometriosis is a chronic inflammatory condition estimated to affect 1.5% (population-based studies) to 15% (clinic-based studies) of women [1]. There is a known association between endometriosis and infertility; however, the strength of this association is not well established [2,3]. Recent research suggests that the infertility risk posed by endometriosis is considerably less than historically stated within the research and medical literature [4,5]. Frequently cited statistics that 30–40% of women with endometriosis experience infertility are largely based on small samples (likely to be under-powered) [3] and from populations known to be more likely to experience adverse outcomes, such as women attending specialist treatment services and endometriosis support groups [4]. Population-based studies suggest a lower percentage of women with endometriosis experience infertility. Of women aged 28-33 years who reported having attempted conception (n=5936) and been diagnosed with endometriosis (n=914) in the Australian Longitudinal Study on Women’s Health survey, 15% (n=137) reported experiencing infertility [6]; 11.6% (n=337) of women aged 18-49 years with endometriosis reported infertility in a United States (US) cross- sectional survey of 48 020 women in the community [7]; and 10% (n=256) of women aged 15 years and older on a Canadian regional hospital database who were diagnosed with endometriosis were also diagnosed with infertility (of a total 6845 studied patients) [8]. This is in comparison to the 9% observed in the general population globally, as determined by a systematic review of 25 population surveys of a total 172 413 women [9]. Endometriosis has been reported in up to 50% of women with infertility [3]. However, this is problematic evidence of endometriosis-associated infertility risk given that these women may have otherwise been asymptomatic (and thus never diagnosed had they not tried to conceive) and that endometriosis may still not explain their infertility [5]. Potential infertility is known to be of concern to many women diagnosed with endometriosis [10,11]. (Women have, however, stated that they do not wish to have their care prioritised around this without consultation [10].) Consistent with women’s accounts of healthcare for endometriosis and fertility [10], clinicians report that this concern is often compounded by “Dr Google, the general public, and some doctors” who overstate the likelihood of infertility [12]. Further, healthcare for endometriosis is known to be subject to ‘medical myths’ (for example, pregnancy as a cure for endometriosis) that reflect sociohistorical constructions of women and their bodies as being ‘biologically destined’ for motherhood, rather than research evidence [10,13,14]. It is not known whether misconceptions around endometriosis and infertility affect women’s reproductive planning and associated care. The aim of this research was to compare the fertility experiences of women with and without endometriosis, using data from a population-based survey of women in Australia of reproductive age. Specifically, we considered self-reported contraception use, attempts to conceive, and pregnancy outcomes.

Study design This was a component of an investigation of the individual and sociocultural factors associated with fertility management among women and men of reproductive age in Australia. A cross-sectional survey was conducted with a population-based sample; the method has been described in detail elsewhere [15,16], and briefly, here. Sample and recruitment Women and men aged 18 to 50 years were randomly selected from the Australian electoral roll by the Australian Electoral Commission with 104 (52 women, 52 men) electors selected from the 150 federal electoral zones. (The analysis reported here includes data from female respondents.) The anonymous, self-administered questionnaire was mailed in late 2013 to eligible people, followed by a reminder letter three weeks later. The survey was available online and in paper format (to be returned by reply-paid envelope). Data source and management The study-specific questionnaire consisted of 91 predominantly fixed-choice questions that assessed respondents’ sociodemographic characteristics, reproductive experiences, contraceptive use, childbearing desires and expectations, and past and present health status. The current study utilised the following survey items. Demographic variables All demographic characteristics were recoded into binary variables: age (35 years or older/34 years or younger); Aboriginal and Torres Strait Islander heritage (yes/no), country of birth (Australia/other), sexual identity (heterosexual/other), relationship status (married or de facto/not married or de facto), highest level of education (post-secondary qualification/no post-secondary qualification), private health insurance status (yes/no), and rurality (metropolitan/rural). Avoiding pregnancy Current contraception method was measured by asking respondents to select all methods that they or their partner were using from a list of 18 options (specified in Table 2). Respondents who selected at least one method were classified as being current users of contraception. To compare contraceptive effectiveness, each method was recoded into one of three categories according to the Centres for Disease Control and Prevention levels of family planning effectiveness [17]. Respondents were asked, Thinking about your life right now, how important is it to you to avoid becoming pregnant? The 5-point response scale was recoded to ‘not important’ (not applicable, not at all important) or ‘important’ (a little important, somewhat important, very important). Respondents not avoiding pregnancy were asked to indicate all applicable reasons from a list of 15 options. Attempting pregnancy Respondents were asked, Have you ever tried to get pregnant or achieve pregnancy with a partner? (yes/no). Those who selected ‘yes’ were asked the youngest age at which they first attempted conception. Responses were recoded into ‘30 years or younger’ (less than 20 years, 21-30 years) or ‘older than 30 years’ (31-40 years, more than 40 years). Two items measured respondents’ experience of infertility: (1) Have you ever had problems with fertility? (yes/no). Those selecting ‘yes’ were asked, (2) Have you and your (current or previous) partner together ever had a diagnosis of infertility? The six response options were recoded to ‘no’ and ‘yes’ (yes, but have not sought help or treatment; yes, have been diagnosed with female infertility; yes, have been diagnosed with male infertility; yes, have been diagnosed with female and male infertility; and yes, have sought help for unexplained infertility [male or female]). Pregnancy and birth experiences Responses to Have you (or a partner with you) ever been pregnant? were recoded as ‘yes’ (previously pregnant, currently pregnant) or ‘no’ (no, I don’t know). A question stem, How many times that you know about have you, or you together with a partner, was linked to the following items: had an accidental pregnancy?; had a live birth?; and had an abortion for other reasons? (that is, excluding fetal abnormalities). Responses were coded as having experienced the outcome or not. Respondents who reported a pregnancy were asked their (or their pregnant partner’s) age in years at first pregnancy and how long it took to conceive. Responses to the latter were recoded as ‘less than 12 months’ or ‘more than 12 months,’ given that 12 months is the clinically expected time to conception with frequent unprotected intercourse [18]. Respondents were also asked whether they used fertility treatment such as IVF to achieve their first pregnancy (yes/no). Data management and analysis Data were entered into an SPSS database and analysed using IBM SPSS Statistics version 20 software. In addition to descriptive statistics, univariate tests were conducted; chi-square tests for independence were used for categorical and t-tests for continuous variables. Four outcomes of theoretical interest (unintended pregnancy, infertility diagnosis, time to conception, live birth) were assessed with separate binomial logistic regressions. Demographic variables and reported endometriosis status were entered as potential predictors for each analysis. Rowe et al. [15] previously identified factors associated with unintended pregnancy for this study sample: living in a rural location, ever having experienced sexual coercion, and experiencing socioeconomic disadvantage (as measured by private health insurance; see [15] for further explanation). Therefore, ‘ever having experienced sexual coercion’ was also included as a potential predictor in each of the logistic regressions. Ethical approval The research was approved by the Human Research Ethics Committees of Monash University (CF12/0302-2012000125) and Monash Health (11280B).

Compared to available Australian population statistics, respondents were less likely to identify as being of Aboriginal and/or Torres Strait Islander heritage or to live in a rural area; and were more likely to have been born in Australia, hold a post-secondary qualification, be partnered, and have private health insurance (see Table 1). Of the 1543 women who completed the survey (response = 19.8%), 107 (6.9%) reported ever having been given a diagnosis of endometriosis. This is consistent with what has been described [19] as the best available Australian population prevalence estimate of 7% [20]. We found no differences in sociodemographic characteristics between women who did and who did not report endometriosis (Table 1). Avoiding pregnancy Women reporting endometriosis were significantly less likely to indicate that avoiding pregnancy was important to them (50.5%) compared to those who did not report endometriosis (68.7%), χ2 (1, n=1454) = 14.11, p < 0.001. The three most frequently reported reasons for not avoiding pregnancy were the same for all women regardless of endometriosis status (E=reported endometriosis; NE=did not report endometriosis): I/my partner has had tubal ligation/vasectomy/hysterectomy (E:16.8%, NE:14.4%), I have no sexual partner (E:10.3%, NE:7.2%), and We want to become pregnant (E:10.3%, NE:6.1%). For women reporting endometriosis, the fourth and fifth most frequent reasons were I don’t think I can get pregnant (6.5%) and I don’t like the side effects of contraception (5.6%), whereas the most common reason selected by women who did not report endometriosis was I don’t/my partner doesn’t mind if we become pregnant (4.2%) and I don’t like the side effects of contraception (4.1%). Women reporting endometriosis did not differ significantly in current use of contraception (50.5%) compared to those who did not report endometriosis (54.2%), nor in the level of effectiveness of the contraceptive method being used (see Table 2). Attempting pregnancy Respondents’ attempts to conceive are presented in Table 2 by reported endometriosis status. Women reporting endometriosis were significantly more likely to indicate that they had tried to become pregnant and had experienced problems with fertility. Of those who reported fertility problems, women with endometriosis were significantly more likely to indicate that they and/or their partner had received a diagnosis of infertility. The most common response option selected by both groups of women reporting fertility problems was Yes, have sought help for unexplained infertility (male or female) (E:39.7%; NE:22.9%). Pregnancy and birth experiences Respondents’ pregnancy and birth experiences are presented in Table 2. Women reporting endometriosis were no less likely to have experienced unintended pregnancy, abortion, pregnancy, and live birth than those who did not report endometriosis. However, they were significantly more likely to report taking longer than 12 months to conceive their first pregnancy than those who did not report endometriosis. They were also significantly more likely to indicate that they had used assisted reproductive technologies to conceive their first pregnancy. Multivariable analyses of factors associated with unintended pregnancy, infertility diagnosis, time to conception, and live birth Reported endometriosis status was a significant predictor of both infertility diagnosis and time taken to conceive first pregnancy; women reporting endometriosis were approximately 3 times more likely to report an infertility diagnosis (for them and/or their partner) and 6 times more likely to report taking longer than 12 months to conceive their first pregnancy than those who did not report endometriosis (see Table 3). However, reported endometriosis status was not found to be significantly associated with whether women reported an unintended pregnancy or live birth.

Drawing on data from a population-based survey, this study compared the fertility experiences of women who did and did not report endometriosis. To the best of our knowledge, this is the first study to explore contraception use and unintended pregnancy among women with endometriosis in a population-based survey. The results are strengthened by the percentage of women reporting endometriosis being consistent with current Australian population prevalence estimates [19,20]. Nevertheless, there were several potential limitations. The instrument measuring infertility diagnosis did not define infertility; it thus may have been understood more broadly by respondents than the clinical definition of “failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse” [18]. Further, the associated survey item did not allow us to determine female-only infertility, as ‘unexplained infertility’ (the most common response option) did not distinguish male from female-factor infertility. Some respondents may have reported endometriosis without the gold standard of surgical diagnosis and histological examination (which the related survey item did not specify) [21]. Respondents may have been subject to recall bias, although no systematic bias would be expected and there is evidence that women reliably report reproductive events [22]. Summary of findings in relation to previous studies Avoiding pregnancy Hormonal contraceptive methods are recommended to women with endometriosis for symptom management [21]. This may partially explain why contraceptive use did not differ by reported endometriosis status despite women with endometriosis being less likely to indicate that avoiding pregnancy was important to them and more commonly indicating a belief they could not get pregnant. Although it has been found that women and men tend to overestimate their fertility [23,24], little is known about the fertility attitudes, knowledge, and behaviour of women with endometriosis [25]. It is possible that women with endometriosis may, in contrast, underestimate their fertility given that the endometriosis-associated infertility risk has historically been overstated in the medical and research literature, and consequently by some clinicians [10,12]. Attempting pregnancy Women reporting endometriosis in our study were more likely to have attempted conception than those who did not report the disease; several factors unique to women with endometriosis may explain this. A qualitative study of women with endometriosis and their male partners found that some couples reported having a child before their originally preferred time having anticipated that they would encounter conception difficulties [26]. This is consistent with reports by women with other conditions where the disease or its treatment may adversely affect fertility, such as breast cancer [27] and diabetes [28]. Further, despite a lack of evidence to support its benefits, many women report that their treating doctors propose pregnancy as a ‘treatment’ option for endometriosis, whether or not they are in a position to welcome parenthood [11,14]. That few women question the legitimacy of this ‘treatment’ suggests its potential influence on women’s decisions [10]. In this study, 41% of all women with endometriosis reported that they and/or their partner had been diagnosed as infertile. While this finding is consistent with the known association between endometriosis and infertility [2,3], it is likely an overestimate. Previous population-based studies which have defined infertility for respondents or who analysed patient records (rather than self- report surveys), report considerably lower percentages (10–15%) of infertility among women diagnosed with endometriosis [6–8]; as discussed above, our instrument did not provide a definition. Further, the findings of this research were likely subject to selection bias. Some women are diagnosed with endometriosis only when they encounter difficulty conceiving (i.e., not due to symptoms); research suggests these women experience a reduced time to diagnosis [29,30]. Women who encounter fertility difficulties may be more likely to complete surveys relevant to their personal experience [15]. Thus, it is possible that this cross-sectional survey captured a higher proportion of women with endometriosis and fertility difficulties than are found in the general population. Pregnancy and birth experiences Despite the higher prevalence of infertility reported by women with endometriosis in the current study, endometriosis status was not associated with having been pregnant, or having an unintended pregnancy, abortion, or live birth. However, women with endometriosis were more likely to have taken longer than 12 months to conceive their first pregnancy and to have used assisted reproductive technology (ART). In one Australian study, 20.7% of women with endometriosis had used assisted conception [6]; in the US Nurses’ Health Study II, of 83% of women with endometriosis who reported having at least one child by age 40, 15% had used ovulation induction and 2% had used IVF [5]. Estimates of ART use in our survey (8.4%) may not be as high because the related item asked only about the first pregnancy and because some participants may have been too young to have been offered or requested ART. In Australia, the average age of women undergoing an autologous ART cycle is 36 years (40.9 with donor oocytes or embryos) [31]; the average age of our respondents was about 36 years. Time to conception and ART use are likely to be influenced by the known diagnosis delay for endometriosis (an average of 5.5 years) [32]; this may also delay treatment—either for the disease or for infertility, specifically—that increases fertility, possibly until beyond a woman’s optimal reproductive period [31, 33]. There is also currently little consensus on best practice for ART use in women with endometriosis [21], suggesting the potential for diversity in practice and women’s experiences. As far as we can establish, this is the first study to have considered unintended pregnancies among women with endometriosis. Similar findings have also been reported for women reporting polycystic ovarian syndrome (PCOS) in another component of this study [34]. Although unintended pregnancy is judged to be a public health problem in many countries, including Australia, little attention has been paid to unintended pregnancy among women with chronic diseases despite evidence that they are at increased risk [35]. We speculate that misconceptions around endometriosis and infertility perpetuated by “some doctors” [12], including the promotion of fertility perseveration such as egg freezing by some clinicians [5,36]; the popular media [37]; and, anecdotally, in online patient literature, may have led some women to underestimate their fertility. (A similar observation has been made regarding PCOS [34].) Further, there is currently little guidance for clinicians as to how to provide fertility care for endometriosis that addresses women’s diverse needs, including contraception [21]. Implications for clinicians and policy-makers The results of this study demonstrate the need for women with endometriosis to receive fertility information and advice as part of standard endometriosis care. Comprehensive care needs to be tailored to each woman, considering her immediate and long-term fertility goals. Women themselves have stated a preference for this approach [10] and it has been proposed as a key component of reducing low-value care in endometriosis [38]. A reproductive life-plan template may facilitate a conversation between women and their care providers within the time constraints of modern healthcare settings [39]. Clinicians may also benefit from guidance which includes evidence-based information about what is and is not known about the association between endometriosis and infertility, and that actively dispels associated common misconceptions (e.g., pregnancy is a treatment option); this is currently absent from leading clinical guidelines (e.g., [21]). Information provided by health organisations, health professionals, and consumer organisations about endometriosis and fertility needs to be balanced and evidence-based. As the majority of women with endometriosis ultimately have children [5], it is unhelpful to women to address infertility only; this fails to reflect most women’s experiences and undermines informed decision-making to bring about optimal childbearing. Future research These results reveal several knowledge gaps which require further research. (A) Further investigation of the use of contraception by women with endometriosis, for both contraceptive and non-contraceptive purposes (such as managing symptoms), may inform appropriate resources for this sub-population of women and their unique fertility management needs. (B) It would be useful to have a more comprehensive picture of women’s perceptions of the potential effect of endometriosis on their fertility and associated decision-making. Despite the emphasis on fertility in biological research into endometriosis, few studies have considered the perspectives of women on this subject [11]. (C) Given the limited research evidence to guide practice, it would be informative to investigate doctors’ opinions of, and practice, in relation to providing care for endometriosis and fertility. (D) There is a need for methodologically sound population data on the prevalence of infertility among women with endometriosis [4,5], including its potential association with the known diagnosis delay for endometriosis (specifically, whether timing of diagnosis explains infertility risk beyond having endometriosis).

We used Australian population data to compare the fertility experiences of women with and without endometriosis. Women with endometriosis were more likely to have attempted conception, to have experienced difficulties in conceiving, and to have used ART. However, there were no differences according to endometriosis status in having been pregnant, having had a live birth, or having an unintended pregnancy. These results support the need for healthcare and information that addresses all aspects of fertility management (not just infertility) for women with endometriosis.

The authors wish to thank all respondents for their generous participation. We would also like to acknowledge the original collaborators of the larger study: Lynne Jordan, Kathy McNamee, Chris Bayly, John McBain, and Vikki Sinnott. We are grateful also to Dr Thach Tran for statistical advice. The study was funded by the Australian Research Council (LP100200432) in partnership with Family Planning Victoria, Melbourne IVF, The Royal Women’s Hospital and the Victorian Government Department of Health. KY receives a stipend scholarship from the National Health and Medical Research Council and Australian Rotary Health. JF is supported by a Monash Professorial Fellowship and the Jean Hailes Professorial Fellowship which receives funding from the L and H Hecht Trust, managed by Perpetual Trustees Pty Ltd.

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Australian Bureau of Statistics. 3412.0 - Migration, Australia, 2009-10 Canberra (ACT): ABS. 2011. Table 1: Demographic characteristics of women who did and did not report endometriosis. Endometriosis reported (n=107) Endometriosis not reported (n=1436) Total Australia Mean (SD) age (years) 37.4 (8.2) 35.8 (9.2) 35.9 (9.1) - n (%) n (%) N (%) % Aboriginal and/or Torres Strait Islander heritage 2 (1.9) 23 (1.6) 25 (1.6) 3.0a** Born in Australia 84 (78.5) 1225 (85.3) 1309 (84.8) 68.3a* Post-secondary qualification 84 (78.5) 1065 (74.3) 1149 (74.5) 56.0b* Heterosexual 103 (96.3) 1367 (95.7) 1470 (95.3) 96.3c Partnered (married or de facto) 80 (74.8) 1050 (73.1) 1130 (73.2) 52.9a* Private health insurance 76 (71.7) 962 (67.2) 1038 (67.3) 51.1d* Rural 28 (26.4) 456 (31.9) 484 (31.4) 27.5e* Note. *p < 0.001; **p = 0.002. aPopulation data for women in Australia aged 15–54 years [40–42] bPopulation data for women in Australian aged 15–64 years [43] cPopulation data for women in Australia aged 16–69 years [44] dPopulation data for persons in Australia aged 15–54 years [45] ePopulation data for persons in Australia aged 15–64 years [46] Table 2: Current contraceptive use; attempting pregnancy; and pregnancy and birth experiences by endometriosis status. Endometriosis reported (n=107) Endometriosis not reported (n=1436) χ2/t p- value/95% CI n % n % Current contraceptive use Least effectivea 25 23.4 417 29.3 1.3 0.254 Moderately effectiveb 19 17.8 320 22.3 0.9 0.332 Most effectivec 16 15.0 142 9.9 2.3 0.133 Attempting pregnancy Ever tried to become pregnant 84 79.2 941 65.9 7.3 0.007 First tried to become pregnant below age 30 60 71.4 650 69.3 0.1 0.777 Ever had fertility problems 58 69.0 301 32.0 44.8 <0.001 Ever had infertility diagnosisd 44 75.9 141 47.5 14.6 12 months to first pregnancy 7 17.9 26 4.7 9.7 0.002 Ever had unintended pregnancy 29 27.1 378 26.3 0.0 0.950 Ever had abortion 14 13.1 216 15.0 0.2 0.683 Ever had live birth 62 57.9 793 55.2 0.2 0.656 ART for first pregnancy 9 8.4 37 2.6 9.8 0.002 Note. For current contraceptive use, respondents could select more than one option. Numbers in bold indicate statistically significant differences. aWithdrawal, male condom, female condom, fertility awareness, abstinence, safe times, spermicide, herbal contraceptive, douching bDiaphragm, injection, progesterone-only pill, oral contraceptive pill, vaginal ring, emergency contraceptive pill cImplant, intrauterine device, vasectomy*, tubal ligation*, hysterectomy* *These were not given as response options but entered as text by participants specifying ‘other.’ dDue to the wording of the survey question, this could include male infertility diagnoses. Respondents to this question were those who had answered ‘yes’ to ever having fertility problems. Table 3: Factors associated with unintended pregnancy, infertility diagnosis, time to conception and live birth. 95% CI for odds ratio Independent variables Odds ratio Lower Upper Sig Unintended pregnancy Age 2.08 1.61 2.70 0.001 Aboriginal and/or Torres Strait Islander heritage 1.16 0.44 3.06 0.760 Country of birth 1.05 0.76 1.46 0.770 Sexuality 0.92 0.49 1.71 0.791 Relationship status 1.63 1.20 2.20 0.002 Education 0.84 0.64 1.12 0.212 Private health insurance 0.60 0.47 0.78 0.935 Rurality 1.16 0.90 1.50 0.273 Experienced sexual coercion 1.83 1.41 2.37 0.000 Endometriosis 1.02 0.64 1.61 0.935 Infertility diagnosis Age 1.45 0.88 2.39 0.141 Aboriginal and/or Torres Strait Islander heritage 0.00 0.00 0.00 0.999 Country of birth 1.15 0.63 2.11 0.656 Sexuality 3.48 0.34 35.2 0.291 Relationship status 0.99 0.45 2.20 0.982 Education 0.98 0.54 1.79 0.941 Private health insurance 0.99 0.60 1.66 0.965 Rurality 1.58 0.97 2.59 0.069 Experienced sexual coercion 1.13 0.70 1.84 0.618 Endometriosis 3.34 1.72 6.50 0.001 Time to conception Age 1.06 0.46 2.43 0.891 Aboriginal and/or Torres Strait Islander heritage 0.00 0.00 0.00 0.999 Country of birth 0.47 0.15 1.48 0.195 Sexuality 0.00 0.00 0.00 0.999 Relationship status 0.92 0.25 3.44 0.905 Education 3.23 0.94 11.12 0.064 Private health insurance 1.67 0.61 4.61 0.320 Rurality 0.97 0.45 2.12 0.942 Experienced sexual coercion 0.98 0.40 2.41 0.942 Endometriosis 5.63 2.12 14.94 0.001 Live birth Age 6.31 4.91 8.10 0.001 Aboriginal and/or Torres Strait Islander heritage 0.72 0.26 2.02 0.535 Country of birth 0.80 0.57 1.13 0.212 Sexuality 0.42 0.21 0.83 0.013 Relationship status 5.90 4.38 7.95 0.001 Education 1.30 0.96 1.74 0.086 Private health insurance 0.90 0.68 1.18 0.427 Rurality 1.43 1.09 1.88 0.010 Experienced sexual coercion 0.94 0.71 1.24 0.648 Endometriosis 1.12 0.70 1.79 0.630 Note. The reference category for each independent variable was the lesser or absence of the variable.