Male Factors Associated With Success Following Assisted Reproduction Technology Among Infertile Couples in Ghana

Objectives: The objective of the study was to evaluate the impact of male human papillomavirus (HPV) sexually transmitted infection on sperm parameters, embryo morphokinetics, and clinical pregnancy outcomes in assisted reproductive technology (ART) procedures. Setting: Between 2019 and 2023, 3,360 ART cycles were performed at the private IVF center MOMO’ Fertilife (Bisceglie, Italy), including 1,035 first-time cycles. Of the 787 males tested for seminal HPV, 62 tested positive. Design: A study group of 57 HPV-positive and a matched control group of 57 HPV-negative males were selected using our clinic management software. Exclusion criteria included female age ≥42, advanced endometriosis, and HPV positivity in both partners. Participants: Couples undergoing homologous ART with only the male partner testing HPV positive were included, while those with both partners positive were excluded. HPV-positive sperm was used without standard preparation, and all semen procedures followed WHO guidelines. All couples enrolled in the study provided written informed consent, which specified that spermatozoa from HPV-positive participants would be used without undergoing standard sperm preparation procedures. Methods: ICSI was the only ART procedure performed in all cycles included in this study. Semen samples were collected following 3–5 days of abstinence and analyzed within 60 min post-ejaculation. Sperm concentration, motility, and morphology were assessed using phase contrast microscopy. For ICSI procedures in both groups, a standardized “horizontal swim-up” technique developed in-house was employed, an alternative method of semen preparation for ICSI developed in our center. Following liquefaction, an aliquot of the semen sample was sent to the virology laboratory, while a duplicate was stored at −80°C. In cases of inconclusive results, reanalysis was conducted using the frozen sample. IVF laboratory personnel were blinded to HPV status. Sperm quality, the morphokinetics of 210 resulting embryos, and pregnancy outcomes were analyzed. Statistical tests included the Student’s t test, Shapiro-Wilk test, Mann-Whitney U test, and Chi-square or Fisher’s exact tests. Results: The study found no statistically significant differences in embryo morphokinetics or ART outcomes between HPV-positive and HPV-negative groups. Pregnancy rates (33.3% vs. 31.6%) and first-trimester miscarriage rates (1 case each) were comparable between the two treatment groups, which also presented similar blastocyst transfer timing and transfer of high-quality embryos. Sperm parameters showed no clinically relevant variation. Limitations: The retrospective cohort design and limited sample size represent study limitations. Furthermore, the absence of data on potentially relevant confounders constrains the analysis. Specifically, abortion rate assessment was limited to the first trimester. The lack of extended follow-up data on long-term pregnancy and neonatal outcomes further restricts the conclusions. Conclusions: Male HPV infection did not adversely affect embryo development or ART success rates. These findings suggest that routine HPV screening in male partners undergoing ART may not be necessary.

After completing this article, readers should be able to: 1. Describe the outcomes of assisted reproductive technologies (ART) for singleton, twin, and other multiple births. 2. Describe the role of fertility in adverse outcomes seen with ART births. 3. Review the association of birth defects with ART. 4. Delineate the association of disease of genomic imprinting with ART. 5. Describe the relationship between ART and the subsequent incidence of neurodevelopmental sequelae. In the 1977 ruling “Carey v. Population Services International,” the United States Supreme Court ruled that the decision to bear children is constitutionally protected. (1) Significant interest already had been shown in the development and improvements of in vitro fertilization (IVF) for infertile couples. The first human pregnancy and human birth using IVF were reported by Steptoe and Edwards in the United Kingdom. (2) Their work resulted in the first baby born via reproductive technologies, Louise Brown, born on July 25, 1978, at Oldham General Hospital in Oldham, United Kingdom. (3) She was born via a planned cesarean section, and her birthweight was 2.61 kg. The first successful viable IVF in the United States was performed by Jones and Seager-Jones in 1981 in Norfolk, Virginia. (4) Assisted reproductive technologies (ART) have seen a recent surge in popularity. The Centers for Disease Control and Prevention (CDC) reported that 122,872 cycles of ART were initiated in 2003, resulting in the delivery of 48,756 neonates, (5) accounting for approximately 1% of all neonates delivered in the United States. The percentage is higher in many countries, including Denmark, where it is estimated that 5% of all deliveries are with the assistance of ART. (6) Couples pursue ART for myriad reasons, including tubal transport factors, ovulatory dysfunction, uterine factors, endometriosis, male- and female-specific factors, and when a cause of infertility is unknown. (5) It would be very …

Background: Unexplained infertility occurs when a couple are unable to get pregnant after actively trying to conceive for any other reason than a specific diagnosis, where, despite numerous and extensive investigations, no discernable cause is identified. The microbiome across the human body is an area of growing research in recent years, and the uterine microbiome, in particular, has gathered attention, especially since the endometrial microbiome is vital in embryo implantation and plays an important role in the outcomes of pregnancy. Nonetheless, its contribution to unexplained infertility is still poorly characterized, although evidence is growing supporting a link between microbial diversity and fertility success. Objective: This study aimed to explore the composition and diversity of the endometrial microbiome in women with unexplained infertility and its potential correlations with fertility outcomes, with an emphasis on assisted reproductive technology (ART) outcomes. Filling a significant knowledge gap, the research incorporated primary data collected during an analysis of fertility and reproductive health from women attending the Baghdad Fertility and Reproductive Health Center and previous studies to assess the association of microbial diversity with ART outcomes and expand understanding of the role of microbiome in unexplained infertility. Methodology: This study included 500 women diagnosed with unexplained infertility between January 2024 and January 2025 at the Baghdad Fertility and Reproductive Health Center. Endometrial samples were collected and 16S rRNA gene sequencing used to identify the microbial bacterial species in the uterine microbiome. Alpha diversity indices: Shannon Index and Simpson Index were used to determine microbial diversity between pregnant and non-pregnant women. In addition, the relative abundance of significant pathogenic genera, including Lactobacillus, Gardnerella, and Prevotella, was compared between the groups and microbials diversity status correlated with ART reproductive outcomes including oocytes number, embryo quality and pregnancy events. Results: Pregnant women had a significantly different microbial diversity than women with no concurrent pregnancies, with the pregnant microbiome found to be more diverse. The Shannon Index and Simpson Index of pregnant women was also significantly higher than those non-pregnant women indicating that the endometrial microbiome status may play a role in successful pregnancy outcomes. Lactobacillus was more abundant in pregnant women and Gardnerella and other possible pathogens were notably higher in non-pregnant women. Highter microbial diversity significantly correlated with ART outcomes in women, including more oocytes retrieved, higher pregnancy rates, and lower miscarriage rates. Conclusion: Through the study, it is providing very strong evidence that a balanced and diverse endometrial microbiome is one essential factor for achieving successful pregnancy in women with unexplained infertility. Their results indicate that the presence of beneficial microbes such as Lactobacillus contributed to this, whereas microbial dysbiosis, defined as an overgrowth of pathogenic species (e.g. Gardnerella), is linked with poor fertility outcomes. These findings highlight the need for clinicians to consider the uterine microbiome in the diagnostics of infertility and as a target for treatment, providing a previously overlooked therapeutic target in ART procedures.

Problem/ConditionSince the first U.S. infant conceived with assisted reproductive technology (ART) was born in 1981, both the use of ART and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which eggs or embryos are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Although the majority of infants conceived through ART are singletons, women who undergo ART procedures are more likely than women who conceive naturally to deliver multiple-birth infants. Multiple births pose substantial risks for both mothers and infants, including obstetric complications, preterm delivery (<37 weeks), and low birthweight (<2,500 g) infants. This report provides state-specific information for the United States (including the District of Columbia and Puerto Rico) on ART procedures performed in 2015 and compares birth outcomes that occurred in 2015 (resulting from ART procedures performed in 2014 and 2015) with outcomes for all infants born in the United States in 2015.Period Covered2015.Description of SystemIn 1995, CDC began collecting data on ART procedures performed in fertility clinics in the United States as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (FCSRCA) (Public Law 102–493 [October 24, 1992]). Data are collected through the National ART Surveillance System, a web-based data collection system developed by CDC. This report includes data from 52 reporting areas (the 50 states, the District of Columbia, and Puerto Rico).ResultsIn 2015, a total of 182,111 ART procedures (range: 135 in Alaska to 23,198 in California) with the intent to transfer at least one embryo were performed in 464 U.S. fertility clinics and reported to CDC. These procedures resulted in 59,334 live-birth deliveries (range: 55 in Wyoming to 7,802 in California) and 71,152 infants born (range: 68 in Wyoming to 9,176 in California). Nationally, the number of ART procedures performed per 1 million women of reproductive age (15–44 years), a proxy measure of the ART utilization rate, was 2,832. ART use exceeded the national rate in 13 reporting areas (California, Connecticut, Delaware, the District of Columbia, Hawaii, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Rhode Island, and Virginia).Nationally, among ART transfer procedures in patients using fresh embryos from their own eggs, the average number of embryos transferred increased with increasing age of the woman (1.6 among women aged <35 years, 1.8 among women aged 35–37 years, and 2.3 among women aged >37 years). Among women aged <35 years, the national elective single-embryo transfer (eSET) rate was 34.7% (range: 11.3% in Puerto Rico to 88.1% in Delaware).In 2015, ART contributed to 1.7% of all infants born in the United States (range: 0.3% in Puerto Rico to 4.5% in Massachusetts). ART also contributed to 17.0% of all multiple-birth infants, 16.8% of all twin infants, and 22.2% of all triplets and higher-order infants. The percentage of multiple-birth infants was higher among infants conceived with ART (35.3%) than among all infants born in the total birth population (3.4%). Approximately 34.0% of ART-conceived infants were twins and 1.0% were triplets and higher-order infants.Nationally, infants conceived with ART contributed to 5.1% of all low birthweight infants. Among ART-conceived infants, 25.5% had low birthweight, compared with 8.1% among all infants. ART-conceived infants contributed to 5.3% of all preterm (gestational age <37 weeks) infants. The percentage of preterm births was higher among infants conceived with ART (31.2%) than among all infants born in the total birth population (9.7%). Among singletons, the percentage of ART-conceived infants who had low birthweight was 8.7% compared with 6.4% among all infants born. The percentage of ART-conceived infants who were born preterm was 13.4% among singletons compared with 7.9% among all infants.InterpretationMultiple births from ART contributed to a substantial proportion of all twins, triplets, and higher-order infants born in the United States. For women aged <35 years, who are typically considered good candidates for eSET, the national average of 1.6 embryos was transferred per ART procedure. Of the four states (Illinois, Massachusetts, New Jersey, and Rhode Island) with comprehensive mandated health insurance coverage for ART procedures (i.e., coverage for at least four cycles of IVF), three (Illinois, Massachusetts, and New Jersey) had rates of ART use exceeding 1.5 times the national rate. This type of mandated insurance coverage has been associated with greater use of ART and likely accounts for some of the difference in per capita ART use observed among states.Public Health ActionTwins account for the majority of ART-conceived multiple births. Reducing the number of embryos transferred and increasing use of eSET when clinically appropriate could help reduce multiple births and related adverse health consequences for both mothers and infants. State-based surveillance of ART might be useful for monitoring and evaluating maternal and infant health outcomes of ART in states with high ART use.

Reducing the number of embryos transferred per ART procedure and increasing use of eSET, when clinically appropriate (typically for women aged <35 years), could help reduce multiple births, particularly ART-conceived twin infants, and related adverse consequences of ART. Because twins account for the majority of ART-conceived multiple births, improved patient education and counseling on the maternal and infant health risks of having twins is needed. Although ART contributes to high rates of multiple births, other factors not investigated in this report (e.g., delayed childbearing and non-ART fertility treatments) also contribute to multiple births and warrant further study.

Assisted reproductive technology (ART) includes fertility treatments in which both eggs and sperm are handled in the laboratory (i.e., in vitro fertilization and related procedures). Patients who undergo ART procedures are more likely to deliver multiple-birth infants than women who conceive naturally. Multiple births are associated with increased risk for mothers and infants (e.g., pregnancy complications, premature delivery, low-birthweight infants, and long-term disability among infants). This report presents the most recent national data and state-specific results.2005.In 1996, CDC initiated data collection regarding ART procedures performed in the United States, as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (FCSRCA) (Public Law 102-493 [October 24, 1992]). Beginning with 2004, CDC has contracted with a statistical survey research organization, Westat, Inc., to obtain data from ART medical centers in the United States. Westat, Inc., maintains CDC's web-based data collection system called the National ART Surveillance System (NASS).In 2005, a total of 134,260 ART procedures were reported to CDC. These procedures resulted in 38,910 live-birth deliveries and 52,041 infants. Nationwide, 73% of ART procedures used freshly fertilized embryos from the patient's eggs, 15% used thawed embryos from the patient's eggs, 8% used freshly fertilized embryos from donor eggs, and 4% used thawed embryos from donor eggs. Overall, 42% of ART transfer procedures resulted in a pregnancy, and 35% resulted in a live-birth delivery (delivery of one or more live-born infants). The highest live-birth rates were observed among ART procedures that used freshly fertilized embryos from donor eggs (52%). The highest numbers of ART procedures were performed among residents of California (18,655), New York (12,032), Illinois (9,449), New Jersey (9,325), and Massachusetts (8,571). These five states also reported the highest number of live-birth deliveries. Of 52,041 infants born through ART, 49% were born in multiple-birth deliveries. The multiple-birth risk was highest for women who underwent ART transfer procedures that used freshly fertilized embryos from either donor eggs (41%) or their own eggs (32%). Approximately 1% of U.S. infants born in 2005 were conceived through ART. Those infants accounted for 17% of multiple births nationwide. Approximately 9% of ART singletons, 57% of ART twins, and 95% of ART triplets or higher-order multiples were low birthweight. Similarly, 15% of ART singletons, 66% of ART twins, and 97% of ART triplets or higher-order multiples were born preterm.Whether an ART procedure resulted in a pregnancy and live-birth delivery varied according to different patient and treatment factors. ART poses a major risk for multiple births that are associated with adverse maternal and infant outcomes (e.g., preterm delivery, low birthweight, and infant mortality). This risk varied according to the patient's age, the type of ART procedure performed, the number of embryos available for transfer to the uterus, the number actually transferred, and the day of transfer (day 3 or day 5).ART-related multiple births represent a sizable proportion of all multiple births nationwide and in selected states. To minimize the adverse maternal and child health effects that are associated with multiple pregnancies, ongoing efforts to limit the number of embryos transferred in each ART procedure should be continued and strengthened. Adverse maternal and infant outcomes (e.g., low birthweight and preterm delivery) associated with ART treatment choices should be explained fully when counseling patients who are considering ART.

IntroductionDespite the considerable progress made in assisted reproductive technologies (ART), the implantation rate of transferred embryos remains low and in many cases, the reasons for failure remain unclear. We aimed to determine the potential impact of female and male partners’ reproductive tract microbiome composition on ART outcome.Material and methodsThe ART couples (n = 97) and healthy couples (n = 12) were recruited into the study. The smaller healthy group underwent a careful selection according to their reproductive and general health criteria. Both vaginal and semen samples were subjected to 16S rDNA sequencing to reveal the bacterial diversity and identify distinct microbial community types.Ethics statementThe study was approved by the Ethics Review Committee on Human Research of Tartu University, Tartu, Estonia (protocol no. 193/T‐16) on 31 May 2010. Participation in the research was voluntary. Written informed consent was obtained from all study participants.ResultsThe men with Acinetobacter‐associated community who had children in the past, had the highest ART success rate (P < 0.05). The women with bacterial vaginosis vaginal microbiome community and with L. iners‐predominant and L. gasseri‐predominant microbiome had a lower ART success rate than women with the L. crispatus‐predominant or the mixed lactic‐acid‐bacteria‐predominant type (P < 0.05). The 15 couples where both partners had beneficial microbiome types had a superior ART success rate of 53%, when compared with the rest of the couples (25%; P = 0.023).ConclusionsMicrobiome disturbances in the genital tract of both partners tend to be associated with couple's infertility as well as lower ART success levels and may thus need attention before the ART procedure. The incorporation of genitourinary microbial screening as a part of the diagnostic evaluation process may become routine for ART patients if our results are confirmed by other studies.

Introduction: The global surge in high body mass index (BMI) and obesity has led to various health complications. While numerous studies have shown that obesity disrupts female fertility, the specific effects of obesity on the success rate of assisted reproductive technology (ART) treatments in Saudi women have been less explored. This study aimed to delve into this gap, especially focusing on the correlation between BMI, ovarian reserve parameters, and ART outcomes among Saudi women.Methods: A cross-sectional study was carried out from January to August 2023, concentrating on Saudi women aged 18 and above who underwent ART treatments for infertility. A total of 1071 women participated, with 155 completing an online survey and 916 responding through a hard copy from several Saudi hospitals. The data encompassed demographics, medical history, anthropometric details, ovarian reserve parameters, and ART results. For the analysis, Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 28.0, Armonk, NY) was utilized, applying descriptive statistics, the Chi-square test, and a linear regression model to discern connections between BMI, participant characteristics, and ART outcomes. A p-value of less than 0.05 was considered statistically significant.Results: Most participants were aged 25-34 (406) years and held a bachelor's degree (707). Over half (560) received fertility treatments in the past, with 37.9% (406) having polycystic ovary syndrome (PCOS) and 23.5% (252) with other fertility-impacting medical conditions. Interestingly, 62.1% (665) had not undergone any ART cycles. Of those who did, 51.6% (553) had clinical pregnancies leading to live births. About 23.8% (308) of those with clinical pregnancies faced miscarriages without successful live births. Furthermore, 17.6% (189) reported complications or side effects from past ART procedures, and 31.4% (336) were on ART-related medications or supplements. The linear regression highlighted that individuals with normal weight tended to undergo more ART cycles. However, those with a higher BMI exhibited increased chances of achieving clinical pregnancies and live births.Conclusion: The study underscores the crucial relationship between BMI and ART efficacy in Saudi women. The data reveals that BMI can significantly influence ART treatment outcomes, especially concerning the number of cycles, clinical pregnancies, and live births. Consequently, BMI should be an essential consideration when evaluating and optimizing the success rates of ART procedures.

Low semen quality often obligates the use of assisted reproductive technology; however, the association between semen quality and assisted reproductive technology outcomes is uncertain. To further assess the impact of semen quality on assisted reproductive technology outcomes. A retrospective cohort study was carried out at a single academic reproductive medicine center (January 2012-December 2018). Patients undergoing at least one assisted reproductive technology cycle utilizing freshly ejaculated spermatozoa from the male partner were included. We assessed the association between semen quality (as stratified based on WHO 5th edition criteria), paternal age (< or ≥40), and reproductive/perinatal outcomes. To evaluate the differences in assisted reproductive technology outcomes by semen parameters and age, generalized estimating equations were applied for rates of fertilization, pregnancy, implantation, miscarriage, live birth, blast formation, gestational age, and normal embryo biopsy. A total of 2063 couples were identified who underwent 4517 assisted reproductive technology cycles. Average ages of the male and female partners were 39.8 and 37.7, respectively. Lower pregnancy rates were observed in cycles with lower sperm motility (ie <40%; 39.9% vs 44.1%) and total motile count (ie <9 million; 38.3% vs 43.5%). When examining only cycles utilizing Intracytoplasmic Sperm Injection, only a lower motility count was associated with a decline in pregnancy rate (39.1% vs 44.9%). No association was identified between semen quality and gestational age or birth weight. Paternal age was not associated with ART outcomes. However, among assisted reproductive technology cycles in women <40, aneuploidy rate was higher for older men (P<.001). In cycles with women >40, no association between aneuploidy and male age was identified. Sperm motility is associated with pregnancy rates, while other semen parameters are not. In cycles in women <40, paternal age is associated with embryo aneuploidy rate. Paternal factors are associated with assisted reproductive technology outcomes, and future studies should explore mechanisms by which semen quality is associated with assisted reproductive technology outcomes.

The decreased rates of triplet births: Temporal trends and biologic speculations

BackgroundIt is not well established whether the increased number of leukocytes in the seminal fluid impairs the outcomes of assisted reproductive technology (ART). This investigation analysed the outcomes of the intracytoplasmic sperm injection (ICSI) and intracytoplasmic morphologically selected sperm injection (IMSI) cycles in couples in which the male partner exhibited leukocytospermia.MethodsA total of 100 cycles in 100 couples were included in this study. For the ICSI or IMSI procedures, the patients were divided into two groups according to the presence or absence of leukocytospermia and then matched by (female) age: ICSI: Group I (n = 25): Leukocytospermia - semen samples with a leukocyte count of greater than or equal to 1 × 10(6)/mL; and Group II (n = 25): Non-leukocytospermia - semen samples with a leukocyte count < 1 × 10(6)/mL. IMSI: Group I (n = 25): Leukocytospermia; and Group II (n = 25): Non-leukocytospermia.The endpoints included the rates of fertilisation, implantation, clinical pregnancy, miscarriage, ongoing pregnancy and live birth. Student’s t-tests, Mann–Whitney tests and Chi-square tests were performed, and P < 0.05 was considered significant.ResultsThe data from the ICSI groups showed that leukocytospermia did not have a negative influence on the rates of fertilisation (Group I: 57.9+/−30.2%, Group II: 61.9+/−27.7%; P = 0.74), implantation (Group I: 12.3%; Group II: 13.5%; P = 0.93), clinical pregnancy (Group I: 24%; Group II: 24%; P = 1.0), miscarriage (Group I: 0, Group II: 0), ongoing pregnancy (Group I: 24%; Group II: 24%; P = 1.0), or live births (Group I: 24%; Group II: 24%; P = 1.0). Similarly, the data from the IMSI groups also showed that the leukocytospermia did not have a negative influence on the rates of fertilisation (Group I: 67.6+/−24.6%, Group II: 59.5+/−28.1%; P = 0.36), implantation (Group I: 17.5%; Group II: 16.7%; P = 0.90), clinical pregnancy (Group I: 28%; Group II: 24%; P = 1.0), miscarriage (Group I: 14.3%; Group II: 0; P = 0.33), ongoing pregnancy (Group I: 24%; Group II: 24%; P = 1.0), or live births (Group I: 24%, 6/25; Group II: 24%, 6/25; P = 1.0).ConclusionsThe results indicate that the leukocytospermia may not have a negative effect on the outcomes of ICSI or IMSI cycles. Nevertheless, it seems that it is necessary to more precisely determine the effects, if any, of seminal leukocytes on fertilisation and implantation processes. Such efforts will help to establish a more reliable leukocyte threshold, which could eventually demonstrate whether there is a negative influence on the ART procedures.

Regulation of assisted reproductive technologies in the United States

To assess the effect on the human sex ratio at birth by assisted reproductive technology (ART) procedures. Retrospective population-based study. Fertility clinics in Australia and New Zealand. The study included 13,368 babies by 13,165 women who had a single embryo transfer (SET) between 2002 and 2006. Logistic regression was used to model the effect on the sex ratio at birth of ART characteristics [in vitro fertilisation (IVF) or intracytoplasmic sperm insemination (ICSI) SET, cleavage-stage or blastocyst SET, and fresh or thawed SET] and biological characteristics (woman's and partner's age and cause of infertility). Proportion of male births. The crude sex ratio at birth was 51.3%. Individual ART procedures had a significant effect on the sex ratio at birth. More males were born following IVF SET (53.0%) than ICSI SET (50.0%), and following blastocyst SET (54.1%) than cleavage-stage SET (49.9%). For a specific ART regimen, IVF blastocyst SET produced more males (56.1%) and ICSI cleavage-stage SET produced fewer males (48.7%). The change in the sex ratio at birth of SET babies is associated with the ART regimen. The mechanism of these effects remains unclear. Fertility clinics and patients should be aware of the bias in the sex ratio at birth when using ART procedures.

Study question How does varicocelectomy impact ejaculated sperm recovery, SRR of microdissection testicular sperm extraction (mTESE), ART outcomes, and the proportion of idiopathic NOA couples achieving pregnancy? Summary answer Varicocelectomy improved SRR and enabled ejaculated sperm recovery. While ART outcomes were unaffected, improved SRR increased the proportion of couples achieving successful pregnancy. What is known already Varicocelectomy is known to improve the SRR of mTESE and result in the recovery of ejaculated sperm in men with NOA. While these benefits are frequently reported, there is limited evidence regarding the impact of varicocelectomy on ART outcomes. In addition, few studies have systematically compared fertilization and pregnancy outcomes among patients with varicocelectomy, untreated varicoceles, and those without varicoceles, highlighting the need for further research to clarify its role in improving overall reproductive success. Study design, size, duration A retrospective analysis of 223 idiopathic NOA patients (mean age: 35.2 ± 4.5 years) treated from 2012 to 2023. Patients were grouped into varicocelectomy-performed (Group_1, n = 39), varicocele-untreated (Group_2, n = 43), and no-varicocele (Group_0, n = 141). The diagnosis of varicocele was made by male infertility specialists using ultrasound. NOA was diagnosed based on a report by Huang et al. (2018), selecting those with FSH &amp;gt;9.2 mIU/mL and right testis size &amp;lt;15 mL. Participants/materials, setting, methods Comparisons were made between groups for patient characteristics (e.g., age, testicular size, serum hormone levels), SRR, partner factors (wife’s age, AMH levels), and ART outcomes (fertilization rates, blastocyst formation rates, pregnancy rates, and live birth rates). In Group_1, mTESE was performed at least six months after varicocelectomy. Special attention was given to cases in which ejaculated sperm were recovered after varicocelectomy and their impact on avoiding invasive mTESE and subsequent ART outcomes was evaluated. Main results and the role of chance Most patient characteristics showed no significant differences between groups, except for total testosterone levels, which were significantly higher in Group_1. In Group_1, four cases showed ejaculated sperm recovery; one case experienced immediate disappearance, and sperm was successfully retrieved via mTESE. The overall SRR was significantly higher in Group_1 (38.5%, 15/39) compared to Group_2 (16.3%, 7/43) and Group_0 (22.7%, 32/141). Two cases in Group_1 discontinued treatment, while 13 cases (including 2 with ejaculated sperm) advanced to ART. In the other groups, all cases with sperm retrieval advanced to ART. Fertilization rates were highest in Group_1 (Group_1 vs Group_2 vs Group_0: 70.9% vs 47.1% vs 59.6%), while blastocyst formation rates were highest in Group_2 (45.5% vs 60.0% vs 37.6%). No significant differences were observed in good blastocyst rates (27.7% vs 30.0% vs 19.3%), GS rates (45.2%, 44.4%, 41.4%), pregnancy rates per transfer (41.9%, 44.4%, 34.2%), or miscarriage rates (7.7%, 0.0%, 28.9%). Pregnancy rates per patient undergoing ART did not differ significantly (84.6% vs 57.1% vs 71.9%). However, considering all patients excluding interrupted cases, pregnancy rates were highest in Group_1 among the three groups (29.7% vs 9.1% vs 16.3%). Limitations, reasons for caution This study’s retrospective design and small sample size limit its generalizability, particularly regarding ART and pregnancy outcomes, where case numbers are smaller. Further prospective studies with larger cohorts are needed to validate the impact of varicocelectomy on SRR, ART outcomes, and overall reproductive success. Wider implications of the findings Varicocelectomy significantly improves SRR and contributes to higher pregnancy and live birth rates among idiopathic NOA patients. These findings suggest integrating varicocelectomy into treatment strategies may benefit selected patients, reducing dependence on invasive mTESE procedures and enhancing treatment outcomes. Trial registration number No

Problem/condition Since the first U.S. infant conceived with assisted reproductive technology (ART) was born in 1981, both the use of ART and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which eggs or embryos are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Although the majority of infants conceived through ART are singletons, women who undergo ART procedures are more likely than women who conceive naturally to deliver multiple-birth infants. Multiple births pose substantial risks for both mothers and infants, including obstetric complications, preterm delivery ( Period covered 2016. Description of system In 1995, CDC began collecting data on ART procedures performed in fertility clinics in the United States as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (FCSRCA) (Public Law 102-493 [October 24, 1992]). Data are collected through the National ART Surveillance System (NASS), a web-based data collection system developed by CDC. This report includes data from 52 reporting areas (the 50 states, the District of Columbia, and Puerto Rico). Results In 2016, a total of 197,706 ART procedures (range: 162 in Wyoming to 24,030 in California) with the intent to transfer at least one embryo were performed in 463 U.S. fertility clinics and reported to CDC. These procedures resulted in 65,964 live-birth deliveries (range: 57 in Puerto Rico to 8,638 in California) and 76,892 infants born (range: 74 in Alaska to 9,885 in California). Nationally, the number of ART procedures performed per 1 million women of reproductive age (15-44 years), a proxy measure of the ART use rate, was 3,075. ART use rates exceeded the national rate in 14 reporting areas (Connecticut, Delaware, the District of Columbia, Hawaii, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Utah, and Virginia). ART use exceeded 1.5 times the national rate in nine states, including three (Illinois, Massachusetts, and New Jersey) that also had comprehensive mandated health insurance coverage for ART procedures (i.e., coverage for at least four oocyte retrievals). Nationally, among ART transfer procedures for patients using fresh embryos from their own eggs, the average number of embryos transferred increased with increasing age (1.5 among women aged 37 years). Among women aged Interpretation Multiple births from ART contributed to a substantial proportion of all twins, triplets, and higher-order infants born in the United States. For women aged 1.5 times the national average. Although other factors might influence ART use, insurance coverage for infertility treatments accounts for some of the difference in per capita ART use observed among states because most states do not mandate any coverage for ART treatment. Public health action Twins account for almost all of ART-conceived multiple births born in multiple deliveries. Reducing the number of embryos transferred and increasing use of eSET, when clinically appropriate, could help reduce multiple births and related adverse health consequences for both mothers and infants. Because multiple-birth infants are at increased risk for numerous adverse sequelae that cannot be ascertained from the data collected through NASS alone, long-term follow-up of ART infants through integration of existing maternal and infant health surveillance systems and registries with data available from NASS might be useful for monitoring adverse outcomes.