Reproductive Technology Clinic Outcome Reporting Research Articles

Development of a novel calculator to predict gonadotropin dose and oocyte yield in oocyte cryopreservation cycles.

To develop a predictive model for estimating the total dose of gonadotropins and the number mature oocytes in planned oocyte cryopreservation cycles. In this retrospective study, oocyte cryopreservation cycles recorded in the Society for Assisted Reproductive Technology Clinic Outcome Reporting System Database from 2013 to 2018 were analyzed. Bivariate copula additive models for location, scale, and shape were performed to create a predictive model for estimating total dose of gonadotropins and number of mature oocytes. A total of 15,806 oocyte cryopreservation cycles between 2013 and 2018 were included in the analysis. The average age of participants was 35.4years, the mean duration of stimulation was 11.8days, and the average number of mature oocytes retrieved was 11.8. The treatment dose increased with age, FSH levels, BMI ≥ 35kg/m2, smoking, and history of diminished ovarian reserve, while it decreased with increasing AMH, ovulatory disorder, and BMI < 25kg/m2. The number of mature oocytes retrieved was positively correlated with AMH and negatively correlated with age, FSH levels, Asian race, and diminished ovarian reserve. With a maximum gonadotropin dosage of 450IU per day for 12 ± 3days of stimulation and a tolerance level of six mature oocytes, the predictive model achieved 70% accuracy. An interactive version of the equation was created as an online tool. We developed a predictive model to estimate the total treatment dosage and the number of mature oocytes. This calculator, utilizing objective patient variables, can assist in patient counseling prior to planned oocyte cryopreservation cycles.

Do aromatase inhibitors and tamoxifen impact the number of oocytes retrieved in oocyte or embryo banking cycles?

Research QuestionDoes the number of oocytes retrieved differ in oocyte/embryo banking cycles using tamoxifen versus aromatase inhibitors versus no adjuvant medications? DesignObservational cohort study of patients 18-43 years old undergoing oocyte or embryo banking cycles between 2016 and 2018 recorded in the Society for Assisted Reproductive Technology Clinic Outcome Reporting System. ResultsAutologous fresh banking cycles from 2016-2018 (n=42,854) were analyzed in three different groups: oocyte and embryo banking cycles using aromatase inhibitors (AI, n= 2096), tamoxifen (TAM, n=58), and no adjuvant medication (NAM, n=40,700). The average age at cycle initiation was 35 and the majority of patients were nulligravid (77%) and nulliparous (92%). The number of oocytes retrieved and cryopreserved in all banking cycles was higher in the NAM group compared to the AI group (oocytes retrieved: 14.2 vs 12.6, p<.05, oocytes cryopreserved: 11.4 vs 10.3, p<.05); however, no difference in oocyte yield was observed between the AI and NAM groups in gonadotoxic treatment cycles. There was no significant difference in the number of oocytes retrieved or cryopreserved between the TAM and NAM group in all banking cycles. In the generalized linear model, the adjusted mean difference of oocytes retrieved was significantly less in the AI vs NAM group (-1.25, 95% CI: -1.7, -0.80), p <.05) in all oocyte and embryo banking cycles combined. ConclusionBanking cycles utilizing AI may compromise oocyte yield when used for non-gonadotoxic indications. Our data supports the continued use of AI for gonadotoxic treatment cycles as IVF cycle outcomes and live birth rates are comparable to those for cycles with NAM.

Perinatal outcomes of women with recurrent pregnancy loss undergoing frozen embryo transfer from the Society of Assisted Reproductive Technology database

To assess whether infants born to women with a history of recurrent pregnancy loss (RPL) have an increased risk of adverse perinatal outcomes after frozen embryo transfer (FET) compared with women without a history of infertility or RPL. Retrospective cohort study utilizing the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System database between 2014 and2020. Not applicable. Patients in the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System database who underwent their first FET resulting in live birth either with a diagnosis of RPL (cases n = 3,299) or without a history of RPL or infertility, the comparison population being tubal ligation (TL) only (n = 1,408). Not applicable. Low birthweight (<2,500 g), additional outcomes included gestational age (continuous), birthweight (continuous), preterm delivery (<37 weeks), mode of delivery, and neonatal death, defined as death before the completion of the 28th day of life. We observed no statistically significant difference in low birthweight, birthweight overall, mode of delivery, or risk of neonatal death between patients with RPL compared with women with TL who underwent their first FET, resulting in live birth. Patients with history of RPL compared with TL utilizing FET were more likely to have a later gestational age at delivery. Patients with RPL were also less likely to have a preterm delivery (imputed adjusted odds ratio, 0.75; 0.64-0.89) than the patients with TL. Furthermore, performing preimplantation genetic testing for aneuploidy (PGT-A) in both patients with RPL or TL did not impact perinatal outcomes compared with patients who did not undergo PGT-A. Patients with history of recurrent pregnancy loss do not have an increased risk of adverse perinatal outcomes when they undergo FET compared with patients without infertility or RPL. In addition, performing invitro fertilization/PGT-A in patients with RPL does not adversely impact birth outcomes of their infants.

Preimplantation genetic testing for aneuploidy is associated with reduced live birth rates in fresh but not frozen donor oocyte in vitro fertilization cycles: an analysis of 18,562 donor cycles reported to Society for Assisted Reproductive Technology Clinic Outcome Reporting System

ObjectiveTo evaluate the impact of preimplantation genetic testing for aneuploidy (PGT-A) on first transfer live birth rate (LBR) and cumulative LBR (CLBR) in donor oocyte IVF cycles. DesignRetrospective cohort study of the SART CORS database. Subjects11,348 fresh and 7,214 frozen-thawed donor oocyte IVF cycles were analyzed. ExposureThe first reported donor stimulation cycle per patient between January 1, 2014 and December 31, 2015, and all linked embryo transfer cycles between January 1, 2014 and December 31, 2016, were included in the study. Main Outcome MeasuresLBR was compared for patients using fresh and frozen-thawed donor oocytes, with or without PGT-A. Logistic regression models were adjusted for age, body mass index, gravidity, infertility etiology, and prior IVF cycles. ResultsAmong patients who had blastocysts available for transfer or PGT-A, use of PGT-A was associated with a decreased first transfer LBR (46.9 vs 53.2%, p <0.001) and CLBR (58.4 vs 66.6%, p <0.001) in fresh oocyte donor cycles compared with no PGT-A. LBR in frozen-thawed oocyte donor cycles with PGT-A were nominally higher than those without PGTA (48.3% vs. 40.5%) but were not statistically significant in multivariable logistic regression models (p=0.14). Early pregnancy loss was not significantly different with and without PGT-A. Multiple gestation, preterm birth, and low birthweight infants were all reduced with addition of PGT-A in fresh donor oocyte cycles, though these outcomes were not significantly different when comparing single embryo transfers in fresh oocyte cycles and also not significantly different among frozen-thawed donor oocyte cycles. ConclusionPGT-A in fresh oocyte donor cycles was associated with decreased LBR and CLBR, while effects on frozen-thawed oocyte donor cycles were clinically negligible. Obstetrical benefits associated with PGT-A in fresh donor cycles appear linked to increased single embryo transfer.

Intracytoplasmic sperm injection versus conventional in vitro fertilization in unexplained infertility

To compare cumulative live birth rate (CLBR) and cost-effectiveness of intracytoplasmic sperm injection (ICSI) vs. conventional invitro fertilization (cIVF). Retrospective cohort study of cycles reported to the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System. Society for Assisted Reproductive Technology (SART) member IVF clinics in the United States. Patients with unexplained infertility who underwent first autologous retrieval cycles between January 2017 and December 2019 with linked fresh and frozen embryo transfers through December2021. ICSI vs. cIVF. The primary outcome was CLBR, defined as ≤1 live birth from a retrieval cycle and all linked embryo transfers. Secondary outcomes included two pronuclear (2PN) per oocyte retrieved, miscarriage rate, and total number of transferred or frozen embryos per 2PN. Subsamples with and without preimplantation genetic testing for aneuploidy (PGT-A) were analyzed. Outcomes were adjusted for age, body mass index, number of oocytes retrieved, length of follow-up, and clinic ICSI use rate. A total of 18,805 patients with unexplained infertility were included. No difference in CLBR was found among cycles without genetic testing (54.4% ICSI vs. 57.5% cIVF) and with PGT-A (47.6% ICSI vs. 51.8% cIVF). Intracytoplasmic sperm injection cycles without genetic testing had a higher miscarriage rate (16.4% vs. 14.4%) but no difference was seen in cycles with PGT-A (13.9% ICSI vs. 13.2% cIVF). Intracytoplasmic sperm injection cycles had a significantly lower ratio of 2PN per oocyte retrieved without genetic testing (59.7% vs. 60.9%) and with PGT-A (63.3% vs. 65.8%). The ratio of embryos transferred or frozen per 2PN was not significantly different in cycles without genetic testing (49.4% vs. 49.6%) or with PGT-A (54.2% vs. 55.2%). Total fertilization failure occurred in 216 patients (4%) who underwent cIVF and in 153 patients (1.1%) who used ICSI.Compared with cIVF alone, an estimated additional $11,011,500 was charged to patients for ICSI without genetic testing and $9,010,500 was charged to patients for ICSI with PGT-A over 2 years by Society for Assisted Reproductive Technology clinics. On the basis of total fertilization failure rates, 35 patients would require treatment with routine ICSI to avoid a single cycle of total fertilization failure with cIVF. Routine use of ICSI in unexplained infertility is not warranted due to the additional cost and lack of CLBR benefit.

Protocol change improves live birth and recurrent cycle cancellation rates after a previous IVF cycle cancellation: an analysis of 13000 autologous cycles reported to SART CORS.

After an IVF cycle cancellation, does changing the stimulation protocol affect the odds of live birth and recurrent cancellation in the subsequent cycle? After IVF cycle cancellation, compared to those who repeated the same stimulation protocol, those who changed their protocol had higher odds of live birth and lower odds of recurrent cycle cancellation. There is limited data addressing the effect of changing the stimulation protocol after an IVF cycle is cancelled during initial stimulation. The odds of live birth outcomes are not known so far in studies addressing the effect of changing the protocol. Retrospective Cohort Study using the 2014-2017 Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) database. The data included 13135 patients with a first autologous IVF cycle that resulted in a cycle cancellation and was followed by a second autologous cycle within the study period. We excluded fertility preservation cycles, supernumerary cycle attempts after the second IVF cycle attempt, and cycles with more than one stimulation protocol documented per cycle start. Patients who received the same protocol for both cycles (n = 6434) were compared to those who changed their protocol in the second cycle (n = 6701). Multivariable logistic regression analyses were performed to estimate the adjusted odds of live birth and recurrent cancellation. Changing the protocol in the second cycle resulted 14% lower odds of recurrent cycle cancellation (P = 0.01) and 17% higher odds of live birth after fresh transfers (P = 0.04). When stratifying the data by specific combinations of protocol change (agonist flare, agonist suppression, antagonist), there was an increase in live birth when switching from antagonist to agonist suppression (odds ratio (OR) = 1.36, P = 0.03) and from agonist suppression to antagonist (OR = 1.73, P = 0.01) compared to those who repeated their same stimulation protocol. Specifically in poor responders, outcomes were worse when using the agonist flare protocol and significantly improved with the agonist suppression protocol. Comparison of response to stimulation between first and second cycles cannot be made in this study because the index IVF cycle was cancelled during ovarian stimulation, and thus there is no reportable outcome data for that cycle. Additionally, SART only tracks the three stimulation protocols addressed in this study and does not have data on more contemporary protocols that are used in poor responders thus limiting the generalizability of our findings. Using the SART CORS database, which includes >90% of all reported IVF cycles in the USA, provides generalizability to the demographically diverse IVF populations found here. In agreement with prior studies assessing change in IVF protocols, the agonist flare protocol seems to result in worse IVF outcomes, and based on our results, we believe that there is no role for the agonist flare protocol in patients with a prior poor response to stimulation. None declared. N/A.

Gestational carrier cycles: embryology trends, national guideline compliance, and resultant perinatal outcomes in the United States, 2014–2020

The increased use of gestational carriers has expanded family-building opportunities for people and couples unable to carry pregnancies on their own. National American Society of Reproductive Medicine guidelines for gestational carriers have changed over time to reflect advances in reproductive technology and mounting evidence supporting the medical benefits associated with singleton gestations. Assess changes in gestational carrier cycle practice patterns and resultant pregnancy outcomes in the United States in relation to changing national American Society of Reproductive Medicine guidelines, which changed in 2013 and2017. This retrospective study used data from the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System and included all cycles that were reported from 2014-2020 involving an embryo transfer to a gestational carrier. Binomial regression models evaluated trends in preimplantation genetic testing for aneuploidy, American Society of Reproductive Medicine guideline adherence, number of embryos transferred, and pregnancy outcomes over time. Of the 40,177 gestational carrier transfer cycles from 2014-2020, there was a significant increase in frozen-thawed cycles (41.3% increase), use of assisted hatching (53.4% increase), intracytoplasmic sperm injection (50.0% increase), and preimplantation genetic testing for aneuploidy (155.7% increase). The likelihood of preimplantation genetic testing for aneuploidy was higher in 2020 than in 2014 for autologous oocyte transfers to gestational carriers, both for those aged ≥38 years (adjusted relative risk, 2.38 [95% confidence interval, 2.11-2.70]) and than those aged <38 years (adjusted relative risk, 2.85 [95% confidence interval, 2.58-3.15]). As preimplantation genetic testing for aneuploidy usage increased, single embryo transfer rose for both autologous (adjusted relative risk, 2.22 [95% confidence interval, 1.94-2.50]) and donor cycles (relative risk, 1.91 [95% confidence interval, 1.81-2.02]). This shift toward single embryo transfer corresponded with a decrease in multiple embryo transfer by 79.2% and subsequent decreases in multiple gestations by 68.8% in donor and 73.6% in autologous oocyte cycles from 2014-2020. Gestational carrier cycles remained highly adherent to changing American Society of Reproductive Medicine guidelines throughout the study period. Among live births, there was a 19.4% and 7.9% increase in term deliveries among donor and autologous oocyte cycles, respectively, from 2014 to2020. Practice patterns have drastically changed throughout the study period, with major increases in the use of preimplantation genetic testing for aneuploidy, intracytoplasmic sperm injection, assisted hatching, and frozen transfers. In response to changing American Society of Reproductive Medicine guidelines, the use of multiple embryo transfers has decreased for gestational carrier cycles with subsequent decreases in multiple gestations and miscarriages and slight increases in live birth rates.

An investigation of racial and ethnic disparities in donor sperm availability in the United States

To determine whether the racial and ethnic distribution of sperm donors contributing to US sperm banks differs from the demographics of the US population and those of US donor sperm recipients undergoing treatment with invitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). Cross-sectional study. United States donor sperm banks, US Census, and fertility clinics reporting to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System. Sperm donors from 18 banks, men aged 18-39 years on the basis of the 2021 Census Current Population Survey, and recipients of donor sperm for IVF and ICSI treatments in clinics reporting to the Assisted Reproductive Technology Clinic Outcome Reporting System from January 1, 2018, to December 31, 2020. None. Proportions of sperm donors and donor sperm recipients undergoing IVF and ICSI treatments identifying as each racial and ethnic group. Eighteen donor sperm banks were identified, encompassing 1,503 donors. Of these donors, 60.9% identified as White compared with 55.1% of the US male population and 67.7% of donor sperm recipients. Proportions of donors identifying as Asian or 2 or more races were larger than those of US men and donor sperm recipients (Asian: 18.6% vs. 6.5%, and 18.6% vs. 10.2%; 2 or more races: 11.6% vs. 2.2%, and 11.6% vs. 1.7%). In contrast, Black donors were underrepresented when compared with the US population of men and donor sperm recipients (2.8% vs. 12.9% and 2.8% vs. 13.0%). Hispanic donors were underrepresented when compared with the US population of men (6.0% vs. 22.2%). The percentages of Hispanic sperm donors and donor sperm recipients were similar (6.0% vs. 7.0%). The racial and ethnic distribution of sperm donors differs significantly from the demographics of the US male population and donor sperm recipients undergoing IVF and ICSI treatments. These findings suggest a need for targeted recruitment efforts for Black sperm donors.

Assessment of a Decade of Change in U.S. Assisted Reproductive Technology Cumulative Live-Birth Rates: 2004-2009 Compared With 2014-2020.

To assess the effects of demographic shifts, changes in contemporaneous clinical practices, and technologic innovation on assisted reproductive technology (ART) success rates by conducting an analysis of cumulative live-birth rates across different time periods, age groups, and infertility diagnoses. We conducted a retrospective cohort study of autologous linked cycles comparing cumulative live-birth rates over successive cycles from patients undergoing their first retrieval between 2014 and 2019 in the SART CORS (Society for Assisted Reproductive Technology Clinic Outcome Reporting System) database. All cycles reported for these individuals up to 2020 were included for analysis. We compared cumulative live-birth rates stratified by age and infertility cause with published data from the 2004-2009 SART CORS database. From 2014 to 2019, 447,042 patients underwent their first autologous index retrieval, resulting in 1,007,374 cycles and 252,215 live births over the period of 2014 to 2020. In contrast, between 2004 and 2008, 246,740 patients underwent 471,208 cycles, resulting in 140,859 births by 2009. Noteworthy shifts in demographics were observed, with an increase in people of color seeking reproductive technology (57.9% vs 51.7%, P <.001). There was also an increase in patients with diminished ovarian reserve and ovulatory disorders and a decrease in endometriosis, tubal, and male factor infertility ( P <.001). Previously associated with decreased odds of live birth, frozen embryo transfer and preimplantation genetic testing showed increased odds in 2014-2020. Preimplantation genetic testing rose from 3.4% to 36.0% and was associated with a lower cumulative live-birth rate for those younger than age 35 years ( P <.001) but a higher cumulative live-birth rate for those aged 35 years or older ( P <.001). Comparing 2014-2020 with 2004-2009 shows that the overall cumulative live-birth rate improved for patients aged 35 years or older and for all infertility diagnoses except ovulatory disorders ( P <.001). This analysis provides insights into the changing landscape of ART treatments in the United States over the past two decades. The observed shifts in demographics, clinical practices, and technology highlight the dynamic nature of an evolving field of reproductive medicine. These findings may offer insight for clinicians to consider in counseling patients and to inform future research endeavors in the field of ART.

U.S. Gestational Carrier Embryo Transfer Trends, 2014–2020 [ID 2683526

INTRODUCTION: Multiple embryo transfers (METs) are common among gestational carriers (GCs) despite increased obstetric risks of multiple gestations and strong recommendations from American Society for Reproductive Medicine (ASRM) for single-embryo transfers. This study assessed GC embryo transfer trends from 2014–2020 to evaluate compliance with national guidelines. METHODS: This retrospective, population-based cohort study used data from the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System. All cycles from 2014 to 2020 involving an embryo transfer to a GC were analyzed. The number of GC embryo transfers, use of preimplantation genetic testing (PGT), and outcome (singleton versus multiple gestation) were assessed. Poisson and linear regression models evaluated trends in number and proportion of cycles over time. Institutional review board approval was obtained. RESULTS: Of the 40,177 GC transfer cycles from 2014 to 2020, 11,081 (27.6%) involved transfer of two or more embryos. Both the number (n=2,001 in 2014; n=814 in 2020) and proportion of METs (56.6% of all transfers in 2014; 11.8% in 2020) (P&lt;.05 for both) decreased. The use of PGT among MET GC cycles increased from 23.9% in 2014 to 61.4% in 2020. Among live births, there was a 71.0% reduction in the proportion of multiple gestations from 2014 (25.5%) to 2020 (7.4%) (P&lt;.05). Among double-embryo transfers, the majority were performed at the blastocyst stage with an increase from 2014 (76.7%) to 2020 (88.1%) (P&lt;.05). CONCLUSION: With increased use of PGT and extended blastocyst culture, MET and subsequent multiple gestation pregnancies have decreased amongst U.S. GCs. These trends suggest increased compliance with ASRM national guidelines.

Psychosocial outcomes of children born via embryo donation.

What are parents' perceptions of their relationships with and the psychosocial adjustments of their children who are born via embryo donation? Families created through embryo donation have well-adjusted parent-child relationships and reassuring child psychosocial outcomes. Embryo donation is an effective and growing form of third-party reproduction, but there is limited research in this field. Prior studies suggest that families created through gamete donation function well regarding parent-child relationship quality and child behavioral and socioemotional adjustment. This is a cross-sectional survey study with 187 total participants. Parents of children born via embryo donation were recruited nationally by contacting all embryo donation programs registered with the Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) as well as medically directed embryo donation or 'embryo adoption' centers. Participants completed three online Qualtrics questionnaires. The first was a survey including 33 questions on demographics, the procurement process, and self-reported obstetric outcomes. Participants also completed two standardized measures assessing children's behavior and parents' adjustment to parenthood: the Strengths and Difficulties Questionnaire (SDQ) and the Parental Acceptance-Rejection Questionnaire (PARQ). Scoring of the SDQ and PARQ was totaled and compared to standardized values (SDQ) or previously published results on other forms of gamete donation (PARQ), such as oocyte donation and sperm donation. On the SDQ (n = 46), the average total difficulties scores by age were: 8.2 ± 0.98 for ages 2-4, 7.6 ± 0.93 for ages 5-10, and 3.5 ± 0.77 for ages 11-17; this is compared to the normal reported range of 0-13, which indicates that clinically significant psychosocial problems are unlikely. Across all ages and individual categories (emotional symptoms, conduct problem, hyperactivity, peer problem, prosocial), scores on the SDQ were within the normal ranges. The average PARQ score (n = 70) for all respondents was 27.5 ± 1.18 (range: 24-96), suggesting perceived parental acceptance. Because this study was cross-sectional, it could not capture familial relationships over time. This survey-based study design allows for potential selection bias (parents of well-adjusted children may be more likely to participate). Additionally, the overall sample size is relatively small; however, it remains one of the largest published to date. Another significant limitation to this study is the lack of generalizability: most participants were recruited from private, faith-based, embryo donation programs who are demographically similar. Though embryo donation is an established form of third-party reproduction, it is significantly less robustly studied compared to other forms of gamete donation (oocyte or sperm donation). This study provides a larger data set with a more expanded age range of children compared to the limited number of previously published studies. Furthermore, these findings indicate a high parental disclosure rate with respect to the use of embryo donation which contrasts previous findings. No external funding source was utilized for the completion of this study. No conflicts are disclosed. N/A.

Similar pregnancy outcomes from fresh and frozen donor oocytes transferred to gestational carriers: a SART database analysis isolating the effects of oocyte vitrification.

This work aimed to study clinical and neonatal outcomes of embryos derived from frozen compared to fresh donor oocytes in gestational carrier cycles. This is a retrospective cohort study using the Society for Assisted Reproductive Technology Clinic Outcome Reporting System database between 2014 and 2015, comprising of 1284 fresh transfer cycles to gestational carrier recipients of embryos resulting from fresh (n = 1119) and vitrified/thawed (n = 165) donor oocytes. Models were adjusted for gestational carrier age, preimplantation genetic testing (PGT-A), number of embryos transferred, multiple gestation, and fetal heart reduction. As our models were part of a larger analysis, intended parent BMI, smoking status, and parity were also adjusted for, but did not influence outcomes in this analysis. There was no significant difference in probability of live birth rates when comparing embryos derived from fresh and frozen donor oocytes in gestational carrier cycles. There were also no significant differences in biochemical pregnancy losses or clinical miscarriage. There were no significant differences noted in low birthweight or high birthweight infants derived from fresh versus frozen donor oocyte after transfer into a gestational carrier. The analysis of fresh and frozen donor oocytes in gestational carrier cycles provides the opportunity to assess for a possible effect of vitrification on the oocyte by controlling for differences in the uterine environment. We observed no significant differences in live birth, pregnancy loss, low birthweight or high birthweight infants when comparing fresh and frozen donor oocytes in gestational carrier cycles.

International gestational surrogacy in the United States, 2014–2020

To describe characteristics, trends, and outcomes of international gestational surrogacy cycles in the United States (US). Retrospective cohort study. All assisted reproductive technology cycles in the US reported to the Society for Assisted Reproductive Technology Clinic Outcome Reporting Systems that included an embryo transfer to a gestational carrier from 2014 to2020. International vs. US intended parents. Cycle characteristics, geographic distributions, and obstetrical outcomes. Of 40,177 embryo transfers to a gestational carrier from 2014 to 2020, 32% were for international intended parents. The number and percent of international intended parents' gestational carrier cycles increased each year from 2014 (n = 2758, 22.0%) to 2019 (n = 4905, 39.8%) with a decrease in 2020 (n = 4713, 31.8%). Compared with cycles for US intended parents, there was a larger decrease in gestational carrier cycles between 2019 and 2020 for international intended parents (3.9% vs. 32.2%). International intended parents were more likely to be male sex (41.3% vs. 19.6%), older than 42 years (33.9% vs. 26.2%) and identify as Asian race (65.6% vs. 16.5%). International intended parents were largely from China (41.7%), followed by France (9.2%) and Spain (8.5%). Gestational carriers for international intended parents were more commonly younger than 30 years (42.8% vs. 29.1%) and identified as Hispanic race (28.6% vs. 11.7%) compared with gestational carriers for US intended parents. Cycles with international intended parents were more likely to use donor eggs (67.1% vs. 43.5%), intracytoplasmic sperm injection (72.8% vs. 55.4%), and preimplantation genetic testing (79.0% vs. 55.8%). Cycles with international and US intended parents had similar obstetrical outcomes, including live birth (adjusted risk ratio 1.01, 95% confidence interval 1.00-1.03) and multiple pregnancy (adjusted risk ratio 1.00, 95% confidence interval 0.94-1.06) rates. An increasing number of international intended parents are utilizing gestational surrogacy in the US and more frequently using cost-enhancing specialized treatment techniques. This increase is potentially because of restrictive international commercial surrogacy laws and the increased availability of reproductive medical expertise. Given this growing demographic, continued examination of the volume of cross-border reproductive treatment, as well as the legal and ethical considerations, is warranted.

Higher live birth rates are associated with a normal body mass index in preimplantation genetic testing for aneuploidy frozen embryo transfer cycles: a Society for Assisted Reproductive Technology Clinic Outcome Reporting System study

To determine whether body mass index (BMI) was associated with live birth in patients undergoing transfer of frozen-thawed preimplantation genetic testing for aneuploidy (PGT-A) embryos. Retrospective cohort study of cycles reported to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System. All autologous and donor recipient PGT-A-tested cycles reported to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System from 2014 to2017. Body mass index. The primary outcome measure was the live birth rate, and the secondary outcome measures were the clinical pregnancy and biochemical pregnancy rates. Multivariable generalized additive mixed models and log-binomial models were used to model the relationship between BMI and outcome measures. A total of 77,018 PGT-A cycles from 55,888 patients were analyzed. Of these cycles, 70,752 were autologous, and 6,266 were donor recipient. In autologous cycles, a statistically significant and clear nonlinear relationship was observed between the BMI and live birth rates, with the highest birth rates observed for the BMI range of 23-24.99 kg/m2. When using 23-24.99 kg/m2 as the referent, other BMI ranges demonstrated a lower probability of live birth and clinical pregnancy that continued to decrease as the BMI moved further from the reference value. Patients with a BMI of <18.5 kg/m2 had a 11% lower probability of live birth, whereas those with a BMI of ≥40 kg/m2 had a 27% lower probability than the referent. A normal-weight BMI range of 23-24.99 kg/m2 was associated with the highest probability of clinical pregnancy and live birth after a frozen-thawed PGT-A-tested blastocyst transfer in both autologous and donor recipient cycles. A BMI outside the range of 23-24.99 kg/m2 is likely associated with a malfunction in the implantation process, which is presumed to be related to a uterine factor and not an oocyte factor, as both autologous and donor recipient cycle outcomes were associated similarly with the BMI of the intended parent.

Frozen autologous and donor oocytes are associated with differences in clinical and neonatal outcomes compared with fresh oocytes: a Society for Assisted Reproductive Technology Clinic Outcome Reporting System Analysis

Frozen autologous and donor oocytes are associated with differences in clinical and neonatal outcomes compared with fresh oocytes: a Society for Assisted Reproductive Technology Clinic Outcome Reporting System Analysis

Obstetric and Neonatal Outcomes After Transferring More Than One Embryo in Patients With Preimplantation Genetic Testing.

To compare obstetric and neonatal outcomes after single embryo transfer (SET) compared with multiple embryo transfer (MET) from frozen-thawed transfer cycles of embryos that underwent preimplantation genetic testing for aneuploidies (PGT-A). We conducted a retrospective cohort study from the SART CORS (Society for Assisted Reproductive Technology Clinic Outcome Reporting System) national database. Clinical and demographic data were obtained from the SART CORS database for all autologous and donor egg frozen-thawed transfer cycles of embryos that underwent PGT-A between 2014 and 2016, after excluding cycles that used frozen oocytes, fresh embryo transfer, and transfers of embryos from more than one stimulation cycle. Multivariable linear and log-binomial regression models were used to estimate the relative and absolute difference in live-birth rate, multiple pregnancy rate, gestational age at delivery, and birth weight between SET compared with MET. In total, 15,638 autologous egg transfer cycles and 944 donor egg transfer cycles were analyzed. Although the live-birth rate was higher with MET compared with SET in the autologous oocyte cycles (64.7% vs 53.2%, relative risk [RR] 1.24, 95% CI, 1.20-1.28), the multiple pregnancy rate was markedly greater (46.2% vs 1.4%, RR 32.56, 95% CI, 26.55-39.92). Donor oocyte cycles showed similar trends with an increased live-birth rate (62.0% vs 49.7%, RR 1.26, 95% CI, 1.11-1.46) and multiple pregnancy rate (54.0% vs 0.8%) seen with MET compared with SET. Preterm delivery rates and rates of low birth weight were significantly higher in MET compared with SET in both autologous and donor oocyte cycles and were also higher in the subanalysis of singleton deliveries that resulted from MET compared with SET. Despite some improvement in live-birth rate, nearly half of the pregnancies that resulted from MET of embryos that underwent PGT-A were multiples. Compared with SET, MET is associated with significantly higher rates of neonatal morbidity, including preterm delivery and low birth weight. The transfer of more than one embryo that underwent PGT-A should continue to be strongly discouraged, and patients should be counseled on the significant potential for adverse outcomes.

Comparing reproductive outcomes between conventional in vitro fertilization and nonindicated intracytoplasmic sperm injection in autologous embryo transfer cycles: a Society for Assisted Reproductive Technology Clinic Outcome Reporting System Study

ObjectiveTo compare clinical outcomes between non-indicated ICSI and conventional insemination. DesignAutologous cycles performed at SART member clinics from 2014-2017 were identified, excluding frozen oocyte cycles. Outcomes conventional insemination (IVF) or non-indicated ICSI were analyzed separately for fresh, frozen-thawed pre-implantation genetic testing (PGT) and frozen-thawed non-PGT cycles. Subjects187,520 patients underwent 318,930 cycles, 57,516 (18.0%) using conventional IVF and 261,414 ICSI (82.0%). ExposureICSI, with or without indications [male factor, prior fertilization failure or any PGT (2012 recommendations)/single-gene PGT (2020 recommendations)]. Main Outcome MeasuresOdds ratios (ORs) for live birth rates and clinical pregnancy rates were calculated after multivariable adjustment for maternal age, BMI, infertility etiologies, prior IVF births and number oocytes retrieved. ResultsICSI was indicated in 151,627 (58.0%) of cycles according to 2012 ASRM Practice Committee recommendations, and 108,895 (41.7%) according to 2020 recommendations.In multivariable models, non-indicated ICSI among fresh cycles was associated with reduced odds of completing a blastocyst-stage transfer (OR 0.72, 95% CI (0.7, 0.75), p<0.001), resulting in reduced odds of live birth (OR 0.80, 95% CI (0.78,0.83), p<0.001). Among completed fresh transfers, clinical pregnancy and live birth rates were comparable between non-indicated ICSI and IVF.Non-indicated ICSI in frozen-thawed cycles with PGT and without PGT was associated with comparable live birth and clinical pregnancy rates to IVF in multivariable models. ConclusionNon-indicated ICSI was associated with reduced blastocyst availability in fresh cycles compared with IVF, leading to lower live birth rates. Outcomes from completed transfers were clinically comparable.

Cumulative live birth rates with autologous oocytes plateau with fewer number of cycles for each year of age > 42

ObjectiveTo disaggregate the Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) age category of “ > 42” and compare age-stratified cumulative live birth rates (CLBR) > 42 years old.DesignRetrospective cohort study of autologous linked ART cycles.SettingUnited States (US) National ART Database.Patient(s)Women > 42 years old without a history of prior ART cycles who underwent ART between 2014–2020 as reported to the SART CORS database.Intervention(s)Disaggregate the SART CORS age category of “ > 42” into age-stratified cumulative live birth rates (CLBR).Main Outcome Measure(s)Age-stratified cumulative live birth rates (CLBR) for women ≥ 43 years old.ResultsBetween 2014–2020, 24,650 women > 42 years old without history of prior ART underwent 58,132 cycles, resulting in 1,982 live births. Women ages 43, 44, 45, 46, 47, 48, 49, ≥ 50 achieved maximal CLBR of 9.7%, 8.6%, 5.0%, 3.6%, 2.5%, 1.5%, 2.7%, 1.3%, respectively. CLBR for women between 43–45 were significantly higher compared to those 46 and older (p < 0.05). Among women 46 and older, CLBR were not significantly different. Women ages 43 and 44 did not exhibit a significant increase in CLBR beyond the 5th cycle. Age 45 and 46 reached CLBR plateau by the 3rd cycle. Age ≥ 47 CLBR plateaued after the first cycle. After adjusting for age, race/ethnicity, BMI, nulliparity, etiology of infertility, number of oocytes retrieved, embryos transferred, blastocyst transfer, use of ICSI, PGT, and ART treatment cycle number, there was no association between markers of ovarian reserve (day 3 FSH and random AMH levels) and live birth for women > 42.ConclusionsWhile CLBR of autologous cycles from women 42 or younger generally plateau by cycle number 5, age-stratified cycles from women > 42 plateau after fewer cycles to maximize CLBR. Patient and physician expectations for maximum CLBR beyond 42 may be practically based on fewer planned cycles before reaching an age-specific CLBR plateau than may have been previously expected.

Assisted reproductive technology use and outcomes in childhood cancer survivors.

Treatment exposures for childhood cancer reduce ovarian reserve. However, the success of assisted reproductive technology (ART) among female survivors is not well established. Five-year survivors of childhood cancer in the Childhood Cancer Survivor Study were linked to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System, which captures national ART outcomes. The authors assessed the live birth rate, the relative risk (RR) with 95% confidence intervals (95% CIs), and associations with treatment exposure using generalized estimating equations to account for multiple ovarian stimulations per individual. Siblings from a random sample of survivors were recruited to serve as a comparison group. Among 9885 female survivors, 137 (1.4%; median age at diagnosis, 10years [range, 0-20 years]; median years of follow-up after age 18 years, 11years [range, 2-11 years]) underwent 224 ovarian stimulations using autologous or donor eggs and/or gestational carriers (157 autologous ovarian stimulation cycles, 67 donor ovarian stimulation cycles). In siblings, 33 (1.4%) underwent 51 autologous or donor ovarian stimulations. Of those who used embryos from autologous eggs without using gestational carriers, 97 survivors underwent 155 stimulations, resulting in 49 live births, for a 31.6% chance of live birth per ovarian stimulation (vs. 38.3% for siblings; p=.39) and a 43.9% chance of live birth per transfer (vs. 50.0%; p=.33). Prior treatment with cranial radiation therapy (RR, 0.44; 95% CI, 0.20-0.97) and pelvic radiation therapy (RR, 0.33; 95% CI, 0.15-0.73) resulted in a reduced chance of live birth compared with siblings. The likelihood of live birth after ART treatment in survivors was not affected by alkylator exposure (cyclophosphamide-equivalent dose, ≥8000mg/m2 vs. none; RR, 1.04; 95% CI, 0.52-2.05). Childhood cancer survivors are as likely to undergo treatment using ART as sibling controls. The success of ART treatment was not reduced after alkylator exposure. The results from the current study provide needed guidance on the use of ART in this population.

O-050 The impact of embryo biopsy on obstetric and neonatal outcomes

Abstract Background Preimplantation genetic testing of embryos (PGT) was performed first in 1990 to prevent the transmission of X-linked disease. Since then, the technique has improved to include couples who are both carriers of the same autosomal recessive disorder, to those with balanced translocations having recurrent pregnancy loss, and to women with advanced maternal age who are at higher risk for having aneuploid embryos. Originally, PGT involved biopsy of the polar body or of one blastomere of a cleavage stage embryo for diagnosis. The contemporary practice of PGT involves the culture of embryos to the blastocyst stage (5-7 days after fertilization), with biopsy of several trophectoderm cells that would become the placenta, transport of biopsy tissue off-site for genetic analysis, and cryopreservation of blastocysts until biopsy results are available. A single euploid embryo is then transferred into the uterus as a frozen embryo transfer. Objective We sought to determine if removal of these cells for preimplantation genetic testing was associated with adverse obstetrical or neonatal outcomes after frozen-thawed single embryo transfer compared to frozen-thawed single embryo transfer without biopsy. Further, we review other studies of contemporary practice of PGT to draw conclusions about the safety of the practice. Study design We linked assisted reproductive technology surveillance data from the Society for Assisted Reproductive Technology Clinic Outcome Reporting System to birth certificates and maternal and neonatal hospitalization discharge diagnoses in Massachusetts, USA, from 2014-2017, considering singleton births after frozen-thawed single embryo transfer. We compared outcomes of cycles having embryo biopsy (n = 585) to those having no biopsy (n = 2,191), adjusting for mother’s age, race, education, parity, body mass index, birth year, insurance, and all infertility diagnoses (Sites CK et al, Am J Obstet Gynecol 2021;225:285.e1-7). Results With no biopsy used as the reference, we found no differences between no biopsy and biopsy groups with respect to preeclampsia, pregnancy-induced hypertension, placental disorders (placental abruption, placenta previa, placenta accreta, placenta increta, and placenta percreta), preterm birth, low birthweight, cesarean delivery, gestational diabetes mellitus, or maternal or infant length of stay after delivery. Comparing our outcomes to 4 other studies of contemporary PGT practice of frozen-thawed embryo transfers (Zhang WY Fertil Steril 2019, Li M Am J Obstet Gynecol 2020, Makhijani R Hum Reprod 2021, He H Fertil Steril 2019), our data are consistent with no effect of biopsy on low birth weight, pregnancy-induced hypertension, gestational diabetes, placenta previa, and placenta accreta. A slight decrease in preterm delivery (RR 1.10, CI 1.02-1.18), slight reduction in cesarean section (RR 0.90, CI 0.82-0.99), and increase in intrauterine growth restriction (RR 1.21, CI 1.06-1.38) are reported with biopsy in a systematic review (Hou W, Fertil Steril 2021). The increase in risk for intrauterine growth restriction with biopsy was influenced by one study (Li M Am J Obstet Gynecol 2020). Conclusion Embryo biopsy of trophectoderm cells for PGT in contemporary practice appears to be safe generally with respect to maternal and neonatal outcomes. There is no clear increase in diagnoses related to placentation (preeclampsia, pregnancy-induced hypertension, placental disorders, preterm birth, low birthweight), cesarean delivery, gestational diabetes mellitus, or maternal or infant length of stay after delivery. Further study of a possible increase in intrauterine growth restriction with biopsy is indicated.