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Objective To assess national trends in the sex distribution of live-born infants in the assisted reproductive technology (ART) and general population and to identify factors correlated with offspring sex. Design Retrospective cohort study. Setting Fertility treatment centers. Patients All live-born infants included in the National Vital Statistics System and resulting from ART cycles reported to the National ART Surveillance System during 2006–14. Interventions Not applicable. Main Outcome Measure(s) Trends in the proportion of male infants in the general population and proportion of males from fresh ART cycles among all ART live-born infants and singletons after single ET. Result(s) There were 214,274 live-born infants resulting from fresh ART cycles; 53.5% (5,492/10,266) of infants resulting from PGD/PGS cycles were male, as compared with 50.6% (103,228/204,008) in the non-PGD/PGS group. Among non-PGD/PGS cycles, blastocyst transfer was positively associated with male infants (adjusted risk ratio [aRR] = 1.03; 95% confidence interval [CI], 1.02–1.04). Intracytoplasmic sperm injection was negatively associated with male infants (aRR = 0.94; 95% CI, 0.93–0.95) and for singletons after single ET (aRR = 0.93; 95% CI, 0.90–0.95), as was transfer of two embryos (aRR 0.98; 95% CI, 0.97–0.99) or three or more embryos (aRR = 0.98; 95% CI, 0.96–0.99) among all live births from cycles without PGD/PGS use. Conclusion(s) The proportion of male live-born infants among ART population did not change during 2006–14, ranging from 50.5% to 51.2%. Factors such as blastocyst transfer, intracytoplasmic sperm injection use, embryo stage, and number of embryos transferred may be associated with infant sex; further investigation is needed to understand possible underlying causes.

Objective To compare indications and trends in intracytoplasmic sperm injection (ICSI) use for in vitro fertilization (IVF) cycles among residents of states with and without insurance mandates for IVF coverage. Design Cross-sectional analysis of the National Assisted Reproductive Technology Surveillance System from 2011 to 2015 for the main outcome and from 2000 to 2015 for trends. Setting IVF cycles performed in U.S. fertility clinics. Patient(s) Fresh IVF cycles. Intervention(s) Residency in a state with an insurance mandate for IVF (n = 8 states) versus no mandate (n = 43 states, including DC). Main Outcome Measure(s) ICSI use by insurance coverage mandate status stratified by male-factor infertility diagnosis. Result(s) During 2000–2015, there were 1,356,377 fresh IVF cycles, of which 25.8% (n = 350,344) were performed for residents of states with an insurance coverage mandate for IVF. ICSI use increased significantly during 2000–2015 in states both with and without a mandate; however, for non–male-factor infertility cycles, the percentage increase in ICSI use was greater among nonmandate states (34.6% in 2000 to 73.9% in 2015) versus mandate states (39.5% in 2000 to 63.5% in 2015). For male-factor infertility cycles, this percentage increase was ∼7.3% regardless of residency in a state with an insurance mandate for IVF. From 2011 to 2015, ICSI use was lower in mandate versus nonmandate states, both for cycles with (91.5% vs. 94.5%), and without (60.3% vs. 70.9%) male-factor infertility. Conclusion(s) Mandates for IVF coverage were associated with lower ICSI use for non–male-factor infertility cycles.

To examine outcomes of singleton pregnancies conceived without assisted reproductive technology (non-ART) compared with singletons conceived with ART by elective single-embryo transfer (eSET), nonelective single-embryo transfer (non-eSET), and double-embryo transfer with the establishment of 1 (DET -1) or ≥2 (DET ≥2) early fetal heartbeats.Retrospective cohort using linked ART surveillance data and vital records from Florida, Massachusetts, Michigan, and Connecticut.Not applicable.Singleton live-born infants.None.Preterm birth (PTB37 weeks), very preterm birth (VPTB32 weeks), small for gestational age birth weight (10th percentile), low birth weight (LBW2,500 g), very low birth weight (VLBW1,500 g), 5-minute Apgar score7, and neonatal intensive care unit (NICU) admission.After controlling for maternal characteristics and employing a weighted propensity score approach, we found that singletons conceived after eSET were less likely to have a 5-minute Apgar7 (adjusted odds ratio [aOR] 0.33; 95% CI, 0.15-0.69) compared with non-ART singletons. There were no differences among outcomes between non-ART and non-eSET infants. We found that PTB, VPTB, LBW, and VLBW were more likely among DET -1 and DET ≥2 compared with non-ART infants, with the odds being higher for DET ≥2 (PTB aOR 1.58; 95% CI, 1.09-2.29; VPTB aOR 2.46; 95% CI, 1.20-5.04; LBW aOR 2.17; 95% CI, 1.24-3.79; VLBW aOR 3.67; 95% CI, 1.38-9.77).Compared with non-ART singletons, singletons born after eSET and non-eSET did not have increased risks whereas DET -1 and DET ≥2 singletons were more likely to have adverse perinatal outcomes.

Objectives To assess trends, predictors, and perinatal outcomes of ovarian hyperstimulation syndrome (OHSS) associated with in vitro fertilization (IVF) cycles in the United States. Design Retrospective cohort study using National Assisted Reproductive Technology Surveillance System (NASS) data. Setting Not applicable. Patient(s) Fresh autologous and embryo-banking cycles performed from 2000 to 2015. Interventions(s) None. Main Outcome Measure(s) OHSS, first-trimester loss, second-trimester loss, stillbirth, low birth weight, and preterm delivery. Result(s) The proportion of IVF cycles complicated by OHSS increased from 10.0 to 14.3 cases per 1,000 from 2000 to 2006, and decreased to 5.3 per 1,000 from 2006 to 2015. The risk of OHSS was highest for cycles with more than 30 oocytes retrieved (adjusted risk ratio [aRR] 3.85). OHSS was associated with a diagnosis of ovulatory disorder (aRR 2.61), tubal factor (aRR 1.14), uterine factor (aRR 1.17) and cycles resulting in pregnancy (aRR 3.12). In singleton pregnancies, OHSS was associated with increased risk of low birth weight (aRR 1.29) and preterm delivery (aRR 1.32). In twin pregnancies, OHSS was associated with an increased risk of second-trimester loss (aRR 1.81), low birth weight (aRR 1.06), and preterm delivery (aRR 1.16). Conclusion(s) Modifiable predictive factors for OHSS include number of oocytes retrieved, pregnancy following fresh embryo transfer, and the type of medication used for pituitary suppression during controlled ovarian hyperstimulation. Patients affected by OHSS had a higher risk of preterm delivery and low birth weight. Clinicians should take measures to reduce the risk of OHSS whenever possible.

Objective To determine factors associated with a positive patient experience (PPE) at fertility clinics. Design Cross-sectional study. Setting Not applicable. Patient(s) Female respondents to the FertilityIQ questionnaire ( www.fertilityiq.com ) reviewing the first or only U.S. clinic visited from July 2015 to July 2018. Intervention(s) None. Main Outcome Measure(s) PPE was defined as a score of 9 or 10 out of 10 on the question, “Would you recommend this fertility clinic to a best friend?” Examined predictors included demographics, payment details, infertility diagnoses and treatment, physician traits, and clinic operations and resources. Multiple imputation was used for missing variables. Logistic regression was used to calculate adjusted odds ratios for factors associated with PPE. Result(s) Of the 7,456 women included, 63.1% reported PPE. Pregnancy resulting from treatment was a predictor of PPE. In multivariable analysis, the strongest predictors of PPE were related to the patient-physician relationship (“feeling treated like a human rather than a number” and having a doctor with good communication skills and who set reasonable expectations). Multiple clinic-related factors were also independently associated with PPE, including satisfaction with billing, shorter wait times, and easy appointment scheduling. Conclusion(s) While pregnancy influences patients’ views of their fertility clinic experience, there are other modifiable patient, physician, and clinic factors associated with PPE. Clinics may be able to optimize patient experience and improve the quality of care that they provide by being cognizant of such factors.

Objective To compare characteristics, explore predictors, and compare assisted reproductive technology (ART) cycle, transfer, and pregnancy outcomes of autologous and donor cryopreserved oocyte cycles with fresh oocyte cycles. Design Retrospective cohort study from the National ART Surveillance System. Setting Fertility treatment centers. Patient(s) Fresh embryo cycles initiated in 2013 utilizing embryos created with fresh and cryopreserved, autologous and donor oocytes. Intervention(s) Cryopreservation of oocytes versus fresh. Main Outcomes Measure(s) Cancellation, implantation, pregnancy, miscarriage, and live birth rates per cycle, transfer, and/or pregnancy. Result(s) There was no evidence of differences in cancellation, implantation, pregnancy, miscarriage, or live birth rates between autologous fresh and cryopreserved oocyte cycles. Donor cryopreserved oocyte cycles had a decreased risk of cancellation before transfer (adjusted risk ratio [aRR] 0.74, 95% confidence interval [CI] 0.57–0.96) as well as decreased likelihood of pregnancy (aRR 0.88, 95% CI 0.81–0.95) and live birth (aRR 0.87, 95% CI 0.80–0.95); however, there was no evidence of differences in implantation, pregnancy, or live birth rates when cycles were restricted to those proceeding to transfer. Donor cryopreserved oocyte cycles proceeding to pregnancy had a decreased risk of miscarriage (aRR 0.75, 95% CI 0.58–0.97) and higher live birth rate (aRR 1.05, 95% CI 1.01–1.09) with the transfer of one embryo, but higher miscarriage rate (aRR 1.28, 95% CI 1.07–1.54) and lower live birth rate (aRR 0.95, 95% CI 0.92–0.99) with the transfer of two or more. Conclusion(s) There was no evidence of differences in ART outcomes between autologous fresh and cryopreserved oocyte cycles. There was evidence of differences in per-cycle and per-pregnancy outcomes between donor cryopreserved and fresh oocyte cycles, but not in per-transfer outcomes.

Objective To determine the effect of elective single ET (eSET) on live birth and multiple birth rates by a cycle-level and clinic-level analysis. Design Retrospective cohort study. Setting Not applicable. Patient(s) Patient ages Intervention(s) None. Main Outcome Measure(s) Clinics were divided into groups based on eSET rate for each age group and aggregate rates of live birth per ET and multiple birth per delivery were calculated. A cycle-level analysis comparing eSET and double ET (DET) live birth and multiple birth rates was also performed, stratified based on total number (2, 3, or 4+) of embryos available, embryo stage, and patient age. Result(s) There was a linear decrease in multiple birth rate with increasing eSET rate and no significant difference in clinic-level live birth rates for each age group. Cycle-level analysis found slightly higher live birth rates with double ET, but this was mainly observed in women aged 35–37 years or with four or more embryos available for transfer, and confirmed the marked reduction in multiple births with eSET. Conclusion(s) Our study showed a marked and linear reduction in multiple birth rates, and important, little to no effect on clinic-level live birth rates with increasing rates of eSET supporting the growing evidence that eSET is effective in decreasing the high multiple birth rates associated with IVF and suggests that eSET should be used more frequently than is currently practiced.

Objective To assess the characteristics of IVF cycles for which preimplantation genetic diagnosis (PGD) was used and to evaluate indications for PGD and treatment outcomes associated with this procedure as compared with cycles without PGD with the data from the U.S. National ART Surveillance System. Design Retrospective cohort study. Setting None. Patient(s) Fresh autologous cycles that involved transfer of at least one embryo at blastocyst when available. Intervention(s) None. Main Outcome Measure(s) PGD indications and age-specific reproductive outcomes. Result(s) There were a total of 97,069 non-PGD cycles and 9,833 PGD cycles: 55.6% were performed for aneuploidy screening (PGD Aneuploidy), 29.1% for other reasons (PGD Other), and 15.3% for genetic testing (PGD Genetic). In comparison to non-PGD cycles, PGD Aneuploidy cycles showed a decreased odds of miscarriage among women 35–37 years (adjusted odds ratio [aOR] 0.62; 95% CI, 0.45–0.87) and women >37 years (aOR 0.55; 95% CI, 0.43–0.70); and an increased odds of clinical pregnancy (aOR 1.18; 95% CI, 1.05–1.34), live-birth delivery (aOR 1.43; 95% CI, 1.26–1.62), and multiple-birth delivery (aOR 1.98; 95% CI, 1.52–2.57) among women >37 years. Conclusion(s) Aneuploidy screening was the most common indication for PGD. Use of PGD was not observed to be associated with an increased odds of clinical pregnancy or live birth for women 35 years, but an increased odds of a live-birth and a multiple live-birth delivery among women >37 years.

Objective To evaluate the effectiveness of intracytoplasmic sperm injection (ICSI) in improving fertilization rates compared to conventional in vitro fertilization rates (IVF) among women aged ≥38 years with a non−male factor diagnosis. Design Systematic review and meta-analysis. Setting Not applicable. Patient(s) Women aged ≥38 years with a non−male factor diagnosis receiving IVF or ICSI. Intervention(s) A systematic review of databases including PubMed and Embase was performed. Study protocol was registered at the International Prospective Register of Systematic Reviews. Studies were selected if they compared fertilization rates from ICSI with those from conventional IVF among women aged ≥38 years with a non−male factor infertility diagnosis. A random effects model was used. Meta-analysis of Observational Studies in Epidemiology guidelines were applied. Main Outcome Measure(s) Fertilization rate. Results Seven studies including 8796 retrieved oocytes (ICSI: 4,369; IVF: 4,427) with mean female age ≥38 years met the inclusion criteria. There was no significant difference in fertilization rates between ICSI and conventional IVF (relative risk [RR] 0.99, 95% confidence interval [CI] 0.93−1.06; P = .8). Heterogeneity was observed between studies (I2 = 58.2; P Conclusions No difference was found in fertilization rates between conventional IVF and ICSI. Further studies are needed to assess the impact of ICSI in this population, controlling for other indications such as preimplantation genetic testing.

Objective To evaluate assisted reproductive technology (ART) ET practices in the United States and assess the impact of these practices on multiple births, which pose health risks for both mothers and infants. Design Retrospective cohort analysis using the National ART Surveillance System data. Setting US fertility centers reporting to the National ART Surveillance System. Patient(s) Noncanceled ART cycles conducted in the United States in 2012. Intervention(s) None. Main Outcome Measure(s) Multiple birth (birth of two or more infants, at least one of whom was live-born). Result(s) Of 134,381 ART transfer cycles performed in 2012, 51,262 resulted in live births, of which 13,563 (26.5%) were multiple births: 13,123 twin and 440 triplet and higher order births. Almost half (46.1%) of these multiple births resulted from the following four cycle types: two fresh blastocyst transfers among favorable or average prognosis patients less than 35 years (1,931 and 1,341 multiple births, respectively), two fresh blastocyst transfers among donor-oocyte recipients (1,532 multiple births), and two frozen/thawed ETs among patients less than 35 years (1,452 multiple births). More than half of triplet or higher order births resulted from the transfer of two embryos (52.5% of births among fresh autologous transfers, 67.2% of births among donor-oocyte recipient transfers, and 42.9% among frozen/thawed autologous transfers). Conclusion(s) A substantial reduction of ART-related multiple (both twin and triplet or higher order) births in the United States could be achieved by single blastocyst transfers among favorable and average prognosis patients less than 35 years of age and donor-oocyte recipients.

To study cross-border reproductive care (CBRC) by assessing the frequency and nature of assisted reproductive technology (ART) care that non-U.S. residents receive in the United States.Retrospective study of ART cycles reported to the Centers for Disease Control and Prevention's National ART Surveillance System (NASS) from 2006 to 2013.Private and academic ART clinics.Patients who participated in ART cycles in the United States from 2006 to 2013.None.Frequency and trend of ART use in the U.S. by non-U.S. residents, countries of residence for non-U.S. residents, differences by residence status for specific ART treatments received, and the outcomes of these ART cycles.A total of 1,271,775 ART cycles were reported to NASS from 2006 to 2013. The percentage of ART cycles performed for non-U.S. residents increased from 1.2% (n = 1,683) in 2006 to 2.8% (n = 5,381) in 2013 (P.001), with treatment delivered to residents of 147 countries. Compared with resident cycles, non-U.S. resident cycles had higher use of oocyte donation (10.6% vs. 42.6%), gestational carriers (1.6% vs. 12.4%), and preimplantation genetic diagnosis or screening (5.3% vs. 19.1%). U.S. resident and non-U.S. resident cycles had similar embryo transfer and multiple birth rates.This analysis showed that non-U.S. resident cycles accounted for a growing share of all U.S. ART cycles and made higher use of specialized treatment techniques. This study provides important baseline data on CBRC in the U.S. and may also prove to be useful to organizations interested in improving access to fertility treatments.

Objective To determine whether assisted reproductive technology (ART) cycles involving cryopreserved-warmed embryos are associated with the development of preeclampsia. Design Retrospective cohort study. Setting IVF clinics and hospitals. Patient(s) A total of 15,937 births from ART: 9,417 singleton and 6,520 twin. Intervention(s) We used linked ART surveillance, birth certificate, and maternal hospitalization discharge data, considering resident singleton and twin births from autologous or donor eggs from 2005–2010. Main Outcome Measure(s) We compared the frequency of preeclampsia diagnosis for cryopreserved-warmed versus fresh ET and used multivariable logistic regression to adjust for confounders. Result(s) Among pregnancies conceived with autologous eggs resulting in singletons, preeclampsia was greater after cryopreserved-warmed versus fresh ET (7.51% vs. 4.29%, adjusted odds ratio=2.17 [95% CI 1.67–2.82]). Preeclampsia without and with severe features, preeclampsia with preterm delivery, and chronic hypertension with superimposed preeclampsia were more frequent after cryopreserved-warmed versus fresh ET (3.99% vs. 2.55%; 2.95% vs. 1.41%; 2.76 vs. 1.48%; and 0.95% vs. 0.43%, respectively). Among pregnancies from autologous eggs resulting in twins, the frequency of preeclampsia with severe features (9.26% vs. 5.70%) and preeclampsia with preterm delivery (14.81% vs. 11.74%) was higher after cryopreserved versus fresh transfers. Among donor egg pregnancies, rates of preeclampsia did not differ significantly between cryopreserved-warmed and fresh ET (10.78% vs. 12.13% for singletons and 28.0% vs. 25.15% for twins). Conclusion(s) Among ART pregnancies conceived using autologous eggs resulting in live births, those involving transfer of cryopreserved-warmed embryos, as compared with fresh ETs, had increased risk for preeclampsia with severe features and preeclampsia with preterm delivery.

Objective To assess trends and outcomes of assisted hatching among assisted reproductive technology (ART) cycles. Design Retrospective cohort analysis using National ART Surveillance System (NASS) data. Setting U.S. fertility centers reporting to NASS. Patient(s) Fresh autologous noncanceled ART cycles conducted from 2000–2010. Intervention(s) None. Main Outcome Measure(s) Implantation, clinical pregnancy, live-birth, miscarriage, multiple gestation. Result(s) Assisted hatching use statistically significantly increased in absolute number (from 25,724 to 35,518 cycles), percentages of day-3 (from 50.7% to 56.3%) and day-5 transfers (from 15.9% to 22.8%), and percentage of transfers among women ≥38 years (from 17.8% to 21.8%) or women with ≥2 prior ART cycles and no live birth(s) (from 4.3% to 7.4%). Both day-3 and day-5 cycles involving assisted hatching were associated with lower odds of implantation (adjusted odds ratios [aOR] 0.7 and 0.6, respectively), clinical pregnancy (aOR 0.8 and 0.7, respectively), live birth (aOR 0.8 and 0.7, respectively), and increased odds of miscarriage (aOR 1.4 and 1.4, respectively), as compared with cycles without assisted hatching. Assisted hatching was associated with lower odds of multiple gestation in day-5 cycles (aOR 0.8). In cycles for women with a "poor prognosis," the association of assisted hatching with pregnancy outcomes was not statistically significant. Conclusion(s) Assisted hatching use had an increasing trend but was not associated with improved pregnancy outcomes, even in poor-prognosis patients. Prospective studies are needed to identify the patients who may benefit from assisted hatching.

To assess trends in elective single ET and identify factors associated with a good perinatal outcome.Retrospective cohort study.Clinic-based data.A total of 886,686 fresh, nondonor cycles reported to the National Assisted Reproductive Technology Surveillance System during 1999-2010, of which 17,166 met criteria for elective single ET.None.Rates of elective single ET and good perinatal outcome (term, singleton infant with normal birth weight).In 2010, elective single ET comprised 5.6% of all fresh transfers, representing an eightfold increase since publication of first guidelines in 2004 recommending elective single ET. Compared with other ETs, elective single ETs were nearly twice as likely to result in a good perinatal outcome (37.1% vs. 18.9%, respectively). Among women using elective single ET, those aged35 and 35-37 years had a good perinatal outcome (40.2% and 32.5%, respectively). In multivariable, log-binomial analyses, factors positively associated with a good perinatal outcome included male factor infertility, day 5 ET, and having ≥3 supernumerary embryos for cryopreservation.Between 1999 and 2010, national rates of elective single ET increased. Given the frequency of good perinatal outcomes among women aged 35-37 years, guidelines for elective single ET could be expanded to include patients in this age group with favorable prognoses.

Objective To evaluate trends and reproductive outcomes of gestational surrogacy in the United States. Design Retrospective cohort study. Setting Infertility clinics. Patient(s) IVF cycles transferring at least one embryo. Intervention(s) Use of a gestational carrier. Main Outcome Measure(s) Trends in gestational carrier cycles during 1999–2013, overall and for non-U.S. residents; reproductive outcomes for gestational carrier and nongestational carrier cycles during 2009–2013, stratified by the use of donor or nondonor oocytes. Result(s) Of 2,071,984 assisted reproductive technology (ART) cycles performed during 1999–2013, 30,927 (1.9%) used a gestational carrier. The number of gestational carrier cycles increased from 727 (1.0%) in 1999 to 3,432 (2.5%) in 2013. Among gestational carrier cycles, the proportion with non-U.S. residents declined during 1999–2005 (9.5% to 3.0%) but increased during 2006–2013 (6.3% to 18.5%). Gestational carrier cycles using nondonor oocytes had higher rates of implantation (adjusted risk ratio [aRR], 1.22; 95% confidence interval [CI], 1.17–1.26), clinical pregnancy (aRR, 1.14; 95% CI, 1.10–1.19), live birth (aRR, 1.17; 95% CI, 1.12–1.21), and preterm delivery (aRR, 1.14; 95% CI, 1.05–1.23) compared with nongestational carrier cycles. When using donor oocytes, multiple birth rates were higher among gestational carrier compared with nongestational carrier cycles (aRR, 1.13; 95% CI, 1.08–1.19). Conclusion(s) Use of gestational carriers increased during 1999–2013. Gestational carrier cycles had higher rates of ART success than nongestational carrier cycles, but multiple birth and preterm delivery rates were also higher. These risks may be mitigated by transferring fewer embryos given the higher success rates among gestational carrier cycles.

Objective To compare risks of adverse perinatal outcomes between assisted reproductive technology (ART) and naturally conceived singleton births using a dual design approach. Design Discordant-sibling and conventional cross-sectional general population comparison. Setting Not applicable. Patient(s) All singleton live births, conceived naturally or via ART. Intervention(s) None. Main Outcome Measure(s) Birth weight, gestational age, low birth weight, preterm delivery, small for gestational age (SGA), low Apgar score. Result(s) A total of 32,762 (0.8%) of 3,896,242 singleton live births in the three states were conceived via ART. In 6,458 sibling pairs, ART-conceived singletons were 33 g lighter (adjusted β = −33.40, 95% confidence interval [CI], −48.60, −18.21) and born half a day sooner (β = −0.58, 95% CI, −1.02, −0.14) than singletons conceived naturally. The absolute risk of low birth weight and preterm birth was 6.8% and 9.7%, respectively, in the ART group and 4.9% and 7.9%, respectively, in the non-ART group. The odds of low birth weight were 33% higher (adjusted odds ratio [aOR] = 1.33; 95% CI, 1.13, 1.56) and 20% higher for preterm birth (aOR = 1.20; 95% CI, 1.07, 1.34). The odds of SGA and low Apgar score were not significantly different in both groups (aOR = 1.22; 95% CI, 0.88, 1.68; and aOR=0.75; 95% CI, 0.54, 1.05, respectively). Results of conventional analyses were similar, although the magnitude of risk was higher for preterm birth (aOR, 1.51; 95% CI 1.46, 1.56). Conclusion(s) Despite some inflated risks in the general population comparison, ART remained associated with an increased likelihood of low birth weight and preterm birth when underlying maternal factors were kept constant using discordant-sibling comparison.

Objective To assess treatment and pregnancy/infant-associated medical costs and birth outcomes for assisted reproductive technology (ART) cycles in a subset of patients using elective double embryo (ET) and to project the difference in costs and outcomes had the cycles instead been sequential single ETs (fresh followed by frozen if the fresh ET did not result in live birth). Design Retrospective cohort study using 2012 and 2013 data from the National ART Surveillance System. Setting Infertility treatment centers. Patient(s) Fresh, autologous double ETs performed in 2012 among ART patients younger than 35 years of age with no prior ART use who cryopreserved at least one embryo. Intervention(s) Sequential single and double ETs. Main Outcome Measure(s) Actual live birth rates and estimated ART treatment and pregnancy/infant-associated medical costs for double ET cycles started in 2012 and projected ART treatment and pregnancy/infant-associated medical costs if the double ET cycles had been performed as sequential single ETs. Result(s) The estimated total ART treatment and pregnancy/infant-associated medical costs were $580.9 million for 10,001 double ETs started in 2012. If performed as sequential single ETs, estimated costs would have decreased by $195.0 million to $386.0 million, and live birth rates would have increased from 57.7%–68.0%. Conclusion(s) Sequential single ETs, when clinically appropriate, can reduce total ART treatment and pregnancy/infant-associated medical costs by reducing multiple births without lowering live birth rates.

Objective To explore whether recently enacted infertility mandates including coverage for assisted reproductive technology (ART) treatment in New Jersey (2001) and Connecticut (2005) increased ART use, improved embryo transfer practices, and decreased multiple birth rates. Design Retrospective cohort study using data from the National ART Surveillance System. We explored trends in ART use, embryo transfer practices and birth outcomes, and compared changes in practices and outcomes during a 2-year period before and after passing the mandate between mandate and non-mandate states. Setting Not applicable. Patient(s) Cycles of ART performed in the United States between 1996 and 2013. Intervention(s) Infertility insurance mandates including coverage for ART treatment passed in New Jersey (2001) and Connecticut (2005). Main Outcome Measures(s) Number of ART cycles performed, number of embryos transferred, multiple live birth rates. Result(s) Both New Jersey and Connecticut experienced an increase in ART use greater than the non-mandate states. The mean number of embryos transferred decreased significantly in New Jersey and Connecticut; however, the magnitudes were not significantly different from non-mandate states. There was no significant change in ART birth outcomes in either mandate state except for an increase in live births in Connecticut; the magnitude was not different from non-mandate states. Conclusion(s) The infertility insurance mandates passed in New Jersey and Connecticut were associated with increased ART treatment use but not a decrease in the number of embryos transferred or the rate of multiples; however, applicability of the mandates was limited.

Background Information regarding the use of donor sperm in assisted reproductive technology, as well as subsequent treatment and perinatal outcomes, remains limited. Outcome data would aid patient counseling and clinical decision making. Objectives The objectives of the study were to report national trends in donor sperm utilization and live birth rates of donor sperm–assisted reproductive technology cycles in the United States and to compare assisted reproductive technology treatment and perinatal outcomes between cycles using donor and nondonor sperm. We hypothesize these outcomes to be comparable between donor and nondonor sperm cycles. Study Design This was a retrospective cohort study using data from all US fertility centers reporting to the Centers for Disease Control and Prevention’s National Assisted Reproductive Technology Surveillance System, accounting for ∼98% of assisted reproductive technology cycles (definition excludes intrauterine insemination). The number and percentage of assisted reproductive technology cycles using donor sperm and rates of pregnancy, live birth, preterm birth ( Results Of all banking and fresh donor and autologous oocyte assisted reproductive technology cycles performed between 1996 and 2014, 74,892 (4.4%) used donor sperm. In 2014, 7351 assisted reproductive technology cycles using donor sperm were performed, as compared with 1763 in 1996 (6.2% vs 3.8% of all cycles). Among all autologous oocyte cycles performed between 2010 and 2014, the live birth rate was lower for donor sperm (27.9%) than nondonor sperm cycles (32.5%); however, after adjustment for maternal age, donor sperm use was associated with an increased likelihood of live birth (adjusted relative risk, 1.06, 95% confidence interval, 1.01–1.10). Per transfer, there was no significant difference in live birth rates for donor vs nondonor sperm (31.9% vs 36.8%; adjusted relative risk, 1.04, 95% confidence interval, 0.998–1.09). Per singleton live birth, there was no significant difference in preterm birth (11.5% vs 11.8%; adjusted relative risk, 0.98, 95% confidence interval, 0.90–1.06); however, low birthweight delivery was slightly lower in donor sperm cycles (8.8% vs 9.4%; adjusted relative risk, 0.91, 95% confidence interval, 0.83–0.99). Conclusion Donor sperm use in assisted reproductive technology has increased in the United States, accounting for approximately 6% of all assisted reproductive technology cycles in 2014. Assisted reproductive technology treatment and perinatal outcomes were clinically similar in donor and nondonor sperm cycles.

TO THE EDITOR: We read the article ‘‘The Status of Public Reporting of Clinical Outcomes in Assisted Reproductive Technology’’ by Kushnir et al. (1) with great interest. As stewards of the National ART Surveillance System (NASS), we are always striving to improve data collection and public reporting of clinical outcomes of assisted reproduction, as required by the Fertility Clinic Success Rates and Certification Act (FCSRCA) of 1992. The article refers to the recent but increasing trend of short-term embryo banking—cycles in which all embryos are created with the intent of cryopreservation for subsequent transfer in frozen/thawed cycle(s) in the next few months—which has followed advances in cryopreservation techniques (2). Some of the potential reasons for delaying embryo transfer include embryo accumulation from several short-term embryo-banking cycles allowing a better choice of good-quality embryos, the desire to avoid potentially negative effects of stimulation on implantation/pregnancy rates and fetal development, and a need to wait for the results of preimplantation genetic screening. In contrast, long-term embryo-banking cycles are generally used for fertility preservation for patients who are undergoing gonadotoxic medical treatments or for those who wish to delay childbearing for other reasons. Although NASS is currently unable to distinguish between short-term and long-term banking cycles, we note that the total number and percentage of embryo-banking cycles in the United States has increased dramatically during recent years (Fig. 1). FIGURE 1 Number and percentage of embryo-banking cycles among all ART cycles, National ART Surveillance System (NASS), United States, 1997–2011. Because FCSRCA requires public reporting of ART success rates, embryo-banking cycles (which by definition do not result in a clinical outcome) are not shown in the national or clinic-specific pregnancy success rate tables. However, all embryo-banking cycles fit the definition of ART and thus must be reported to the CDC. Thus, we believe that the authors incorrectly assumed that embryo-banking cycles are unreported or excluded by clinics. The outcomes of all frozen/thawed embryo transfers have been publicly reported for cycles started during or after 1995, the first year that national ART surveillance began. In addition, the reporting of embryo-banking cycles is validated annually (3). We agree that with recent increases in embryo-banking cycles, concurrent changes in the information provided to consumers are warranted. For that reason, the 2011 ART Fertility Clinic Success Rates Report will include the number of embryo-banking cycles reported. Ideally, the outcomes of embryo-banking cycles would be reported both per cycle and per transfer, and separately for short-term and long-term embryo banking. This approach, however, would require the collection of additional information on cycle intent and/or on the linkage between embryo-banking cycles and subsequent frozen/thawed embryo transfer cycles, which often occur in different reporting years. Reporting the number of cycles using frozen/thawed embryos from previous transfer cycles and the number of short-term and long-term embryo banking cycles will inform potential ART consumers about differences in clinical practices and outcomes. Public reporting on the clinical outcomes of ART has been providing useful information for ART providers, patients, researchers, and the general public for the last 16 years (4). The use of NASS data has contributed to improvements in the field and has made studies such as the one by Kushnir et al. (1) possible. That study serves as a reminder that the reporting of ART clinical outcomes needs to keep pace with rapidly changing clinical practice. We are considering revisions to the NASS data collection to better assess new methods and technologies and to include some of the measures we have described here.

OBJECTIVE: To examine and compare cycle outcomes among patients demonstrating poor response to ovarian hyperstimulation that proceeded to oocyte retrieval to those that converted to intrauterine insemination (IUI). DESIGN: Cohort Study. MATERIALS AND METHODS: Comparison Groups Women demonstrating poor ovarian response while undergoing planned assisted reproductive technology (ART) cycles who proceeded to oocyte retrieval and In Vitro Fertilization (IVF) Women demonstrating poor ovarian response while undergoing planned ART cycles who converted to IUI. Inclusion Criteria -Cycle data from Greenville Health System REI Office, January 2004 October 2013 -Patients received gonadotropins as part of an ART cycle -Five or fewer follicles measuring greater than or equal to 15 mm in average diameter -Peak estradiol (E2) level less than 1000 pg/dL at time of human chorionic gonadotropin (hCG) trigger -Patients converted to IUI must have had at least one patent fallopian tube and were inseminated with a post-wash total motile sperm count >5 million/mL -Underwent standard stimulation protocols Exclusion Criteria -Sperm counts 39 -Bilateral tubal blockage for IUI group Primary Outcome: Live birth Secondary Outcome: Clinical pregnancy Demographics and Patient Information -Baseline FSH, Anti-M€ullerian hormone, TSH, prolactin, DHEA-S -E2 levels at time of hCG trigger -Height & weight -Ethnicity -Age -Gravidity/Parity -Prior treatment.