Search

Numerous studies have demonstrated that assisted reproductive technology (ART: defined here as including only

To compare the obstetric and perinatal outcomes of deliveries conceived with embryos from single-step vs. sequential culture media systems.Historical cohort of Massachusetts vital records linked to assisted reproductive technology clinic data from the Society for Assisted Reproductive Technology Clinic Outcome Reporting System and laboratory embryology data from two large academic hospital fertility centers.Not applicable.Patients with singleton live birth deliveries between 2004 and 2017 conceived with autologous assisted reproductive technology cycles with fresh blastocyst transfer using either single-step (n = 1,058) or sequential (n = 474) culture media systems.None.Associations of single-step vs. sequential culture with obstetric outcomes (mode of delivery, placental abnormalities, pregnancy-induced hypertension, and gestational diabetes) and perinatal outcomes (preterm birth, low birthweight, small-for-gestational-age, and large-for-gestational-age [LGA]) were assessed with multivariate logistic modeling, adjusted for maternal age, race/ethnicity, education, parity, insurance type, protein supplementation, oxygen concentration, fertilization method, and number of transferred embryos.Compared with sequential culture, single-step culture was associated with increased odds of LGA (adjusted odds ratio 2.1, 95% confidence interval 1.04-4.22). There were no statistically significant differences between single-step and sequential culture media systems in the odds of placental abnormalities, pregnancy-induced hypertension, gestational diabetes, prematurity, small-for-gestational-age, or low birthweight.Single-step culture is associated with increased odds of LGA, indicating that embryo culture media systems may affect perinatal outcomes.

To determine whether assisted reproductive technology (ART) treatment adds obstetric and neonatal risks over and above that of underlying infertility-related diagnoses.Retrospective study of linked ART, birth certificate, hospital discharge data, and outpatient insurance claims data in Massachusetts (2013-2017).Database.Singleton deliveries in women with and without diagnoses of tubal disease, polycystic ovarian syndrome (PCOS), other ovulatory conditions, or endometriosis, identified from the insurance claims and ART data.None.ART and non-ART pregnancy and delivery outcomes were compared with each other and with women with no history of infertility or usage of fertility treatment (fertile group). Generalizing estimating equations with Poisson distribution and exchangeable correlation structure were used to obtain adjusted relative risk ratios (aRRs) and 95% confidence intervals (CIs).Infertility-related diagnoses significantly increased the risks of pregnancy hypertension (PCOS: aRR, 1.13, 95% CI 1.00-1.27), preeclampsia/eclampsia (tubal: aRR 1.28, 95% CI 1.02-1.61; PCOS: aRR 1.23, 95% CI 1.06-1.43; other ovulatory: aRR 1.11, 95% CI 1.02-1.20), gestational diabetes (tubal: aRR 1.28, 95% CI 1.08-1.50; PCOS: aRR 1.58, 95% CI 1.42-1.75; other ovulatory: aRR 1.19, 95% CI 1.12-1.26), and placental problems (tubal aRR 1.47, 95% CI 1.11-1.94), as well as low birthweight and prematurity, compared with deliveries from the fertile group. Within each diagnosis, the use of ART consistently increased the risk of placental problems (aRR 1.49-2.86) but varied for other conditions.Our study demonstrated that compared with the fertile group, risk was elevated in pregnancies and deliveries from women with tubal, PCOS, other ovulatory, and endometriosis diagnoses who did/did not undergo ART treatment. Placental abnormalities were particularly elevated in ART compared to non-ART deliveries having the same diagnosis.

OBJECTIVE: To investigate hospitalizations up to 8 years after livebirth among women who utilized ART or who were subfertile, compared to women who conceived naturally. DESIGN: Retrospective cohort SETTING: Massachusetts deliveries among privately insured women ≥18 years old between 2004–2017 from state vital records were linked to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS), and hospital observational/inpatient stays. PATIENTS: We compared patients with ART, medically assisted reproduction, and unassisted subfertile delivery to fertile delivery. INTERVENTION: NA MAIN OUTCOME MEASURED: Post-delivery hospitalization information was derived from ICD codes for discharges and were combined by type. The relative risks (RR) and 95% confidence intervals (CI) of hospitalization for up to the first 8 years post-delivery were modeled. RESULTS: Among 492,515 deliveries, 5.6% used ART, 1.6% used medically assisted reproduction, and 1.8% were unassisted subfertile. Compared to fertile deliveries, deliveries that utilized ART, medically assisted reproduction or were unassisted subfertile were more likely to have hospital utilization (inpatient or observational stay) for any reason for up to 8 years of follow-up (unassisted subfertile aRR:1.18 (1.12–1.25); medically assisted reproduction:1.20 (1.13–1.27); ART aRR:1.29 (1.25–1.34)). ART deliveries had an increased risk of hospitalization for conditions of the cardiovascular system(aRR: 1.31 (1.20–1.41)), overweight/obesity(aRR:1.30 (1.17–1.44)), diabetes(aRR:1.25 (1.05–1.49)), reproductive tract(aRR:1.62 (1.47–1.79)), digestive tract(aRR:1.39 (1.30–1.49), thyroid(aRR:2.02 (1.80–2.26)), respiratory system(aRR: 1.13 (1.03–1.24)), and cancer(aRR:1.40 (1.18–1.65)) up to 8 years after delivery. Deliveries with medically assisted reproduction and subfertility had similar patterns of hospitalization as ART deliveries. CONCLUSION: Women who conceived through fertility treatment or who experienced subfertility were at an increased risk for subsequent hospitalization resulting from a variety of chronic and acute conditions. FUNDING: NIH R01HD067270

To determine the maternal demographic, health, and fertility variables underlying prematurity.Retrospective: Society for Assisted Reproductive Technology Clinic Outcome Reporting System data linked to Massachusetts birth certificates and hospital stays.Not applicable.We included 166,963 privately insured, singleton, first births to women ≥18 years of age between 2004 and 2013. Deliveries were as follows: assisted reproductive technology (ART) when linked to Society for Assisted Reproductive Technology Clinic Outcome Reporting System, medically assisted reproduction (MAR) when fertility treatment was indicated on the birth certificate, unassisted subfertile (USF) when there were indications of subfertility but no treatment, and fertile if none of the above.None.Late preterm birth (LPTB; 34-36 weeks) and early preterm birth (EPTB;34 weeks) were compared with term deliveries (≥37 weeks). Covariates that statistically significantly influenced prematurity in binary analysis were modeled by using multinomial logistic regression. Backward elimination and mediation analysis were used to determine the influence of single parameters on outcomes of others.LPTB was increased in the USF (adjusted odds ratio [AOR] 1.32, 95% confidence interval [CI] 1.06-1.65) and ART (AOR 1.42, 95% CI 1.30-1.56) but not MAR (AOR 1.16, 95% CI 0.98-1.37). ETPB was increased in all (USF: AOR 1.67, 95% CI 1.21-2.31; MAR: AOR 1.67, 95% CI 1.31-2.12; ART: AOR 1.40, 95% CI 1.21-1.61). The strongest effectors of prematurity were placental problems (LPTB: AOR 4.02; EPTB: AOR 10.28), pregnancy hypertension (LPTB: AOR 2.14; EPTB: AOR 2.88), and chronic hypertension (LPTB: AOR 1.85; EPTB: AOR 2.79). Mediation analysis demonstrated a statistically significant indirect effect of placental problems for ART and subfertility.The greatest effectors of prematurity were placental problems and hypertensive disorders. ART and, to a lesser extent, subfertility were both associated with preterm birth directly and indirectly mediated by placenta problems.

Objective To evaluate the quantity and use of embryos cryopreserved at assisted reproductive technology (ART) clinics in the United States from 2004 through 2013 and to characterize trends in ART cycles in which all embryos were cryopreserved. Design Retrospective analysis. Setting Not applicable. Patient(s) Registry data from the Society for Assisted Reproductive Technology. Intervention(s) Historical cohort of U.S. ART cycles reported to the Society for Assisted Reproductive Technology Clinical Outcomes Reporting System between 2004 and 2013. Main Outcome Measure(s) Number of embryos cryopreserved and factors associated with having cryopreserved embryos. Result(s) The percentage of fresh cycles in which all embryos were frozen increased dramatically each year after 2010: 15.6% (2010), 19.9% (2011), 30.7% (2012), and 40.7% (2013). During 10 years, 1,954,548 embryos were cryopreserved and 717,345 embryos were transferred. In freeze-only cycles from 2004 to 2013, there was a significant increase in the percentage of women with diminished ovarian reserve (19.9% to 34.1%) and in those who used preimplantation genetic testing (3.2% to 6.9%). During the 10-year period, there were 294,575 fresh cycles with embryo transfer and at least one embryo cryopreserved. Overall, 52.5% (n = 154,543) did not undergo a subsequent frozen embryo transfer, 29.5% (n = 40,462) were left with no frozen embryos, 50.4% (n = 68,875) had one–five embryos, and 20.0% (n = 27,396) had ≥six. Factors associated with having excess embryos included donor oocyte cycles and increased antimullerian hormone levels. Conclusion(s) There has been a sharp increase in U.S. ART cycles in which all embryos are frozen and this may result in more embryos in storage.

Objective To compare neonatal health outcomes after fresh versus frozen ET (FET). Design Retrospective analysis of a population-based database of linked clinically assisted reproductive technology (ART) data with state vital records. Multivariable logistic regression was used to model the association between deliveries from fresh versus FET and adverse health outcomes, controlling for maternal characteristics. Setting Not applicable. Patient(s) Live-born singleton infants born to Massachusetts women who conceived by fresh or FET after ART using autologous oocytes between July 1, 2004, and December 31, 2013. Intervention(s) None. Main Outcome Measure(s) Preterm birth, low birth weight, neonatal mortality, birth defects, organ system conditions. Result(s) Compared with infants conceived from fresh embryos, those born to mothers who underwent FET were less likely to be small for gestational age (adjusted odds ratio [AOR] = 0.56; 95% confidence interval [CI], 0.44–0.70) and low birth weight (AOR = 0.72; 95% CI, 0.59–0.88) but more likely to be large for gestational age (AOR = 1.47; 95% CI, 1.26–1.70) and to experience greater odds of infectious disease (AOR = 1.46; 95% CI, 1.03–2.06), respiratory (AOR = 1.23; 95% CI, 1.07–1.41), and neurologic (AOR = 1.32; 95% CI, 1.04–1.68) conditions. There were no statistically significant differences in preterm birth, neonatal mortality, birth defects, cardiovascular, hematologic, and gastrointestinal/feeding conditions, and for infants ≥ 35 weeks, no statistically significant differences in prolonged hospital stay (>3 days for vaginal delivery, >5 days for cesarean). Conclusion(s) Compared with infants conceived from fresh ET, those born by FET have higher birth weight but increased odds of infectious disease, hematologic, respiratory, and neurologic abnormalities. These risks should be considered when making decisions on fresh versus FET.

Background Contemporary embryo biopsy in the United States involves the removal of several cells from a blastocyst that would become the placenta for preimplantation genetic testing. Embryos are then cryopreserved while patients await biopsy results, with transfers occurring in a subsequent cycle as a single frozen-thawed embryo transfer, if euploid. 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. 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 from 2014 to 2017, considering only singleton births after frozen-thawed single embryo transfers. We compared outcomes of cycles having embryo biopsy (n=585) to those having no biopsy (n=2191) using chi-square for categorical and binary variables and logistic regression for adjusted odds ratios and 95% confidence intervals, adjusting for mother’s age, race, education, parity, body mass index, birth year, insurance, and all infertility diagnoses. Results Considering no biopsy as the reference, there was no difference between groups with respect to preeclampsia (adjusted odds ratio, 0.82; 95% confidence interval, 0.42–1.61; P=.5685); pregnancy-induced hypertension (adjusted odds ratio, 0.85; 95% confidence interval, 0.46–1.59; P=.6146); placental disorders, including placental abruption, placenta previa, placenta accreta, placenta increta, and placenta percreta (adjusted odds ratio, 1.16; 95% confidence interval, 0.60–2.24; P=.6675); preterm birth (adjusted odds ratio, 1.22; 95% confidence interval 0.73–2.03; P=.4418); low birthweight (adjusted odds ratio, 1.12; 95% confidence interval, 0.58–2.15; P=.7355); cesarean delivery (adjusted odds ratio, 1.04; 95% confidence interval, 0.79–1.38; P=.7762); or gestational diabetes mellitus (adjusted odds ratio, 0.83; 95% confidence interval, 0.50–1.38; P=.4734). In addition, there was no difference between the groups for prolonged hospital stay for mothers (adjusted odds ratio, 1.23; 95% confidence interval, 0.83–1.80; P=.3014) or for infants (95% confidence interval, 1.29; 95% confidence interval, 0.72–2.29; P=.3923). Conclusion Embryo biopsy for preimplantation genetic testing does not increase the odds for diagnoses related to placentation (preeclampsia, pregnancy-related hypertension, placental disorders, preterm delivery, or low birthweight), maternal conditions (gestational diabetes mellitus), or maternal or infant length of stay after delivery.

Objective To compare incidence, risk factors, and etiology of women's deaths in fertile, subfertile, and undergoing assisted reproductive technology (ART) in the years after delivery. Design Retrospective cohort. Setting University hospital. Patient(s) Women who had delivered in Massachusetts. Intervention(s) This study used data from the Society for Assisted Reproductive Technology Clinic Outcome Reporting System linked to vital records, hospital stays, and the Massachusetts death file. Mortality of patients delivered from 2004-2013 was evaluated through 2015. The exposure groups, determined on the basis of the last delivery, were ART-treated (linked to Society for Assisted Reproductive Technology Clinic Outcome Reporting System), subfertile (no ART but with indicators of subfertility including birth certificate checkbox for fertility treatment, prior hospitalization for infertility [International Classification of Disease codes 9 628 or V23], and/or prior delivery with checkbox or ART), or fertile (neither ART nor subfertile). Numbers (per 100,000 women-years) and causes of death were obtained from the Massachusetts death file. Main Outcome Measure(s) Mortality of women after delivery in each of the three fertility groups and the most common etiology of death in each. Result(s) We included 483,547 women: 16,429 ART, 11,696 subfertile, and 455,422 fertile among whom there were 1,280 deaths with 21.1, 25.5, and 44.7 deaths, respectively, per 100,000 women-years. External causes (violence, accidents, and poisonings) were the most common reasons for death in the fertile group. Deaths occurred on average 46 months after delivery. When external causes of death were removed, there were 19.1, 17.0, and 25.6 deaths per 100,000 women-years and leading causes of death in all groups were cancer and circulatory problems. Conclusion(s) The study presents reassuring data that death rates within 5 years of delivery in ART-treated and subfertile women do not differ from those in fertile women.

Objective To evaluate risks for adverse pregnancy outcomes by number of embryos transferred (ET) and fetal heartbeats (FHB) in assisted reproductive technology–conceived singleton live births. Design Longitudinal cohort using cycles reported to the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System between 2004 and 2008 among women who were treated and gave birth in Massachusetts. Setting Not applicable. Patient(s) Assisted reproductive technology data on 6,073 births between 2004 and 2008 were linked to vital records and hospital data. Likelihood of ET ≥3 vs. 1–2, FHB >1 vs. 1, and risks of preterm birth (PTB, 1 were modeled with binary logistic regression using a backward-stepping algorithm, and presented as adjusted odds ratios (95% confidence intervals). Intervention(s) None. Main Outcome Measure(s) ET ≥3, FHB >1, PTB, LBW, and SGA. Result(s) Higher ET was significantly more likely with older maternal age, intracytoplasmic sperm injection, assisted hatching, cleavage-stage embryos, and thawed embryos. The likelihood of FHB >1 with ≥3 ET vs. 1–2 ET was 2.04 (1.68–2.48). Risks of PTB and LBW with FHB >1 were 1.63 (1.27–2.09) and 1.81 (1.36–2.39), respectively; the risk of SGA was not significant. Nulliparity was associated with higher risks of PTB (1.34 [1.12–1.59]), LBW (1.48 [1.20–1.83]), and SGA (2.17 [1.69–2.78]). Conclusion(s) Number of embryos transferred was strongly associated with FHBs, with twice the risk of FHB >1 with ≥3 ET vs. 1–2 ET. Increasing FHBs were associated with significantly greater risks for PTB and LBW outcomes.

Objective To compare the risks for adverse pregnancy and birth outcomes by diagnoses with and without assisted reproductive technology (ART) treatment to non-ART pregnancies in fertile women. Design Historical cohort of Massachusetts vital records linked to ART clinic data from Society for Assisted Reproductive Technology Clinic Outcome Reporting System. Setting Not applicable. Patient(s) Diagnoses included male factor (ART only), endometriosis, ovulation disorders, tubal (ART only), and reproductive inflammatory disorders (non-ART only). Pregnancies resulting in singleton and twin live births from 2004 to 2008 were linked to hospital discharges in women who had ART treatment (n = 3,689), women with no ART treatment in the current pregnancy (n = 4,098), and non-ART pregnancies in fertile women (n = 297,987). Intervention(s) None. Main Outcome Measure(s) Risks of gestational diabetes, prenatal hospitalizations, prematurity, low birth weight, and small for gestational age were modeled using multivariate logistic regression with fertile deliveries as the reference group adjusted for maternal age, race/ethnicity, education, chronic hypertension, diabetes mellitus, and plurality (adjusted odds ratios [AORs] and 95% confidence intervals [CIs]). Result(s) Risk of prenatal hospital admissions was increased for endometriosis (ART: 1.97, 1.38–2.80; non-ART: 3.34, 2.59–4.31), ovulation disorders (ART: 2.31, 1.81–2.96; non-ART: 2.56, 2.05–3.21), tubal factor (ART: 1.51, 1.14–2.01), and reproductive inflammation (non-ART: 2.79, 2.47–3.15). Gestational diabetes was increased for women with ovulation disorders (ART: 2.17, 1.72–2.73; non-ART: 1.94, 1.52–2.48). Preterm delivery (AORs, 1.24–1.93) and low birth weight (AORs, 1.27–1.60) were increased in all groups except in endometriosis with ART. Conclusion(s) The findings indicate substantial excess perinatal morbidities associated with underlying infertility-related diagnoses in both ART-treated and non-ART-treated women.

Objective To assess the validity of maternally reported assisted reproductive technologies (ART) use and to identify predictors of reporting errors. Design Linkage study. Setting Not applicable. Patient(s) A total of 5,034 (27%) mothers enrolled, from whom 4,886 (97%) self-reported information about use of infertility treatment, including ART, for the index birth. Intervention(s) None. Main Outcome Measure(s) Four measures of validity (sensitivity, specificity, positive and negative predictive values) and use of net reclassification improvement (NRI) methods to identify predictors associated with concordant/discordant maternal reporting. Result(s) The Upstate New York Infant Development Screening Program (Update KIDS Study) was linked with the Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) using a defined algorithm for 2008–2010. The sensitivity, specificity, positive and negative predictive values were high (0.93, 0.99, 0.80, and 1.00, respectively). The validity of maternal report was high, reflecting few differences by participant characteristics except for maternal age dichotomized at 29 years as identified with NRI methods. Conclusion(s) Maternally reported ART is valid, with little variation across various characteristics. No strong predictors of discordant reporting were found, supporting the utility of population-based research with SART CORS linkage.

Objective To compare on a population basis the birth outcomes of women treated with assisted reproductive technologies (ART), women with indicators of subfertility but without ART, and fertile women. Design Longitudinal cohort study. Setting Not applicable. Participant(s) A total of 334,628 births and fetal deaths to Massachusetts mothers giving birth in a Massachusetts hospital from July 1, 2004, to December 31, 2008, subdivided into three subgroups for comparison: ART 11,271, subfertile 6,609, and fertile 316,748. Intervention(s) None. Main Outcome Measure(s) Four outcomes—preterm birth, low birth weight, small for gestational age, and perinatal death—were modeled separately for singletons and twins with the use of logistic regression for the primary comparison between ART births and those to the newly created population-based subgroup of births to women with indicators of subfertility but no ART. Result(s) For singletons, the risks for both preterm birth and low birth weight were higher for the ART group (adjusted odds ratios [AORs] 1.23 and 1.26, respectively) compared with the subfertile group, and risks in both the ART and the subfertile groups were higher than those among the fertile births group. For twins, the risk of perinatal death was significantly lower among ART births than fertile (AOR 0.55) or subfertile (AOR 0.15) births. Conclusion(s) The use of a population-based comparison group of subfertile births without ART demonstrated significantly higher rates of preterm birth and low birth weight in ART singleton births, but these differences are smaller than differences between ART and fertile births. Further refinement of the measurement of subfertile births and examination of the independent risks of subfertile births is warranted.

Objective To model morphological assessments of embryo quality that are predictive of live birth. Design Longitudinal cohort using cycles reported in the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System (SART CORS) between 2007 and 2011. Setting Clinic-based data. Patient(s) Fresh autologous assisted reproductive technology (ART) cycles with ETs on day 3 or day 5 and morphological assessments reported (25,409 cycles with one embryo transferred and 96,093 cycles with two embryos transferred). Live-birth rates were modeled by morphological assessments using backward-stepping logistic regression for cycle 1 and over five cycles, separately for day 3 and day 5 transfers and number of embryos transferred (1 or 2). Additional models for each day of transfer also included the number of oocytes retrieved and the number of embryos cryopreserved. Intervention(s) None. Main Outcome Measure(s) Live births. Result(s) Morphological assessments of grade, stage, fragmentation, and symmetry were significant for the day 3 models; grade, stage, and trophectoderm were significant in the day 5 model; inner-cell mass was significant in the models when two embryos were transferred. Number of oocytes retrieved and number of embryos cryopreserved were significant for both day 3 and day 5 models. Conclusion(s) These findings confirm the significant association between embryo quality parameters reported to SART CORS and live-birth rate after ART.

Objective To develop a model predictive of live-birth rates (LBR) and multiple birth rates (MBR) for an individual considering assisted reproduction technology (ART) using linked cycles from Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) for 2004–2011. Design Longitudinal cohort. Setting Clinic-based data. Patient(s) 288,161 women with an initial autologous cycle, of whom 89,855 did not become pregnant and had a second autologous cycle and 39,334 did not become pregnant in the first and second cycles and had a third autologous cycle, with an additional 33,598 women who had a cycle using donor oocytes (first donor cycle). Intervention(s) None. Main Outcome Measure(s) LBRs and MBRs modeled by woman's age, body mass index, gravidity, prior full-term births, infertility diagnoses by oocyte source, fresh embryos transferred, and cycle, using backward-stepping logistic regression with results presented as adjusted odds ratios (AORs) and 95% confidence intervals. Result(s) The LBRs increased in all models with prior full-term births, number of embryos transferred; in autologous cycles also with gravidity, diagnoses of male factor, and ovulation disorders; and in donor cycles also with the diagnosis of diminished ovarian reserve. The MBR increased in all models with number of embryos transferred and in donor cycles also with prior full-term births. For both autologous and donor cycles, transferring two versus one embryo greatly increased the probability of a multiple birth (AOR 27.25 and 38.90, respectively). Conclusion(s) This validated predictive model will be implemented on the Society for Assisted Reproductive Technology Web site (www.sart.org) so that patients considering initiating a course of ART can input their data on the Web site to generate their expected outcomes.

Objective To identify a group of deliveries to mothers with indicators of subfertility (SUBFERTILITY). Design Longitudinal cohort study. Setting Hospital. Patient(s) A total of 334,152 deliveries to Massachusetts mothers in a Massachusetts hospital between July 1, 2004, and December 31, 2008. Intervention(s) None. Main Outcome Measure(s) Subfertility was defined by an indication on a current or past birth certificate or hospital utilization data of infertility or assisted reproductive technology (ART) cycle before index delivery and no indication of ART use with index delivery. Result(s) Initially, 12,367 deliveries met the inclusion criteria for SUBFERTILITY (8,019 from birth certificates, 2,777 from hospital data, 1,571 from prior ART treatment). Removing deliveries from more than one data source resulted in 10,764 unique deliveries. Removing deliveries resulting from ART treatments left 6,238 deliveries in the SUBFERTILITY category. Demographic analysis indicated that deliveries in SUBFERTILITY were more similar to those in the ART population than to those in the fertile population. Conclusion(s) We have demonstrated the feasibility of using existing population-based linked public health data sets to identify SUBFERTILITY deliveries, and we have used ART data to distinguish ART and SUBFERTILITY births. The SUBFERTILITY category can serve as a comparison group of subfertile patients for studies of ART delivery and longitudinal health outcomes.

Objective To evaluate the effect of a prior assisted reproductive technology (ART) live birth on subsequent live-birth rates. Design Historical cohort study. Setting Clinic-based data. Patient(s) The study population included 297,635 women with 549,278 cycles from 2004 to 2010 from the Society for Assisted Reproductive Technology Clinic Outcome Reporting System. Try 1 refers to ART cycles up to and including the first live birth, try 2 to ART cycles after a first live birth. Intervention(s) None. Main Outcome Measure(s) Live-birth rates by cycle number, try number, and oocyte source. Result(s) Younger women at try 1 are more likely to return for try 2. Women returning for try 2 were more likely to have had an ART singleton versus multiple birth (33.2% after a try 1 singleton versus 8.1% after twins and 4.9% after triplets) and were less likely to have a diagnosis of diminished ovarian reserve or tubal factors. Live-birth rates were significantly higher for try 2 compared with try 1 for autologous fresh cycles, averaging 7.7 percentage points higher over five cycles. Live-birth rates were not significantly different for try 2 versus try 1 with thawed autologous cycles or either fresh or thawed donor cycles. Conclusion(s) These results indicate that when fresh autologous oocytes can be used, live-birth rates per cycle are significantly greater after a prior history of an ART live birth.

Objective To assess whether total reproductive potential (TRP), the chance of a live birth from each fresh cycle (fresh cycle plus frozen transfers), could be calculated from the national Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) database and whether information not available in SART CORS resulted in significant changes to the TRP calculation. Design Retrospective study using SART CORS and clinic data. Setting Three assisted reproductive technology clinics. Patient(s) Women undergoing ART. Intervention(s) None. Main Outcome Measure(s) Two- and three-year TRPs for 2005 and 2006 were calculated according to patient age at cycle start by linking fresh to frozen cycles up to first live birth. Clinic records were used to adjust for (remove) frozen cycles that used more than one fresh cycle as a source of embryos and for any embryos donated to other patients or research or shipped to another facility before a live birth. Result(s) TRP was higher than fresh per-cycle rates for most ages at all clinics, although accuracy was compromised when there were fewer than 20 cycles per category. Two- and 3-year TRPs differed in only 2 of 24 calculations. Adjusted TRPs differed less than three percentage points from unadjusted TRPs when volume was sufficient. Conclusion(s) Clinic TRP can be calculated from SART CORS. Data suggest that calculations of clinic TRP from the national dataset would be meaningful.

Objective To evaluate the effect of increasing female obesity on response to and outcome of assisted reproductive technology (ART) treatment. Design Historical cohort study. Setting Clinic-based data. Patient(s) A total of 152,500 ART cycle starts from the Society for Assisted Reproductive Technology Clinical Outcomes Reporting System for 2007–2008, limited to women with documented height and grouped by body mass index (BMI, [weight/height 2 ]). Intervention(s) None. Main Outcome Measure(s) Cycle cancellation overall, cycle cancellation due to low response, treatment failure (not pregnant vs. pregnant), and pregnancy failure (fetal loss or stillbirth vs. live birth), as adjusted odds ratios and 95% confidence intervals, with cycles among normal-weight women as the reference group. Result(s) Cycle cancellation overall and cancellation due to low response using autologous oocytes significantly paralleled increasing BMI. The odds of treatment failure rose significantly with autologous-fresh cycles, from 1.03 for cycles among overweight women (BMI 25.0–29.9) to 1.53 for cycles among women with BMIs ≥50.0 kg/m 2 . Likewise, the odds of pregnancy failure were most significant with increasing BMI among women with autologous-fresh cycles, increasing from 1.10 for cycles to overweight women to 2.29 for cycles to women with BMI ≥50.0 kg/m 2 . Conclusion(s) These results indicate significantly higher odds of cycle cancellation. In addition, treatment and pregnancy failures with increasing obesity significantly increased starting with overweight women.

Objective To evaluate the validity of collecting day 3 embryo morphology variables into the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System (SART CORS). Design Retrospective. Setting National database—SART CORS. Patient(s) Fresh autologous assisted reproductive technology (ART) cycles from 2006–2007 in which embryos were transferred singly (n = 1,020) or in pairs (n = 6,508) and embryo morphology was collected. Intervention(s) None. Main Outcome Measure(s) Relationship between live birth, maternal age, and morphology of transferred day 3 embryos as defined by cell number, fragmentation, and blastomere symmetry. Logistic multiple regressions and receiver operating characteristic curve analyses were applied to determine specificity and sensitivity for correctly classifying embryos as either failures or successes. Result(s) Live birth rate was positively associated with increasing cell number up to eight cells ( 8 cells: 16.2%), but was negatively associated with maternal age, increasing fragmentation, and asymmetry scores. An area under the receiver operating curve of 0.753 (95% confidence interval 0.740–0.766) was derived, with a sensitivity of 45.0%, a specificity of 83.2%, and 76.4% of embryos being correctly classified with a cutoff probability of 0.3. Conclusion(s) This analysis provides support for the validity of collecting morphology fields for day 3 embryos into SART CORS. Standardization of morphology collections will assist in controlling for embryo quality in future database analyses.

Objective To evaluate the effect of maternal race and ethnicity within body mass index (BMI) categories on assisted reproduction technology (ART) pregnancy and live birth rates. Design Historical cohort study. Setting Clinic-based data. Patient(s) 31,672 ART embryo transfers from the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System for 2007, limited to women with documented race, ethnicity, height, and weight, with women grouped as white, Asian, Hispanic, or black and by BMI. Intervention(s) None. Main Outcome Measure(s) Failure to achieve a clinical intrauterine gestation and failure to achieve a live birth as adjusted odds ratios within BMI categories overall with normal-weight women as the reference group, and by race and ethnicity with white women as the reference group. Result(s) Failure to achieve a clinical intrauterine gestation was significantly more likely among obese women overall (1.22), normal-weight and obese Asian women (1.36 and 1.73, respectively), normal-weight Hispanic women (1.21), and overweight and obese black women (1.34 and 1.47, respectively). Among women who did conceive, failure to achieve a live birth was significantly more likely among overweight and obese women overall (1.16 and 1.27, respectively), overweight and obese Asian women (1.56 and 2.20, respectively) and Hispanic women (1.57 and 1.76, respectively), and normal-weight and obese black women (1.45 and 1.84, respectively). Conclusion(s) These findings indicate significant disparities in pregnancy and live birth rates by race and ethnicity, even within BMI categories.

To evaluate factors associated with the use of elective single embryo transfer (eSET) and its effect on assisted reproductive technology (ART) outcome.Historical cohort.Clinic-based data.A total of 69,028 ART cycles of autologous fresh embryo transfers with additional embryos cryopreserved during the same cycle performed during 2004-06 and reported to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System database.None.Factors associated with the number of embryos transferred, and the odds of pregnancy, live birth, and multiple-infant live birth by number of embryos transferred as adjusted odds ratios (AORs).Single embryo transfer was used more with uterine factor (AOR 1.76) and less with male factor, endometriosis, or tubal factor (AOR 0.81, 0.72, 0.83, respectively). Compared with women aged30 years, eSET was used less among women aged 35-39 years andor =40 years (AOR 0.74 and 0.39, respectively). Compared with White women, eSET was used more with Asian (AOR 1.52) and less with Black or Hispanic women (AOR 0.73 and 0.67, respectively). Compared with eSET, the likelihood of pregnancy, live birth, or multiple-infant live birth was more likely with two embryos (AOR 1.33, 1.34, and 27.4, respectively).Elective SET, used more for younger women with specific diagnoses, is associated with slightly reduced likelihood of a live birth but much reduced likelihood of multiples.

Objective To determine the optimal number of day 3 embryos to transfer in women ≥38 years by conducting an evidence-based evaluation. Design Retrospective analysis of 2000–2004 national SART data. Setting National writing group. Patient(s) A total of 36,103 day 3 embryo transfers in women ≥38 years undergoing their first assisted reproductive technology cycle. Intervention(s) None. Main Outcome Measure(s) Logistic regression was used to model the probability of pregnancy, delivery, and multiple births (twin or high order) based on age- and cycle-specific parameters. Result(s) Pregnancy rates, delivery rates, and multiple rates increased up to transfer of three embryos in 38-year-olds and four in 39-year-olds; beyond this number, only multiple rates increased. In women ≥40 years, delivery rates and multiple rates climbed steadily with increasing numbers transferred. Multivariate analysis confirmed the statistically significant effect of age, number of oocytes retrieved, and embryo cryopreservation on delivery and multiple rates. Maximum FSH level was not an independent predictor by multivariate analysis. Use of intracytoplasmic sperm injection was associated with lowered delivery rate. Conclusion(s) No more than three or four embryos should be transferred in 38- and 39-year-olds, respectively, whereas up to five embryos could be transferred in ≥40-year-olds. Numbers of embryos to transfer should be adjusted according to number of oocytes retrieved and availability of excess embryos for cryopreservation.

[1] To evaluate trends in number of embryos transferred and resultant high-order multiple (HOM) pregnancy rates by Society for Assisted Reproductive Technology (SART)-member clinics between 1996 and 2003 and [2] to relate these practice patterns and outcomes to clinic compliance with SART-American Society for Reproductive Medicine (ASRM) embryo transfer guidelines.Retrospective.Society for Assisted Reproductive Technology-member fertility centers in the United States.Five hundred thirty-six thousand, five hundred twenty-four fresh, nondonor IVF cycles.None.Number of embryos transferred; pregnancy rates; implantation rates; and proportion of singleton, twin, and HOM pregnancies.The number of embryos transferred declined each year. High-order multiple pregnancy rates also declined, whereas the twin rates remained stable. The most pronounced declines in number transferred occurred immediately after publication of SART-ASRM embryo transfer guidelines. After stratifying clinics according to mean and modal number of embryos transferred, clinics transferring the fewest embryos in women35 years of age had the highest mean implantation and pregnancy rates. Furthermore, the percentage of clinics transferring two embryos to a majority of women35 years of age increased from 3.3% in 1996 to 49.9% in 2003.The implementation of SART-ASRM embryo transfer guidelines is associated with significant reductions in the number of embryos being transferred, along with reductions of HOM pregnancies. Initiatives to further reduce twin pregnancies and encourage singleton gestation outcomes are outlined.

The past decade has seen a fall in the number of embryos transferred accompanied by a reduction in the rate of higher order multiple pregnancies occurring from U.S. assisted reproductive technology (ART) cycles, which is temporally related to voluntary adherence to embryo transfer guidelines. The twin rate has remained relatively constant. The ability to continue the reduction in multiple pregnancies while maintaining advocacy positions for both patient couples and offspring will best occur with attention to scientific, sociologic, economic, and provider issues.