OBJECTIVE: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. METHODS: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. RESULTS: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). CONCLUSION: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.

OBJECTIVE: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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.

Abstract Background The landscape of assisted reproductive technology (ART) has seen a significant shift towards frozen-thawed embryo transfers (FET) over fresh transfers, driven by technological advancements and clinical considerations. This study aimed to compare live birth outcomes between primary FET and fresh transfers, focusing on cycles without preimplantation genetic testing (PGT), using United States national data from the SART CORS database spanning from 2014 to 2020. Methods We performed a retrospective cohort study of autologous first ART cycles without PGT comparing primary embryo transfer (frozen thaw vs. fresh) success rates from the 2014–2020 SARTCORS database. Live-birth rates (LBR) and cumulative live-birth rates (CLBR) were compared between first FET versus first fresh embryo transfer from an index retrieval. Multivariate logistic regression (MLR) determined association between live birth outcomes and method of transfer. In a subsequent sub-analysis, we compared these two embryo transfer methods among patients with either diminished ovarian reserve (DOR) or male factor infertility. Results 228,171 first ART cycles resulted in primary embryo transfer. 62,100 initial FETs and 166,071 fresh transfers were compared. Initial FETs demonstrated higher LBR and CLBR compared to fresh transfers (LBR 48.3% vs. 39.8%, p < 0.001; CLBR 74.0% vs. 60.0%, p < 0.0001). MLR indicated greater chances of live birth with FET across all age groups, with adjusted odds ratio (aOR) of live-birth incrementally increasing with advancing age groups. For DOR cycles, LBR and CLBR were significantly higher for FET compared to fresh (33.9% vs. 26.0%, p < 0.001, 44.5% vs. 37.6%, p < 0.0001), respectively. MF cycles also demonstrated higher LBR and CLBR with FET (52.3% vs. 44.2%, p < 0.001, 81.2% vs. 68.9%, p < 0.0001), respectively. MLR demonstrated that in DOR cycles, initial FET was associated with greater chance of live birth in age groups ≥ 35yo (p < 0.01), with aOR of live birth increasingly considerably for those > 42yo (aOR 2.63, p < 0.0001). Conclusions Overall LBR and CLBR were greater for first FET than fresh transfers with incremental increases in odds of live birth with advancing age, suggesting the presence of a more favorable age-related change in endometrial receptivity present in frozen-thawed cycles. For both DOR and MF cycles, LBR and CLBR after primary transfer were greater for first FET than fresh. However, this was particularly evident in older ages for DOR cycles. This suggests that supraphysiologic stimulation in older DOR cycles may be detrimental to endometrial receptivity, which is in part corrected for in FET cycles.

Objective To 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. Design Retrospective cohort study of autologous linked ART cycles. Setting United 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. Results Between 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. Conclusions While 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.

There is limited data regarding age-stratified autologous assisted reproductive technology (ART) outcomes in the SARTCORS database for advancing age beyond 42 years old. Patients older than 42 are summarily grouped in the SARTCORS age category of ">42". The aim of this study was to "unbundle" this category and compare cumulative live birth rates (CLBR) stratified by patient age beyond age 42. This would define the point at which additional ART cycles no longer increased success rates. We performed a retrospective cohort study of autologous linked ART cycles of patients older than 42 years without history of prior ART cycles from the 2014-2020 SARTCORS database. CLBR was calculated for each sequential cycle number, defined as number of live births up to and including a specific cycle divided by the total number of patients undergoing initial cycle start. Multivariate logistic regression (MLR) was performed to determine association between markers of ovarian reserve and live birth outcomes. Between 2014-2020, 24,650 women ≥ 42 years old without history of prior ART underwent 58,878 cycles, resulting in 1,982 live births. CLBR stratified by age was significantly different, with patients aged 43 years with the highest CLBR and patients older than 50 years old with the lowest CLBR (p<0.001). By the third ART cycle, patients who were 43 years old had a CLBR of 8.7% compared to 1.3% in patients older than 50 years old. For each advancing year beyond 42, the CLBR reached a plateau with fewer cycles. Patients who were 43 had a plateau of 8.7% by cycle number 3, while those who were 44 and 45 reached this plateau by cycle 2, with CLBR of 6.2% and 3.8%, respectively. For patients ≥46 years old, CLBR plateaued following their first cycle. Patients who were 46, 47, 48, and 49 years old had plateaus of 2.1%, 1.8%, 1.0%, and 2.2%, respectively. Patients age 50 and older had a CLBR plateau of 1.3%. Maximal CLBR for patients between 43-45 were significantly higher compared to patients 46 and older (p<0.05). Among patients 46 and older, plateaued CLBR were not significantly different (p>0.05). MLR demonstrated no association between markers of ovarian reserve (day 3 FSH and AMH levels) and live birth outcomes (p>0.05). While cycles from women 42 or younger generally plateau by cycle number 4 (our unpublished data), cycles from women older than 42 plateau after fewer cycles. Fewer autologous ART cycles are necessary to maximize CLBR for patients 43 and older compared to those that are 42 and younger. For women 43 and older, markers of ovarian reserve are not predictive of live birth.