International Committee for Monitoring Assisted Reproductive Technologies (ICMART): world report for cycles conducted in 2017-2018

What were the rates of utilization, effectiveness, and safety for assisted reproductive technology (ART) throughout the world in 2017 and 2018, and what trends were observed?

The total reported number of ART fresh and frozen cycles conducted in 83 participating countries was 2 913 498 in 2017 and 3 303 505 in 2018, with 5-year trends including an increasing proportion of cycles utilizing frozen embryo transfer (FET) and an increasing number of cycles utilizing pre-implantation genetic testing (PGT).

Prior reports from the International Committee Monitoring ART (ICMART) have reported on the utilization, effectiveness, and safety of ART from participating countries, with an increase in the number of cycles and number of participating countries over time. These reports have described regional differences in the utilization of ART overall, as well as differences in the utilization of specific practices such as ICSI, PGT and single embryo transfer. Past reports demonstrated that rates of delivery per cycle have increased and rates of multiple gestations have decreased over time.

This retrospective, cross-sectional survey describes ART procedures performed globally in 2017 and 2018. Data were submitted to ICMART by participating countries from national or regional registries.

There were 83 countries which provided data for cycles performed in 2017 or 2018, with the majority of countries providing data for both years. Aggregate data are reported for each participating country and analysed using methods developed by ICMART to calculate measures of utilization, effectiveness, and safety.

A total of 2 913 498 cycles and 671 012 babies born were reported for treatment performed in 2017, increasing to 3 303 505 cycles and 728 383 babies born for treatment performed in 2018. After imputing data for non-reporting centres in reporting countries, the estimated number of cycles performed in 2017 was 3 107 188 resulting in an estimated 814 588 babies. For 2018, the estimated number of cycles was 3 568 635 resulting in an estimated 870 814 babies. Utilization of ICSI for autologous fresh non-PGT cycles declined slightly compared with 2014 (54.6% in 2017 and 57.3% in 2018 compared with 64.8% in 2014). The percentage of transfers which were of frozen embryos was 55.7 % in 2017 and 57.9% in 2018, up from 38.9% in 2014. Among all countries, including those which reported no 'freeze all' cycles, the percentage of 'freeze all' cycles was 30.5% in 2017 and 32.7% in 2018, up from 13.1% in 2014. In countries reporting at least one retrieval cycle in which all embryos were frozen, the percentage of retrievals with no fresh embryo transfer increased (36.2% in 2017 and 36.8% in 2018, up from 20.1% in 2014). The number of PGT cycles in 2018 (172 247) was nearly 5-fold higher than the number reported in 2014 (36 512) with wide regional variation in utilization of PGT observed. In 2017, the delivery rate for autologous oocytes was 23.5% per oocyte retrieval, with a cumulative delivery rate of 36.4% per retrieval (excluding cycles which utilized PGT). The delivery rates per embryo transfer were 31.8% per autologous fresh transfer, 32.5% per autologous frozen transfer, and 47.3% per transfer after PGT. The delivery rate for transfers utilizing donor oocytes was 33.1% (combined fresh transfer and frozen transfers). In 2018, the delivery rate for autologous oocytes was 23.8% per oocyte retrieval, with a cumulative delivery rate of 37.3% per retrieval (excluding cycles which utilized PGT). The delivery rates per embryo transfer were 31.3% per autologous fresh transfer, 31.9% per autologous frozen transfer, and 48.4% per transfer after PGT. The delivery rate for transfers utilizing donor oocytes was 34.3%. The multiple delivery rate with autologous fresh transfer was 19.7% in 2017, and 18.3% in 2018. For autologous FET, the multiple delivery rate was 16.2% in 2017, and 14.9% in 2018. With oocyte donation (combined fresh and frozen embryo transfers), the multiple delivery rate was 15.9% in 2017, and 13.4% in 2018. Finally, the multiple delivery rate for cycles utilizing PGT was 6.9% in 2017 and 5.5% in 2018.

The data and analysis presented are dependent on the quality and completeness of the data submitted to ICMART, which varies globally. There is little data from the Middle East and some countries in Asia. It is important to note that delivery rates per transfer after PGT required the availability of embryos suitable for transfer, and therefore should not be interpreted as suggesting that PGT increases the overall success of ART per oocyte retrieval. Because of an updated methodology in the calculation of delivery rates and number of babies born, direct comparisons with past reports for these metrics cannot be made. Data are observational and it is not possible to determine the causes for regional differences in utilization, effectiveness, and safety, which are likely due at least in part to regional differences in socioeconomics, culture, resources, and regulations.

The ICMART report is the most comprehensive summary of global ART utilization, effectiveness and safety, currently available. There remain regional disparities in the utilization of ART, suggesting differences in access to care. These data can be used by healthcare professionals, healthcare authorities, patients, and the general public to guide research, decision-making, and policy. The reasons behind regional differences in utilization and effectiveness need to be better understood and addressed.

ICMART received unrestricted grants from Abbott and Ferring Pharmaceuticals. ICMART also received financial support from the following organizations: American Society for Reproductive Medicine; Asia Pacific Initiative on Reproduction; European Society of Human Reproduction and Embryology; Fertility Society of Australia and New Zealand; Japan Society for Reproductive Medicine; Japan Society of Fertilization and Implantation; Red Latinoamericana de Reproducción Asistida; and the Society for Assisted Reproductive Technology. ICMART appreciates the efforts of each of the participating countries and centres which provided data. Disclosures were provided by all authors, with none indicating a conflict of interest for this manuscript. V.L.B. provides an unpaid service as a regional representative for ICMART and is a former Board member of the Executive Council of the Society for Assisted Reproductive Technology. S.D.: Ferring Pharmaceuticals provided an unrestricted grant paid to her institution in support of the African Registry and Network of ART (ANARA). Merck provided an honorarium for presentation at an educational symposium. ESHRE, the African Federation of Fertility Societies, the Egyptian Foundation of Reproductive Medicine and Embryology, the Egyptian Fertility and Sterility Society, and the Latin American Network of Assisted Reproduction provided support for conference attendance as invited speakers (travel/accommodation). S.D. is a member of Science and Technology Advisory Group, HRP WHO, and received support from the WHO to attend the annual meeting. S.D. provides unpaid services as an ICMART Board member, Director of ANARA, and an Observer on the Board of the African Federation of Fertility Societies. G.M.C.: The National Perinatal Epidemiology and Statistics Unit (NPESU) of the University of New South Wales (UNSW), Sydney was contracted by ICMART to validate the ICMART data submission and prepare the statistics tables for this report. G.M.C. is the Director of the NPESU and a UNSW employee. G.M.C. is an unpaid board member of ICMART. E.K. is an employee of the NPESU and UNSW. M.B. has received honoraria from Abbott India, Ferring, Intas Pharmaceuticals, Merk Spec, and Organon. J.d.M. has nothing to report. E.E. has no disclosures to report. F.M.B. has no disclosures to report. O.I. has received honoraria for lectures from Ferring and Organon and is an unpaid Board member of ICMART. S.C.J. is on the advisory board of Ferring. M.S.K.: Ferring and Merck have paid consultancy fees, speaker and travel support. M.S.K. participates in EIM ESHRE, German IVF registry, and ICMART. F.Z.-H.: Ferring has paid travel expenses for attending a meeting organized by Ferring. F.Z.-H. is a Latin American Network of ART Founder and honorary member, an Instituto Chileno de Medicina Reproductiva Board member, Director of the Latin American Registry of ART, and a member of Comité de ética y Políticas Publicas Sociedad Chilena de Ginecologia ny Obstetricia. G.D.A. has received travel support from ESHRE to present the ICMART annual report, as the current chair of ICMART.

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