Cross-Border Use of Assisted Reproductive Technology (ART) in the United States, 2014-2022.

OBJECTIVE To characterize cross-border reproductive care in the United States (US) and compare Assisted Reproductive Technology (ART) utilization patterns and outcomes between US and non-US residents.

STUDY DESIGN Retrospective cohort study using data from the Society for Assisted Reproductive Technology Clinic Outcome Reporting System characterizing temporal trends, treatment characteristics, and live-birth outcomes among 2,275,167 ART cycles from 2014-2022, including 59,246 (2.6%) cycles from non-US residents representing 182 countries. Outcomes were stratified by oocyte source and plurality (for preterm birth) and analyzed using multivariable log-binomial regression with generalized estimating equations.

RESULTS The number and percentage of ART cycles among non-US residents rose steadily from 2014-2019 (2.8% to 3.4%) before declining in 2020. China accounted for the highest volume of international patients (19,718 cycles), nearly threefold higher than the next closest country, Canada (6,990 cycles). Compared to US residents, non-US patients were more likely to use intracytoplasmic sperm injection (93% vs. 84%), preimplantation genetic testing (68% vs. 43%), donor oocytes (52% vs. 9%), and gestational carriers (45% vs. 2%). Live birth rate was slightly higher among non-US residents for autologous (48.3% vs. 44.2%, aRR:1.02; 95% CI:1.00-1.04) and donor oocyte cycles (55.5% vs. 48.4%%, aRR:1.10; 95% CI:1.09-1.13).

CONCLUSIONS CBRC accounts for a growing proportion of ART cycles in the US, with non-US residents more frequently utilizing advanced and third-party reproductive technologies. Despite differences in ART treatments, non-US residents experienced slightly better outcomes. These findings highlight persistent global disparities in ART access and underscore the US's role as a key destination for complex fertility care.