Cross-border use of assisted reproductive technology in the United States, 2014 to 2022

The United States has become a major destination for cross-border reproductive care, yet limited national data exist on international assisted reproductive technology users and their outcomes.

To characterize cross-border reproductive care in the United States and compare assisted reproductive technology utilization patterns and outcomes between US and non-US residents.

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 assisted reproductive technology cycles from 2014 to 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.

The number and percentage of assisted reproductive technology cycles among non-US residents rose steadily from 2014 to 2019 (2.8% to 3.4%) before declining in 2020. China accounted for the highest volume of international patients (19,718 cycles), nearly 3-fold higher than the next closest country, Canada (6990 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%; adjusted risk ratio, 1.02; 95% confidence interval, 1.00-1.04) and donor oocyte cycles (55.5% vs 48.4%; adjusted risk ratio, 1.10; 95% confidence interval, 1.09-1.13).

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