Intracytoplasmic sperm injection utilization relative to reported male factor infertility prevalence and its association with preimplantation genetic testing use: a national clinic-level study

Abstract

PURPOSE: Intracytoplasmic sperm injection (ICSI) is frequently used in assisted reproductive technology practice beyond cycles with reported male factor infertility (MFI). We conducted a hypothesis-generating clinic-level analysis to characterize the relationship between reported ICSI utilization and MFI prevalence and to evaluate the association of their descriptive differential with preimplantation genetic testing (PGT) utilization. Live birth rate (LBR) per transfer was examined as a secondary exploratory outcome. METHODS: We conducted a retrospective, hypothesis-generating ecological analysis of publicly available 2021-2022 Centers for Disease Control and Prevention clinic-level data. The ICSI-MFI differential was defined as the reported ICSI utilization percentage minus the reported MFI percentage and was interpreted as a descriptive index because the component variables used nonidentical denominators and populations. Spearman correlation evaluated associations involving PGT utilization, and LBR per transfer was compared across data-derived ICSI utilization tiers as a secondary exploratory analysis. Clustering-aware and clinic-volume-weighted sensitivity analyses were performed. RESULTS: Median reported ICSI utilization was 87.8% (IQR, 70.9%-94.3%), compared with a median reported MFI percentage of 27.7% (IQR, 19.0%-36.0%). The ICSI percentage was numerically higher than the MFI percentage in 97.9% of clinic-years. The ICSI-MFI differential demonstrated a modest positive correlation with PGT utilization (Spearman rho = 0.312, p < 0.001), and raw ICSI utilization was also positively correlated with PGT utilization (rho = 0.231, p < 0.001). In the secondary LBR analysis, an unweighted difference across ICSI tiers (p = 0.003) did not persist after accounting for clinic-level clustering, either through a random intercept model (p = 0.058) or clinic-volume weighting with clinic-clustered standard errors (p = 0.070). CONCLUSION: At the clinic level, the reported ICSI utilization percentage was frequently and substantially higher than the reported MFI percentage, although these measures had nonidentical denominators and cannot identify nonindicated ICSI use in individual cycles. PGT utilization demonstrated a modest positive association with the descriptive ICSI-MFI differential, but the ecological data do not establish causation or the underlying laboratory mechanism. These findings should be interpreted as a hypothesis-generating assessment of contemporary practice patterns.