{"paper_id":"473fc030-ea44-4277-973b-d640b20cfba4","body_text":"The Efficacy of PGT-A versus Conventional IVF/ICSI in Infertile Women of Advanced Maternal Age (≥38 Years): A Comparative Analysis of Cumulative Live Birth Rates per Oocyte Retrieval Cycle | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Efficacy of PGT-A versus Conventional IVF/ICSI in Infertile Women of Advanced Maternal Age (≥38 Years): A Comparative Analysis of Cumulative Live Birth Rates per Oocyte Retrieval Cycle Xiangjie Yin, Fuju Tian, Yuan Zhang, Miao Li, Shanshan Liang, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8394709/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 14 You are reading this latest preprint version Abstract Background As advanced maternal age is associated with decreased ovarian reserve and higher embryo aneuploidy rates, preimplantation genetic testing for aneuploidies (PGT-A) intends to select chromosomally normal embryos but remains clinically controversial due to frequently limited retrievable oocytes and blastocyst formation. This study compares the efficacy of PGT-A versus conventional in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) in infertile women aged 38 years or older, and aims to assess the feasibility and clinical value of PGT-A in improving reproductive outcomes for this population. Methods A retrospective cohort study was conducted including women who underwent their first PGT-A or conventional IVF/ICSI cycle between January 2019 and June 2025. Propensity score matching (PSM) was applied to balance baseline characteristics. Ovarian stimulation, embryo culture, biopsy (for PGT-A), and embryo transfer protocols followed standardized clinical procedures. The primary outcome measures were the cumulative live birth rates (CLBRs) following a single stimulation cycle and subsequent embryo transfers and live birth rates per transfer. Secondary outcomes included fertilization rate, clinical pregnancy rate, miscarriage rate, and cycle cancellation rate. Statistical analyses employed generalized estimating equations (GEE) and binary logistic regression to account for confounding variables. Results After PSM, 352 patients remained in each group. The euploidy rate significantly declined with advancing maternal age (57.94% at 38 ≤ age < 40 years, 34.18% at 40 ≤ age < 42 years, and 21.21% at 42 ≤ age ≤ 45 years). Compared to the IVF/ICSI group, the PGT-A group showed significantly lower cumulative live birth and clinical pregnancy rates per retrieval (P < 0.05). In contrast, when analyzed per embryo transfer, biochemical pregnancy, clinical pregnancy, implantation, ongoing pregnancy, and live birth rates were all significantly higher in the PGT-A group (all P < 0.001). Subgroup analyses indicated that the benefits of PGT-A were most pronounced in women under 41 and those with higher ovarian reserve (AMH > 1 ng/ml or AFC ≥ 10). Conclusions PGT-A may not improve cumulative live birth outcomes in women aged 38–45 compared to conventional IVF/ICSI, though its clinical applicability depends on individual ovarian response and embryo availability. These findings support personalized treatment strategies for this patient population. In vitro fertilization (IVF) intracytoplasmic sperm injection (ICSI) preimplantation genetic testing for aneuploidy (PGT-A) propensity score matching (PSM) cumulative live birth rates (CLBRs) cumulative clinical pregnancy rates (CCPRs) euploidy rate Figures Figure 1 Figure 2 Introduction In recent years, accelerated modern lifestyles, evolving attitudes toward childbearing, and increasing life and work pressures have led to a growing trend of delayed childbearing among women( 1 , 2 ). However, advanced maternal age (AMA) is associated with significant reproductive challenges. Studies indicate that female fertility begins to decline markedly after the age of 37, with conception rates becoming exceedingly low beyond 40 years( 3 , 4 ). This decline is largely attributable to an age-related increase in the incidence of chromosomal aneuploidy in oocytes and embryos, leading to higher risks of infertility, miscarriage, and offspring with birth defects among older women. Therefore, assisted reproductive technology (ART) has become a crucial method for infertile patients aged 38 and above (classified as AMA) to achieve their reproductive goals. Although ART has advanced considerably-with improvements in in-vitro fertilization-embryo transfer (IVF-ET) success rates, managing older patients (≥ 38 years) remains a clinical challenge. To address the elevated aneuploidy rate in this population, PGT-A offers a promising option. This technique involves screening blastocyst-stage embryos for chromosomal normality prior to transfer, thereby increasing the likelihood of a healthy offspring. Since 2018, Chinese and international expert consensus guidelines have included advanced age (≥ 38 years) as an indication for PGT-A( 5 , 6 ). A retrospective cohort study by Haviland et al( 7 ). demonstrated a 28% increase in clinical pregnancy rates among women ≥ 38 years who underwent PGT-A compared to those who did not. Nevertheless, older patients often exhibit diminished ovarian reserve (DOR), resulting in fewer retrieved oocytes and reduced oocyte quality, which can significantly impair blastocyst formation rates. In PGT-A cycles, these biological limitations may lead to either failure of blastocyst formation during in vitro culture or the absence of transferable euploid embryos after genetic testing. Both outcomes result in cycle cancellation and loss of embryo transfer opportunity. Thus, the optimal ART strategy for older infertile women remains controversial. This study aims to compare the efficacy and clinical outcomes of PGT-A versus conventional IVF/ICSI in infertile women aged ≥ 38 years, using the CLBRs and CCPRs per oocyte retrieval cycle as the primary endpoint. The findings will evaluate the feasibility and clinical value of PGT-A, providing evidence-based guidance for selecting the most suitable treatment strategy for AMA patients. Materials and methods Study design and participants We analyzed the data of women with infertility who underwent their first PGT-A cycles or IVF/ICSI cycles in our center between January 2019 and June 2025. Some of the patients may have undergone previous IVF cycles in other IVF centers before their treatment cycle. Women were included if they fulfilled the following inclusion criteria: 1) 38 to 45 years of age; 2) having indications for IVF or ICSI; and using ovarian stimulation during IVF. Women were excluded if they had 1) an abnormal uterine cavity shown on hysterosalpingogram or hysteroscopy; 2) had moderate or severe endometriosis; 3) used donor eggs or sperm; 4) failed to retrieve oocytes; 5) with transferable embryos but never undergoing embryo transfer or those with remaining embryos but still did not achieve live birth; 6) underwent transfer of embryos from 2 different stimulated cycles; 7) or had oocyte activation or oocytes freezing cycles. Each patient completed a telephonic interview during each trimester of pregnancy and 1 week after delivery. Women were offered either PGT-A or IVF/ICSI treatment at the discretion of the attending physicians or subject to the wishes of the couple after extensive counseling, and informed written consents were obtained prior to participation. The study had been approved by the Institutional Review Board of the hospital (No. KS21302). Ovarian stimulation Women underwent ovarian stimulation using either GnRH agonist /antagonist or mild stimulation, progestin-primed ovarian stimulation (PPOS) protocol according to their ovarian reserve at the discretion of the attending physicians according to the standard operating procedures of the center( 8 ). Ovarian response was monitored by serial transvaginal scanning with or without hormonal monitoring. Further dosage adjustments were based on the ovarian response at the discretion of the clinicians in charge. When 3 leading follicles reached 18 mm in diameter, triptorelin (0.1mg; Decapeptyl, Ferring Pharmaceuticals, the Netherlands) and human chorionic gonadotropin (2000 IU; Lizhu Pharmaceutical Trading Co., China) or Ovidrel 250 µg (Merck Serono S.p.A., Modugno, Italy) were given to trigger final maturation of the oocytes. Oocyte retrieval was performed approximately 36 hours later. Fertilization, embryo evaluation, and blastocyst culture and fresh embryo transfer In the PGT-A group, approximately 4h after oocyte retrieval, intracytoplasmic sperm injection was performed. In the control group, each oocyte was inseminated with approximately 20,000–30,000 motile spermatozoa 2 hours after the oocyte retrieval. If the total number of motile sperm was < 10 5 after washing or if normal morphology was < 1%, ICSI was performed. Oocytes were decoronated and checked for the presence of two pronuclei to confirm fertilization. Embryos were graded on day 3 after retrieval as grade one to grade six according to the evenness of each blastomere and the percentage of fragmentation( 9 ). Embryos with 6–8 cells and grade one or two were considered top quality embryos. In the PGT-A group, all good embryos were cultured to blastocysts, which were vitrified on day 5 or 6 of the embryo culture. Blastocysts were graded according to the Gardner classification( 10 ). Blastocysts with either an inner cell mass or a trophectoderm score of B or higher were regarded as utilizable. In the control group, a maximum of 2 embryos were transferred on day 3 after retrieval under transabdominal ultrasound guidance in patients using antagonist/agonist protocols. Some non–top-quality embryos were placed in extended culture until they reached the blastocyst stage. Surplus viable embryos or blastocysts were cryopreserved using vitrification. Preimplantation genetic testing for aneuploidy (PGT-A) In PGT-A group, trophectoderm biopsy was performed on utilizable blastocysts, and approximately five cells were aspirated gently through a zona pellucida opening created by a non-contact 1.48-µm diode laser (Saturn 5 Active™, Cooper Surgical, Inc., CT, USA). The biopsied cells were subsequently washed three times in 1×phosphate buffered saline (PBS) (Life Technologies, NY, USA), transferred to a polymerase chain reaction tube containing 2.5 µL 1×PBS, and cryopreserved at -80°C until analysis was performed. The samples were analyzed and interpreted in an accredited genetic laboratory using next generation sequencing-based VeriSeq PGS assay, following standard protocols and manufacturer’s recommendations (Illumina Inc., San Diego, USA). The PGT-A report classified embryos as euploid, aneuploid, mosaic, or inconclusive. Aneuploid, mosaic, and biopsy-failed embryos were categorized as \"Undetermined\" (non-transferable); and no re-biopsy was performed. Only euploid embryos were transferred. Vitrification of blastocysts and frozen embryo transfer Utilizable embryos in the control group or blastocysts after trophectoderm biopsy in PGT-A group were cryopreserved using a vitrification protocol. Details of the vitrification and warming procedures were described before( 11 ). Vitrification was performed with MediCult Vitrification Cooling (Origio, Denmark) using ethyleneglycol, propylene glycol, and sucrose as cryoprotectants. For the warming procedure following vitrification, the straw was cut, and the capillary was pulled out of the liquid nitrogen and immediately warmed individually using MediCult Vitrification Warming (Origio, Denmark). After warming, the embryos were transferred to a culture dish for evaluation and further embryo development. Women in PGT-A groups underwent frozen embryo transfer at least one month after the stimulation cycle if they had at least one euploid blastocyst, and those who did not get pregnant in the stimulated IVF cycle and those who postponed fresh transfer in the control group would undergo FET at least 2 months. FET were performed in natural cycles for ovulatory women and clomiphene-induced or hormone-replacement cycles for either ovulatory or anovulatory women. Only one euploid blastocyst was transferred in the frozen embryo transfer cycle, and in the control group, up to 2 embryos or blastocysts were transferred in the FET cycles. Outcomes measures The primary outcome measure was the CLBRs and CCPRs of which the live birth and clinical pregnancy status had to be achieved within one stimulation cycles followed by subsequent embryo transfers. Secondary outcome measures included, fertilization rate, clinical pregnancy, ongoing pregnancy, abortion, multiple pregnancy, and implantation rates in both fresh and FET cycles. The number of cycle cancellations, number of oocytes retrieved, number of obtained oocytes, number of embryos available for transfer, number of cryopreserved embryos were also compared. An infant born alive after 22 weeks gestation was classified as a live birth. Clinical pregnancy was defined as the presence of at least 1 gestational sac on ultrasound at 6 weeks. Ongoing pregnancy was the presence of at least 1 fetus with heart pulsation on ultrasound beyond 10 weeks. Live birth was calculated by including the first live birth generated during the one complete IVF cycle. Abortion rates (ARs) were defined as the number of abortions before 22 weeks divided by the number of women with clinical pregnancy. Cancellation rate was defined as the number of patients with no viable embryo to transfer divided by the number of patients that started ovarian stimulation. Statistical analysis Continuous variables are given as mean ± SD if normally distributed and as median (interquartile range) if not normally distributed. Because of the large gap in the sample size and imbalance of basal characteristic between the groups, standard PSM was conducted. We used nearest neighbor matching with a caliper of 0.02. The baseline characteristics, including age, BMI, infertility year, AFC, AMH, oocyte retrieval count, infertility types, cause of infertility, basal FSH, and ovarian stimulation protocols, were 1:1 matched without replacement. Women who were not matched were excluded from the analyses. Statistical comparison was performed using the Student’s t-test and the Mann-Whitney U test for continuous variables and chi-square test for categorical variables, where appropriate. GEE (Generalized Estimating Equations) was performed for the individual treatment groups in all ET/FET cycles to evaluate the impact of independent variables on the CPRs and LBRs per single transfer and accounts for correlations among repeated measurements within subjects. Binary logistic regression analyses were used to analyze factors predicting the cumulative proportion of clinical pregnancies and live births. Subgroup analysis was performed in three independent covariates. For age of women, subjects were categorized into three age strata: 38 ≤ age < 41, 41 ≤ age < 43, 43 ≤ age ≤ 45. For AFC, subjects were categorized into three strata: AFC < 5, 5 ≤ AFC < 10 and AFC ≥ 10. AMH also categorized into ≤ 0.5ng/ml, 0.5-1.1ng/ml, and > 1.1ng/ml. Statistical analyses were performed using the Statistical Program for Social Sciences (SPSS Inc., Version 24.0, Chicago, USA). The two-tailed value of P < 0.05 was considered statistically significant. Results Participant flow chart A total of 1,144 women were screened, all of whom met the selection criteria. Among them, 630 women underwent PGT-A treatment and 514 underwent IVF/ICSI. After PSM, 704 patients were ultimately included, with 352 patients in each group. All patients completed follow-up, and pregnancy outcomes were communicated to them. The patient flowchart is presented in Fig. 1. Demographic and cycle characteristics Significant differences were found in female age, infertility years, infertility types, number of oocytes retrieved, AMH levels, infertility factors, and ovarian stimulation protocols between the two groups ( P < 0.05). To eliminate the bias caused by unbalanced characteristics, all cycles were 1:1 matched in above mentioned variables using PSM to obtain a highly comparable control group. Thus, 352 patients in each group remained after PSM, and the baseline demographic characteristics of the couples after matching are presented in Table 1. No significant differences were found with regard to all of the baseline characteristics between the two groups ( P ≥ 0.05). There were no statistical differences between the two groups in terms of the number of oocytes retrieved, number of fertilized oocytes, fertilization rate, number of cleaved embryos, number of high-quality embryos at day 3, and number of transferable embryos at day 3 (Table 2). However, the IVF/ICSI group had a higher proportion of embryos on day 2/3 compared to those in the PGT-A group, while the PGT-A group had a significantly higher proportion of blastocysts and blastocyst formation rates than those in the IVF/ICSI group. Cycle cancellation rate due to no transferable embryos was significantly higher in the PGT-A compared to the IVF/ICSI group (72.72% vs 42.90%, P < 0.001). Table 3 presents the euploidy rate of embryos based on PGT stratified by female age. In the age group 38 ≤ age < 40 years, out of 107 embryos tested, 62 (57.94%) were euploid; among the 85 embryos from women aged 40 ≤ age < 42 years, 29 (34.18%) were euploid; in the oldest age group (42 ≤ age ≤ 45 years), only 7 of 33 embryos (21.21%) were euploid, while 26 (78.79%) yielded undetermined (including aneuploid, mosaic, or inconclusive) results. These data indicate a decline in the proportion of euploid embryos with increasing maternal age. Pregnancy outcomes The PGT-A group had significantly higher biochemical pregnancy rates (60.71% vs 31.30%, P < 0.001,), clinical pregnancy rates (58.04% vs 28.41%, P < 0.001,), embryo implantation rates (58.04% vs 21.92%, P < 0.001), ongoing pregnancy rates (52.68% vs 21.45%, P < 0.001), and live birth rates (44.64% vs 20%, P < 0.001) compared to the IVF/ICSI group (Table 4). However, there were no significant differences between the IVF/ICSI group and the PGT-A group in miscarriage rates per transfer cycle (12.04% vs 10.29%, P = 0.723), ectopic pregnancy rates per transfer cycle (1.85% vs 1.47%, P = 0.849), and multiple pregnancy rates per transfer cycle (7.14% vs 3.08%, P = 0.266) (Table 4). Conversely, the live birth rate per woman (19.60% vs 14.20%, P = 0.036) and clinical pregnancy rate per woman (25.85% vs 17.90%, P = 0.011) were higher in the IVF/ICSI group, with statistically significant differences (Table 4). Analysis of factors influencing pregnancy outcomes GEE was performed to analyze the predictive factors of CPRs and LBRs per embryo transfer, incorporating the following variables: performing PGT-A, female age, infertility years, BMI, infertility factors, infertility types, ovarian stimulation protocols, basal AFC, basal FSH levels, endometrial preparation protocols, endometrial thickness on the day of transfer, number of embryos transferred, and whether blastocysts were transferred. The results showed that performing PGT-A [Exp(B) = 5.74, 95%CI 1.63–20.59; P = 0.007] and blastocyst transfer [Exp(B) = 21.93, 95%CI 6.65–72.37; P < 0.001] was an independent significant predictor of CPRs per embryo transfer (Table 5a). Additionally, performing PGT-A is significantly associated with LBRs per embryo transfer (Table 5b). The following variables were analyzed for CCPRs and CLBRs in the binary logistic regression model: performing PGT-A, female age, infertility years, BMI, ovarian stimulation protocols, infertility factors, infertility types, basal AFC, basal-FSH levels, number of oocytes retrieved, and number of usable embryos. Only female age and number of usable embryos were independent significant predictors of CCPRs and CLBRs (Table 5d), However, other indicators including performing PGT-A showed no significant association with CCPRs and CLBRs (Table 5c-5d). Subgroup analyses In the 38 ≤ age < 41 subgroup, the CPRs ( P < 0.001) and LBRs per embryo transfer ( P < 0.001) in the PGT-A group were significantly higher than those in the IVF/ICSI group, with no statistical differences in other pregnancy outcomes (Fig. 2a). In the 41 ≤ age < 43 subgroup, there were no significant differences in all pregnancy outcomes between the IVF/ICSI and PGT-A groups (Fig. 2b). However, in the 43 ≤ age ≤ 45 subgroup, the LBRs per embryo transfer ( P = 0.033) in the PGT-A group was significantly higher than in the IVF/ICSI group, but with no statistical differences in cumulative pregnancy outcomes (Fig. 2c). In patients with AMH ≤ 0.5ng/ml and 0.5 < AMH ≤ 1.1ng/ml, there were no differences in all pregnancy outcomes between the two groups (Fig. 2d-2e). While in patients with AMH > 1.1ng/ml, PGT-A group had significantly higher CPRs ( P < 0.001) and LBRs per embryo transfer ( P < 0.001) than those in the IVF/ICSI group, whereas the CCPRs ( P = 0.01) and CLBRs ( P = 0.027) were significantly lower in the PGT-A group than those in the IVF/ICSI group (Fig. 2f). In patients with AFC < 5, PGT-A group had significantly higher LBRs per embryo transfer ( P = 0.02) than that in the IVF/ICSI group, with no statistical differences in other pregnancy outcomes (Fig. 2g). In patients with 5 ≤ AFC < 10, the CPRs ( P = 0.01) and LBRs per embryo transfer ( P = 0.004) in the PGT-A group were higher than in those in the IVF/ICSI group, with no statistical differences in other pregnancy outcomes (Fig. 2h). In patients with AFC ≥ 10, the CPRs ( P < 0.001) and LBRs per embryo transfer ( P < 0.001) in the PGT-A group were significantly higher than those in the IVF/ICSI group, conversely the CCPRs ( P = 0.003) and CLBRs ( P = 0.024) in the PGT-A group were significantly lower than those in the IVF/ICSI group (Fig. 2i). Discussion This study demonstrated that in infertile women aged ≥ 38 years, those who underwent preimplantation genetic testing for aneuploidy (PGT-A) showed superior outcomes per transfer cycle, with significantly higher clinical pregnancy and live birth rates compared to the conventional IVF/ICSI group. However, the cumulative clinical pregnancy and live birth rates per oocyte retrieval cycle were lower in the PGT-A group than in the conventional IVF/ICSI group. Advanced maternal age is associated with an increased incidence of meiotic chromosomal segregation errors, resulting in a higher rate of aneuploid embryos. This phenomenon may be attributed to mechanisms such as weakened cohesin complexes( 12 ), dysregulated spindle assembly checkpoint signaling, reduced spindle stability, centromere fragmentation, and age-related telomere shortening( 13 – 15 ). In this study, compared to the conventional IVF/ICSI group, the PGT-A group demonstrated higher clinical pregnancy and live birth rates per embryo transfer. This finding is consistent with the results of group in Boston( 7 ) and one randomized controlled study from Carmen Rubio et al( 16 ). The superior outcomes per transfer in the PGT-A group are likely attributable to the selection of embryos through genetic testing and culture to the blastocyst stage, which filters out a portion of chromosomally abnormal embryos, thereby improving pregnancy outcomes( 17 , 18 ). Our study revealed that the PGT-A group exhibited a notably high proportion of cycles with no transferable embryos, exceeding 70% in patients over age of 38. This may be closely associated with factors such as DOR, impaired oocyte quality, and increased chromosomal abnormality rates in advanced maternal age patients( 19 ). Additionally, the possibility of having no usable blastocysts due to extensive culture cannot be excluded. Although blastocyst culture systems aim to mimic the in vivo environment through optimized culture media, controlled atmospheric conditions, and stable temperature/pH maintenance, potential risks including fluctuations in incubator parameters and technical variations among operators may still lead to blastocyst culture failure and the absence of transfer opportunities. In assisted reproduction, cumulative live birth rates per complete stimulation cycle is widely used to evaluate treatment efficacy( 20 ). Currently, there is ongoing debate regarding whether PGT-A improves cumulative clinical pregnancy and cumulative live birth rates. A cohort study by Murphy et al. indicated no significant difference in cumulative live birth rates per retrieval between PGT-A and conventional IVF/ICSI groups in women aged ≥ 38 years( 21 ). Similarly, Yan et al. reported that PGT-A did not increase cumulative live birth rates( 22 ). In contrast, Casteleiro et al. suggested that PGT-A could improve both live birth rates and cumulative live birth rates in women over 37 years undergoing IVF( 23 ). However, several studies, including ours, observed lower cumulative live birth rates in the PGT-A group compared to the conventional IVF/ICSI group. For instance, a retrospective cohort study based on the SART CORS database evaluated patients with transferable blastocysts who underwent either fresh transfer or PGT-A( 24 ). The results showed that the cumulative live birth rates per cycle was lower in the PGT-A group across all age strata except women > 40 years. Similarly, a 2023 propensity score-matched retrospective study demonstrated significantly lower cumulative live birth rates in the PGT-A group than in the conventional IVF/ICSI group( 17 ). The discrepancy among these studies may be largely attributed to differences in control group selection. Some studies required control groups (IVF/ICSI) culture all embryos to blastocyst stage and included only cases with at least three high-quality blastocysts( 25 , 26 ). In such designs, the control group employed embryo developmental potential and morphology for selecting blastocysts for transfer, while the PGT-A group transferred euploid blastocysts identified through biopsy. In contrast, our study adopted a real-world approach: the IVF/ICSI control group followed standard practices in most reproductive centers, where most patients transfer or freeze high-quality cleavage-stage embryos, and only some non-top-quality embryos are subjected to extended blastocyst culture. It must be clarified that, despite the potential for embryonic self-correction and reports of healthy live births following the transfer of low-level mosaic embryos (< 30%) after thorough patient counseling at some centers, our center currently maintains a conservative policy by generally not recommending the transfer of mosaic embryos. This policy may be reconsidered in the future as more literature and evidence-based data become available. Consequently, the control group had a considerably higher number of transferable embryos than the PGT-A group. In the PGT-A group, a significant proportion of embryos were lost as a result of blastocyst culture failure. Furthermore, the subsequent biopsy identified additional aneuploid embryos, which were consequently not viable for transfer. These factors ultimately led to the cancellation of the treatment cycle. Although pregnancy outcomes per transfer were superior in the PGT-A group, the higher number of transferable embryos in the control group allowed for more subsequent frozen embryo transfers. Our multivariate regression analysis also indicated that the number of usable embryos significantly influenced cumulative live birth rates, which may explain the lower cumulative pregnancy and live birth rates observed in the PGT-A group compared to the IVF/ICSI controls. Subgroup analyses in this study demonstrated that across all stratification criteria, cumulative live birth rates (CLBRs) and cumulative clinical pregnancy rates (CCPRs) were consistently higher in the conventional IVF/ICSI group than in the PGT-A group. These differences were particularly pronounced in patients with AMH > 1.1 ng/mL and AFC > 10, where both CLBRs and CPRs were significantly superior without preimplantation testing. This advantage may be explained by their relatively preserved ovarian reserve, which often allows for retrieval of more oocytes, increasing the number of usable embryos and transfer opportunities. Notably, PGT-A was associated with improved clinical pregnancy and live birth rates per transfer cycle in certain subgroups, including women aged 38–41 years, those with AMH ≤ 1.1 ng/mL, and those with AFC > 10. However, even within these cohorts, cumulative outcomes remained lower compared to the IVF/ICSI group, its benefit was offset by the elevated aneuploidy rate associated with advanced maternal age and the risk of having no transferable embryos after testing. Therefore, the benefit of PGT-A was not significant observed. Nevertheless, due to the limited sample size within these subgroups, these findings should be interpreted with caution. As the retrospective nature, this study is inevitably subject to potential confounding factors that may influence the outcomes. To address this, PSM was initially employed. After matching, the baseline characteristics of the two groups showed no statistically significant differences, thereby minimizing bias caused by confounding factors in the observed outcomes. Importantly, the number of oocytes retrieved was rigorously adjusted to ensure consistency between the two groups, which is critical for a valid comparison of cumulative pregnancy outcomes. According to national regulations, the PGT-A group was required to undergo single blastocyst transfer, while the conventional IVF/ICSI group was permitted to transfer two cleavage-stage embryos. As a result, it was not possible to control for uniformity in the number of embryos transferred or the day of transfer between the groups. Additionally, all cycles in the PGT-A group involved frozen-thawed embryo transfer (FET), whereas the conventional group included some fresh embryo transfers. To further account for these discrepancies, multivariate regression analysis was performed for both live birth rate per transfer and cumulative live birth rate. After adjusting for the aforementioned confounders, the only use of PGT-A was identified as independent factors influencing live birth rate per transfer. However, only the age of women and number of available embryos but not the PGT-A treatment was associated with a negative impact on cumulative live birth rates. This study included only the first oocyte retrieval cycle per patient at our center, with first live birth as the endpoint. Cycles that did not result in live birth were included only if all available embryos had been transferred. While this design facilitates the calculation of the actual cumulative live birth rates per retrieval cycle, it also leads to the exclusion of patients who had not achieved live birth but still had frozen embryos remaining, resulting in loss of information for these cases, and the CLBRs might be over or underestimated. A sensitivity or time-to-event analysis would be helpful to handle these problems. Future studies could include multiple retrieval cycles and extended follow-up periods. The standardized practice at our center only allow to use euploid embryos for transfer and discard all the mosaic embryos. This policy maybe more strict and conservatory since some studies have reported the birth of healthy offspring from transplanted mosaic embryos( 27 – 29 ). This is because the embryo has a powerful self-correcting ability. This differs from the approach at some other international centers, where the transfer of low-level mosaics is permitted, and it is likely that our policy may contribute to the observed outcomes in the PGT-A group, including a higher cycle cancellation rate due to the absence of transferable embryos, and a consequent reduction in the cumulative pregnancy rate. If feasible, multi-center randomized controlled trials (RCTs) with the standardized embryo selection policy should be conducted to further validate the findings of this study. Conclusion In summary, for women of advanced maternal age (≥ 38 years), the use of PGT-A is associated with higher clinical pregnancy and live birth rates per embryo transfer, as well as a reduction in early abortion rates, compared to conventional IVF/ICSI. However, among women aged 38 ≤ to < 41, those with AMH > 1.1ng/ml, and AFC ≥ 10, conventional IVF/ICSI may yield higher cumulative clinical pregnancy rates per oocyte retrieval. It is particularly important to note that the risk of having no transferable embryos increases with age, which may lead to cycle cancellation. Therefore, clinical decision-making should incorporate a comprehensive evaluation of patient age, ovarian reserve to develop an optimal individualized treatment strategy. Abbreviations AMA Advanced maternal age ARs Absorption rates CCPRs Cumulative clinical pregnancy rates CLBRs Cumulative live birth rates CPRs Clinical pregnancy rates DOR Diminished ovarian reserve ICSI Intracytoplasmic sperm injection IVF In vitro fertilization IVF-ET In vitro fertilization-embryo transfer LBRs Live birth rates PGT-A Preimplantation genetic testing for aneuploidy PSM Propensity score matching RCTs Randomized controlled trials Declarations Ethical approval The study was approved by the ethics committee of the Shanghai first maternity and infant hospital (Approval No. KS21302). Consent for publication Not applicable. Clinical trial number Not applicable. Competing interests The authors declare no competing interests. Author details 1 Centre for Assisted Reproduction, Shanghai Key Laboratory of Maternal-Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, China. 2 Clinical and Translational Research Center of Shanghai First Maternity and Infant Hospital, Shanghai Key Laboratory of Maternal-Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, China. 3 Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, China. Funding There is no funding for this project. Author Contribution Both Xiangjie Yin and Zhiqin Chen were involved in the study concept and design, interpreting the data, performing the analyses, and writing and revising the manuscript. Yuan Zhang, Shanshan Liang, and Miao Li contributed to data interpretation. Xiaocui Li, Fuju Tian, Xiaoming Teng and Haibing Li were involved in the critical revision of the manuscript. All authors reviewed and approved the final version of the manuscript, and no other individuals made substantial contributions to this work. Acknowledgements We would like to express our gratitude to all the patients and their families, without whom this study would not have been possible. We wish them all the best. Data availability Data regarding any of the subjects in the study has not been previously published. References Zuo Y, Jiang TT, Teng Y, Han Y, Yin YP, Chen XS. Associations of Chlamydia trachomatis serology with fertility-related and pregnancy adverse outcomes in women: a systematic review and meta-analysis of observational studies. EBioMedicine. 2023;94:104696. Zymperdikas CF, Zymperdikas VF, Mastorakos G, Grimbizis G, Goulis DG. Assisted reproduction technology outcomes in women with infertility and preexisting diabetes mellitus: a systematic review. Horm (Athens). 2022;21(1):23–31. Zhao X, Wu Y, Hu H. Relationship between relative fat mass and infertility: A cross-sectional study. Med (Baltim). 2024;103(41):e39990. Yang D, Mu Y, Wang J, Zou W, Zou H, Yang H, et al. Melatonin enhances the developmental potential of immature oocytes from older reproductive-aged women by improving mitochondrial function. Heliyon. 2023;9(9):e19366. Practice Committees of the American Society for Reproductive M, the Society for Assisted Reproductive Technology. Electronic address Aao, Practice Committees of the American Society for Reproductive M, the Society for Assisted Reproductive T. The use of preimplantation genetic testing for aneuploidy (PGT-A): a committee opinion. Fertil Steril. 2018;109(3):429–36. Xu C-M, Lu S-J, Chen S-C, Zhang J-L, Xu C-J, Gao Y, et al. Preimplantation genetic testing guidelines of International Society of Reproductive Genetics. Reproductive Dev Med. 2023;7(1):3–11. Haviland MJ, Murphy LA, Modest AM, Fox MP, Wise LA, Nillni YI, et al. Comparison of pregnancy outcomes following preimplantation genetic testing for aneuploidy using a matched propensity score design. Hum Reprod. 2020;35(10):2356–64. Ge QL, Teng XM, Chen MX, Li KM, Ng EHY, Chen ZQ. The impact of the embryo banking on the cumulative live birth rate in women with poor ovarian response according to the Bologna criteria. Reprod Med Biol. 2023;22(1):e12533. Veeck LL. Oocyte assessment and biological performance. Ann N Y Acad Sci. 1988;541:259–74. Gardner DK, Schoolcraft WB. Culture and transfer of human blastocysts. Curr Opin Obstet Gynecol. 1999;11(3):307–11. Chen ZQ, Wang Y, Ng EHY, Zhao M, Pan JP, Wu HX, et al. A randomized triple blind controlled trial comparing the live birth rate of IVF following brief incubation versus standard incubation of gametes. Hum Reprod. 2019;34(1):100–8. Al-Ali H, Baig A, Alkhanjari RR, Murtaza ZF, Alhajeri MM, Elbahrawi R, et al. Septins as key players in spermatogenesis, fertilisation and pre-implantation embryogenic cytoplasmic dynamics. Cell Commun Signal. 2024;22(1):523. Wartosch L, Schindler K, Schuh M, Gruhn JR, Hoffmann ER, McCoy RC, et al. Origins and mechanisms leading to aneuploidy in human eggs. Prenat Diagn. 2021;41(5):620–30. Porokh V, Kyjovska D, Martonova M, Klenkova T, Otevrel P, Kloudova S, et al. Zygotic spindle orientation defines cleavage pattern and nuclear status of human embryos. Nat Commun. 2024;15(1):6369. Ono Y, Shirasawa H, Takahashi K, Goto M, Ono T, Sakaguchi T, et al. Shape of the first mitotic spindles impacts multinucleation in human embryos. Nat Commun. 2024;15(1):5381. Rubio C, Bellver J, Rodrigo L, Castillon G, Guillen A, Vidal C, et al. In vitro fertilization with preimplantation genetic diagnosis for aneuploidies in advanced maternal age: a randomized, controlled study. Fertil Steril. 2017;107(5):1122–9. Ma S, Liao J, Zhang S, Yang X, Hocher B, Tan J, et al. Exploring the efficacy and beneficial population of preimplantation genetic testing for aneuploidy start from the oocyte retrieval cycle: a real-world study. J Transl Med. 2023;21(1):779. 孔娜娜 陈蕾. 王伟周, 李敏, 闫玲. 沈玉良 et al 胚胎植入前遗传学非整倍体检测在高龄和复发性流产患者中的应用 海军医学杂志. 2021;42(04):451–5. Nair J, Shetty S, Kasi CI, Thondehalmath N, Ganesh D, Bhat VR, et al. Preimplantation genetic testing for aneuploidy (PGT-A)-a single-center experience. J Assist Reprod Genet. 2022;39(3):729–38. Maheshwari A, McLernon D, Bhattacharya S. Cumulative live birth rate: time for a consensus? Hum Reprod. 2015;30(12):2703–7. Murphy LA, Seidler EA, Vaughan DA, Resetkova N, Penzias AS, Toth TL, et al. To test or not to test? A framework for counselling patients on preimplantation genetic testing for aneuploidy (PGT-A). Hum Reprod. 2019;34(2):268–75. Yan Y, Zhang Q, Li J, Huang Y, Zhou W, Ni T et al. P-700 preimplantation genetic testing for aneuploidy failed to improve cumulative live birth rate in patients with limited good-quality embryos. Hum Reprod. 2023;38(Supplement_1). Casteleiro Alves MF, Santos-Ribeiro S, Mascarós Martinez JM, Nunes S, De M, Santos L et al. O-152 Pre-implantation genetic testing for aneuploidies (PGT-A) improves reproductive outcomes in advanced maternal age patients undergoing IVF/ICSI: a multicentre retrospective cohort study with propensity score matching. Hum Reprod. 2024;39(Supplement_1). Kucherov A, Fazzari M, Lieman H, Ball GD, Doody K, Jindal S. PGT-A is associated with reduced cumulative live birth rate in first reported IVF stimulation cycles age = 40: an analysis of 133,494 autologous cycles reported to SART CORS