Background: The number of couples experiencing difficulties conceiving and seeking treatment for infertility has increased dramatically over time. Treatment options for infertility have evolved significantly over the past four decades, expanding to include assisted reproductive technologies (ART). However, the impact of ART on pregnancy outcomes remains unclear. Studies have shown that ART pregnancies are associated with a higher risk of maternal and neonatal adverse outcomes compared to those resulting from spontaneous conception. To this date, no comprehensive studies have been conducted in Lebanon to assess this association. Therefore, it is crucial to evaluate whether Lebanese women who conceive via ART are at higher risk for maternal and birth-related complications.

Objective: The aim of this study is to evaluate maternal and neonatal outcomes among women who conceived through assisted reproductive technology (ART), compared to those who conceived via other fertility treatments or naturally, at Dr. Ghazeeri's clinic at the American University of Beirut Medical Center.

Methods: Investigators propose to conduct an observational retrospective cohort study involving all pregnant women treated by Dr. Ghazeeri who delivered at the American University of Beirut Medical Center between 2018 and 2023. Pregnancies exposed to assisted reproductive technology (ART) or other fertility treatments will be matched to a group of spontaneous pregnancies based on propensity scores. The study has been initiated following approval from the Institutional Review Board (IRB) at the American University of Beirut Medical Center. Data analysis will be performed using SPSS version 26.

Expected Results: If no associations are found between ART or other fertility treatments and an increased risk of maternal and neonatal outcomes, the results will provide reassurance for mothers seeking these treatments. However, if associations are identified, policymakers will need to establish comprehensive regulations outlining the appropriate use of these technologies. Additionally, these findings would lay the groundwork for obstetricians to implement closer monitoring and more careful management during pregnancy.

i. Study Design Investigators propose to conduct an observational retrospective cohort study on all pregnant women who delivered at Dr. Gahzeeri's clinic at the American University of Beirut Medical Center between 2018 and 2023. Investigators have obtained approval from the Institutional Review Board (IRB) at AUB, which is valid until August 2025.

ii. Sample Size: As this is a retrospective cohort study, the sample size will be determined by the number of participants who meet the inclusion criteria.

iii. Population The patient characteristics will be extracted from the Epic electronic health record system at the hospital. Pregnancies exposed to ART or other fertility treatments will be matched to spontaneous pregnancies based on propensity scores

In this study, the subjects will be divided into two groups:

1. Exposed group:

   • Group One (ART group): pregnancies conceived via either IVF/ICSI and/or Assisted hatching (AH) and/or Pre-implantation genetic testing (PGT).
   • Group one will also be subdivided into fresh embryo transfer (ET) and frozen embryo transfer (FET) subgroups based on the type of embryo transfer method used.
   • Group Two (Non-ART group): pregnancies conceived through ovulation induction (OI) and/or intrauterine insemination (IUI) and/or corrective gynecological surgery.

2. Non-exposed group: spontaneous pregnancies, defined as pregnancies resulting from natural conception.

Inclusion Criteria:

• All pregnant ladies of Lebanese Nationality only who delivered at the American University of Beirut Medical Center (AUB-MC) between Nov 2018- Nov 2023
• Pregnancies that were delivered at least 20 weeks of gestation (≥ 20 weeks)
• All pregnant women who are in procreation age (20-50 years old)
• For pregnant women by ART: only if ART is done at the AUB-MC
• Subject's file being accessible for all the three trimesters
• Subjects being followed up until delivery only at the AUB-MC
• Subjects whom their baby or babies' records are available (it could be multiples)

Exclusion Criteria:

• Subjects who started their follow-up after the 1st trimester (missing data before 12 weeks).
• All subjects with history of severe chronic conditions before gestation such as, pre-existing cancer, heart diseases (coronary artery disease, arrhythmia, cardiac defects, ischemic stroke, venous thromboembolism, liver disease and/or kidney disease, history of nervous system disorders (seizures, depression).
• Subjects who undergone ART elsewhere
• Subjects who lost to follow up during their pregnancies (missing data)
• Moms who delivered outside the AUBMC hospital

The eligibility for participation in this study is restricted to individuals who identify as female and are currently pregnant.

It is an observational retrospective cohort study on all pregnant women who delivered at the American University of Beirut Medical Center between 2018 and 2023. The patient characteristics will be extracted from the Epic electronic health record system at the hospital. Pregnancies exposed to ART or other fertility treatments will be matched to spontaneous pregnancies based on propensity scores.

All individual participant data (IPD) shared will be fully de-identified. No personally identifiable information (PII) will be included in the dataset. All data will be anonymized to ensure participant privacy and confidentiality, in accordance with applicable privacy and ethical guidelines.

The data collection sheet includes information on sociodemographic factors, past medical and surgical history, lifestyle habits, previous pregnancy details, medication use before and during pregnancy, assisted reproductive technology (ART) procedures (including type, year, embryo type, and ovulation induction medication), infertility history and its causes, as well as pregnancy-related and neonatal outcomes. Specifically, it captures details such as age, medical conditions, medications, mode of delivery, maternal complications (e.g., hypertension, diabetes, and others), and neonatal outcomes (e.g., APGAR score, birth weight, prematurity, and others).