Maternal Morbidity and Medically Assisted Reproduction Treatment Types

We commend Pelikh et al1 for their comprehensive investigation into the association between medically assisted reproduction treatments and maternal morbidity, published in the February 2025 issue. This study is a valuable addition to the field, particularly in highlighting the differential risks associated with treatment types. However, we propose several avenues to extend and enhance their findings, focusing on assisted reproductive technology (ART) protocol types and underlying health factors. First, although the study underscores the influence of multifetal gestation and obstetric comorbidities on maternal morbidity, it stops short of addressing specific ART protocols. Variations such as fresh compared with frozen embryo transfer and single compared with multiple embryo transfer are critical. Evidence suggests that frozen embryo transfer is associated with reduced maternal morbidity, particularly in minimizing multifetal pregnancies, a key risk factor.2 Distinguishing these protocols could clarify how ART practices directly influence maternal health and enable targeted risk-mitigation strategies. Additionally, Pelikh et al acknowledge subfertility's role in maternal morbidity but do not delve into its specific etiologies. Chronic inflammatory or autoimmune conditions, such as polycystic ovarian syndrome or endometriosis, are common in patients undergoing medically assisted reproduction and independently increase the risk of adverse maternal outcomes.3 These conditions may predispose patients to higher morbidity, even absent medically assisted reproduction procedures. Incorporating detailed analyses of subfertility diagnoses would refine the understanding of maternal risks, distinguishing those due to ART from those inherent in underlying health conditions. Moreover, the study's focus on Utah's relatively homogeneous population limits the generalizability of its findings. Diverse cohorts reflecting broader racial, ethnic, and socioeconomic spectra could identify disparities in maternal outcomes, enhancing clinical and public health applicability.4 Addressing these gaps would bolster the study's effect and translational value. Finally, adoption of elective single embryo transfer protocols, shown to reduce multifetal pregnancies and maternal morbidity in Nordic countries, should be emphasized.2 Promoting single embryo transfer through public health campaigns could align U.S. practices with global standards, improving maternal outcomes and reducing health care costs. In conclusion, Pelikh et al provide a robust foundation for understanding medically assisted reproduction–related maternal morbidity. Expanding analyses to ART protocol variations, subfertility etiologies, and diverse populations will enhance their findings' relevance and utility.