Economics of Fertility Care.

Family building is a human right. The high cost and lack of insurance coverage associated with fertility treatments in the United States have made treatment inaccessible for many patients. The universal uptake of "add-on" services has further contributed to high out-of-pocket costs. Expansion in access to infertility care has occurred in several states through implementation of insurance mandates, and more employers are offering fertility benefits to attract and retain employees. An understanding of the economic issues shaping fertility should inform future policies aimed at promoting evidence-based practices and improving access to care in the United States.

Lights out? COVID-19 containment policies and economic activity.

This paper estimates how strongly COVID-19 containment policies have impacted aggregate economic activity. We use a difference-in-differences methodology to estimate how containment zones of different severity across India impacted district-level nighttime light intensity, as well as household income and consumption. From May to July 2020, nighttime light intensity was 9.1 % lower in districts with the most severe restrictions compared with districts with the least severe restrictions, which could imply between 5.8 % and 6.6 % lower GDP. Nighttime light intensity was only 1.6 % lower in districts with intermediate restrictions. The differences were largest in May during the graded lockdown, and tapered in June and July. Lower house-hold income and consumption corresponding to zone-wise restrictions corroborate these results. Stricter containment measures had larger impacts in districts with greater population density, older residents, and more services employment. The large magnitudes of the findings suggest that governments should carefully consider the economic costs of country-wide pandemic containment policies while weighing the trade-offs against public health benefits. Keywords: Containment policies, COVID-19, Nighttime lights, India.

Association of State Insurance Mandates for Fertility Treatment With Multiple Embryo Transfer After Preimplantation Genetic Testing for Aneuploidy.

Importance: Multiple gestation is one of the biggest risks after in vitro fertilization (IVF), largely due to multiple embryo transfer (MET). Single embryo transfer (SET) uptake has increased over time and has been attributed to various factors, such as mandated insurance coverage for IVF and preimplantation genetic testing for aneuploidy (PGT-A). Objective: To investigate whether mandates for IVF insurance coverage are associated with decreased use of MET after PGT-A. Design, Setting, and Participants: This cohort study was conducted using data on embryo transfers reported to the Society for Assisted Reproductive Technology between 2014 and 2016. Data were analyzed from January to October 2021. Exposures: State-mandated coverage for fertility treatment and type of cycle transfer performed (PGT-A, untested fresh, and untested frozen). Main Outcomes and Measures: Use of MET compared with SET, live birth, and live birth of multiples. Results: There were 110 843 embryo transfers (mean [SD] patient age, 34.0 [4.5] years; 5520 individuals identified as African American [5.0%], 10 035 as Asian [9.0%], 5425 as Hispanic [4.9%], 45 561 as White [41.1%], and 44 302 as other or unknown race or ethnicity [40.0%]); 17 650 transfers used embryos that underwent PGT-A. Overall, among transferred embryos that had PGT-A, there were 9712 live births (55.0%). The odds of live birth were 70% higher with MET vs SET after frozen embryo transfer with PGT-A (OR, 1.70; 95% CI, 1.61-1.78), but the risk of multiples was 5 times higher (OR, 5.33; 95% CI, 5.22-5.44). The odds of MET in cycles with PGT-A in states with insurance mandates were 24% lower than in states without mandates (OR, 0.76; 95% CI, 0.68-0.85). Conclusions and Relevance: This study found that despite the promise of using SET with PGT-A, MET after PGT-A was not uncommon. This practice was more common in states without insurance mandates and was associated with a high risk of multiples.

Impact of in vitro fertilization state mandates for third party insurance coverage in the United States: a review and critical assessment.

The American Society for Reproductive Medicine estimates that fewer than a quarter of infertile couples have sufficient access to infertility care. Insurers in the United States (US) have long considered infertility to be a socially constructed condition, and thus in-vitro fertilization (IVF) an elective intervention. As a result, IVF is cost prohibitive for many patients in the US. State infertility insurance mandates are a crucial mechanism for expanding access to fertility care in the US in the absence of federal legislation. The first state insurance mandate for third party coverage of infertility services was passed by West Virginia in 1977, and Maryland passed the country's first IVF mandate in 1985. To date, twenty states have passed legislation requiring insurers to cover or offer coverage for the diagnosis and treatment of infertility. Ten states currently have "comprehensive" IVF mandates, meaning they require third party coverage for IVF with minimal restrictions to patient eligibility, exemptions, and lifetime limits. Several studies analyzing the impact of infertility and IVF mandates have been published in the past 20 years. In this review, we characterize and contextualize the existing evidence of the impact of state insurance mandates on access to infertility treatment, IVF practice patterns, and reproductive outcomes. Furthermore, we summarize the arguments in favor of insurance coverage for infertility care and assess the limitations of state insurance mandates as a strategy for increasing access to infertility treatment. State mandates play a key role in the promotion of evidence-based practices and represent an essential and impactful strategy for the advancement of gender equality and reproductive rights.

State-Mandated Insurance Coverage and Preimplantation Genetic Testing in the United States.

OBJECTIVE: To examine the association between state-mandated insurance coverage for infertility treatment in the United States and the utilization of and indication for preimplantation genetic testing. METHODS: This was a retrospective cohort study of 301,465 in vitro fertilization (IVF) cycles reported to the Society for Assisted Reproductive Technology between 2014 and 2016. Binomial logistic regression was performed to examine associations between state-mandated insurance coverage and preimplantation genetic testing use. The neonate's sex from each patient's first successful cycle was used to calculate sex ratios. Sex ratios then were compared by state mandates and preimplantation genetic testing indication for elective sex selection. RESULTS: The proportion of IVF cycles using preimplantation genetic testing increased from 17% in 2014 to 34% in 2016. This increase was driven largely by preimplantation genetic testing for aneuploidy testing. Preimplantation genetic testing was less likely to be performed in states with mandates for insurance coverage than in those without mandates (risk ratio [RR] 0.69, 95% CI 0.67-0.71, P<.001). Preimplantation genetic testing use for elective sex selection was also less likely to be performed in states with mandates (RR 0.44, 95% CI 0.36-0.53, P<.001). Among liveborn neonates, the male/female sex ratio was higher for IVF cycles with preimplantation genetic testing for any indication (115) than for those without preimplantation genetic testing (105) (P<.001), and the use of preimplantation genetic testing specifically for elective sex selection had a substantially higher (164) male/female sex ratio than preimplantation genetic testing for other indications (112) (P<.001). CONCLUSION: The proportion of IVF cycles using preimplantation genetic testing in the United States is increasing and is highest in states where IVF is largely self-funded. Preimplantation genetic testing for nonmedical sex selection is also more common in states where IVF is self-funded and is more likely to result in male offspring. Continued surveillance of these trends is important, because these practices are controversial and could have implications for future population demographics.

Impact of comprehensive state insurance mandates on in vitro fertilization utilization, embryo transfer practices, and outcomes in the United States.

BACKGROUND: Previous studies have demonstrated that state mandated coverage of in vitro fertilization may be associated with increased utilization, fewer embryos per transfer, and lower multiple birth rates, but also lower overall live birth rates. Given new legislation and the delay between enactment and effect, a revisit of this analysis is warranted. OBJECTIVE: This study aimed to characterize the current impact of comprehensive state in vitro fertilization insurance mandates on in vitro fertilization utilization, live birth rates, multiple birth rates, and embryo transfer practices. STUDY DESIGN: We conducted a retrospective cohort study of in vitro fertilization cycles reported by the 2018 Centers for Disease Control and Prevention Assisted Reproductive Technology Fertility Clinic Success Rates Report in the United States. In vitro fertilization cycles were stratified according to state mandate as follows: comprehensive (providing coverage for in vitro fertilization with minimal restrictions) and noncomprehensive. The United States census estimates for 2018 were used to calculate the number of reproductive-aged women in each state. Outcomes of interest (stratified by state mandate status) included utilization rate of in vitro fertilization per 1000 women aged 25 to 44 years, live birth rate, multiple birth rate, number of embryo transfer procedures (overall and subdivided by fresh vs frozen cycles), and percentage of transfers performed with frozen embryos. Additional subanalyzes were performed with stratification of outcomes by patient age group. RESULTS: In 2018, 134,997 in vitro fertilization cycles from 456 clinics were reported. Six states had comprehensive mandates; 32,029 and 102,968 cycles were performed in states with and without comprehensive in vitro fertilization mandates, respectively. In vitro fertilization utilization in states with comprehensive mandates was 132% higher than in noncomprehensive states after age adjustment; increased utilization was observed regardless of age stratification. Live birth rate per cycle was significantly higher in states with comprehensive mandates (35.4% vs 33.4%; P<.001), especially among older age groups. Multiple birth rate as a percentage of all births was significantly lower in states with comprehensive mandates (10.2% vs 13.8%; P<.001), especially among younger patients. Mean number of embryos per transfer was significantly lower in states with comprehensive mandates (1.30 vs 1.36; P<.001). Significantly fewer frozen transfers were performed as a percentage of all embryo transfers in states with comprehensive mandates (66.1% vs 76.3%; P<.001). Among fresh embryo transfers, significantly fewer embryos were transferred in comprehensive states among all patients (1.55 vs 1.67; P<.001). CONCLUSION: Comprehensive state mandated insurance coverage for in vitro fertilization services is associated with greater utilization of these services, fewer embryos per transfer, fewer frozen embryo transfers, lower multiple birth rates, and higher live birth rates. These findings have important public health implications for reproductive-aged individuals in the United States and present notable opportunities for research on access to fertility care.

Disparities in access to fertility care: who's in and who's out.

OBJECTIVE: To study the racial and socioeconomic characteristics of women seeking fertility care in a state with mandated insurance coverage for fertility testing and treatment. DESIGN: Cross-sectional, self-administered survey. SETTING: Academic fertility center in Illinois. PATIENTS: Of 5,000 consecutive fertility care patients, 1,460 completed the survey and were included in the study sample. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Details about demographic characteristics and health care access on the basis of patient race/ethnicity and socioeconomic status. RESULTS: The mean age of participants was 36.1 years; 75.5% were White, 10.2% Asian, 7.3% Black, 5.7% Latinx, and 1.3% Other. Most women had a bachelor's (35.5%) or master's degree (40.5%) and an annual household income of >$100,000 (81.5%). Black and Hispanic women traveled twice as far (median 10 miles) as White and Asian women (median 5 miles for both) for treatment. Black women (14.7%) were more likely to report that their race was a barrier to getting fertility treatment compared with White (0.0%), Hispanic (5.1%), and Asian (5.4%) women. Black and Hispanic women were approximately twice as likely to report income level (26.5% and 20.3%, respectively) and weight (7.8% and 8.9%, respectively) as barriers compared with White and Asian respondents. CONCLUSIONS: Significant racial and socioeconomic disparities exist among fertility patients accessing care. Beyond providing all Americans with health insurance that covers fertility treatment, further research in the general population is needed to understand the complex social, cultural, racial, and economic factors that prohibit many individuals from accessing needed fertility care.

R2 and R2* MRI assessment of liver iron content in an undifferentiated diagnostic population with hyperferritinaemia, and impact on clinical decision making.

PURPOSE: To confirm the linear correlation between Ferriscan® R2 (1/T2 Relaxomatry) and R2* (1/T2* Relaxometry) derived 3D Gradient echo (GRE) mDIXON-Quant sequence (Philips) with simultaneous production of a proton density fat fraction (PDFF) in undifferentiated patients with hyperferritinaemia, and to prospectively determine the clinical utility of this tool in these patients by recording the impact on clinical decision-making. MATERIALS AND METHODS: Participants referred to a hospital haematology outpatient clinic for investigation and management of elevated serum ferritin (two serum ferritin levels > 500 µg/L 4 weeks apart) were included in the study. EXCLUSION CRITERIA: contraindications to MRI; clinically relevant investigations for alternative causes of hyperferritinaemia pending; and terminal illness. Thirty-two participants were recruited: 27 men, 5 women. All MRIs performed at 1.5 T. For R2* quantification, 3D six echo GRE sequence (mDIXON-Quant) was acquired. R2 images were acquired over 20 min as dictated and reported by the licensee (Ferriscan®). Clinician interpretation and patient management based on R2* and liver iron content derived from R2 (LICR2) was recorded. Pearson's correlations, linear regression analyses, and ROC curves were calculated. P value <0.05 was considered significant. RESULTS: A high degree of correlation between mean R2* and LICR2 was observed in this novel patient population (slope ±â€¯SE of 43.35 ±â€¯1.88 s-1 permg/g; 95 % CI 39.5-47.2; P < 0.001; R2 = 0.87). Clinical decision making was amended in 14/32 (44 %) patients with hyperferritinaemia following the disclosure of R2* results to clinicians, compared with serum ferritin alone. Liver biopsy was avoided in one patient based on LICR2 and R2*. Unrecognised hepatic steatosis was diagnosed in one patient from the PDFF map. CONCLUSION: We have confirmed the linear correlation between R2 and R2* in a real-world diagnostic population with hyperferritinaemia. Non-invasive assessment of liver iron content (LIC) by R2 and R2* MRI is a useful clinical tool and alters management in these patients.

Trends and Outcomes of Intravascular Imaging-guided Percutaneous Coronary Intervention in the United States.

INTRODUCTION: Intravascular imaging-guided percutaneous coronary intervention (PCI) has shown to improve outcomes in randomized controlled trials. However, there are little real-world data about intravascular imaging utilization during PCI and its outcomes in the United States. METHODS: We conducted an observational analysis on the use of intravascular imaging (Intravascular Ultrasound or Optical Coherence Tomography)-guided PCI in 2,425,036 patients undergoing PCI between January 2010 and December 2014 from the Nationwide Inpatient Sample database. Utilizing propensity score matching, 83,988 matched pairs were identified. The primary outcome was in-hospital mortality. The secondary outcomes included cardiogenic shock and acute kidney injury. RESULTS: Among the 2,425,036 patients, 161,808 (6.7%) underwent imaging-guided PCI. Use of imaging-guidance increased from 6% in 2010 to 6.6% in 2014 (Ptrend < 0.001). The in-hospital mortality was significantly different between imaging-guided PCI and angiography-guided PCI [1.0% vs. 1.5%; adjusted OR: 0.67; 95% confidence interval (CI): 0.54-0.83, P < 0.001]. The rates of cardiogenic shock (2.5% vs. 3.1%; adjusted OR: 0.78; 95% CI: 0.66-0.93; P = 0.005) were significantly lower in imaging-guided PCI group and acute kidney injury rates (7.0% vs. 7.1%; adjusted OR: 0.99; 95% CI: 0.89-1.12; P = 0.919) were not significantly different. CONCLUSIONS: Imaging-guided PCI is associated with lower in-hospital mortality. Yet, a small proportion of patients undergoing PCI have imaging-guidance.

Social connections and tertiary health-care utilization.

The use of tertiary health care by socially proximate peers helps individuals learn about program and treatment procedures, signals that using such care is socially appropriate, and could support the use of formal health care, all of which could increase program utilization. Using complete administrative claims data from a publicly financed tertiary care program in India, we estimate that the elasticity of first-time claims with respect to claims by members of caste groups within the village is 0.046, with smaller effects of more socially distant individuals. The point elasticity of inpatient care expenditure with respect to claims filed by the same group in village peers in the previous quarter is - 0.035. We find support for an information channel as peers increase awareness of the program and its features. Our findings have implications for the development of network-based models to determine health-care demand, as well as in use of network-based targeting to boost tertiary health-care utilization.

Cultural factors contributing to health care disparities among patients with infertility in Midwestern United States.

OBJECTIVE: To identify cultural differences in access to infertility care. DESIGN: Cross-sectional, self-administered survey. SETTING: University hospital-based fertility center. PATIENT(S): Thirteen hundred fifty consecutive women who were seen for infertility care. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Details about demographic characteristics, health care access, and treatment opinions based on patient race or ethnicity. RESULT(S): The median age of participants was 35 years; 41% were white, 28% African American, 18% Hispanic, and 7% Asian. Compared with white women, African American and Hispanic women had been attempting to conceive for 1.5 years longer. They also found it more difficult to get an appointment, to take time off from work, and to pay for treatment. Forty-nine percent of respondents were concerned about the stigma of infertility, 46% about conceiving multiples, and 40% about financial costs. Disappointing one's spouse was of greater concern to African-American women, whereas avoiding the stigmatization of infertility was of greatest concern to Asian-American women. CONCLUSION(S): While the demand for infertility treatment increases in the United States, attention to cultural barriers to care and cultural meanings attributed to infertility should be addressed. Enhanced cultural competencies of the health care system need to be employed if equal access is to be realized as equal utilization for women of color seeking infertility care.

Proceedings from the conference on Reproductive Problems in Women of Color.

The purpose of the National Institutes of Health conference on Reproductive Problems in Women of Color that convened on July 25, 2009 was to bring investigators together to examine data related to reproductive health care access and ethnic disparities in reproductive problems, fertility treatments, and pregnancy outcomes. One of the goals discussed at this conference was to initiate a research network of investigators interested in studying these problems through the development of an American Society of Reproductive Medicine special interest group and Society of Assisted Reproductive Technology writing groups.

Racial and ethnic disparities in assisted reproductive technology outcomes in the United States.

OBJECTIVE: To evaluate ethnic differences in assisted reproductive technology (ART) outcomes in the United States. DESIGN: Historical cohort study. SETTING: Clinic-based data. PATIENT(S): A total of 139,027 ART cycles from the Society for Assisted Reproductive Technology Clinic Outcome Reporting System online database for 2004-2006, limited to white, Asian, black, and Hispanic women. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Logistic regression was used to model the odds of pregnancy and live birth; among singletons and twins, the odds of preterm birth and fetal growth restriction. Results are presented as adjusted odds ratios, with white women as the reference group. RESULT(S): The odds of pregnancy were reduced for Asians (0.86), and the odds of live birth were reduced for all groups: Asian (0.90), black (0.62), and Hispanic (0.87) women. Among singletons, moderate and severe growth restriction were increased for all infants in all three minority groups (Asians [1.78, 2.05]; blacks [1.81, 2.17]; Hispanics [1.36, 1.64]), and preterm birth was increased among black (1.79) and Hispanic women (1.22). Among twins, the odds for moderate growth restriction were increased for infants of Asian (1.30) and black women (1.97), and severe growth restriction was increased among black women (3.21). The odds of preterm birth were increased for blacks (1.64) and decreased for Asians (0.70). CONCLUSION(S): There are significant disparities in ART outcomes according to ethnicity.

Geographic distribution of reproductive endocrinology and infertility (REI) fellowships in the United States.

OBJECTIVE: To examine in detail the geographic distribution of reproductive endocrinology and infertility (REI) fellowships in the United States. DESIGN: Ecological. SETTING: University-based REI fellowship program. PATIENT(S): None. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Number and location of REI fellowship positions. RESULT(S): A significant association was found between the number of REI fellowship positions and the number of categorical postgraduate year-1 (PGY-1) obstetrics and gynecology (OBGYN) residency positions within states. No association was observed among the land area, population, or population density within states. However, despite the fact that in the East, as in the United States overall, there was no association between population density and number of fellowships, West of the Mississippi River, as the population density increased, the number of REI fellowships increased linearly (test for heterogeneity = 0.007). CONCLUSION(S): First-year REI fellowship positions in the United States are correlated with the number of categorical PGY-1 OBGYN residency positions within a state. The geographically uneven distribution of fellowship positions may limit the choices for OBGYN residents wishing to pursue further training in REI.

Support for selling embryos among infertility patients.

OBJECTIVE: To determine the opinions of infertility patients regarding selling extra embryos, and to investigate the relation between patient choice and demographic and socioeconomic characteristics. DESIGN: Cross-sectional, self-administered survey. SETTING: University hospital-based fertility center. PATIENT(S): 1350 consecutive women who presented for infertility care. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Patient opinion regarding selling extra embryos to other couples, and correlations with their demographic and socioeconomic background. RESULT(S): Of respondents with a definitive opinion, 56% felt that selling extra embryos to other couples should be allowed. After adjustment for observed predictors favoring selling extra embryos, we found statistically significantly lower support for selling embryos among patients who were Hispanic (relative to Caucasians) or had never been pregnant, whereas significantly greater support was observed among Hindu and secular women, patients being treated for male factor infertility, and those who in the past had or were currently undergoing intrauterine insemination. Age, education, marital status, and parity were not statistically significantly associated with the opinions about selling extra embryos to other couples. CONCLUSION(S): A large proportion of infertility patient participants approved of selling leftover embryos to other couples. However, some demographic and reproductive factors are significantly associated with patient opinion.

Continuous quality improvement and assisted reproductive technology multiple gestations: some progress, some answers, more questions.

The past decade has seen a fall in the number of embryos transferred accompanied by a reduction in the rate of higher order multiple pregnancies occurring from U.S. assisted reproductive technology (ART) cycles, which is temporally related to voluntary adherence to embryo transfer guidelines. The twin rate has remained relatively constant. The ability to continue the reduction in multiple pregnancies while maintaining advocacy positions for both patient couples and offspring will best occur with attention to scientific, sociologic, economic, and provider issues.

Trends in the use of intracytoplasmic sperm injection in the United States.

BACKGROUND: Intracytoplasmic sperm injection (ICSI) was initially developed as part of in vitro fertilization (IVF) to treat male-factor infertility. However, despite the added cost, uncertain efficacy, and potential risks of ICSI, its use has been extended to include some patients without documented male-factor infertility. METHODS: We analyzed national data on assisted reproductive technology reported to the Centers for Disease Control and Prevention, to determine temporal trends in the use of ICSI and IVF in the United States, and we examined differences in the use of ICSI between states with and those without mandated insurance coverage. RESULTS: From 1995 to 2004, the number of fertility clinics and fresh-embryo cycles and the rates of IVF-related pregnancies and live births increased. The percentage of IVF cycles with the use of ICSI also increased dramatically (from 11.0% to 57.5%), while the percentage of diagnoses of infertility attributed to male-factor conditions remained stable. The ratio of ICSI procedures to diagnoses of male-factor infertility steadily increased each year, suggesting an increasing use of ICSI for conditions other than male-factor infertility. From 1999 to 2004, there was an increasing use of ICSI relative to the percentage of patients with male-factor infertility in states with and those without mandated insurance coverage. For any given year, however, states with insurance coverage had a higher ratio of ICSI use to diagnoses of male-factor infertility than did states without insurance coverage (P<0.001). CONCLUSIONS: Since 1995, the use of ICSI in the United States has increased dramatically, while the proportion of patients receiving treatment for male-factor infertility has remained stable. State-mandated health insurance coverage for IVF services is associated with greater use of ICSI for infertility that is not attributed to male-factor conditions.

Assessment of United States fertility clinic websites according to the American Society for Reproductive Medicine (ASRM)/Society for Assisted Reproductive Technology (SART) guidelines.

OBJECTIVE: To evaluate SART-member fertility clinic websites for their compliance with the 2004 ASRM/SART guidelines for advertising (which is deemed mandatory for clinic membership), to survey the general characteristics of the websites, and to assess differences between academic and private clinic websites. DESIGN: Cross-sectional evaluation. SETTING: The Internet. PATIENTS: None. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Eleven objective criteria based on 2004 ASRM/SART guidelines for advertising and eight objective criteria for general characteristics of fertility clinic websites. RESULTS: All 384 SART-registered clinics were evaluated; 289 (75.3%) had functional websites (211 private, 78 academic). Success rates were published on 51% of websites (117 private, 31 academic), the majority of which were private clinics (p=.025). The percentage of fertility clinic websites adhering to ASRM/SART guidelines was low in all categories (ranging from 2.8%-54.5% in private centers and 1.3%-37.2% in academic centers). No statistically significant difference was found in the services offered at private versus academic clinics. CONCLUSION: A significant proportion of SART-member fertility clinics, both private and academic, that have websites are not following the ASRM/SART guidelines for advertising. Increased dissemination and awareness of the guidelines is warranted.

Preconception sex selection demand and preferences in the United States.

OBJECTIVE: Preconception sex selection for nonmedical reasons raises important moral, legal, and social issues. The main concern is based upon the assumption that a widely available service for sex selection will lead to a socially disruptive imbalance of the sexes. For a severe sex ratio distortion to occur, however, at least two conditions have to be met. First, there must be a significant preference for children of a particular sex, and second, there must be a considerable interest in employing sex selection technology. Our objective was to ascertain such demand and preferences among the United States general population. DESIGN: Cross-sectional web-based survey. SETTING: United States general population. PATIENT(S): One thousand one hundred ninety-seven men and women aged 18 to 45 years. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Web-based questionnaire assessing preferences for sex of children and demand for preconception sex selection for nonmedical reasons. RESULT(S): Eight percent of respondents would use preconception sex selection technology, 74% were opposed, and 18% were undecided. If the sex selection process was simplified to taking a pill, 18% would be willing to use such a medication, 59% were opposed, and 22% were undecided. In terms of gender choices, 39% of respondents would like their first child to be a son, 19% would like their first child to be a daughter, and 42% had no preference. Overall, 50% wished to have a family with an equal number of boys and girls, 7% with more boys than girls, 6% with more girls than boys, 5% with only boys, 4% with only girls, and 27% had no preference. CONCLUSION(S): Preconception sex selection technology via sperm separation is unlikely to be used by the majority of the United States population and is unlikely to have a significant impact on the natural sex ratio.