The Frontier of Fertility: A 2023-2025 Review of Groundbreaking Advances in IVF and Reproductive Technology
By CARE Fertility and Women's Health
July 29, 2025
The field of Assisted Reproductive Technology (ART) is advancing at an unprecedented pace, fueled by breakthroughs in artificial intelligence, genomics, and cellular biology.¹ As the utilization of in vitro fertilization (IVF) continues to rise, with over 432,000 cycles performed in the U.S. in 2023 alone, the demand for more effective and less burdensome treatments has never been greater.⁴ This report provides a definitive, evidence-based analysis of the most impactful developments from 2023 to 2025. We will move beyond the headlines to dissect the science, critically evaluate the latest clinical data, and navigate the significant controversies surrounding these innovations. Our central theme is the crucial tension between groundbreaking potential and the non-negotiable demand for rigorous scientific validation, offering a clear-eyed view of the current and future landscape of fertility.

I. The AI Revolution in the Embryology Lab: Automating and Optimizing Selection
The integration of artificial intelligence into the core of the IVF process—embryo assessment—represents one of the most significant shifts in modern reproductive medicine. This technology promises to overcome the inherent limitations of human subjectivity and standardize a critical decision-making step.
The Problem AI Solves: The Limits of Human Subjectivity
The cornerstone of conventional IVF success, embryo selection, has historically relied on the morphological assessment by a trained embryologist. This process, while skillful, is inherently subjective, leading to significant inter- and intra-observer variability.⁵ This subjectivity is a contributing factor to a live birth rate per transfer that has remained stubbornly low, often below 30%.⁷ Artificial intelligence promises to introduce objectivity, standardization, and the ability to analyze vast, complex datasets of visual and clinical information that are beyond human capacity, with the ultimate goal of improving IVF outcomes.¹
Methodology: How AI Learns to Choose
AI systems in ART primarily use deep learning (DL) and convolutional neural networks (CNNs), which are computational models inspired by the human brain's visual cortex.⁸ These algorithms are trained on immense datasets of embryo images—either static microscope pictures or time-lapse videos from specialized incubators—which are linked to known outcomes like successful implantation, chromosomal status (ploidy), or live birth.¹ By identifying and correlating thousands of subtle patterns in embryo morphology and developmental kinetics with these outcomes, the AI learns to generate a score or prediction of an embryo's viability.¹²
Key Systems and Their Developers (2023-2025)
Several key AI systems have emerged, each with a unique approach to improving embryo assessment:
BELA (Weill Cornell Medicine): Described in a September 2024 Nature Communications paper, BELA represents a significant step towards full automation. It analyzes a sequence of nine time-lapse video images captured around day five post-fertilization, combining this visual data with maternal age to predict an embryo's chromosomal status. Critically, BELA was developed to be independent of embryologists' subjective scores, making it a more objective and generalizable tool than its predecessor, STORK-A. Its successful validation on external datasets from separate clinics in Florida and Spain is a crucial step toward ensuring its broad applicability.¹¹
DeepEmbryo: Detailed in a 2024 Frontiers in AI publication, this tool is notable for its accessibility. It uses just three static images captured at different time points, which can be acquired in nearly any IVF lab without the need for expensive time-lapse incubator systems. The model achieved up to 75.0% accuracy in predicting pregnancy outcomes, demonstrating the potential to democratize advanced embryo assessment for clinics worldwide.⁸
Alife Health's Investigational AI: This system, developed to analyze static images of day 5, 6, and 7 blastocysts, is the subject of the first major U.S. Randomized Controlled Trial (RCT) on AI for embryo selection. The trial, which completed enrollment of 440 patients in October 2024, is designed to evaluate whether AI-assisted selection improves ongoing pregnancy rates compared to traditional morphology grading alone. With final data analysis expected in April 2025, its results will be pivotal in providing the high-level evidence needed for widespread clinical adoption.¹³
The Data: AI vs. Human Accuracy
The evidence from 2023-2024 consistently shows AI outperforming human embryologists in predictive accuracy.
A 2023 systematic review published in Human Reproduction Open found that when combining embryo images with patient clinical data, AI models achieved a median accuracy of 81.5% for predicting clinical pregnancy, compared to just 51% for embryologists performing the same task.⁷
A prospective survey-based study published in 2024 provided a stark, head-to-head comparison: in a test to select embryos that ultimately led to pregnancy, AI alone was 66% accurate, AI-assisted embryologists were 50% accurate, and embryologists working alone were only 38% accurate.⁶
This same study revealed that AI can act as a great equalizer. The use of AI guidance significantly improved the agreement between embryologists (inter-observer agreement) and elevated the performance of junior embryologists (less than 5 years of experience) to a level statistically indistinguishable from their senior colleagues, promising a new, higher standard of care across the board.⁶
The trajectory of this technology suggests its role is solidifying not as a replacement for the embryologist, but as an indispensable decision support tool. The initial fear of a "black box" AI making opaque decisions is giving way to a more collaborative model where AI handles the immense data processing, freeing the embryologist for critical oversight and helping to reduce the documented stress and workload in modern labs.³
The Frontier: Full Laboratory Automation
The role of AI is expanding from assessment to direct intervention. In a landmark event reported in April 2025, the first baby was born using a fully automated, AI-controlled Intracytoplasmic Sperm Injection (ICSI) system, marking a major milestone in reducing human variability in the delicate fertilization process itself.³ This signals a paradigm shift from AI as a diagnostic tool to AI as a therapeutic agent. This development is part of a broader trend toward automation in cryopreservation, microfluidics for sperm sorting, and integrated data management systems, all of which promise to make the entire IVF workflow more efficient, reliable, and less prone to human error.⁴ This leap will require a new level of validation to ensure safety and efficacy, raising new questions about liability and the role of human supervision in a progressively automated laboratory.
II. The Evolving Landscape of Genetic Testing: From Invasive Biopsy to Non-Invasive Frontiers
The field of preimplantation genetic testing (PGT) is in a state of profound flux. The most common form of PGT is undergoing a critical reassessment based on high-level evidence, even as new non-invasive and ethically complex forms of the technology emerge.
Part A: The PGT-A Reckoning - A Critical Reassessment
Preimplantation genetic testing for aneuploidy (PGT-A) involves an invasive biopsy of a day 5-7 embryo to screen its 24 chromosomes. The goal is to select only chromosomally normal (euploid) embryos for transfer, thereby theoretically improving IVF success rates and reducing miscarriage risk.¹⁵ Despite a persistent lack of definitive evidence, its use has soared, with PGT being utilized in 44% of U.S. IVF cycles by 2019.¹⁷
The simple and compelling logic of PGT-A—that aneuploidy is a primary cause of IVF failure, so testing for it should improve outcomes—has driven its widespread adoption. However, this narrative reveals a troubling disconnect between clinical practice and evidence-based guidelines. In a landmark 2024 committee opinion, the American Society for Reproductive Medicine (ASRM) delivered a critical verdict after reviewing the highest-quality evidence available. The committee concluded that the value of PGT-A as a routine screening test for all IVF patients has not been demonstrated.¹⁷
This opinion was based on recent large, multicenter RCTs, such as the STAR trial, which found that the overall live birth rates via frozen embryo transfer were similar between cycles using PGT-A and those using conventional morphological assessment. The potential benefit of PGT-A in lowering miscarriage rates was also deemed "unclear".¹⁷ While ASRM notes a possible benefit for a narrow subgroup of patients (women aged 35–40 with good ovarian reserve), it explicitly argues against its routine use in donor egg cycles or for male factor infertility alone.¹⁷
Part B: The Non-Invasive Frontier - The Promise and Challenge of niPGT
Non-invasive PGT (niPGT) aims to eliminate the potential risks and costs of embryo biopsy by analyzing the cell-free DNA (cfDNA) that an embryo naturally sheds into its surrounding culture medium.¹ However, its clinical adoption has been stalled by significant concerns about its accuracy. Studies have reported widely variable and often poor concordance rates with the "gold standard" trophectoderm (TE) biopsy, with some as low as 63.6%.¹⁹ The grave danger is a false-positive result leading to the discarding of a healthy, viable embryo. One 2024 study reported that four of six embryos deemed "aneuploid" by niPGT resulted in healthy live births after transfer—a clinically unacceptable error rate.¹⁹
A potential breakthrough emerged in a November 2024 preprint from a collaboration including researchers at Peking University and Yikon Genomics. Using an improved DNA amplification method and a sophisticated Bayesian analysis model, the researchers reported 100% accuracy for detecting monogenic diseases (niPGT-M) in the samples that yielded a result. They also successfully reconstructed the embryonic genome to assess polygenic risk.²¹ While this is preliminary, un-reviewed research, it marks the most promising advance to date in solving the accuracy problem of niPGT.
The quest for a reliable niPGT is not just a technical challenge; its success would fundamentally reshape the entire PGT-A debate. The primary, undeniable risk of PGT-A is the invasive biopsy. If the accuracy issues of niPGT are solved, this risk disappears, making the test safer and cheaper. This would shift the debate away from risk-benefit and back to the central, unresolved question: does selecting for euploidy, in and of itself, actually improve cumulative live birth rates from a single retrieval? A validated niPGT could paradoxically lead to more PGT-A, even as current evidence questions its routine efficacy.
Part C: The Ethical Minefield - PGT for Polygenic Risk (PGT-P)
A new frontier in genetic testing, PGT for polygenic disorders (PGT-P), moves beyond screening for single-gene or whole-chromosome disorders. It uses "polygenic risk scores" to assess an embryo's genetic predisposition for complex, multifactorial conditions like diabetes, heart disease, and certain cancers.²²
This technology is fraught with ethical and practical concerns and has been met with significant reservations from clinicians and professional bodies.²² The absolute risk reduction offered by PGT-P is often minuscule, with models suggesting that between 10 and 5,000 embryos would need to be tested to prevent one future case of a given disease.²² It raises profound questions about unrealistic patient expectations for a "perfect" child, the potential to exacerbate health inequities based on the ability to pay, and the very definition of a disease worth preventing.²² PGT-P represents a significant ethical leap from disease prevention to genetic selection, pushing reproductive medicine toward a new frontier of "enhancement" for which society is unprepared.

III. The Uterine Environment: The Contentious Science of Endometrial Receptivity
One of the most fiercely debated topics in modern IVF is the value of testing the uterine lining's "receptivity." This controversy serves as a quintessential cautionary tale of a commercially successful IVF "add-on" that gained widespread use before, and in spite of, high-quality evidence demonstrating its inefficacy and potential for harm.
The Premise: The "Window of Implantation" (WOI)
Successful IVF requires not only a healthy embryo but also a receptive endometrium. It is theorized that the uterus is only receptive for a brief, specific period known as the WOI. A mismatch between the timing of embryo transfer and this window—a so-called "displaced" WOI—is thought to be a major cause of Recurrent Implantation Failure (RIF).²⁴
The Technology: Endometrial Receptivity Analysis/Testing (ERA/ERT)
To address this theorized problem, commercial tests were developed. These tests require an invasive and often painful endometrial biopsy. The tissue's gene expression profile is then analyzed—for example, the endometrial receptivity array (ERA) test uses a 238-gene microarray—to classify the endometrium as "receptive," "pre-receptive," or "post-receptive".²⁴ If the endometrium is found to be non-receptive, the test provides a recommendation to adjust the timing of a future frozen embryo transfer, a process called personalized embryo transfer (pET).²⁴
The Evidence: A Field Divided and a Damning Reanalysis
The evidence base for this technology is starkly divided, a conflict that highlights a critical weakness in the field: the lack of a standardized definition for RIF. Proponents of ERA/ERT often focus on this poorly defined RIF population, a group for whom clinicians and patients are desperate for solutions. A 2025 secondary analysis of a prospective trial, for instance, reported that for RIF patients, ERT-guided transfer led to significantly higher live birth rates (53.3% vs. 30.0%) compared to standard transfer.²⁷
However, a growing body of higher-quality evidence has challenged the test's fundamental validity. The most powerful refutation came from a 2023 paper in Human Reproduction by Richter and Richter. The authors re-examined the data from a large, well-conducted RCT and came to two devastating conclusions ²⁸:
The ERA diagnosis is invalid: Patients diagnosed as "non-receptive" by the test had the exact same live birth rate as those diagnosed "receptive" when both groups received a standard timed transfer. The test simply could not predict outcomes.
Personalized transfer is harmful: Acting on this faulty ERA diagnosis and adjusting the transfer time based on its recommendation significantly reduced the live birth rate by a relative 13%.
The authors concluded that the test is inadvertently harming the patients it is intended to help and stated that all clinical use should be discontinued outside of a controlled research setting.²⁸ Other studies have also found no benefit to ERA-guided transfers.²⁴ The scientific implosion of ERA will likely cast a long shadow, leading to increased skepticism and a higher evidence bar for all future endometrial assessment technologies.
The Future: A Non-Invasive Path?

Given the invasiveness of the biopsy and the intense controversy over its utility, research is shifting toward non-invasive methods. The PRO-BIOMER-CM clinical trial, for example, is actively investigating whether protein biomarkers of endometrial receptivity can be reliably detected in cervical mucus, a completely non-invasive approach that could provide similar information without the cost, pain, and risk of a biopsy.³¹
IV. Pushing the Boundaries of Ovarian Function: Rejuvenation or Reactivation?
For patients with the most challenging diagnoses—Diminished Ovarian Reserve (DOR) and Premature Ovarian Insufficiency (POI)—several novel strategies have gained prominence. However, the scientific arc of these treatments, particularly platelet-rich plasma, serves as a textbook example of why plausible biology and promising preliminary data are not substitutes for rigorous, controlled trials.
Part A: Platelet-Rich Plasma (PRP) - The "Rejuvenation" Debate
In this procedure, a patient's own blood is processed to create a concentrate of platelets and growth factors (PRP), which is then injected directly into the ovaries. The widely promoted claim is that this can "rejuvenate" the ovaries, improving both the quantity and, crucially, the quality of eggs, thereby boosting fertility.¹⁴
The highest-quality evidence to date emerged in 2024 from two pivotal RCTs published in the top-tier journal Human Reproduction. Both the Herlihy et al. and Barrenetxea et al. trials reached the same unambiguous conclusion: PRP injection did not improve oocyte quality, the percentage of euploid embryos, or pregnancy rates.³³ While several 2024 meta-analyses have suggested PRP improves hormonal markers and oocyte counts, these are heavily criticized for pooling data from lower-quality, non-randomized observational studies, which are prone to bias and are less reliable than RCTs.³³
Based on the definitive RCT evidence, the term "ovarian rejuvenation" is scientifically unsupported and misleading, as the key element—quality improvement—is absent. The debate over terminology is not mere semantics; it is a crucial ethical issue concerning informed consent. "Rejuvenation" implies a restoration of youthful function, creating a powerful and unsupported expectation of success. A more cautious term like "ovarian reactivation," suggesting a potential increase in oocyte yield, might be more appropriate, though even this remains debated.³³
Part B: Next-Generation Approaches - Beyond PRP
The most significant future breakthroughs for DOR/POI patients are likely to come from biotechnologies that bypass the failing ovary rather than those that attempt to "rejuvenate" it.
Drug-Free In Vitro Activation (IVA): Highlighted in a 2025 F&S Science report, this technique involves removing a small piece of ovarian tissue, activating it in the lab without drugs, and immediately transplanting it back to the patient. In a small study of POR/POI patients, this novel biological approach showed potential to increase follicle counts and led to successful oocyte retrievals and one live birth.²³
Fertilo (by Gameto) - iPSC-Powered In Vitro Maturation (IVM): This is a truly paradigm-shifting technology. On January 30, 2025, the U.S. Food and Drug Administration (FDA) granted clearance for a Phase 3 clinical trial of Fertilo.³ This technology represents a strategic pivot: it effectively accepts that the in-vivo ovarian environment is failing and aims to create a perfect, optimized maturation environment in the lab.
Methodology: Fertilo uses lab-grown ovarian support cells, which are derived from induced pluripotent stem cells (iPSCs), to mature a patient's immature eggs completely outside the body.
The Advantage: This approach dramatically reduces the physical, emotional, and financial burden of IVF. It slashes the need for hormonal stimulation from a typical 10–14 days to just 2–3 days, with an 80% lower dose of medication. This makes the IVF process safer, more patient-friendly, and potentially more accessible to a wider range of patients.³

V. The Ultimate Frontier: Creating Life in a Dish with In Vitro Gametogenesis (IVG)
The most revolutionary and futuristic science in the field is In Vitro Gametogenesis (IVG), an experimental technique to create functional eggs and sperm from ordinary body cells. This is not merely an incremental advance; it is a disruptive technology that will force a complete re-evaluation of our biological, ethical, and legal definitions of parenthood.

The Concept: The "Holy Grail" of ART
IVG is the process of creating gametes (sperm and eggs) from somatic cells, such as skin or blood cells, that have been reprogrammed into a stem-cell-like state.¹ If perfected for human use, IVG would be revolutionary. It could provide a source of genetically-related children for individuals who cannot produce their own gametes (e.g., due to cancer treatment, genetic conditions, or age) and, for the first time, allow same-sex couples to have children who are genetically related to both partners. It could render the concept of gamete donation obsolete.¹
The Pioneers and Their Landmark Approaches (2023-2024)
Two distinct, competing strategies have made historic progress in mouse models, creating a powerful scientific dynamic that could significantly accelerate progress.
Approach 1: The Hayashi Method (iPSC Differentiation):
Who: The laboratory of Professor Katsuhiko Hayashi at Kyushu and Osaka Universities in Japan.
Methodology: This is a "bottom-up" approach. It involves taking a somatic cell, reprogramming it into an induced pluripotent stem cell (iPSC), and then meticulously culturing these iPSCs with a complex cocktail of signaling molecules that guides their differentiation into functional oocytes.³⁷
The Landmark (Nature, March 2023): Hayashi's team achieved what was once thought impossible. They took skin cells from a male (XY) mouse, converted them to iPSCs, managed the loss of the Y chromosome and duplication of the X to create XX cells, and then differentiated these cells into fully functional eggs. When fertilized with normal sperm, these eggs produced healthy, fertile offspring. This was the first-ever demonstration of viable bipaternal reproduction and a profound demonstration that biological sex, at the cellular level, may be far more malleable than previously understood.³⁸
Approach 2: The Mitalipov Method (Somatic Cell Nuclear Transfer - SCNT):
Who: The laboratory of Shoukhrat Mitalipov at Oregon Health & Science University (OHSU) in the U.S.
Methodology: This approach bypasses the time-consuming iPSC step. It involves transplanting the nucleus from a somatic cell into a donor egg from which the original nucleus has been removed. The donor egg's cytoplasm contains all the necessary factors to "reprogram" the transplanted nucleus, coaxing it to undergo a meiosis-like process where it halves its chromosome number, thus creating a new, haploid egg.³⁶
The Landmark (Science Advances, March 2024): Mitalipov's team published the detailed science behind their technique in a mouse model, meticulously sequencing the chromosomes to show that the process of chromosome reduction works. While still imperfect, it provides a viable, alternative pathway to IVG.³⁶
The Road to Human Application
This technology is still many years, if not decades, from clinical use.³⁶ Significant hurdles remain in ensuring the safety, efficiency, and long-term genetic and epigenetic integrity of human gametes created in this way. Hayashi's team is now attempting to replicate the work in marmoset monkeys, a crucial step toward primates.³⁷
Conclusion: Navigating the Future of Fertility with Evidence and Caution
The 2023-2025 period has been one of extraordinary dynamism in reproductive medicine. We have witnessed the maturation of AI into a powerful clinical support tool, the tantalizing promise of non-invasive diagnostics, and the dawn of biological engineering with IVG that was once the stuff of science fiction. Four key trends have emerged: the inexorable integration of AI, the determined push toward non-invasive technologies, the fierce and necessary debate over the evidence for clinical "add-ons," and the emergence of revolutionary iPSC-based therapies.
Yet, for every exhilarating advance, there is a necessary note of caution. The stories of PGT-A, ERA, and PRP serve as potent reminders that in the quest to help patients build families, technological enthusiasm must be tempered by scientific rigor. The gap between a plausible idea and a validated, effective therapy can only be bridged by high-quality, unbiased evidence, most notably from randomized controlled trials. As we look to the future, the challenge for clinicians, researchers, and patients alike will be to embrace innovation while demanding the evidence needed to ensure that new technologies truly improve outcomes, embodying the first principle of medicine: first, do no harm.
Table 1: A Critical Review of Key IVF "Add-On" Technologies (2023-2025 Evidence)
Technology | Stated Clinical Goal | Summary of Recent Evidence (2023-2025) | Current Expert Consensus / Level of Controversy |
PGT-A | Increase Live Birth Rate (LBR) by selecting euploid embryos. | 2024 ASRM opinion, based on multiple RCTs, does not support routine use. No proven benefit for overall LBR in the general IVF population.¹⁷ | High Controversy / Not Recommended for Routine Use |
Non-Invasive PGT (niPGT) | Provide PGT-A information without risky embryo biopsy. | Historically poor accuracy. A Nov 2024 preprint shows a potential breakthrough with 100% accuracy for niPGT-M, but this is not yet peer-reviewed or clinically validated for niPGT-A.¹⁹ | Emerging / Highly Promising but Not Yet Clinically Validated |
Endometrial Receptivity Analysis (ERA) | Increase LBR by personalizing the timing of embryo transfer. | A 2023 reanalysis of a large RCT found the test is invalid and that acting on its results significantly reduces LBR. This conflicts with lower-quality studies on RIF patients.²⁷ | Extreme Controversy / Discredited by High-Level Evidence |
Intra-ovarian PRP | "Rejuvenate" ovaries to improve egg quantity and quality, increasing LBR. | Two 2024 RCTs in Human Reproduction found no improvement in egg quality or pregnancy rates. The term "rejuvenation" is deemed a misnomer.³³ | High Controversy / Key Claims Refuted by RCTs |
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