Limited generalizability due to homogeneous sample
The study population consisted of predominantly white women (95%) residing in the United States, which may not be generalizable to other populations due to cultural, religious, or socioeconomic factors influencing sex preferences and stopping behaviors.
Lack of data on paternal factors
The study lacked data on the biological fathers, including paternal age and other potential paternal factors, potentially overlooking their contribution to offspring sex.
Potential for unmeasured confounding
Although the study considered infertility treatments, other unmeasured factors related to the couples (e.g., stress levels, environmental exposures, specific lifestyle aspects) could influence the sex of their offspring and may confound the observed associations.
Exclusion of non-live births
The study analyzed live births only, excluding multiple births, stillbirths, and miscarriages, which could influence the overall distribution of offspring sex within and between families.