Assisted Reproductive Technology Surveillance—

United States, 2009

CDC released today the latest Assisted Reproductive Technology (ART) Surveillance Summary presenting state-specific data on the number and outcomes of all ART procedures initiated in the 50 states, the District of Columbia, Guam, the Federated Republic of Micronesia, the Commonwealth of Puerto Rico, and the U.S. Virgin Islands in 2009. This report provides detailed information on rates of preterm birth and low birthweight for infants conceived with ART as well as for overall U.S. births. In addition, state-specific data on determinants of multiple gestations (e.g., the number of embryos transferred) and the prevalence of elective single-embryo transfers (eSET) are presented for women who underwent ART procedures.

Learn more about ART from CDC’s Division of Reproductive Health.

Assisted Reproductive Technology Surveillance — United States, 2009

Surveillance Summaries

November 2, 2012 / 61(SS7);1-23

Saswati Sunderam, PhD

Dmitry M. Kissin, MD

Lisa Flowers, MPA

John E. Anderson, PhD

Suzanne G. Folger, PhD

Denise J. Jamieson, MD

Wanda D. Barfield, MD

Division of Reproductive Health

National Center for Chronic Disease Prevention and Health Promotion

Corresponding author: Saswati Sunderam, PhD, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC, 1600 Clifton Road N.E., MS K-34, Atlanta, GA 30333. Telephone: 770-488-6356; Fax: 770-488-6391; E-mail: zga0@cdc.gov.

Abstract

Problem/Condition: Since the birth of the first U.S. infant conceived with Assisted Reproductive Technology (ART) in 1981, use of advanced technologies to overcome the problem of infertility has increased steadily, as has the number of fertility clinics providing ART services in the United States. ART includes fertility treatments in which both eggs and sperm are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Women who undergo ART procedures are more likely to deliver multiple-birth infants than those who conceive naturally. Multiple births pose substantial risks to both mothers and infants, including pregnancy complications, preterm delivery, and low birthweight infants. This report presents the most recent data on ART use and birth outcomes for U.S. states and territories.
Reporting Period Covered: 2009.
Description of System: In 1996, CDC began collecting data on all ART procedures performed in the United States, as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (FCSRCA) (Public Law 102-493 [October 24, 1992]). ART data for 1995–2003 were obtained from the Society of Assisted Reproductive Technology (SART) through its proprietary Clinical Outcomes Reporting System data base (SART CORS). Since 2004, CDC has contracted with Westat, Inc., a statistical survey research organization, to obtain data from fertility clinics in the United States through the National ART Surveillance System (NASS), a web-based data collection system developed by CDC.
Results: In 2009, a total of 146,244 ART procedures were reported to CDC. These procedures resulted in 45,870 live-birth deliveries and 60,190 infants. The largest numbers of ART procedures were performed among residents of California (18,405), New York (14,539), Illinois (10,192), Massachusetts (9,845), New Jersey (9,146), and Texas (8,244). Together, these six states reported the highest number of live-birth deliveries as a result of ART and accounted for 48% of all ART procedures initiated, 46% of all infants born from ART, and 45% of all ART multiple-birth deliveries but only 34% of all births in the United States. Nationally, the average number of ART procedures performed per 1 million women of reproductive age (15–44 years), which is a proxy indicator of ART utilization, was 2,361. In four states (Massachusetts, New York, New Jersey, and Connecticut) and the District of Columbia, this proxy measure of ART use exceeded twice the national average. Nationally, the average number of embryos transferred was 2.1 among women aged <35 2.5="2.5" 3.0="3.0" 35="35" aged="aged" among="among" and="and" women="women" years="years">40 years (and varied most in this age group from 1.7 in Maine to 3.5 in Missouri). Age-specific elective single-embryo transfer (eSET) rates were approximately 7% among women aged <35 0.5="0.5" 35="35" 3="3" aged="aged" among="among" and="and" women="women" years="years">40 years. The highest rates of eSET were observed among women aged <35 17="17" 20="20" and="and" delaware="delaware" in="in" iowa="iowa" massachusetts="massachusetts" p="p" years="years">Overall, ART contributed to 1.4% of U.S. births (ranging from 0.2% in Puerto Rico to 4.3 % in Massachusetts). The proportion of ART to total infants born in the state or territory, which is another measure of ART utilization, was highest in Massachusetts (>4%) with high rates also observed in New Jersey, New York, Connecticut, and the District of Columbia (>3% of all infants born). Infants conceived with ART accounted for 20% of all multiple-birth infants (ranging from 4% in Maine to 41% in New York), 19% of all twin births (ranging from 4% in Maine to 42% in New York) and 34% of triplet or higher order births (ranging from 0 in several states to 61.5% in New Jersey). Among infants conceived with ART, 47% were born as multiple-birth infants (ranging from 35% in Delaware to 60.8% in Wyoming), compared with only 3% of infants among the general birth population (ranging from 1% in New York to 5% in Connecticut).
Nationally, infants conceived with ART contributed to approximately 6% of all low birthweight (<2 0.5="0.5" 1.3="1.3" 1.4="1.4" 1.5="1.5" 11.1="11.1" 12.2="12.2" 12="12" 13="13" 14.7="14.7" 15="15" 18.0="18.0" 1="1" 20="20" 21.3="21.3" 2="2" 3.9="3.9" 32="32" 33.4="33.4" 3="3" 4.5="4.5" 47.1="47.1" 48="48" 5.8="5.8" 6.1="6.1" 6="6" 8="8" 9.3="9.3" accounted="accounted" alaska="alaska" all="all" among="among" and="and" art-conceived="art-conceived" art="art" birth="birth" births="births" birthweight="birthweight" born="born" columbia="columbia" compared="compared" conceived="conceived" dakota="dakota" district="district" finally="finally" for="for" from="from" general="general" grams="grams" in="in" infants="infants" jersey.="jersey." low="low" massachusetts="massachusetts" mississippi="mississippi" new="new" of="of" oregon="oregon" overall="overall" p="p" population="population" preterm="preterm" puerto="puerto" range:="range:" ranging="ranging" rico="rico" south="south" the="the" to="to" utah="utah" vermont="vermont" very="very" washington="washington" weeks="weeks" were="were" with="with" wyoming="wyoming" york="york">Interpretation: The proportion of births from ART varied considerably by state and territory (ranging from 0.2% to 4.3%) with substantial impact on perinatal outcomes in some states. In most states, multiple births from ART accounted for substantial proportions of twins and triplets and higher order infants, and the rates of low birthweight and preterm births were disproportionately higher among ART infants than in the general birth population. More than one embryo was transferred per procedure in most states and territories for all age groups, influencing the overall multiple birth rates in the United States. ART use was represented disproportionately in the United States, with only 13 states having above-average ART use. High rates of ART utilization were observed in Massachusetts and New Jersey, which have comprehensive statewide-mandated health insurance coverage for ART procedures. Insurance mandates might influence ART utilization and ART-related birth outcomes.
Public Health Actions: Promotion of single-embryo transfer, where feasible, is needed to reduce multiple births and related adverse consequences of ART. Nevertheless, because ART accounts for a relatively small fraction of total births in most states and territories, the overall prevalence of low birthweight and preterm births cannot be explained solely by the use of ART, and therefore non-ART causes of these adverse outcomes must be examined. Monitoring the use of non-ART infertility treatments (e.g., ovulation stimulation medications without ART) in the general population might be useful because these treatments also might be associated with high rates of multiple births and adverse outcomes such as preterm delivery and infants born with low birthweight.