Assisted Reproductive Technology Surveillance - United States, 2018.

PROBLEM/CONDITION: Since the first U.S. infant conceived with assisted reproductive technology (ART) was born in 1981, both the use of ART and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which eggs or embryos are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Although the majority of infants conceived through ART are singletons, women who undergo ART procedures are more likely than women who conceive naturally to have multiple births because multiple embryos might be transferred. Multiple births can pose substantial risks for both mothers and infants, including obstetric complications, preterm birth (<37 weeks), and low birthweight (<2,500 g). This report provides state-specific information for the United States (including the District of Columbia and Puerto Rico) on ART procedures performed in 2018 and compares birth outcomes that occurred in 2018 (resulting from ART procedures performed in 2017 and 2018) with outcomes for all infants born in the United States in 2018. PERIOD COVERED: 2018. DESCRIPTION OF SYSTEM: In 1995, CDC began collecting data on ART procedures performed in fertility clinics in the United States as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (Public Law 102-493 [October 24, 1992]). Data are collected through the National ART Surveillance System (NASS), a web-based data collection system developed by CDC. This report includes data from the 50 U.S. states, the District of Columbia, and Puerto Rico. RESULTS: In 2018, a total of 203,119 ART procedures (range: 196 in Alaska to 26,028 in California) were performed in 456 U.S. fertility clinics and reported to CDC. These procedures resulted in 73,831 live-birth deliveries (range: 76 in Puerto Rico and Wyoming to 9,666 in California) and 81,478 infants born (range: 84 in Wyoming to 10,620 in California). Nationally, among women aged 15-44 years, the rate of ART procedures performed was 3,135 per 1 million women. ART use exceeded 1.5 times the national rate in seven states (Connecticut, Illinois, Maryland, Massachusetts, New Jersey, New York, and Rhode Island) and the District of Columbia. ART use rates exceeded the national rate in an additional seven states (California, Delaware, Hawaii, New Hampshire, Utah, Vermont, and Virginia). Nationally, among all ART transfer procedures, the average number of embryos transferred was similar across age groups (1.3 among women aged <35 years, 1.3 among women aged 35-37 years, and 1.4 among women aged >37 years). The national single-embryo transfer (SET) rate among all embryo-transfer procedures was 74.1% among women aged <35 years (range: 28.2% in Puerto Rico to 89.5% in Delaware), 72.8% among women aged 35-37 years (range: 30.6% in Puerto Rico to 93.7% in Delaware), and 66.4% among women aged >37 years (range: 27.1% in Puerto Rico to 85.3% in Delaware). In 2018, ART contributed to 2.0% of all infants born in the United States (range: 0.4% in Puerto Rico to 5.1% in Massachusetts) from procedures performed in 2017 and 2018. Approximately 78.6% of ART-conceived infants were singleton infants. Overall, ART contributed to 12.5% of all multiple births, including 12.5% of all twin births and 13.3% of all triplets and higher-order births. ART-conceived twins accounted for approximately 97.1% (15,532 of 16,001) of all ART-conceived multiple births. The percentage of multiple births was higher among infants conceived with ART (21.4%) than among all infants born in the total birth population (3.3%). Approximately 20.7% (15,532 of 74,926) of ART-conceived infants were twins, and 0.6% (469 of 74,926) were triplets and higher-order multiples. Nationally, infants conceived with ART contributed to 4.2% of all low birthweight (<2,500 g) infants. Among ART-conceived infants, 18.3% were low birthweight compared with 8.3% among all infants. ART-conceived infants contributed to 5.1% of all preterm (gestational age <37 weeks) infants. The percentage of preterm births was higher among infants conceived with ART (26.1%) than among all infants born in the total birth population (10.0%). The percentage of low birthweight among singletons was 8.3% among ART-conceived infants and 6.6% among all infants born. The percentage of preterm births among ART-conceived singleton infants was 14.9% compared with 8.3% among all singleton infants. The percentages of small for gestational age infants was 7.3% among ART-conceived infants compared with 9.4% among all infants. INTERPRETATION: Although singleton infants accounted for the majority of ART-conceived infants, multiple births from ART varied substantially among states and nationally, contributing to >12% of all twins, triplets, and higher-order multiple infants born in the United States. Because multiple births are associated with higher rates of prematurity than singleton births, the contribution of ART to poor birth outcomes continues to be noteworthy. Although SET rates increased among all age groups, variations in SET rates among states and territories remained, which might reflect variations in embryo-transfer practices among fertility clinics and might in part account for variations in multiple birth rates among states and territories. PUBLIC HEALTH ACTION: Reducing the number of embryos transferred and increasing use of SET, when clinically appropriate, can help reduce multiple births and related adverse health consequences for both mothers and infants. Whereas risks to mothers from multiple-birth pregnancy include higher rates of caesarean delivery, gestational hypertension, and gestational diabetes, infants from multiple births are at increased risk for numerous adverse sequelae such as preterm birth, birth defects, and developmental disabilities. Long-term follow-up of ART infants through integration of existing maternal and infant health surveillance systems and registries with data available from NASS might be useful for monitoring adverse outcomes on a population basis.

Assisted Reproductive Technology Surveillance - United States, 2017.

PROBLEM/CONDITION: Since the first U.S. infant conceived with assisted reproductive technology (ART) was born in 1981, both the use of ART and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which eggs or embryos are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Although the majority of infants conceived through ART are singletons, women who undergo ART procedures are more likely than women who conceive naturally to have multiple-birth infants because multiple embryos may be transferred. Multiple births can pose substantial risks for both mothers and infants, including obstetric complications, preterm birth (<37 weeks), and low birthweight (<2,500 g). This report provides state-specific information for the United States (including the District of Columbia and Puerto Rico) on ART procedures performed in 2017 and compares birth outcomes that occurred in 2017 (resulting from ART procedures performed in 2016 and 2017) with outcomes for all infants born in the United States in 2017. PERIOD COVERED: 2017. DESCRIPTION OF SYSTEM: In 1995, CDC began collecting data on ART procedures performed in fertility clinics in the United States as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (Public Law 102-493 [October 24, 1992]). Data are collected through the National ART Surveillance System (NASS), a web-based data collection system developed by CDC. This report includes data from the 50 states, the District of Columbia, and Puerto Rico. RESULTS: In 2017, a total of 196,454 ART procedures (range: 162 in Alaska to 24,179 in California) with at least one embryo transferred were performed in 448 U.S. fertility clinics and reported to CDC. These procedures resulted in 68,908 live-birth deliveries (range: 67 in Puerto Rico to 8,852 in California) and 78,052 infants born (range: 85 in Puerto Rico to 9,926 in California). Nationally, the number of ART procedures performed per 1 million women of reproductive age (15-44 years) was 3,040. ART use rates exceeded the national rate in 14 states (Connecticut, Delaware, District of Columbia, Hawaii, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Rhode Island, Utah, Vermont, and Virginia). ART use exceeded 1.5 times the national rate in seven states (Connecticut, the District of Columbia, Illinois, Maryland, Massachusetts, New Jersey, and New York). Nationally, among all ART transfer procedures, the average number of embryos transferred increased slightly with increasing age (1.3 among women aged <35 years, 1.4 among women aged 35-37 years, and 1.5 among women aged >37 years). This year, single-embryo transfer (SET) rates among all embryo-transfer procedures are presented instead of elective single-embryo transfer procedures previously reported. Nationally, SET rates were 67.3% (range: 38.9% in South Dakota to 90.4% in Delaware), 65.0% (range: 23.6% in Puerto Rico to 89.4% in Delaware), and 60.0% (range: 28.6% in Puerto Rico to 83.1% in Delaware) among women aged <35 years, aged 35-37 years, and aged >37 years, respectively. In 2017, ART contributed to 1.9% of all infants born in the United States (range: 0.4% in Puerto Rico to 5.0% in Massachusetts). Approximately 73.6% of ART-conceived infants were singleton infants. Overall, ART contributed to 14.7% of all multiple births, including 14.7% of all twin infants and 17.3% of all triplets and higher-order infants. ART-conceived twins accounted for approximately 96.5% (18,890 of 19,570) of all ART-conceived infants born in multiple deliveries. The percentage of multiple births was higher among infants conceived with ART (26.4%) than among all infants born in the total birth population (3.4%). Approximately 25.5% of ART-conceived infants were twins, and 0.9% were triplets and higher-order infants. Nationally, infants conceived with ART contributed to 4.5% of all low birthweight (<2,500 g) infants. Among ART-conceived infants, 20.2% had low birthweight, compared with 8.3% among all infants. ART-conceived infants contributed to 5.3% of all preterm (gestational age <37 weeks) infants. The percentage of preterm births was higher among infants conceived with ART (27.8%) than among all infants born in the total birth population (9.9%). The percentage of low birthweight among singletons was 8.1% among ART-conceived infants and 6.6% among all infants born. The percentage of preterm births among ART-conceived singleton infants was 14.0%, compared with 8.1% among all singleton infants. The percentages of small for gestational age infants was 7.6% among ART-conceived infants, compared with 9.9% among all infants. INTERPRETATION: Although singleton infants accounted for the majority of ART-conceived infants, multiple births from ART still contributed to a substantial proportion of all twins, triplets, and higher-order infants born in the United States. Variations in SET rates among states and territories were noted, reflecting variations in embryo-transfer practices among fertility clinics, which might in part account for higher multiple birth from ART observed in some states and territories. PUBLIC HEALTH ACTION: Reducing the number of embryos transferred and increasing use of SET, when clinically appropriate, can help reduce multiple births and related adverse health consequences for both mothers and infants. Because infants from multiple births are at increased risk for numerous adverse sequelae that cannot be ascertained from the data collected through NASS alone, long-term follow-up for ART infants through integration of existing maternal and infant health surveillance systems and registries with data available from NASS might be useful for monitoring adverse outcomes on a population basis.

Comparing fertilization rates from intracytoplasmic sperm injection to conventional in vitro fertilization among women of advanced age with non-male factor infertility: a meta-analysis.

OBJECTIVE: To evaluate the effectiveness of intracytoplasmic sperm injection (ICSI) in improving fertilization rates compared to conventional in vitro fertilization rates (IVF) among women aged ≥38 years with a non-male factor diagnosis. DESIGN: Systematic review and meta-analysis. SETTING: Not applicable. PATIENT(S): Women aged ≥38 years with a non-male factor diagnosis receiving IVF or ICSI. INTERVENTION(S): A systematic review of databases including PubMed and Embase was performed. Study protocol was registered at the International Prospective Register of Systematic Reviews. Studies were selected if they compared fertilization rates from ICSI with those from conventional IVF among women aged ≥38 years with a non-male factor infertility diagnosis. A random effects model was used. Meta-analysis of Observational Studies in Epidemiology guidelines were applied. MAIN OUTCOME MEASURE(S): Fertilization rate. RESULTS: Seven studies including 8796 retrieved oocytes (ICSI: 4,369; IVF: 4,427) with mean female age ≥38 years met the inclusion criteria. There was no significant difference in fertilization rates between ICSI and conventional IVF (relative risk [RR] 0.99, 95% confidence interval [CI] 0.93-1.06; P = .8). Heterogeneity was observed between studies (I2 = 58.2; P < .05). Heterogeneity was significant (I2 = 57.1; P < .05) when cycles with prior fertilization failure were excluded; however, when analysis was restricted to poor responders (RR 1.01, 95% CI 0.97-1.05; P = .6), heterogeneity was no longer significant (I2 = 0.0; P = .5). CONCLUSIONS: No difference was found in fertilization rates between conventional IVF and ICSI. Further studies are needed to assess the impact of ICSI in this population, controlling for other indications such as preimplantation genetic testing.

Assisted Reproductive Technology Surveillance - United States, 2016.

PROBLEM/CONDITION: Since the first U.S. infant conceived with assisted reproductive technology (ART) was born in 1981, both the use of ART and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which eggs or embryos are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Although the majority of infants conceived through ART are singletons, women who undergo ART procedures are more likely than women who conceive naturally to deliver multiple-birth infants. Multiple births pose substantial risks for both mothers and infants, including obstetric complications, preterm delivery (<37 weeks), and low birthweight (<2,500 g). This report provides state-specific information for the United States (including the District of Columbia and Puerto Rico) on ART procedures performed in 2016 and compares birth outcomes that occurred in 2016 (resulting from ART procedures performed in 2015 and 2016) with outcomes for all infants born in the United States in 2016. PERIOD COVERED: 2016. DESCRIPTION OF SYSTEM: In 1995, CDC began collecting data on ART procedures performed in fertility clinics 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]). Data are collected through the National ART Surveillance System (NASS), a web-based data collection system developed by CDC. This report includes data from 52 reporting areas (the 50 states, the District of Columbia, and Puerto Rico). RESULTS: In 2016, a total of 197,706 ART procedures (range: 162 in Wyoming to 24,030 in California) with the intent to transfer at least one embryo were performed in 463 U.S. fertility clinics and reported to CDC. These procedures resulted in 65,964 live-birth deliveries (range: 57 in Puerto Rico to 8,638 in California) and 76,892 infants born (range: 74 in Alaska to 9,885 in California). Nationally, the number of ART procedures performed per 1 million women of reproductive age (15-44 years), a proxy measure of the ART use rate, was 3,075. ART use rates exceeded the national rate in 14 reporting areas (Connecticut, Delaware, the District of Columbia, Hawaii, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Utah, and Virginia). ART use exceeded 1.5 times the national rate in nine states, including three (Illinois, Massachusetts, and New Jersey) that also had comprehensive mandated health insurance coverage for ART procedures (i.e., coverage for at least four oocyte retrievals). Nationally, among ART transfer procedures for patients using fresh embryos from their own eggs, the average number of embryos transferred increased with increasing age (1.5 among women aged <35 years, 1.7 among women aged 35-37 years, and 2.2 among women aged >37 years). Among women aged <35 years, the national elective single-embryo transfer (eSET) rate was 42.7% (range: 8.3% in North Dakota to 83.9% in Delaware). In 2016, ART contributed to 1.8% of all infants born in the United States (range: 0.3% in Puerto Rico to 4.7% in Massachusetts). ART also contributed to 16.4% of all multiple-birth infants, including 16.2% of all twin infants and 19.4% of all triplets and higher-order infants. ART-conceived twins accounted for approximately 96.5% (21,455 of 22,233) of all ART-conceived infants born in multiple deliveries. The percentage of multiple-birth infants was higher among infants conceived with ART (31.5%) than among all infants born in the total birth population (3.4%). Approximately 30.4% of ART-conceived infants were twins and 1.1% were triplets and higher-order infants. Nationally, infants conceived with ART contributed to 5.0% of all low birthweight (<2,500 g) infants. Among ART-conceived infants, 23.6% had low birthweight compared with 8.2% among all infants. ART-conceived infants contributed to 5.3% of all preterm (gestational age <37 weeks) infants. The percentage of preterm births was higher among infants conceived with ART (29.9%) than among all infants born in the total birth population (9.9%). The percentage of ART-conceived infants who had low birthweight was 8.7% among singletons, 54.9% among twins, and 94.9% among triplets and higher-order multiples; the corresponding percentages among all infants born were 6.2% among singletons, 55.4% among twins, and 94.6% among triplets and higher-order multiples. The percentage of ART-conceived infants who were born preterm was 13.7% among singletons, 64.2% among twins, and 97.0% among triplets and higher-order infants; the corresponding percentages among all infants were 7.8% for singletons, 59.9% for twins, and 97.7% for triplets and higher-order infants. INTERPRETATION: Multiple births from ART contributed to a substantial proportion of all twins, triplets, and higher-order infants born in the United States. For women aged <35 years, who typically are considered good candidates for eSET, on average, 1.5 embryos were transferred per ART procedure, resulting in higher multiple birth rates than could be achieved with single-embryo transfers. Of the four states (Illinois, Massachusetts, New Jersey, and Rhode Island) with comprehensive mandated health insurance coverage, three (Illinois, Massachusetts, and New Jersey) had rates of ART use >1.5 times the national average. Although other factors might influence ART use, insurance coverage for infertility treatments accounts for some of the difference in per capita ART use observed among states because most states do not mandate any coverage for ART treatment. PUBLIC HEALTH ACTION: Twins account for almost all of ART-conceived multiple births born in multiple deliveries. Reducing the number of embryos transferred and increasing use of eSET, when clinically appropriate, could help reduce multiple births and related adverse health consequences for both mothers and infants. Because multiple-birth infants are at increased risk for numerous adverse sequelae that cannot be ascertained from the data collected through NASS alone, long-term follow-up of ART infants through integration of existing maternal and infant health surveillance systems and registries with data available from NASS might be useful for monitoring adverse outcomes.

Assisted Reproductive Technology Surveillance - United States, 2015.

PROBLEM/CONDITION: Since the first U.S. infant conceived with assisted reproductive technology (ART) was born in 1981, both the use of ART and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which eggs or embryos are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Although the majority of infants conceived through ART are singletons, women who undergo ART procedures are more likely than women who conceive naturally to deliver multiple-birth infants. Multiple births pose substantial risks for both mothers and infants, including obstetric complications, preterm delivery (<37 weeks), and low birthweight (<2,500 g) infants. This report provides state-specific information for the United States (including the District of Columbia and Puerto Rico) on ART procedures performed in 2015 and compares birth outcomes that occurred in 2015 (resulting from ART procedures performed in 2014 and 2015) with outcomes for all infants born in the United States in 2015. PERIOD COVERED: 2015. DESCRIPTION OF SYSTEM: In 1995, CDC began collecting data on ART procedures performed in fertility clinics 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]). Data are collected through the National ART Surveillance System, a web-based data collection system developed by CDC. This report includes data from 52 reporting areas (the 50 states, the District of Columbia, and Puerto Rico). RESULTS: In 2015, a total of 182,111 ART procedures (range: 135 in Alaska to 23,198 in California) with the intent to transfer at least one embryo were performed in 464 U.S. fertility clinics and reported to CDC. These procedures resulted in 59,334 live-birth deliveries (range: 55 in Wyoming to 7,802 in California) and 71,152 infants born (range: 68 in Wyoming to 9,176 in California). Nationally, the number of ART procedures performed per 1 million women of reproductive age (15-44 years), a proxy measure of the ART utilization rate, was 2,832. ART use exceeded the national rate in 13 reporting areas (California, Connecticut, Delaware, the District of Columbia, Hawaii, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Rhode Island, and Virginia). Nationally, among ART transfer procedures in patients using fresh embryos from their own eggs, the average number of embryos transferred increased with increasing age of the woman (1.6 among women aged <35 years, 1.8 among women aged 35-37 years, and 2.3 among women aged >37 years). Among women aged <35 years, the national elective single-embryo transfer (eSET) rate was 34.7% (range: 11.3% in Puerto Rico to 88.1% in Delaware). In 2015, ART contributed to 1.7% of all infants born in the United States (range: 0.3% in Puerto Rico to 4.5% in Massachusetts). ART also contributed to 17.0% of all multiple-birth infants, 16.8% of all twin infants, and 22.2% of all triplets and higher-order infants. The percentage of multiple-birth infants was higher among infants conceived with ART (35.3%) than among all infants born in the total birth population (3.4%). Approximately 34.0% of ART-conceived infants were twins and 1.0% were triplets and higher-order infants. Nationally, infants conceived with ART contributed to 5.1% of all low birthweight infants. Among ART-conceived infants, 25.5% had low birthweight, compared with 8.1% among all infants. ART-conceived infants contributed to 5.3% of all preterm (gestational age <37 weeks) infants. The percentage of preterm births was higher among infants conceived with ART (31.2%) than among all infants born in the total birth population (9.7%). Among singletons, the percentage of ART-conceived infants who had low birthweight was 8.7% compared with 6.4% among all infants born. The percentage of ART-conceived infants who were born preterm was 13.4% among singletons compared with 7.9% among all infants. INTERPRETATION: Multiple births from ART contributed to a substantial proportion of all twins, triplets, and higher-order infants born in the United States. For women aged <35 years, who are typically considered good candidates for eSET, the national average of 1.6 embryos was transferred per ART procedure. Of the four states (Illinois, Massachusetts, New Jersey, and Rhode Island) with comprehensive mandated health insurance coverage for ART procedures (i.e., coverage for at least four cycles of IVF), three (Illinois, Massachusetts, and New Jersey) had rates of ART use exceeding 1.5 times the national rate. This type of mandated insurance coverage has been associated with greater use of ART and likely accounts for some of the difference in per capita ART use observed among states. PUBLIC HEALTH ACTION: Twins account for the majority of ART-conceived multiple births. Reducing the number of embryos transferred and increasing use of eSET when clinically appropriate could help reduce multiple births and related adverse health consequences for both mothers and infants. State-based surveillance of ART might be useful for monitoring and evaluating maternal and infant health outcomes of ART in states with high ART use.

Effects of patient education on desire for twins and use of elective single embryo transfer procedures during ART treatment: A systematic review.

Twin births among users of assisted reproductive technology (ART) pose serious risks to both mothers and infants. However, patients may prefer twins and may be unaware of the risks of twin pregnancies. Increasing use of elective single embryo transfers (eSET) through improved patient education could help to reduce twin births and related adverse health consequences. A systematic review of PUBMED and EMBASE databases was conducted to evaluate the effectiveness of patient education among ART users on knowledge of twin pregnancy risks, desire for twins, preference for or use of eSET, and twin pregnancy rates. Of 187 references retrieved, six met the selection criteria. Most focused on patients undergoing their first ART cycle aged < 35 years. Patient education was delivered via written materials, DVDs or discussion. Four studies reporting on knowledge of risks or desire for twins showed significant effects of oral and written descriptions of multiple pregnancy complications, risks of twins versus singletons, and DVDs with factual information. Five studies showed increased eSET use or preference after patients were educated on the risks of multiple pregnancy and success rates associated with different types of ART procedures, when combined with clinic policies that supported single blastocyst transfers or provided options for insurance. In younger ART users, patient education on twin pregnancy risks and success rates of eSET may improve knowledge of twin pregnancy risks and increase use of eSET, and may be important for wider implementation of eSET in countries such as the USA where the use of eSET remains low. Clinic policies of single blastocyst transfers or financial incentives may strengthen these effects.

Affordability of Fertility Treatments and Multiple Births in the United States.

BACKGROUND: Affordability plays an important role in the utilisation of in vitro fertilisation (IVF) and non-IVF fertility treatments. Fertility treatments are associated with increased risk of multiple births. The objective of this study was to investigate the association between the affordability of fertility treatments across US states and the percentage of multiple births due to natural conception, non-IVF treatments, and IVF, and the association between these percentages and state-specific multiple birth rates. METHODS: State-specific per capita disposable personal income and state-specific infertility insurance mandates were used as measures of affordability. Maternal age-adjusted percentages of multiple births due to natural conception, non-IVF treatments, and IVF were estimated for each state using birth certificate and IVF data. Scatter plots and regression analysis were used to explore associations between state-level measures of affordability, the percentage of multiple births due to natural conception and fertility treatments, and state-specific multiple birth rates. RESULTS: In 2013, age-adjusted contributions of natural conception, non-IVF fertility treatments, and IVF to multiple births in US were 58.2, 22.8, and 19.0% respectively. States with greater affordability of fertility treatments had higher percentages of multiples due to IVF and lower percentages due to natural conception. Higher percentages of multiples due to IVF and lower percentages due to natural conception were associated with higher state-specific multiple birth rates. CONCLUSION: Increasing affordability of fertility treatments may increase state-specific multiple birth rates. Policies and treatment practices encouraging single-gestation pregnancies may help reduce multiple births resulting from these treatments.

Strategies for Preventing HIV Infection Among HIV-Uninfected Women Attempting Conception with HIV-Infected Men - United States.

By the end of 2014, a total of 955,081 persons in the United States (299.5 per 100,000 population) had received a diagnosis of human immunodeficiency virus type 1 (HIV-1) infection (1). The annual estimated number of HIV infections and incidence rate in the United States decreased from 2010 to 2014, and the survival rate has increased over time (1). Effective highly active antiretroviral therapy (HAART) is helping persons with HIV to live longer, healthier lives. Many of these persons, including an unknown percentage in discordant relationships (i.e., one partner is HIV-infected, and the other is HIV-uninfected), might wish to have their own biologic children. When the female partner is HIV-infected and the male partner is not, a discordant couple can undergo autologous sperm intrauterine inseminations to achieve conception without placing the man at risk for infection. However, for HIV-discordant couples in which the man is HIV-infected and the woman is not, strategies to minimize the risk for sexual transmission are needed. In 1988, CDC recommended against insemination with semen from HIV-infected men (2). Since 1988, new information has emerged regarding prevention of HIV transmission in HIV-discordant couples. This report reviews laboratory and epidemiologic information regarding the prevention of HIV transmission for HIV-discordant couples, in which the male is HIV-infected and the female is HIV-uninfected, who would like to attempt conception.

Assisted Reproductive Technology Surveillance - United States, 2014.

PROBLEM/CONDITION: Since the first U.S. infant conceived with assisted reproductive technology (ART) was born in 1981, both the use of ART and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which eggs or embryos are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Women who undergo ART procedures are more likely than women who conceive naturally to deliver multiple-birth infants. Multiple births pose substantial risks to both mothers and infants, including obstetric complications, preterm delivery, and low birthweight infants. This report provides state-specific information for the United States (including the District of Columbia and Puerto Rico) on ART procedures performed in 2014 and compares birth outcomes that occurred in 2014 (resulting from ART procedures performed in 2013 and 2014) with outcomes for all infants born in the United States in 2014. PERIOD COVERED: 2014. DESCRIPTION OF SYSTEM: In 1996, CDC began collecting data on ART procedures performed in fertility clinics in the United States as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (FCSRCA) (Public Law 102-493). Data are collected through the National ART Surveillance System (NASS), a web-based data collection system developed by CDC. This report includes data from 52 reporting areas (the 50 states, the District of Columbia, and Puerto Rico). RESULTS: In 2014, a total of 169,568 ART procedures (range: 124 in Wyoming to 21,018 in California) with the intent to transfer at least one embryo were performed in 458 U.S. fertility clinics and reported to CDC. These procedures resulted in 56,028 live-birth deliveries (range: 52 in Wyoming to 7,230 in California) and 68,782 infants born (range: 64 in Wyoming to 8,793 in California). Nationally, the total number of ART procedures performed per million women of reproductive age (15-44 years), a proxy measure of the ART usage rate, was 2,647 (range: 364 in Puerto Rico to 6,726 in Massachusetts). ART use exceeded the national average in 13 reporting areas (Connecticut, Delaware, the District of Columbia, Hawaii, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Virginia). Eight reporting areas (Connecticut, the District of Columbia, Hawaii, Illinois, Maryland, Massachusetts, New Jersey, and New York) had rates of ART use exceeding 1.5 times the national average. Nationally, among ART transfer procedures in patients using fresh embryos from their own eggs, the average number of embryos transferred increased with increasing age of the woman (1.7 among women aged <35 years, 1.9 among women aged 35-37 years, and 2.3 among women aged >37 years). Among women aged <35 years, who typically are considered to be good candidates for elective single embryo transfer (eSET) procedures, the national eSET rate was 28.5% (range: 4.3% in Puerto Rico to 67.9% in Delaware). In 2014, ART contributed to 1.6% of all infants born in the United States (range: 0.4% in Puerto Rico to 4.7% in Massachusetts) and 18.3% of all multiple-birth infants (range: 5.5% in Alaska and West Virginia to 37.3% in Hawaii), including 18.0% of all twin infants (range: 5.2% in some states to 36.2% in Hawaii) and 26.4% of all triplets and higher-order infants (range: 0% in some states to 65.2% in Hawaii). Percentages of live births that were multiple-birth deliveries were higher among infants conceived with ART (39.4%; range: 11.5% in Delaware to 55.6% in Puerto Rico) than among all infants born in the total birth population (3.5%; range: 2.2% in Puerto Rico to 4.4% in New Jersey). Approximately 38.0% of ART-conceived infants were twin infants, and 2.0% were triplets and higher-order infants. ART-conceived twins accounted for approximately 95.3% of all ART-conceived infants born in multiple deliveries. Nationally, infants conceived with ART contributed to 5.5% of all low birthweight (<2,500 g) infants (range: 1.2% in West Virginia to 14.2% in Massachusetts). Among ART-conceived infants, 27.8% were low birthweight (range: 10.6% in Delaware to 44.4% in Puerto Rico), compared with 8.0% among all infants (range: 5.9% in Alaska to 11.3% in Mississippi). ART-conceived infants contributed to 4.7% of all preterm (<37 weeks) infants (range: 1.2% in Puerto Rico to 13.4% in Massachusetts). Percentages of preterm births were higher among infants conceived with ART (33.2%; range: 18.9% in the District of Columbia to 45.9% in Puerto Rico) than among all infants born in the total birth population (11.3%; range: 8.5% in California to 16.0% in Mississippi). The percentage of ART-conceived infants who were low birthweight was 8.9% (range: 3.2% in some states to 16.1% in Vermont) among singletons and 55.2% (range: 38.5% in Delaware to 77.8% in Alaska) among twins; the corresponding percentages of low birthweight infants among all infants born were 6.3% for singletons (range: 4.6% in Alaska, North Dakota, and Oregon to 9.5% in Puerto Rico) and 55.2% for twins (range: 46.1% in Alaska to 65.6% in Mississippi). The percentage of ART-conceived infants who were preterm was 13.2% (range: 7.5% in Rhode Island to 23.4% in West Virginia) among singletons and 62.2% (range: 33.3% in some states to 81.4% in Mississippi) among twins; the corresponding percentages of preterm infants among all infants were 9.7% for singletons (range: 1.7% in the District of Columbia to 14.2% in Mississippi) and 56.6% for twins (range: 47.2% in Vermont to 66.9% in Wyoming). INTERPRETATION: The percentage of infants conceived with ART varied considerably by reporting area. Multiple births from ART contributed to a substantial proportion of all twins, triplets, and higher-order infants born. Low birthweight and preterm infant birth rates were disproportionately higher among ART-conceived infants than among the overall birth population. Although women aged <35 years are typically considered good candidates for eSET, on average two embryos were transferred per ART procedure with women in this group. Compared with ART-conceived singletons, ART-conceived twins were approximately five times more likely to be born preterm and approximately six times more likely to be born with low birthweight. Singleton infants conceived with ART had higher percentages of preterm birth and low birthweight than all singleton infants born in the United States. ART use per population unit was geographically variable, with 13 reporting areas showing ART use higher than the national rate. Of the four states (Illinois, Massachusetts, New Jersey, and Rhode Island) with comprehensive statewide-mandated health insurance coverage for ART procedures (i.e., coverage for at least four cycles of IVF), three (Illinois, Massachusetts, and New Jersey) had rates of ART use exceeding 1.5 times the national rate. This type of mandated insurance has been associated with greater use of ART and likely accounts for some of the difference in per capita ART use observed among states. PUBLIC HEALTH ACTION: Reducing the number of embryos transferred and increasing use of eSET when clinically appropriate could help reduce multiple births and related adverse health consequences. Because twins account for the majority of ART-conceived multiple births, improved provider practices and patient education and counseling on the maternal and infant health risks of having twins are needed. Although ART contributes to high percentages of multiple births, other factors not investigated in this report (e.g., delayed childbearing and use of non-ART fertility treatments) also contribute to multiple births and warrant further study.

Assisted Reproductive Technology and Birth Defects Among Liveborn Infants in Florida, Massachusetts, and Michigan, 2000-2010.

IMPORTANCE: Use of assisted reproductive technology (ART) has been associated with increased risks for birth defects. Variations in birth defect risks according to type of ART procedure have been noted, but findings are inconsistent. OBJECTIVES: To examine the prevalence of birth defects among liveborn infants conceived with and without ART and to evaluate risks associated with certain ART procedures among ART-conceived infants. DESIGN, SETTING, AND PARTICIPANTS: Used linked ART surveillance, birth certificates, and birth defects registry data for 3 states (Florida, Massachusetts, and Michigan). Methods for ascertaining birth defect cases varied by state. Resident live births during 2000 to 2010 were included, and the analysis was conducted between Feburary 2015 and August 2015. EXPOSURES: Use of ART among all live births and use of certain ART procedures among ART births. MAIN OUTCOME AND MEASURES: Prevalence of selected chromosomal and nonchromosomal birth defects that are usually diagnosed at or immediately after birth. RESULTS: Of the 4 618 076 liveborn infants between 2000 and 2010, 64 861 (1.4%) were conceived using ART. Overall, the prevalence of 1 or more of the selected nonchromosomal defects was 58.59 per 10 000 for ART infants (n = 389) vs 47.50 per 10 000 for non-ART infants (n = 22 036). The association remained significant after adjusting for maternal characteristics and year of birth (adjusted risk ratio [aRR], 1.28; 95% CI, 1.15-1.42). Similar differences were observed for singleton ART births vs their non-ART counterparts (63.69 per 10 000 [n = 218] vs 47.17 per 10 000 [n = 21 251]; aRR, 1.38; 95% CI, 1.21-1.59). Among multiple births, the prevalence of rectal and large intestinal atresia/stenosis was higher for ART births compared with non-ART births (aRR, 2.39; 95% CI, 1.38-4.12). Among ART births conceived after fresh embryo transfer, infants born to mothers with ovulation disorders had a higher prevalence of nonchromosomal birth defects (aRR, 1.53; 95% CI, 1.13-2.06) than those born to mothers without the diagnosis, and use of assisted hatching was associated with birth defects among singleton births (aRR, 1.55; 95% CI, 1.10-2.19). Multiplicity-adjusted P values for these associations were greater than .05. CONCLUSIONS AND RELEVANCE: Infants conceived after ART had a higher prevalence of certain birth defects. Assisted hatching and diagnosis of ovulation disorder were marginally associated with increased risks for nonchromosomal birth defects; however, these associations may be caused by other underlying factors.

Assisted Reproductive Technology Surveillance - United States, 2013.

PROBLEM/CONDITION: Since the first U.S. infant conceived with assisted reproductive technology (ART) was born in 1981, both the use of ART and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which eggs or embryos are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Women who undergo ART procedures are more likely than women who conceive naturally to deliver multiple-birth infants. Multiple births pose substantial risks to both mothers and infants, including obstetric complications, preterm delivery, and low birthweight infants. This report provides state-specific information for the United States (including Puerto Rico) on ART procedures performed in 2013 and compares infant outcomes that occurred in 2013 (resulting from ART procedures performed in 2012 and 2013) with outcomes for all infants born in the United States in 2013. REPORTING PERIOD COVERED: 2013. DESCRIPTION OF SYSTEM: In 1996, CDC began collecting data on ART procedures performed in fertility clinics in the United States as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (FCSRCA) (Public Law 102-493). Data are collected through the National ART Surveillance System (NASS), a web-based data collection system developed by CDC. This report includes data from 52 reporting areas (the 50 states, the District of Columbia [DC], and Puerto Rico). RESULTS: In 2013, a total of 160,521 ART procedures (range: 109 in Wyoming to 20,299 in California) with the intent to transfer at least one embryo were performed in 467 U.S. fertility clinics and were reported to CDC. These procedures resulted in 53,252 live-birth deliveries (range: 47 in Alaska to 6,979 in California) and 66,691 infants (range: 61 in Alaska to 8,649 in California). Nationally, the total number of ART procedures performed per million women of reproductive age (15-44 years), a proxy measure of the ART usage rate, was 2,521 (range: 352 in Puerto Rico to 7,688 in DC). ART use exceeded the national rate in 13 reporting areas (California, Connecticut, Delaware, Hawaii, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Rhode Island, Virginia, and DC). Nationally, among ART transfer procedures in patients using fresh embryos from their own eggs, the average number of embryos transferred increased with increasing age of the woman (1.8 among women aged <35 years, 2.0 among women aged 35-37 years, and 2.5 among women aged >37 years). Among women aged <35 years, who typically are considered to be good candidates for elective single embryo transfer (eSET) procedures, the national eSET rate was 21.4% (range: 4.0% in Idaho to 77.5% in Delaware). In 2013, ART contributed to 1.6% of all infants born in the United States (range: 0.2% in Puerto Rico to 4.8% in Massachusetts) and 18.7% of all multiple-birth infants (range: 4.5% in Puerto Rico to 35.7% in Massachusetts), including 18.5% of all twin infants (range: 4.5% in Mississippi to 35.3% in Massachusetts) and 25.2% of all triplet and higher-order infants (range: 0% in several reporting areas to 51.5% in New Jersey). Multiple-birth deliveries were higher among infants conceived with ART (41.1%; range: 20.4% in Delaware to 61.6% in Wyoming) than among all infants born in the total birth population (only 3.5%; range: 1.8% in Puerto Rico to 4.5% in Massachusetts and New Jersey). Approximately 39% of ART-conceived infants were twin infants, and 2% were triplet and higher-order infants. ART-conceived twins accounted for approximately 95.4% of all ART-conceived infants born in multiple deliveries. Nationally, infants conceived with ART contributed to 5.8% of all low birthweight (<2,500 grams) infants (range: 0.9% in Puerto Rico to 15.1% in Massachusetts). Among ART-conceived infants, 29.1% were low birthweight (range: 18.3% in Delaware to 42.6% in Louisiana), compared with 8.0% among all infants (range: 5.8% in Alaska to 11.5% in Mississippi). ART-conceived infants contributed to 4.6% of all preterm (<37 weeks) infants (range: 0.6% in Puerto Rico to 13.3% in Massachusetts). Preterm birth rates were higher among infants conceived with ART (33.6%; range: 22.3% in DC to 50.7% in Louisiana) than among all infants born in the total birth population (11.4%; range: 8.8% in California to 16.6% in Mississippi). The percentage of ART-conceived infants who were low birthweight was 9.0% (range: 5.1% in Mississippi to 19.7% in Puerto Rico) among singletons and 56.3% (range: 48.3% in Maine to 72.4% in Puerto Rico) among twins; the corresponding percentages among all infants born were 6.3% for singletons (range: 4.6% in Alaska to 9.6% in Mississippi and Puerto Rico) and 55.3% for twins (range: 43.6% in Alaska to 65.6% in Mississippi). The percentage of ART-conceived infants who were preterm varied from 13.3% (range: 8.7% in Rhode Island to 26.9% in West Virginia) among singletons to 61.0% (range: 47.8% in DC to 78.8% in Oklahoma) among twins; the corresponding percentages among all infants were 10.1% for singletons (range: 6.8% in Vermont to 14.8% in Mississippi) and 56.6% for twins (range: 44.7% in New Hampshire to 68.9% in Louisiana). INTERPRETATION: The percentage of infants conceived with ART varied considerably by reporting area. In most reporting areas, multiple births from ART contributed to a substantial proportion of all twins, triplets, and higher-order infants born, and the low birthweight and preterm infant birth rates were disproportionately higher among ART-conceived infants than among the overall birth population. Although women aged <35 years are typically considered good candidates for eSET, on average two embryos were transferred per ART procedure with women in this group, increasing the overall multiple-birth rates in the United States. Compared with ART-conceived singletons, ART-conceived twins were approximately four-and-a-half times more likely to be born preterm, and approximately six times more likely to be born with low birthweight. Singleton infants conceived with ART had slightly higher rates of preterm delivery and low birthweight than all singleton infants born in the United States. ART use per population unit was geographically variable, with 13 reporting areas showing ART use above the national rate. Of the four states (Illinois, Massachusetts, New Jersey, and Rhode Island) with comprehensive statewide-mandated health insurance coverage for ART procedures (i.e., coverage for at least four cycles of IVF), two states (Massachusetts and New Jersey) had rates of ART use exceeding twice the national level. This type of mandated insurance has been associated with greater use of ART and likely accounts for some of the difference in per capita ART use observed among states. PUBLIC HEALTH ACTIONS: Reducing the number of embryos transferred per ART procedure and increasing use of eSET, when clinically appropriate (typically for women aged <35 years), could help reduce multiple births, particularly ART-conceived twin infants, and related adverse consequences of ART. Because twins account for the majority of ART-conceived multiple births, improved patient education and counseling on the maternal and infant health risks of having twins is needed. Although ART contributes to high rates of multiple births, other factors not investigated in this report (e.g., delayed childbearing and non-ART fertility treatments) also contribute to multiple births and warrant further study.

Assisted Reproductive Technology Surveillance ­ United States, 2012.

PROBLEM/CONDITION: Since the first U.S. infant conceived with Assisted Reproductive Technology (ART) was born in 1981, both the use of advanced technologies to overcome infertility and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which eggs or embryos are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Because more than one embryo might be transferred during a procedure, women who undergo ART procedures, compared with those who conceive naturally, are more likely to deliver multiple birth infants. Multiple births pose substantial risks to both mothers and infants, including obstetric complications, preterm delivery, and low birthweight infants. This report provides state-specific information for the United States (including Puerto Rico) on ART procedures performed in 2012 and compares infant outcomes that occurred in 2012 (resulting from ART procedures performed in 2011 and 2012) with outcomes for all infants born in the United States in 2012. PERIOD COVERED: 2012. DESCRIPTION OF SYSTEM: In 1996, CDC began collecting data on ART procedures performed in fertility clinics in the United States, as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (FCSRCA) (Public Law 102-493). Data are collected through the National ART Surveillance System, a web-based data collecting system developed by CDC. This report includes data from 52 reporting areas (the 50 states, the District of Columbia [DC], and Puerto Rico). RESULTS: In 2012, a total of 157,635 ART procedures performed in 456 U.S. fertility clinics were reported to CDC. These procedures resulted in 51,261 live-birth deliveries and 65,151 infants. The largest numbers of ART procedures were performed among residents of six states: California (20,241), New York (19,618), Illinois (10,449), Texas (10,281), Massachusetts (9,754), and New Jersey (8,590). These six states also had the highest number of live-birth deliveries as a result of ART procedures, and together they accounted for 50.1% of all ART procedures performed, 48.3% of all infants born from ART, and 48.3% of all ART multiple live-birth deliveries. Nationally, the total number of ART procedures performed per 1 million women of reproductive age (15-44 years), which is a proxy indicator of ART use, was 2,483. This indicator of ART use exceeded the national ratio in 13 reporting areas (California, Connecticut, Delaware, Hawaii, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Rhode Island, Virginia, and DC) and was more than twice the national ratio in three reporting areas (Massachusetts, New Jersey, and DC). Nationally, among ART cycles with patients using fresh embryos from their own eggs, in which at least one embryo was transferred, the average number of embryos transferred increased with the increasing age of the woman (1.9 among women aged <35 years, 2.2 among women aged 35-40 years, and 2.7 among women aged >40 years). The percentage of elective single-embryo transfer (eSET) procedures varied substantially between reporting areas for all ages. Among women aged <35 years, who are typically considered to be good candidates for eSET procedures, the national eSET rate was 15.3% (range: 2.1% in Oklahoma to 60.4% in Delaware). Overall, ART contributed to 1.5% of all infants born in the United States (range: 0.2% in Puerto Rico to 4.7% in Massachusetts) with the highest rates (≥3.0% of all infants born) observed in four reporting areas (Connecticut, Massachusetts, New Jersey, and DC). Infants conceived with ART comprised 19.6% of all multiple-birth infants (range: 5.5% in Maine to 39.3% in Massachusetts), 19.2% of all twin infants (range: 4.4% in Puerto Rico to 39.1% in Massachusetts), and 29.6% of all triplet or higher order infants (range: 0 in West Virginia to 69.7% in Idaho). Among infants conceived with ART, 43.6% were born in multiple-birth deliveries (range: 18.7% in Delaware to 56.0% in Idaho), compared with only 3.4% among all infants born in the general population (range: 2.1% in Puerto Rico to 4.5% in New Jersey). Approximately 41% of ART-conceived infants were twin infants, and 2% were triplet and higher order infants. Nationally, infants conceived with ART comprised 5.7% of all low birthweight (<2,500 grams) infants (range: 0.8% in Puerto Rico to 15.3% in Massachusetts) and 5.8% of all very low birthweight (<1,500 grams) infants (range: 0 in West Virginia to 15.1% in New Jersey). Overall, among ART-conceived infants, 30.2% were low birthweight (range: 18.8% in DC to 45.1% in New Mexico), compared with 8.0% among all infants (range: 5.6% in Alaska to 11.6% in Mississippi and Puerto Rico); 5.5% of ART infants were very low birthweight (range: 0 in West Virginia to 12.9% in Puerto Rico), compared with 1.4% among all infants (range: 0.9% in Alaska and Idaho to 2.1% in Mississippi). ART-conceived infants comprised 4.6% of all preterm (<37 weeks) infants (range: 0.7% in Puerto Rico to 13.4% in Massachusetts) and 5.2% of all very preterm (<32 weeks) infants (range: 1.0% in Puerto Rico to 14.9% in Vermont). Overall, among infants conceived with ART, 34.9% were born preterm (range: 20.8% in Delaware and DC to 49.4% in Puerto Rico), compared with 11.6% among all infants born in the general population (range: 8.7% in Vermont to 17.1% in Mississippi); 6.5% of ART infants were born very preterm (range: 3.3% in Nevada to 14.8% in South Dakota), compared with 1.9% among all infants born in the general population (range: 1.1% in Vermont to 2.9% in Mississippi). The percentage of infants conceived with ART who were low birthweight varied from 9.3% (range: 4.1% in South Carolina to 20.9% in Puerto Rico) among singletons, to 55.2% (range: 41.5% in New Hampshire to 83.3% in South Dakota) among twins, and 95.3% (range: 85.2% in Oklahoma to 100% in several reporting areas) among triplets or higher-order multiples; comparable percentages for all infants were 6.3% (range: 4.5% in Alaska to 10.3% in Puerto Rico), 55.4% (range: 46.0% in Alaska to 69.0% in Puerto Rico), and 91.6% (range: 80.6% in Missouri to 100% in several reporting areas), respectively. The percentage of ART infants who were preterm varied from 13.2% (range: 9.4% in West Virginia to 25.4% in North Dakota) among singletons, to 61.0% (range: 47.8% in DC to 80.0% in Maine and West Virginia) among twins, and 97.7% (range: 92.7% in Massachusetts to 100% in several reporting areas) among triplets or higher-order multiples; comparable percentages for all infants were 9.9% (range: 7.3% in Vermont to 15.8% in Puerto Rico), 56.8% (range: 47.2% in Connecticut to 67.2% in Puerto Rico), and 92.6% (range: 36.4% in Oregon to 96.8% in Ohio), respectively. INTERPRETATION: The percentage of infants conceived with ART varied considerably by reporting area. In most reporting areas, multiples from ART comprised a substantial proportion of all twin, triplet, and higher-order infants born, and the rates of low birthweight and preterm infants were disproportionately higher among ART infants than in the birth population overall. Among women aged <35 years, eSET procedures warrant consideration because these patients might have extra embryos available for cryopreservation, which is a good predictor of embryo quality, and might have a more favorable prognosis for a live birth than older patients. However, on average, two embryos were transferred per cycle in ART procedures among women aged <35 years, influencing the overall multiple-birth rates in the United States. Compared with ART singletons, ART twins were approximately four and a half times more likely to be born preterm, and approximately six times more likely to be born with low birthweight. Singleton infants conceived with ART had slightly higher rates of preterm delivery and low birthweight than all singleton infants born in the United States. ART use per population unit was geographically varied, with 12 states showing ART use above the national rate. Of the four states (Illinois, Massachusetts, New Jersey, and Rhode Island) with comprehensive statewide-mandated health insurance coverage for ART procedures (e.g., coverage for at least four cycles of in vitro fertilization), two states (Massachusetts and New Jersey) had rates of ART use exceeding twice the national level. This type of mandated insurance has been associated with greater use of ART and might account for some of the difference in per capita ART use observed among states. PUBLIC HEALTH ACTIONS: Reducing the number of embryos transferred per ART procedure and increasing use of eSET, when clinically appropriate (typically age <35 years), might reduce multiple births and related adverse consequences of ART. Improved patient education and counseling on the maternal and infant health risks of having twins are needed given that twins account for the majority of ART-conceived multiple births. Although ART contributes to increasing rates of multiple births, it does not explain all of the increases. Other explanations for multiple births not investigated in this report might include age-related factors and the role of non-ART fertility treatments, and warrant further study.

Embryo transfer practices and perinatal outcomes by insurance mandate status.

OBJECTIVE: To use linked assisted reproductive technology (ART) surveillance and birth certificate data to compare ET practices and perinatal outcomes for a state with a comprehensive mandate requiring coverage of IVF services versus states without a mandate. DESIGN: Retrospective cohort study. SETTING: Not applicable. PATIENT(S): Live-birth deliveries ascertained from linked 2007-2009 National ART Surveillance System and birth certificate data for a state with an insurance mandate (Massachusetts) and two states without a mandate (Florida and Michigan). INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Number of embryos transferred, multiple births, low birth weight, preterm delivery. RESULT(S): Of the 230,038 deliveries in the mandate state and 1,026,804 deliveries in the nonmandate states, 6,651 (2.9%) and 8,417 (0.8%), respectively, were conceived by ART. Transfer of three or more embryos was more common in nonmandate states, although the effect was attenuated for women 35 years or older (33.6% vs. 39.7%; adjusted relative risk [RR], 1.46; 95% confidence interval [CI], 1.17-1.81) versus women younger than 35 (7.0% vs. 26.9%; adjusted RR, 4.18; 95% CI, 2.74-6.36). Lack of an insurance mandate was positively associated with triplet/higher order deliveries (1.0% vs. 2.3%; adjusted RR, 2.44; 95% CI, 1.81-3.28), preterm delivery (22.6% vs. 30.7%; adjusted RR, 1.31; 95% CI, 1.20-1.42), and low birth weight (22.3% vs. 29.5%; adjusted RR, 1.28; 95% CI, 1.17-1.40). CONCLUSION(S): Compared with nonmandate states, the mandate state had higher overall rates of ART use. Among ART births, lack of an infertility insurance mandate was associated with increased risk for adverse perinatal outcomes.

Assisted reproductive technology surveillance--United States, 2011.

PROBLEM/CONDITION: Since the first U.S. infant conceived with Assisted Reproductive Technology (ART) was born in 1981, both the use of advanced technologies to overcome infertility and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which both eggs and embryos 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 because more than one embryo might be transferred during a procedure. Multiple births pose substantial risks to both mothers and infants, including pregnancy complications, preterm delivery, and low birthweight infants. This report provides state-specific information on U.S. ART procedures performed in 2011 and compares infant outcomes that occurred in 2011 (resulting from procedures performed in 2010 and 2011) with outcomes for all infants born in the United States in 2011. REPORTING PERIOD COVERED: 2011. DESCRIPTION OF SYSTEM: In 1996, CDC began collecting data on all ART procedures performed in fertility clinics in the United States as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (FCSRCA) (Public Law 102-493). Data are collected through the National ART Surveillance System (NASS), a web-based data collecting system developed by CDC. RESULTS: In 2011, a total of 151,923 ART procedures performed in 451 U.S. fertility clinics were reported to CDC. These procedures resulted in 47,818 live-birth deliveries and 61,610 infants. The largest numbers of ART procedures were performed among residents of six states: California (18,808), New York (excluding New York City) (14,576), Massachusetts (10,106), Illinois (9,886), Texas (9,576), and New Jersey (8,698). These six states also had the highest number of live-birth deliveries as a result of ART procedures and together accounted for 47.2% of all ART procedures performed, 45.3% of all infants born from ART, and 45.1% of all multiple live-birth deliveries, but only 34% of all infants born 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 use, was 2,401. In 11 states (Connecticut, Delaware, Hawaii, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Rhode Island, and Virginia), the District of Columbia, and New York City, this proxy measure was higher than the national rate, and of these, in three states (Massachusetts, New Jersey, and New York) and the District of Columbia, it exceeded twice the national rate. Nationally, among ART cycles with patients using fresh embryos from their own eggs in which at least one embryo was transferred, the average number of embryos transferred increased with increasing age (2.0 among women aged <35 years, 2.3 among women aged 35-40 years, and 2.9 among women aged >40 years). Elective single-embryo transfer (eSET) rates decreased with increasing age (12.2% among women aged <35 years, 4.7% among women aged 35-40 years, and 0.7% among women aged >40 years). Rates of eSET also varied substantially between states (range: 0.7% in Idaho to 53% in Delaware among women aged <35 years). The number of ART births as a percentage of total infants born in the state is considered as another measure of ART use. Overall, ART contributed to 1.5% of U.S. births (range: 0.2% in Puerto Rico to 4.5% in Massachusetts) with the highest rates (≥3.5% of all infants born) observed in four states (Connecticut, Massachusetts, New Jersey, and New York state), and the District of Columbia. Infants conceived with ART comprised 20% of all multiple-birth infants (range: 4.7% in Puerto Rico to 41.3% in New York state), 19% of all twin infants (range: 4.1% in Mississippi to 39.7% in Massachusetts), and 32% of triplet or higher order infants (range: 0 in several states to 71.4% in Hawaii). Among infants conceived with ART, 45.6% were born in multiple-birth deliveries (range: 23.1% in Delaware to 61.3% in Wyoming), compared with only 3.4% of infants among all births in the general population (range: 1.9% in Puerto Rico to 4.8% in New Jersey). Approximately 43% of ART-conceived infants were twins, and 3% were triplets and higher order infants. Nationally, infants conceived with ART comprised 5.7% of all low birthweight (<2,500 grams) infants (range: 0.6% in Puerto Rico to 15% in Massachusetts) and 5.9% of all very low birthweight (<1,500 grams) infants (range: 0.8% in Mississippi to 17.3% in Massachusetts). Overall, among ART-conceived infants, 31% were low birthweight (range: 18% in District of Columbia to 44.6% in Puerto Rico), compared with 8.1% among all infants (range: 6% in Alaska to 12.5% in Puerto Rico); 5.7% of ART infants were very low birthweight (range: 0 in North Dakota to 8.5% in Hawaii), compared with 1.4% among all infants (range: 0.9% in Alaska to 2.2% in Mississippi). Finally, ART-conceived infants comprised 4.6% of all infants born preterm (<37 weeks; range: 0.5% in Puerto Rico to 13% in Massachusetts) and 5.2% of all infants born very preterm (<32 weeks; range: 0 in Wyoming to 17.1% in Massachusetts). Overall, among infants conceived with ART, 36.2% were born preterm (range: 12.5% in Vermont to 56.9% in Puerto Rico), compared with 11.8% among all infants born in the general population (range: 8.8% in Vermont to 17.6% in Puerto Rico); 6.7% of ART infants were born very preterm (range: 0 in Wyoming to 12.5% in Alaska), compared with 1.9% among all infants born in the general population (range: 1.3% in Wyoming to 3.0% in Puerto Rico). The percentage of infants conceived with ART who were low birthweight varied from 8.8% (range: 3.9% in the District of Columbia to 17.9% in Puerto Rico) among singletons, to 56.4% (range: 34.6% in Vermont to 70.4% in Mississippi) among twins, and 95.7% (range: 79.5% in North Carolina to 100% in several states) among triplets or higher-order multiples; comparable percentages for all infants were 6.4% (range: 4.5% in Idaho and Oregon to 11.3% in Puerto Rico), 56.3% (range: 47.7% in Vermont to 72.1% in Puerto Rico), and 93.9% (range: 50% in Wyoming to 100% in several states), respectively. The percentage of ART infants who were preterm varied from 13.2% (range: 7.3% in the District of Columbia to 28.6% in Puerto Rico) among singletons, to 61.8% (range: 46% in the District of Columbia to 82.7% in Oklahoma) among twins, and 97.1% (range: 76.9% in Iowa to 100% in several states) among triplets or higher-order multiples; comparable percentages for all infants were 10.1% (range:7.5% in Oregon to 16.6% in Puerto Rico), 57.3% (range: 46.8% in New Hampshire to 68.8% in Louisiana), and 93.4% (range: 73.3% in Rhode Island to 100% in several states), respectively. Only nonsuppressed values from reporting areas are provided to protect confidentiality. INTERPRETATION: The percentage of infants conceived with ART varied considerably by state (range: 0.2% to 4.5%). In most states, multiples from ART comprised a substantial proportion of all twin, triplet, and higher-order infants born in the state, and the rates of low birthweight and preterm infants were disproportionately higher among ART infants than in the birth population overall. Even among women aged <35 years, for whom elective single embryo transfers should be considered (particularly in patients with a favorable prognosis), on average, two embryos were transferred per cycle in ART procedures, influencing the overall multiple infant rates in the United States. Compared with ART singletons, ART twins were approximately 5 times more likely to be born preterm, and approximately six times more likely to be low birthweight. Singleton infants conceived with ART had slightly higher rates of preterm delivery and low birthweight than among all singleton infants born in the United States. However, all multiple-birth infants, regardless of whether they were ART-conceived or not, were more likely to be preterm and low birthweight compared with singletons. Further, ART use per population unit was distributed disproportionately in the United States, with 11 states showing ART use above the national rate. Of the four states (Illinois, Massachusetts, New Jersey, and Rhode Island) with comprehensive statewide-mandated health insurance coverage for ART procedures (e.g., coverage for at least four cycles of in vitro fertilization, three states (Illinois, Massachusetts, and New Jersey) also had rates of ART use >1.5 times the national level. This type of mandated insurance has been associated with greater use of ART and might account for the differences in per capita ART use observed among states. PUBLIC HEALTH ACTIONS: Reducing the number of embryos transferred per ART procedure and promoting eSET procedures, when clinically appropriate, are needed to reduce multiple births and related adverse consequences of ART. Improved patient education and counseling on the health risks of having twins might be useful in reducing twin births given that twins account for the majority of ART-conceived multiple births. Although ART contributes to increasing rates of multiple births, it does not explain all of the increases, and therefore other explanations for multiple births not investigated in this report, such as the possible role of non-ART fertility treatments, warrants further study.

Assisted reproductive technology surveillance -- United States, 2010.

PROBLEM/CONDITION: Since the first U.S. infant conceived with Assisted Reproductive Technology (ART) was born in 1981, both the use of advanced technologies to overcome infertility and the number of fertility clinics providing ART services have increased steadily 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 because more than one embryo might be transferred during a procedure. Multiple births pose substantial risks to both mothers and infants, including pregnancy complications, preterm delivery, and low birthweight infants. This report provides state-specific information on U.S. ART procedures performed in 2010 and compares infant outcomes that occurred in 2010 (resulting from procedures performed in 2009 and 2010) with outcomes for all infants born in the United States in 2010. REPORTING PERIOD COVERED: 2010. DESCRIPTION OF SYSTEM: In 1996, CDC began collecting data on all ART procedures performed in fertility clinics in the United States and U.S. territories, as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (FCSRCA) (Public Law 102-493). Data are collected through the National ART Surveillance System (NASS), a web-based data collecting system developed by CDC. RESULTS: In 2010, a total of 147,260 ART procedures performed in 443 U.S. fertility clinics were reported to CDC. These procedures resulted in 47,090 live-birth deliveries and 61,564 infants. The largest numbers of ART procedures were performed among residents of six states: California (18,524), New York (excluding New York City) (14,212), Illinois (10,110), Massachusetts (9,854), New Jersey (8,783), and Texas (8,754). These six states also had the highest number of live-birth deliveries as a result of ART procedures and together accounted for 48.0% of all ART procedures performed, 45.0% of all infants born from ART, and 45.0% of all multiple live-birth deliveries but only 34.0% of all infants born in the United States and U.S. territories. 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 use, was 2,331. In 13 states (California, Connecticut, Delaware, Hawaii, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Virginia), this proxy measure was higher than the national rate, and in four states (Connecticut, Massachusetts, New Jersey, and New York) and the District of Columbia, it exceeded twice the national rate. Nationally, among cycles in which at least one embryo was transferred, the average number of embryos transferred increased with increasing age (2.0 among women aged <35 years, 2.4 among women aged 35-40 years, and 3.0 among women aged >40 years). Elective single-embryo transfer (eSET) rates decreased with increasing age (10.0% among women aged <35 years, 3.8% among women aged 35-40 years, and 0.6% among women aged >40 years). ESET rates also varied substantially between states (range: 0 to 45.0% among women aged <35 years). The number of ART births as a percentage of total infants born in the state or territory is considered as another measure of ART use. Overall, ART contributed to 1.5% of U.S. births (range: 0.1% in Guam to 4.8% in Massachusetts) with the highest rates (>3.5% of all infants born) observed in four states (Connecticut, Massachusetts, New Jersey, and New York), and the District of Columbia. The proportion of ART births was ≤2.5% in the remaining states and territories. Infants conceived with ART comprised 20.0% of all multiple-birth infants (range: 0 in Guam to 40.5% in Massachusetts), 19.0% of all twin infants (range: 0 in Guam to 40.0% in Massachusetts), and 33.0% of triplet or higher order infants (range: 0 in several states to 60.0% in Arizona). Among infants conceived with ART, 46.0% were born in multiple deliveries (range: 0 in Guam to 55.4% in Utah), compared with only 3.0% of infants among all births in the general population (range: 1.3% in Guam to 4.7% in Connecticut). A substantial proportion (43.4%) of ART-conceived infants were twin infants, and a smaller proportion (3.0%) were triplets and higher order infants. Nationally, infants conceived with ART comprised 5.6% of all low birthweight (<2,500 grams) infants (range: 0 in Guam to 16.0% in Massachusetts) and 5.6% of all very low birthweight (<1,500 grams) infants (range: 0 in Guam to 15.8% in Massachusetts). Overall, among ART-conceived infants, 31.6% were low birthweight (range: 22.6% in New Hampshire to 48.2% in Puerto Rico), compared with 8.0% among all infants (range: 5.7% in Alaska to 12.6% in Puerto Rico); 5.6% of ART infants were very low birthweight (range: 1.9% in Maine to 14.3% in Montana), compared with 1.4% among all infants (range: 0.9% in Alaska to 2.3% in the District of Columbia). Finally, ART-conceived infants comprised 4.4% of all infants born preterm (<37 weeks; range: 0 in Guam to 13.3% in Massachusetts) and 4.9% of all infants born very preterm (<32 weeks; range: 0 in Guam to 16.2% in Massachusetts). Overall, among infants conceived with ART, 36.6% were born preterm (range: 23.6% in New Hampshire to 56.8% in Wyoming), compared with 12.0% among all infants born in the general population (range: 8.4% in Vermont to 17.9% in Guam); 6.6% of ART infants were born very preterm (range: 0 in Maine to 14.5% in Puerto Rico), compared with 2.0% among all infants born in the general population (range: 1.3% in Alaska to 3.0% in the District of Columbia). INTERPRETATION: The percentage of infants conceived with ART varied considerably by state and territory (range: 0.1% to 4.8%). In most states, multiples from ART comprised a substantial proportion of all twin, triplet, and higher-order infants born in the state, and the rates of low birthweight and preterm infants were disproportionately higher among ART infants than in the birth population overall. Even among women aged <35 years, for whom single embryo transfers should be considered (particularly in patients with a favorable prognosis) according to American Society of Reproductive Medicine (ASRM) guidelines, on average, two embryos were transferred per cycle in ART procedures, influencing the overall multiple infant rates in the United States. ART use per population unit was distributed disproportionately in the United States, with only 13 states showing ART use above the national rate, which might suggest barriers to ART services in the remaining states. Of the four states (Illinois, Massachusetts, New Jersey, and Rhode Island) with comprehensive statewide-mandated health insurance coverage for ART procedures (e.g., coverage for at least four cycles of IVF), three states (Illinois, Massachusetts, and New Jersey) also had rates of ART use >1.5 times the national level. This type of mandated insurance has been associated with greater use of ART and might account for the differences observed in other states. PUBLIC HEALTH ACTIONS: Reducing the number of embryos transferred per ART procedure among all age groups and promotion of eSET procedures, when clinically appropriate, is needed to reduce multiple births, including twin births, and related adverse consequences of ART. Improved patient education and counseling on the risks of twins might be useful in reducing twin births because twins account for the majority of multiples. Although ART contributes to increasing rates of multiple births, it does not explain all of the increases, and therefore the possible role of non-ART fertility treatments warrants further study.

States Monitoring Assisted Reproductive Technology (SMART) Collaborative: data collection, linkage, dissemination, and use.

Assisted reproductive technology (ART) refers to fertility treatments in which both eggs and sperm are handled outside the body. The Centers for Disease Control and Prevention (CDC) oversees the National ART Surveillance System (NASS), which collects data on all ART procedures performed in the United States. The NASS, while a comprehensive source of data on ART patient demographics and clinical procedures, includes limited information on outcomes related to women's and children's health. To examine ART-related health outcomes, CDC and three states (Massachusetts, Florida, and Michigan) established the States Monitoring ART (SMART) Collaborative to evaluate maternal and perinatal outcomes of ART and improve state-based ART surveillance. To date, NASS data have been linked with states' vital records, disease registries, and hospital discharge data with a linkage rate of 90.2%. The probabilistic linkage methodology used in the SMART Collaborative has been validated and found to be both accurate and efficient. A wide breadth of applied research within the Collaborative is planned or ongoing, including examinations of the impact of insurance mandates on ART use as well as the relationships between ART and birth defects and cancer, among others. The SMART Collaborative is working to improve state-based ART surveillance by developing state surveillance plans, establishing partnerships, and conducting data analyses. The SMART Collaborative has been instrumental in creating linked datasets and strengthening epidemiologic and research capacity for improving maternal and infant health programs and evaluating the public health impact of ART.

Assisted reproductive technology surveillance--United States, 2009.

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 years, 2.5 among women aged 35-40 years, and 3.0 among women aged >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 years, 3% among women aged 35-40 years, and 0.5% among women aged >40 years. The highest rates of eSET were observed among women aged <35 years (41% in Delaware, 20% in Iowa, and 17% Massachusetts). 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 (<2,500 grams) infants, ranging from 1.3% in Mississippi to 15% in Massachusetts and to 6% of all very low birthweight (<1,500 grams) infants, ranging from 1% in Alaska to 15% in New Jersey. Overall, among ART-conceived infants, 32% were low birthweight (ranging from 20% in Alaska to 48% in Puerto Rico), compared with 8% among the general birth population (ranging from 5.8% in South Dakota to 12.2% in Mississippi), and 6% of ART infants were very low birthweight (ranging from 1.5% in Alaska to 13% in South Dakota), compared with 1% among the general birth population (ranging from 1% in Alaska to 2% in Mississippi and District of Columbia). Finally, ART-conceived infants accounted for 3.9% of all preterm (<37 weeks; range: 0.5% in Puerto Rico to 11.1% in Massachusetts) and 4.5% of all very preterm births (<32 weeks; range: 0.5% in Puerto Rico to 12% in New York). Overall, among infants conceived with ART, 33.4% were born preterm (ranging from 21.3% in Vermont to 47.1% in Wyoming), compared with 12.2% of the general birth population (ranging from 9.3% in Vermont to 18.0% in Mississippi), and 6.1% of ART infants were very preterm births (ranging from 1.5% in Alaska to 14.7% in South Dakota), compared with 2% among the general birth population (ranging from 1.4% in Alaska, Oregon, Utah, and Washington to 3% in Mississippi). 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.

Assisted reproductive technology surveillance--United States, 2006.

PROBLEM/CONDITION: Assisted Reproductive Technology (ART) includes fertility treatments in which both eggs and sperm are handled in the laboratory (i.e., in vitro fertilization and related procedures).Patients who undergo ART procedures are more likely to deliver multiple-birth infants than women who conceive naturally. Multiple births are associated with increased risk for mothers and infants (e.g., pregnancy complications, premature delivery, low-birthweight infants, and long-term disability among infants). This report presents the most recent national data and state-specific results. REPORTING PERIOD COVERED: 2006. DESCRIPTION OF SYSTEM: In 1996, CDC initiated data collection regarding 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]). Beginning with 2004, CDC has contracted with Westat, Inc., a statistical survey research organization, to obtain data from ART medical centers in the United States. Westat, Inc., maintains the National ART Surveillance System (NASS), CDC's web-based data collection system. RESULTS: In 2006, a total of 138,198 ART procedures were reported to CDC. These procedures resulted in 41,343 live-birth deliveries, and 54,656 infants. ART procedures are categorized into four major procedure types: procedures that used embryos from freshly fertilized eggs (fresh embryos) from the patient's eggs (72%); procedures that used thawed embryos from the patient's eggs (16%); procedures that used fresh embryos from donor eggs (8%); and procedures that used thawed embryos from donor eggs (4%). Overall, 44% of ART transfer procedures resulted in a pregnancy, and 36% in a live-birth delivery (delivery of one or more live-born infants). Live-birth rates were generally higher among ART procedures that used fresh embryos from donor eggs (54%) than among other types. The highest numbers of ART procedures were performed among residents of California (18,886); New York (13,259); Illinois (9,594); New Jersey (9,237); and Massachusetts (8,305). All five states reported the highest number of live-birth deliveries as a result of ART. Of 54,656 infants born through ART, 48% were multiple-birth deliveries. The risk for a multiple-birth delivery was highest for women who underwent ART transfer procedures that used fresh embryos from either donor eggs (39%) or their own eggs (31%). Approximately 1% of U.S. infants born in 2006 were conceived through ART. Those infants accounted for 18% of multiple births nationwide. Approximately 9% of ART singletons, 57% of ART twins, and 96% of ART triplets or higher-order multiples were low birthweight. Similarly, 14% of ART singletons, 65% of ART twins, and 97% of ART triplets or higher-order multiples were born preterm. INTERPRETATION: Whether an ART procedure resulted in a pregnancy and live-birth delivery varied, according to different patient and treatment factors. ART poses a major risk for multiple births associated with adverse maternal and infant outcomes (e.g., placenta previa, preterm delivery, cesarean delivery, low birthweight, and infant mortality). This risk varied according to the patient's age, the type of ART procedure performed, the number of embryos available for transfer to the uterus, the number transferred, and the day of transfer (day 3 or 5). PUBLIC HEALTH ACTIONS: ART-related multiple births represent a sizable proportion of all multiple births nationwide and in selected states. To minimize the adverse maternal and child health effects associated with multiple pregnancies, ongoing efforts to limit the number of embryos transferred in each ART procedure should be continued and strengthened. Adverse maternal and infant outcomes (e.g., low birthweight and preterm delivery) associated with ART treatment choices should be explained thoroughly when counseling patients considering ART.

Safe conception for HIV discordant couples through sperm-washing: experience and perceptions of patients in Milan, Italy.

Our research explored the reproductive desires of HIV-negative women and their HIV-positive partners who underwent assisted conception based on sperm-washing and intrauterine insemination in Italy. Twenty-two semi-structured interviews were conducted with former patients (6 women, 5 men and 11 couples). Desire for children, perceived risk from treatment and acceptability of the insemination technique were some of the issues explored. Participants had the treatment for a mean duration of 3.5 years, with a mean number of cycles of 5.3. They were highly motivated to conceive a biological child to bring purpose to their lives, and strongly desired options to conceive safely. Most rejected spontaneous conception. Those who successfully conceived reported a positive impact on their quality of life, fulfilling their desire to be parents and restoring their sense of "normalcy". Participants strongly supported extending assisted conception services to all HIV negative women living with HIV positive partners who wished to become pregnant and felt that withholding such treatment was not ethically justified. They perceived assisted conception services to be a safe and effective alternative to spontaneous conception, and felt that society has a moral obligation to provide such services.

Linking birth and infant death records with assisted reproductive technology data: Massachusetts, 1997-1998.

OBJECTIVES: To link data from the US assisted reproductive technology (ART) registry with the Massachusetts birth-infant death file to create a comprehensive dataset on the circumstances surrounding conception and maternal and infant outcomes for a population of ART-conceived infants. METHODS: The authors sought to link data for 3704 ART-conceived live-born infants from 2703 deliveries in 1997-1998 involving Massachusetts resident mothers who gave birth in Massachusetts, Rhode Island, New Hampshire, or Connecticut to their corresponding Massachusetts birth record using a two-stage algorithm. Maternal and infant dates of birth served as the primary linkage variables. Maternal names for a subset of the ART-conceived infants were obtained and used in the second stage of the algorithm to confirm a sample of records that matched in Stage I, to resolve duplicate matches, and to link unmatched records. RESULTS: In Stage I, 78% of ART deliveries matched with only one Massachusetts record, 2% matched with two records, and 20% remained unmatched. Overall, the complete algorithm using maternal name data for a portion of records yielded an 89% linkage rate. Nearly all of the records that matched during Stage I that were evaluated with maternal name data in Stage II were confirmed as correctly linked. CONCLUSIONS: This project confirms that high-yield data linkage can be achieved in the absence of specific identifiers (e.g., name and social security number). Nonetheless, additional matches were achieved when name data were obtained. This linkage creates the first population-based file in the US capturing detailed information on ART births.