State-Specific Assisted Reproductive Technology Surveillance

In 2016, 1.8% of all infants born in the United States were conceived with the use of assisted reproductive technology (ART). ART is defined as fertility treatments where eggs or embryos are handled for the purpose of establishing a pregnancy. The most common type of ART is in vitro fertilization (IVF). Although ART-conceived infants accounted for a small proportion of all infants born, ART contributed to 16.4% of all multiple infants (such as twins, triplets, etc.) born in the United States.

Use of ART, embryo transfer practices, and outcomes of ART-conceived births vary by state. For example, in 2016, the proportion of ART-conceived infants among all infants ranged from 0.3% in Puerto Rico to 4.7% in Massachusetts, and rates of ART-conceived multiple infants ranged from 13.9% in Delaware to 55.0% in North Dakota. State-based ART surveillance is vital for monitoring variations among states in ART use, practice, and outcomes such as multiple birth rates and prematurity. State-specific data can help policy makers develop targeted risk-reduction interventions related to ART. CDC annually publishes a state-specific surveillance summary using data from National ART Surveillance System (NASS) and National Vital Statistics System (NVSS)  as data become available.

Assisted Reproductive Technology Use

Two measures of ART use are 1) the proportion of ART among all infants born in a particular reporting area and 2) the number of ART procedures performed per 1 million women of reproductive age (15 to 44 years). In 2016, both measures of ART use showed substantial variations by reporting areas in the United States.

Proportion of ART infants among all infants born, 2016

Map showing Proportion of ART use among all infants born, 2016 - Nationally, ART accounted for 1.8% of all infants born in the United States. The proportion of ART use among all infants born was highest in Massachusetts (4.7%), Connecticut and New Jersey (3.9%). The proportion of ART among all infants born was lowest in Puerto Rico (0.3%), New Mexico (0.4%), and Arkansas and Mississippi (0.6%).
  • Nationally, ART accounted for 1.8% of all infants born in the United States.
  • The proportion of ART use among all infants born was highest in Massachusetts (4.7%), Connecticut and New Jersey (3.9%).
  • The proportion of ART among all infants born was lowest in Puerto Rico (0.3%), New Mexico (0.4%), and Arkansas and Mississippi (0.6%).

ART procedures performed per 1 million women of reproductive age (15 to 44 years), 2016

Map showing Proportion of ART use among all infants born, 2016 - Nationally, ART accounted for 1.8% of all infants born in the United States. The proportion of ART use among all infants born was highest in Massachusetts (4.7%), Connecticut and New Jersey (3.9%). The proportion of ART among all infants born was lowest in Puerto Rico (0.3%), New Mexico (0.4%), and Arkansas and Mississippi (0.6%).
  • The national rate of ART use was 3,075 procedures performed per 1 million women of reproductive age (15 to 44 years).
  • Fourteen reporting areas—Connecticut, Delaware, the District of Columbia, Hawaii, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Utah, and Virginia—had ART use rates higher than the national rate.
  • Three reporting areas—Massachusetts, New Jersey, and the District of Columbia—had rates exceeding twice the national level.
  • Some states have passed insurance mandates requiring private insurers to cover at least two ART treatment cycles. This type of mandated insurance coverage has been associated with greater use of ART, and may explain some of the differences in ART use among states.

Assisted Reproductive Technology Practice

Women who undergo ART procedures are more likely to deliver multiple-birth infants than women who conceive naturally. This is because more than one embryo may be transferred during an ART procedure. Guidelinespdf iconexternal icon issued by American Society of Reproductive Medicine (ASRM) and Society of Assisted Reproductive Technology (SART) in 2017 focused on promoting single-embryo transfer where medically feasible, especially among younger women. Elective single embryo transfer (eSET) rates (transfer of one embryo, selected from a larger number of available embryos) in the United States varied among states.

Elective single embryo transfer rates among women <35 years, 2016

Map showing elective single embryo transfer rates (< 35 years), 2016 - In thirteen reporting areas—Delaware, Iowa, Maine, Maryland, Massachusetts, Mississippi, Montana, New Hampshire, New Jersey, Rhode Island, Virginia, Washington, and the District of Columbia—eSET rates among women younger than 35 years were greater than 50%.
  • Nationally, the eSET rate among women younger than 35 years using their own fresh eggs was 42.7%.
  • In thirteen reporting areas—Delaware, Iowa, Maine, Maryland, Massachusetts, Mississippi, Montana, New Hampshire, New Jersey, Rhode Island, Virginia, Washington, and the District of Columbia—eSET rates among women younger than 35 years were greater than 50%.

Assisted Reproductive Technology and Multiple Births

ART infants were less likely to be singletons (68.5%), and more likely to be multiples (31.5%) compared with all infants born in the general population (96.6% and 3.4%, respectively). A substantial proportion (96.5%) of ART-conceived multiple infants were twins, and a smaller proportion (3.5%) were triplets and higher-order infants. Nationally, ART contributed to 16.4% of all multiples born in the United States, even though ART infants accounted for only 1.8% of all infants born in the United States.

Percentage of multiple-birth infants among ART infants, 2016

Map showing Percentage multiple-birth infants from ART, 2016 -ART infants were less likely to be singletons (68.5%), and more likely to be multiples (31.5%) compared with all infants born in the general population (96.6% and 3.4%, respectively). A substantial proportion (96.5%) of ART-conceived multiple infants were twins, and a smaller proportion (3.5%) were triplets and higher-order infants. Nationally, ART contributed to 16.4% of all multiples born in the United States, even though ART infants accounted for only 1.8% of all infants born in the United States.
  • The percentage of multiple-birth infants conceived with ART was 31.5%.
  • ART-conceived multiple infant rates were highest in North Dakota (55%) and lowest in Delaware (13.9%).
  • Nationally, ART-conceived infants accounted for 16.4% of all multiple-birth infants.

Assisted Reproductive Technology and Preterm (<37 weeks of gestation) Births

ART-conceived infants were three times more likely to be born preterm (29.9%) than all infants (9.9%) born in the general population. In 2012, the societal economic costs associated with ART-conceived preterm infants in the United States were estimated at approximately $1.3 billion. Even among singletons, the rate of preterm infants was higher among ART-conceived infants (13.7%) than among all infants (7.8%).

Proportion of ART preterm infants among all preterm infants, 2016

Map showing Proportion of ART preterm infants among all preterm infants, 2016 -ART-conceived infants were three times more likely to be born preterm (29.9%) than all infants (9.9%) born in the general population. In 2012, the societal economic costs associated with ART-conceived preterm infants in the United States were estimated at approximately $1.3 billion. Even among singletons, the rate of preterm infants was higher among ART-conceived infants (13.7%) than among all infants (7.8%).
  • Nationally, ART-conceived infants accounted for 5.3% of all infants born preterm.
  • In three reporting areas—Connecticut, Massachusetts, and New Jersey—more than 10% of all infants born preterm were conceived with ART.
  • The contribution of ART-conceived preterm infant rates was highest in Massachusetts (12.3%) and lowest in Puerto Rico (0.7%).