IVF in the United States, 2016: 197,706 Procedures, 1.8% of Births — and the Problem of Twins

Assisted reproductive technology (ART) covers fertility treatments in which eggs or embryos are handled in a laboratory — in vitro fertilization (IVF) and related procedures. Since the first U.S. baby conceived with ART was born in 1981, both ART use and the number of clinics offering it have grown steadily. Most ART babies are single births, but women who undergo ART are more likely to have twins or more — and multiple births carry real risks for mothers and babies: obstetric complications, preterm delivery (before 37 weeks) and low birthweight (under 2,500 g).

Under the Fertility Clinic Success Rate and Certification Act of 1992, every U.S. fertility clinic performing ART must report every procedure to CDC, which has collected the data since 1995 through the National ART Surveillance System (NASS). This report covers procedures in 2016 across 52 reporting areas — the 50 states, DC and Puerto Rico — and compares babies born in 2016 with all U.S. births that year.

How much ART

ART clinics by location and number, United States and Puerto Rico, 2016. CDC

Outcomes of ART procedures, 2016. CDC

Where it's used

Nationally there were 3,075 procedures per million women aged 15–44 — a proxy for how widely ART is used. Fourteen areas were above that rate: Connecticut, Delaware, DC, Hawaii, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Utah and Virginia. In nine states use was more than 1.5 times the national rate.

Insurance seems to matter. Four states had comprehensive mandated insurance coverage for ART (at least four egg retrievals): Illinois, Massachusetts, New Jersey and Rhode Island. Three of them — Illinois, Massachusetts and New Jersey — had use above 1.5 times the national rate. Other factors play a part, but because most states require no ART coverage at all, coverage explains some of the difference between states.

Reporting areas by ART use rate, 2016. CDC

Embryos per transfer

For women using fresh embryos from their own eggs, the average number of embryos transferred rose with age:

Women under 35 are generally considered good candidates for elective single-embryo transfer (eSET) — yet their national eSET rate was only 42.7%, ranging from 8.3% in North Dakota to 83.9% in Delaware. Transferring 1.5 embryos on average means more multiple births than single transfers would produce.

Multiples — and their risks

About 30.4% of ART infants were twins and 1.1% triplets or more; twins made up 96.5% (21,455 of 22,233) of ART babies born in multiple deliveries. ART accounted for 16.4% of all U.S. multiple-birth infants — 16.2% of twins and 19.4% of triplets and higher — as well as 5.0% of all low-birthweight infants and 5.3% of all preterm infants.

By plurality:

What should change

Twins make up almost all ART multiple births. Transferring fewer embryos and using single-embryo transfer more often, when clinically appropriate, could cut multiple births and the harm that comes with them for mothers and babies. And because multiple-birth infants face many later problems that NASS alone can't capture, linking NASS with maternal and infant health surveillance systems and registries could allow long-term follow-up of ART children.

Sources

Based on Sunderam S, Kissin DM, Zhang Y, et al., "Assisted Reproductive Technology Surveillance — United States, 2016," MMWR Surveillance Summaries volume 68, number 4, Centers for Disease Control and Prevention; a work of the United States government in the public domain. The report's state-by-state tables are summarized, not reproduced.