Although various definitions have been used for assisted reproductive technology (ART), it generally involves surgically removing eggs from a woman’s ovaries, combining them with sperm in the laboratory, and returning them to the woman’s body or donating them to another woman. ART generally does NOT include treatments in which only sperm are handled (i.e., intrauterine—or artificial—insemination) or procedures in which a woman takes medicine only to stimulate egg production without the intention of having eggs retrieved.
ART has been used in the United States since 1981 to help women become pregnant, most commonly through the transfer of fertilized human eggs into a woman’s uterus (in vitro fertilization). Connecticut now ranks fourth in the country in its per capita use of ART, with a 2010 rate of 5 per 1,000 women aged 15-44 years old.1
ART significantly increases the likelihood of multiple births and low birth weight. In Connecticut during 2010, 43% of ART infants were born in a twin birth, compared to just 5% of all infants in the 2010 cohort.1 Only 2.8% of ART infants were born in a triplet birth,1 and this relatively low percentage among other states in the country is linked to an insurance mandate that limits the number of embryos that can be transferred (Public Act 05-196). An estimated 14% of low birth weight babies born in CT are the result of ART, due in part to the high percentage of twin births that result from ART.1
CDC and the SMART Collaborative
The Centers for Disease Control and Prevention (CDC) Division of Reproductive Health (DRH) monitors all ART procedures performed in the U.S. using the National ART Surveillance System (NASS), a web-based ART reporting system (http://www.cdc.gov/art/SMART.htm
). In 2001, CDC began to establish select partnerships with state health agencies through the States Monitoring Assisted Reproductive Technology (SMART) Collaborative. The Collaborative seeks to strengthen the capacity of states to evaluate ART-related maternal and perinatal outcomes and programs through state-based public health surveillance systems. The SMART Collaborative links information from ART surveillance with birth records, infant and fetal death records, hospital discharge registries, birth defects registries, and cancer registries. The linked data set creates a population-based data registry of ART and non-ART births that can monitor and examine ART pregnancy outcomes.
Connecticut joined the SMART collaborative of three other states (Massachusetts, Michigan, and Florida) in Spring, 2013, and recently received permissions needed at both the CDC Internal Review Board, and DPH Human Investigations Committee
to share record-level vital statistics and hospitalization records with CDC for linkage with its NASS database, for years beginning in 2000 and continuing into the future. In this first phase, the Connecticut annual vital records data have been matched to create longitudinal files that identify each mother and also identify the delivery sets for each mother. Procedures for adding linked newborn hospitalization data are being evaluated and the feasibility of adding newborn hearing screening records is also under review. These data, once linked to the NASS database, will provide a wealth of health information about mothers who have undergone ART, and their babies. The CT SMART team is located within the Health Statistics and Surveillance Section of the DPH.
DPH is currently working with both the state March of Dimes, as well as the Medical Director for the state Medicaid program on ART. These partnerships will ensure that surveillance efforts are incorporated into consumer awareness strategies across the state to encourage the use of elective single embryo transfer (eSET), an ART technique that results in single births with a high success rate. These partnerships will also allow the state to understand the degree to which families of all income levels access ART treatments. DPH is also working in partnership with CDC and a group of other states that offered questions in the 2013 Behavioral Risk Factor Surveillance System about reproductive health, family planning, and infertility. The results of these analyses will help DPH understand the magnitude of infertility in the state, and the choices families make when faced with infertility.
DPH is conducting surveillance in partnership with CDC to better understand the impact of ART on adverse maternal and infant outcomes in the state, and to encourage consumers to choose eSET, when appropriate. DPH also plans to reach out to fertility clinics in the state to explore ways in which eSET can be more fully incorporated into clinical practice.
Participation in the SMART Collaborative is part of a larger initiative within the state to reduce low birth weight and associated infant mortality. Over the past few years, DPH has built momentum and partnerships at the local, county and state levels and is now working with a statewide multi-sector coalition to reduce low birth weight. Reduction of low birth weight is an objective in the State’s Health Improvement Plan,2 and was recently selected by the Commissioner of DPH as one of six priorities in the plan.3
Publications and Presentations
ASTHO webinar on Assisted Reproductive Technology:
Factsheet for General Audiences:
More information about infertility and ART can be found at:
1 Sunderam, S, Kissin, DM, Crawford, S, Anderson, JE, Folger, SG, Jamieson, DJ, Barfield, WD (2013) Assisted reproductive technology surveillance – United States, 2010 MMWR Vol 62(ss09):1-24 (http://www.cdc.gov/mmwr/pdf/ss/ss6209.pdf), accessed on June 9, 2014.