Reports of assisted reproductive technology (ART) use in the United States have more than doubled in the past decade; more than 138,000 procedures were reported in 2006.1
These procedures resulted in 41,343 deliveries of 65,656 infants, comprising an estimated 1.2% of all live births that occurred in 2006 in the U.S. The increased use of ART for conception among people with infertility issues is of interest because of adverse health outcomes reported for ART pregnancies and births. ART has been associated with an increased rate of multiple-gestation pregnancies, which increases risk for preterm delivery, low birthweight (<1,500 grams), infant death, and long-term disability among infant survivors.2–6
ART has also been linked to low birthweight, preterm delivery, and birth defects among single-gestation pregnancies.7–11
Currently, three population-based data sources are available in the U.S. to examine ART prevalence and associated risks: the National ART Surveillance System (NASS), vital records, and the Pregnancy Risk Assessment Monitoring System (PRAMS). Each of these data systems has strengths and limitations. The most well-known source of ART information is NASS, established in response to the Fertility Clinic Success Rate and Certification Act of 1992.12
NASS is a system in which U.S. providers are mandated by Congress to report data annually to the Centers for Disease Control and Prevention (CDC) for all ART treatments performed and all pregnancies and live births resulting from these treatments.1
Because of the federal mandate, the reporting level is high (89% in 2004), and NASS is a near complete source of data on ART treatments in the U.S. However, ART providers typically do not provide prenatal care once a pregnancy is established. While NASS providers actively follow up with women to ascertain pregnancy outcomes, they obtain only limited information on pregnancy and perinatal risks and outcomes. Thus, although NASS has complete data on whether a live birth occurred, the date of birth, plurality, and infant birthweights, it lacks data on specific pregnancy complications and prenatal maternal behaviors such as maternal smoking.
A second source of data is vital records.13
Birth records and fetal death certificates capture information on various maternal medical and behavioral characteristics, pregnancy outcomes, and newborn morbidity and mortality. However, vital records data do not include post-discharge infant care and morbidity. To date, only 19 states have adopted the revised birth certificate that captures data on ART use. Moreover, a recent validity analysis in Massachusetts suggests that the current method of birth certificate reporting based on prenatal care record review likely leads to incomplete data; the sensitivity of ART reporting on the birth certificate was 27%.14
The third data source is PRAMS, an ongoing surveillance system maintained by CDC. PRAMS collects state-specific, population-based data on various maternal attitudes and experiences before, during, and shortly after pregnancy.15
Topics addressed in the PRAMS core questionnaire include barriers to and content of prenatal care, obstetric history, maternal use of alcohol and cigarettes, physical abuse, contraception, economic status, maternal stress, and early infant development and health status. PRAMS offers a unique opportunity to combine vital records data and behavioral survey data. (This surveillance system is further described in the Methods section of this article.)
An ART question was first added to PRAMS in 2000. Examination of this initial ART data item indicated that PRAMS respondents in five states likely overreported use of ART to conceive the index pregnancy. The PRAMS estimated that the number of births resulting from ART was 2.6 times higher than the NASS count based on data from the same states and time period.16
One likely explanation for the discrepancy was that these PRAMS questions lacked specificity on the timing of ART use; thus, some respondents may have reported ART use that occurred many months or years prior to the index pregnancy, even if ART was not the eventual mode of conception. The ART questions were revised in 2004, and different states elected to include the fertility treatment items in their questionnaire. Our analysis attempts to assess and compare estimates of ART use items on the 2004 revision of the PRAMS survey with data from NASS.