Access to assisted reproductive technology centers in the United States

Transcription

1 Access to assisted reproductive technology in the United s Ajay K. Nangia, M.B.B.S., a Donald S. Likosky, Ph.D., b,c and Dongmei Wang, M.S. c a Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon; b Department of Surgery and c The Dartmouth Institute for Health Policy and Clinical Practice, and Community & Family Medicine, Dartmouth Medical School, Hanover, New Hampshire Objective: To describe the disparity of assisted reproductive technology (ART) in the United s as they relate to residential locations of populations in their reproductive years and state-mandated coverage for infertility services. Design: Cross-sectional study. Setting: reproductive years (women years; men years) based on US Census 2000 data. Assisted reproductive technology registered with the Society for Assisted Technology (SART) in Main Outcome Measure(s): s within service area served by in- state ART as defined by a 60-minute travel time along road networks from each center. Result(s): Service areas for 387 of 390 ART were calculated. Fourteen states had some form of mandated coverage. Underserved states included Alaska, Montana, Wyoming, and West Virginia. The northeastern United s had the greatest percentage of overserved population with 66% 100% study population within 60 minutes of an ART center. Female age stratification showed the highest age group (35 44 years) per state in northern New England and the youngest in Utah and District of Columbia. Median total study population within 60 minutes of an ART center in their own state was higher in mandated versus nonmandated states. Conclusion(s): Disparity of access to care for infertility services exists from the standpoint of population service areas for ART and state-mandated coverage. Female age stratification may help anticipate future need for services with existing resource distribution. (Fertil Steril Ò 2010;93: Ó2010 by American Society for Medicine.) Key Words: ART, SART, population, service areas, mandated coverage Infertility for a couple in the United s is defined as the inability to achieve a pregnancy within 1 year of unprotected intercourse. Nearly 85% of couples achieve a pregnancy in this time frame, leaving 15% of couples potentially seeking reproductive assistance (1, 2). The 2002 National Survey of Family Growth showed that among 62 million women of reproductive age (15 44 years), 1.2 million (2%) had an infertility-related medical appointment within the previous year. An additional 7.4% of women in the survey were infertile (3). Assisted reproductive technology (ART), which has been available since 1981, is the leading surgical treatment for couples diagnosed with infertility. Assisted reproductive technology refers to all fertility treatments in which both egg and sperm are handled. The ART includes IVF and related technologies. These procedures involve surgical egg retrieval from the ovaries and laboratory handling of the Received July 9, 2008; revised October 15, 2008; accepted October 17, 2008; published online December 10, A.K.N. has nothing to disclose. D.S.L. has nothing to disclose. D.W. has nothing to disclose. Supported by an academic grant, Department of Surgery, Dartmouth- Hitchcock Medical Center, Lebanon, New Hampshire. Reprint requests: Ajay K. Nangia, M.B.B.S., F.A.C.S., Dept. of Urology, MS3016, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS (FAX: ; anangia@kumc. edu). egg and sperm with transfer of the embryo back into the female partner or donated. As mandated by the 1992 Fertility Clinic Success Rate and Certification Act (FCSRCA), the Center for Disease Control (CDC) has monitored and publicly reported the performance of ART, specifically IVF practices, including pregnancies, deliveries, and multiple births. Although for many couples ART offers the only viable opportunity for having children without seeking adoption, finances and transportation proximity have prevented many from accessing these services. Until recently, insurance coverage for ART/infertility services has not been available to couples. In 2005, there were 14 states that mandated partial or complete ART coverage be included in insurance packages (4). The effect of this insurance status has also not been studied in relation to the supply of ART and populations likely to consume such services. In addition, the number and location of providing ART in relation to the distribution of those most likely needing these resources has not been the focus of research to date. The effect of this insurance status has also not been studied in relation to the supply of ART and populations likely to consume such services. The objectives of our study were twofold: [1] describe the spatial disparity of ART based on their location in relation to the male and female populations in their reproductive years, and [2] identify any association between state /10/$36.00 Fertility and Sterility â Vol. 93, No. 3, February doi: /j.fertnstert Copyright ª2010 American Society for Medicine, Published by Elsevier Inc.

2 mandated coverage for infertility services and number and location of ART. We hypothesize that higher potential populations in their reproductive years and potential need correlate with higher numbers of ART services. We also hypothesize that rational distribution of infertility care secondary to mandated status should result in the placement of ART in proximity to populations in their reproductive years. FIGURE 1 Diagrammatic representation of service areas for assisted reproductive technology (ART) (60 minutes driving distance from each ART center) and methodology to define population served by in and out-of-state ART center service areas. MATERIALS AND METHODS Databases The 2000 US Census estimates by sex and age groups for the reproductive years (women years and men years) and defined as the study populations, were calculated from block group and county level (aggregated from census block groups). The ART registered with the Society for Assisted Technology (SART) in 2005 were retrieved from the website org. Street network and speed limit data from ESRI/Geographic Data Technologies (now TeleAtlas) was used. Analytical Tools Geographic Information System (GIS) software ArcGIS 9.2 and Network Analyst Extension of ArcGIS 9.1 by Environmental System Research Institute () was used to map. Sixty-minute travel distances from were calculated using US highways and major roads Environmental System Research Institute /TeleAtlas ( com). The software programs MS Access and Excel were used to compile data tables. Analysis Methods s with partial or complete mandated insurance coverage for ART services in 2005 were identified and stratified versus nonmandated states. The male and female study populations and the total male and female state population (all ages) were calculated from the 2000 Census data and tabulated for each state. All the ART included in the 2005 SART database were located geographically based on their full street addresses. ArcGIS 9.2 and Environmental System Research Institute /TeleAtlas street network data were used to process the addresses and calculate coordinates of the points representing the locations of the ART. Some manual process was involved to locate approximately 15% of the addresses. The US Census data were used to calculate and describe study populations per ART center within each state. Driving distance within 60 minutes from each ART center was calculated exclusive of the three ART located in Puerto Rico, due to inadequate road mapping. Driving distance was calculated using data of street networks and speed limits for all the road segments that could be reached within a 60-minute travel time from the exact address of the ART. All the road segments reached from one ART center Nangia. Access to ART in the United s. Fertil Steril were then generalized into an area, which defined an ART service area. This step used the Network Analyst extension (module) of ArcGIS 9.1. Service areas were overlaid on top of census block groups. Census block groups touched by the ART service areas were considered as being served by these ART. These populations were aggregated for each state, thereby determining the total populations served by ART within a state. The proportion of each state the reproductive years ART services within a 60-minute driving distance was calculated. In addition, the proportion of a state s population served by in- and out-of-state ART was determined (Fig. 1). The female study population per state was stratified by age, as permitted by the 2000 Census database: 20; 21; 22 24; 25 29; 30 34; 35 39; and years old. Statistical Methods Comparisons of means and medians by mandated status were performed using the t-test and Wilcoxon rank sum test (Stata 10.0, College Station, TX). RESULTS The SART database for 2005 identified 390 ART in the United s and its territories. The 60-minute service areas were calculated for 387. Three ART located in Puerto Rico were excluded from analyses due to this territory s inadequate road maps. In 2005, 14 states had partial or complete state-mandated insurance coverage for ART 746 Nangia et al. Access to ART in the United s Vol. 93, No. 3, February 2010

3 TABLE 1 the reproductive years and number of assisted reproductive technology (ART) by insurance-mandated status for ART services. status in state Number of ART Arkansas AR 1,021,661 1 California CA 14,248, Connecticut CT 1,344,132 6 Hawaii HI 490,875 4 Illinois IL 5,076, Maryland MD 2,169,901 7 Massachusetts MA 2,619,091 8 Montana MT 340,506 0 New Jersey NJ 3,402, New York NY 7,725, Ohio OH 4,465, Rhode Island RI 419,151 1 Texas TX 8,725, West Virginia WV 691,564 1 Median 2,394,496 8 Not mandated Alabama AL 1,748,501 5 Alaska AK 271,364 0 Arizona AZ 2,037, Colorado CO 1,874,094 7 Delaware DE 314,606 1 District of Columbia DC 260,007 4 Florida FL 6,027, Georgia GA 3,523,509 7 Idaho ID 502,685 1 Indiana IN 2,435, Iowa IA 1,119,282 2 Kansas KS 1,055,915 5 Kentucky KY 1,638,757 1 Louisiana LA 1,772,314 5 Maine ME 490,492 1 Michigan MI 3,967, Minnesota MN 2,003,604 5 Mississippi MS 1,113,156 1 Missouri MO 2,189,473 7 Nebraska NE 668,488 2 Nevada NV 829,718 4 New Hampshire NH 498,907 1 New Mexico NM 701,080 1 North Carolina NC 3,355,761 9 North Dakota ND 249,745 1 Oklahoma OK 1,341,408 3 Oregon OR 1,362,436 3 Pennsylvania PA 4,703, South Carolina SC 1,606,792 4 South Dakota SD 286,608 1 Tennessee TN 2,306,198 7 Utah UT 917,804 2 Vermont VT 238,861 1 Virginia VA 2,974, Washington WA 2,431,911 8 Wisconsin WI 2,139,603 7 Wyoming WY 192,725 0 Median 1,362,436 4 Nangia. Access to ART in the United s. Fertil Steril Fertility and Sterility â 747

4 services. California had the greatest number of ART (n ¼ 49) among states with mandated insurance, whereas Florida had the most (n ¼ 25) among states without mandated coverage. Three states had no ART Alaska (nonmandated), Wyoming (nonmandated), and Montana (mandated). The median number of ART was higher, albeit not significantly, among mandated (n ¼ 8) versus nonmandated (n ¼ 4) states (P¼0.10). As a percentage of the total state populations, total population in the reproductive years ranged between 38% and 42% (median 40%) for mandated states, with the highest shared by Texas and California and lowest in Montana (Table 1, Appendix 1). Among nonmandated states, the proportion ranged from 38% 45% (median 40%), the highest in District of Columbia and lowest shared by South Dakota, Florida, Pennsylvania, Iowa, and South Dakota. These findings were not affected by the state s gender distribution. The total study population (i.e., men plus women in the reproductive years) per ART center is displayed for each state, and stratified by state-mandated coverage status, in Figure 2. In the majority of the states, the study population ranged between 200,000 and 500,000 per ART center, with the median population not significantly different between states with mandated versus nonmandated coverage (P¼0.31). The highest study population density was seen in Kentucky with more than 1.5 million men and women in their reproductive years served per in-state ART center. The lowest density was found in the District of Columbia with 65,000 per center. Neither of the states has mandated insurance coverage for ART. Service Areas Figure 3 shows ART by state, as well as total population density of the study population. s within 60- minute driving distance from each ART center are overlaid. The ART appear well distributed in areas of highest population density, with the greatest disparity in the Midwest states and areas of the Northwest. s without an ART center included Montana, Wyoming, Alaska, most of North Dakota, Nebraska, South Dakota, Kentucky, West Virginia, Nevada, Idaho, and Oregon. Table 2 and Appendix 2 list ART coverage for male and female study populations, stratified by mandated insurance status. The most underserved states, defined as %25% of the total study population of a state within 60 minutes of any ART center, include Alaska, Montana, Wyoming, and West Virginia. Other poorly served states include North and South Dakota with 28% and 36%, respectively. The most overserved states, defined as R95% of the total study group of a state within 60 minutes of any ART center include Connecticut, Massachusetts, New Jersey, Rhode Island, and District of Columbia. All these overserved states, except the District of Columbia, had mandated insurance coverage for infertility. FIGURE 2 the reproductive years per state as a function of the total number of assisted reproductive technology (ART) per state service areas not considered. Each state is colorcoded by insurance coverage status for ART to show clustering of populations served. Nangia. Access to ART in the United s. Fertil Steril Another method of assessing overserved and underserved study populations was to identify the percentage of the population communally/jointly served by in- state ART service areas. This analysis identified that the Northeast of the United s had the most overserved population with 66% 100% of a state study population jointly served. Median total study population within any ART center service area was higher among states with mandated (2,227,330) versus nonmandated (797,781) insurance coverage (P¼.03). Similarly, the median total study population within a 60-minute driving distance of its own state ART was higher in mandated states (2,245,220) versus nonmandated states (777,556) (P<.025). Stratification of female study to age groups revealed that the highest percentage of older women in the reproductive years (35 39 and years) as a proportion of the state female study population (20 44 years) was found in northern New England (New Hampshire, Vermont, and Maine), Arkansas and Montana with 23% 25% of the female study each of these age groups. The youngest female study population stratification was seen in Utah and the District of Columbia. Little variability was seen in the proportion of each age group as a function of the overall female population (i.e., women of all ages) for each state. The female study population served was studied in terms of the 60-minute service areas and also analyzed by the 748 Nangia et al. Access to ART in the United s Vol. 93, No. 3, February 2010

5 FIGURE 3 Assisted reproductive technology (ART) in the United s based on the 2005 SART database overlaid on total population densities in the reproductive years. A driving distance of 60 minutes in all directions (the service area) from each ART center is shown. Nangia. Access to ART in the United s. Fertil Steril different female age stratifications (Table 3). The most women served in the 22 24, 25 29, and year age groups were found in the District of Columbia with the age groups representing 14%, 22%, and 20%, respectively, of the overall women in the reproductive years for that location/state. The highest proportion of female the and year age groups within an ART service area was found in Connecticut, with these age groups each accounting for 24% of the overall female study population for that state. Figure 4 shows wide variability in the percentage of state female the reproductive years (22-44 years) living within 60-minutes of any ART service area. The distribution shows the spread between % for the majority of the states. states had a statistically higher percentage of potential women living in proximity to ART relative to non-mandated states (90 vs. 71%, P¼0.01). DISCUSSION In this cross-sectional study, we found wide variability in the allocation of ART in relationship to populations likely needing those services. Median numbers of ART were higher among states with some form of mandated coverage. ART were located adjacent to a larger study population among mandated states. states had a higher percentage of potential women living within 60-minutes of an ART center relative to non-mandated states. ART has been used to treat patients with infertility in the United s since The SART, an organization of ART providers affiliated with the American Society for Medicine (ASRM), has been collecting data and publishing annual reports of pregnancy success rates from IVF for fertility clinics in the United s and Canada since Since 1995, as a result of the FCSRCA, the CDC has worked in consultation with SART and ASRM to report ART success rates publicly (5). These data undoubtedly are helpful to couples needing these services. However, these aggregate and center-specific data do not reveal potential regional and national disparity in services as a function of their location. Although the relationship between mandated ART insurance status and socioeconomic, educational, and racial discrepancies have been described (6 10), the number and location of ART in relation to the population density/the potential population who may need access to these resources has not been the focus of research to date. Of note, the number of ART needed to service a reproductive population is unknown. Several studies have been performed to investigate travel burden on populations ranging from travel time to general medical and dental care to access to family planning Fertility and Sterility â 749

6 750 Nangia et al. Access to ART in the United s Vol. 93, No. 3, February 2010 TABLE 2 reproductive years and access to assisted reproductive technology (ART) (60 minutes driving distance) by insurance-mandated status for ART services. Living within 60 mins of an ART Center in reproductive years (men and women) within 60 mins of an ART Center in state own state s ART ART in state state s ART in state in state s ART Arkansas AR 379,435 1,021,661 37% 345,130 34% 34,305 3% 0 0% California CA 12,882,984 14,248,648 90% 12,865,215 90% 18,810 0% 1,041 0% Connecticut CT 1,343,122 1,344, % 1,323,442 98% 1,303,298 97% 1,283,618 95% Hawaii HI 363, ,875 74% 363,738 74% 0 0% 0 0% Illinois IL 4,191,069 5,076,530 83% 3,927,468 77% 512,705 10% 249,104 5% Maryland MD 2,003,541 2,169,901 92% 1,956,147 90% 1,930,220 89% 1,882,826 87% Massachusetts MA 2,553,119 2,619,091 97% 2,534,293 97% 1,984,465 76% 1,965,639 75% Montana MT 0 340,506 0% 0 0% 0 0% 0 0% New Jersey NJ 3,376,174 3,402,070 99% 3,375,487 99% 3,304,974 97% 3,304,287 97% New York NY 7,095,852 7,725,464 92% 7,061,679 91% 5,150,581 67% 5,116,408 66% Ohio OH 3,938,244 4,465,190 88% 3,897,321 87% 286,358 6% 245,435 5% Rhode Island RI 418, , % 418, % 334,556 80% 334,556 80% Texas TX 6,226,087 8,725,781 71% 6,177,210 71% 48,877 1% 0 0% West Virginia WV 176, ,564 25% 113,532 16% 62,514 9% 0 0% Median 2,278,330 2,394,496 89% 2,245,220 89% 310,457 10% 247,270 5% Not mandated Alabama AL 797,781 1,748,501 46% 777,556 44% 115,412 7% 95,187 5% Alaska AK 0 271,364 0% 0 0% 0 0% 0 0% Arizona AZ 1,681,205 2,037,807 83% 1,680,706 82% 499 0% 0 0% Colorado CO 1,577,427 1,874,094 84% 1,577,427 84% 0 0% 0 0% Delaware DE 246, ,606 78% 246,032 78% 217,519 69% 217,519 69% District of DC 260, , % 260, % 260, % 260, % Columbia Florida FL 5,526,963 6,027,720 92% 5,526,963 92% 89,562 1% 89,562 1% Georgia GA 2,560,708 3,523,509 73% 2,415,102 69% 176,930 5% 31,324 1% Idaho ID 258, ,685 51% 213,576 42% 44,889 9% 0 0% Indiana IN 1,872,191 2,435,095 77% 1,396,833 57% 492,607 20% 17,249 1% Nangia. Access to ART in the United s. Fertil Steril 2010.

7 Fertility and Sterility â 751 TABLE 2 Continued. Living within 60 mins of an ART Center in reproductive years (men and women) within 60 mins of an ART Center in state own state s ART ART in state state s ART in state in state s ART Iowa IA 592,128 1,119,282 53% 534,325 48% 58,126 5% 323 0% Kansas KS 651,543 1,055,915 62% 651,543 62% 355,820 34% 355,820 34% Kentucky KY 753,422 1,638,757 46% 465,185 28% 296,593 18% 8,356 1% Louisiana LA 1,292,200 1,772,314 73% 1,291,749 73% 451 0% 0 0% Maine ME 266, ,492 54% 266,271 54% 12,218 2% 12,218 2% Michigan MI 3,195,360 3,967,855 81% 3,187,306 80% 761,893 19% 753,839 19% Minnesota MN 1,511,455 2,003,604 75% 1,468,086 73% 43,369 2% 0 0% Mississippi MS 456,386 1,113,156 41% 261,299 23% 195,087 18% 0 0% Missouri MO 1,441,910 2,189,473 66% 1,428,187 65% 483,331 22% 469,608 21% Nebraska NE 404, ,488 60% 404,132 60% 0 0% 0 0% Nevada NV 764, ,718 92% 764,709 92% 0 0% 0 0% New Hampshire NH 393, ,907 79% 79,488 16% 332,979 67% 18,961 4% New Mexico NM 409, ,080 58% 340,324 49% 68,717 10% 0 0% North Carolina NC 2,387,314 3,355,761 71% 2,277,812 68% 115,348 3% 5,846 0% North Dakota ND 70, ,745 28% 70,030 28% 0 0% 0 0% Oklahoma OK 890,784 1,341,408 66% 889,883 66% 901 0% 0 0% Oregon OR 817,969 1,362,436 60% 807,853 59% 10,116 1% 0 0% Pennsylvania PA 3,939,669 4,703,453 84% 3,851,641 82% 2,611,762 56% 2,523,734 54% South Carolina SC 1,238,343 1,606,792 77% 1,116,335 69% 223,293 14% 101,285 6% South Dakota SD 102, ,608 36% 102,396 36% 0 0% 0 0% Tennessee TN 1,895,737 2,306,198 82% 1,895,737 82% 0 0% 0 0% Utah UT 757, ,804 83% 757,655 83% 0 0% 0 0% Vermont VT 191, ,861 80% 136,677 57% 65,245 27% 10,217 4% Virginia VA 2,318,228 2,974,817 78% 2,274,911 76% 980,757 33% 937,440 32% Washington WA 1,960,740 2,431,911 81% 1,787,554 74% 176,686 7% 3,500 0% Wisconsin WI 1,570,566 2,139,603 73% 1,509,187 71% 718,667 34% 657,288 31% Wyoming WY 33, ,725 17% 0 0% 33,182 17% 0 0% Median 797,781 1,362,436 73% 777,556 66% 68,717 7% 3,500 0% Nangia. Access to ART in the United s. Fertil Steril 2010.

8 TABLE 3 Female the reproductive years by state stratified by age and mandated status. female population within 60 minutes of ART center status 20 y 21 y y y y y y Arkansas AR 2% 1% 4% 7% 7% 8% 8% California CA 3% 3% 10% 18% 19% 20% 19% Connecticut CT 3% 3% 9% 16% 21% 24% 24% Hawaii HI 3% 3% 8% 14% 15% 16% 15% Illinois IL 3% 3% 9% 16% 17% 18% 18% Maryland MD 3% 3% 8% 16% 19% 22% 21% Massachusetts MA 4% 3% 10% 18% 20% 22% 21% Montana MT 0% 0% 0% 0% 0% 0% 0% New Jersey NJ 3% 3% 9% 17% 21% 23% 23% New York NY 3% 3% 10% 17% 19% 20% 20% Ohio OH 3% 3% 9% 16% 17% 19% 20% Rhode Island RI 4% 4% 10% 17% 20% 22% 22% Texas TX 3% 3% 8% 14% 14% 15% 15% West Virginia WV 1% 1% 3% 4% 5% 5% 6% Not mandated Alabama AL 2% 2% 5% 9% 9% 10% 10% Alaska AK 0% 0% 0% 0% 0% 0% 0% Arizona AZ 3% 3% 9% 17% 16% 17% 17% Colorado CO 3% 3% 9% 16% 17% 19% 19% Delaware DE 3% 3% 8% 14% 16% 17% 17% District of Columbia DC 5% 4% 14% 22% 20% 18% 17% Florida FL 3% 3% 9% 17% 18% 21% 21% Georgia GA 2% 2% 7% 15% 15% 16% 15% Idaho ID 2% 2% 6% 10% 10% 11% 11% Indiana IN 3% 3% 8% 14% 15% 17% 17% Iowa IA 2% 2% 6% 10% 10% 11% 11% Kansas KS 2% 2% 7% 11% 12% 14% 14% Kentucky KY 2% 2% 5% 9% 9% 10% 10% Louisiana LA 3% 3% 8% 14% 14% 16% 16% Maine ME 2% 2% 5% 9% 11% 13% 13% Michigan MI 3% 3% 8% 15% 16% 18% 18% Minnesota MN 3% 3% 8% 14% 15% 17% 17% Mississippi MS 2% 2% 4% 8% 8% 9% 9% Missouri MO 2% 2% 7% 12% 13% 15% 15% Nebraska NE 3% 3% 7% 12% 11% 13% 13% Nevada NV 3% 3% 10% 18% 19% 20% 19% New Hampshire NH 3% 3% 7% 13% 16% 19% 19% New Mexico NM 2% 2% 6% 11% 11% 13% 13% North Carolina NC 3% 3% 7% 14% 15% 16% 15% North Dakota ND 2% 2% 4% 5% 5% 5% 6% Oklahoma OK 3% 3% 8% 13% 12% 14% 15% Oregon OR 2% 2% 7% 12% 12% 12% 13% Pennsylvania PA 3% 3% 8% 14% 17% 19% 20% South Carolina SC 3% 3% 8% 14% 15% 17% 17% South Dakota SD 2% 2% 5% 7% 6% 8% 7% Tennessee TN 3% 3% 9% 16% 16% 18% 18% Utah UT 5% 5% 13% 17% 14% 15% 14% Nangia. Access to ART in the United s. Fertil Steril Nangia et al. Access to ART in the United s Vol. 93, No. 3, February 2010

9 TABLE 3 Continued. female population within 60 minutes of ART center status 20 y 21 y y y y y y Vermont VT 3% 3% 8% 13% 15% 19% 20% Virginia VA 3% 3% 8% 14% 16% 18% 17% Washington WA 3% 3% 8% 15% 16% 18% 18% Wisconsin WI 3% 3% 8% 13% 14% 17% 17% Wyoming WY 1% 1% 2% 3% 3% 4% 4% Nangia. Access to ART in the United s. Fertil Steril facilities (11 14). These analyses afford investigators to begin quantifying the geographic burden of health care services, defined as travel time from a patient s residence to the nearest health care service facility. Researchers and health policy experts may then begin having educated discussions regarding allocation of increasingly sparse health care services. The definition used to determine an ART service area was chosen to represent a practical situation for access to care for patients. Patients undergoing these services are often required to travel to their center for a variety of monitoring studies. For example, couples will need monitoring during ART treatment, access to andrology and cryopreservation resources. They will also have to travel to the ART center for egg retrieval and embryology services. Rationalization of Study and Methodology The number of ART listed by the CDC does not correlate exactly with that listed by SART. The CDC in 2005 listed 422, but SART listed 390. The reason for this discrepancy is related to the standards followed in defining reporting. The ART either report directly to the CDC, to the CDC through SART, and finally those that do not report data to anyone. In 2005, SART was responsible for reporting 94% of ART cycles in the United s to the CDC. We opted to use the SART database due to the strict criteria required to report services (i.e., center identification) and outcome results from IVF. This choice afforded us the ability to determine access to providing full embryology services and not just outpatient office settings. We did not include any satellite clinics of listed ART, unless listed separately by SART. Although the National Survey of Family Growth (NSFG) survey defined the reproductive age in women to start at 15 years, for purposes of ART many will not consider womens for treatment until years of age. The upper age limit for women of 44 years was chosen as reproductive ability with egg stimulation for ART/IVF has shown no success (0%) beyond the 44th year (15). For men, we chose the upper age of reproductive ability as 49 years of age as the chromosomal risk in men may double after the age of 50 years, although effect on fecundity success is far from clear (16). The NSFG survey in 2002 reviewed fatherhood for men years, albeit the indication for this age range was arbitrary and perhaps based on onset of sexual intercourse. This survey of nearly 5,000 men showed that 15% of men had their first child at less than the age of 20 years, 64% between the ages of 20 and29 years, with 21% after the age of 30 years (3). Location of ART Centers in Relation to Potential s We hypothesized that an association exists between highdensity populations and numbers of ART. Analysis of the study population distribution in the United s (Fig. 1) showed a focus of ART in most states, with these residing in or approximate to large cities. Some large cities abut more than one state. Accordingly, we defined the ART service area to include populations residing within the 60 minutes driving distance, both those living in and outside of the ART center s state (Table 2). In this regard, we are able to document overserved and underserved states, as well as populations jointly/mutually both states. The northeast of the United s had a relative high concentration of ART service, perhaps related to a combination of the following factors: [1] a higher number of states with mandated coverage in this region, and [2] relatively large number of metropolitan cities. Three states (Montana, Wyoming, and Alaska) had no ART services, suggesting a lack of fair and equitable allocation of these resources to some populations in the United s. Due to the age-dependent effect of ART success, we stratified our findings by age according to census data (Table 3). The age of 44 years is a significant physiological milestone from an ART reproductive standpoint, with zero success rates reported with ART (15). Such age-stratified analyses may provide insight to the planning and reallocation of ART services as it relates to a changing age demographic across the United s. In the present study, Maine, New Hampshire, and Vermont, had nearly 50% of their female the reproductive (35 44) years. By the year 2010 many states will witness a significant decrease in their populations in their reproductive years. Therefore the usage of ART services will Fertility and Sterility â 753

10 FIGURE 4 Stratification of percentage of women in the reproductive years (20 44 years) living within 60 minutes of an assisted reproductive technology (ART) center in each color-coded by insurance coverage for ART. in spending between Manhattan, New York, and Portland, Oregon, without concomitant benefits in quality or patient satisfaction. In 2003, Fisher published a study of regional variations in Medicare spending. In 2000, for example, per capita Medicare spending was $10,550 in Manhattan, but only $4,823 in Portland, Oregon. Despite such a disparity, they found that neither the quality of care nor patients satisfaction with it was related to costs (18, 19). These findings suggest that greater access and use of expensive health care services does not always equate with increased quality. It remains to be seen whether regions with high ART utilization have greater fertility successes, measured not only as total number of cycles, but number of cycles per pregnancy, percentage of cycles resulting in live births, and percentage of live births having multiple infants. Nangia. Access to ART in the United s. Fertil Steril be impacted, a finding further supported by the CDC ART report from 2005 that 60% of women using ART services were R35 years (5). Influence of Status on ART Centers From a strictly rational standpoint, mandated infertility care status should result in less population per ART center (or per ART service area) as strive to serve the population that has immediate/less restrictive access to this service. To partially address the impact of mandated ART status, we performed a comparison of one state with mandated state coverage for ART, New Jersey, with Georgia and North Carolina, two states having comparable study population sizes. In this example, New Jersey had 81,458 potential residents in the reproductive years per ART center, whereas the nonmandated states on average had 141,780. Whether this is due to an increased number of ART in New Jersey as a result of mandated coverage is debatable. However, it appears that the size of the study population did not dictate the number of ART (19 in New Jersey vs. 7 in Georgia and 9 in North Carolina). Rather, the supply of ART services appears to be insensitive to mandated coverage and thus dictated by some other factor. Based on a more specific and practical parameter, percentage of female study population served by an ART center was higher in mandated (90%) than in nonmandated (71%) states (P<.01). Does More Access to ART Centers Lead to Improvements in Quality? Fisher (17) and colleagues from the Dartmouth Institute for Health Policy and Practice have revealed twofold variability Limitations A relative limitation of this study is our definition of reproductive age, which differs from that used by the CDC. The scope of this article was focused on access to care for women most likely using ART. We chose to consider women from the age of 20 years and not younger because most ART center set guidelines for the youngest age they will treat and also younger patients are more likely to wait longer than a year to seek help if unable to get pregnant. The reproductive age for men was arbitrary but based on literature that shows that genetic risks increase significantly in men more than 50 years of age (16). The authors do acknowledge that men are still in their reproductive years both less than 20 years and more than the age of 50 years, but because the start and end of reproductive years are not well defined for men unlike women, a cutoff had to be applied. The analysis may potentially underestimate the population overall and the underserved. A second limitation is our choice of ART. We relied on a list managed by SART. Thirty-two not in SART still reported findings to the CDC directly in 2005 and may not follow the similar reporting or operational standards as SART. In addition, not all infertility services for ART are provided by ART. As such, our study may underestimate the services available to couples using ARTrelated services in Finally, we used the 2000 US Census to determine the number and age distribution of the state populations but used 2005 SART data. populations do not appear to be very different in the 2004 US Census projects relative to the 2000 data. Accordingly, we herein used the 2000 Census data. In conclusion, the current study showed that location of ART in the United s appear aligned with populations in their reproductive years. However, significant overserved and underserved areas do exist. Although allocation of mandated status of infertility services did not always result in equitable allocation of ART, mandated status did result, however, in a greater proportion of potentially fertile women living within 60 minutes of an ART center. The impact of this variability in ART services is unknown. It remains to be seen whether greater access to ART results in 754 Nangia et al. Access to ART in the United s Vol. 93, No. 3, February 2010

11 improvement in the quality and delivery of populations needing and using these services. Acknowledgment: The authors thank Judy Stern, Ph.D., Department of Obtetrics and Gynecology, Dartmouth-Hitchcock Medical Center, for her input in reviewing the manuscript. REFERENCES 1. Mosher WD, Pratt WF. Fecundity and infertility in the United s: incidence and trends. Fertil Steril 1991;56: Mosher WD, Pratt WF. Fecundity and infertility in the United s, Advance data from vital and health statistics. Hyattsville, MD: National Center for Health Statistics, Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility, family planning, and reproductive health of U.S. women: data from the 2002 National Survey of Family Growth. Vital and Health Statistics 2005;25: Kaminski J. OLR Research report 2005-R-0236; Assisted Reproduction Technology Success Rates. National summary and fertility clinic reports. Atlanta, GA: Center for Disease Control and Prevention, American Society for Medicine, Society for Assisted Technology, Bitler M, Schmidt L. Health disparities and infertility: impacts of statelevel insurance mandates. Fertil Steril 2006;85: Schmidt L. Effects of infertility insurance mandates on fertility. J Health Econ 2007;26: Jain T. Socioeconomic and racial disparities among infertility patients seeking care. Fertil Steril 2006;85: Jain T, Harlow BL, Hornstein MD. Insurance coverage and outcomes of in vitro fertilization. N Engl J Med 2002;347: Jain T, Hornstein MD. Disparities in access to infertility services in a state with mandated insurance coverage. Fertil Steril 2005;84: Chan L, Hart LG, Goodman DC. Geographic access to health care for rural Medicare beneficiaries. J Rural Health 2006;22: Mooney C, Zwanziger J, Phibbs CS, Schmitt S. Is travel distance a barrier to veterans use of VA hospitals for medical surgical care? Soc Sci Med (1982) 2000;50: Probst JC, Laditka SB, Wang JY, Johnson AO. Effects of residence and race on burden of travel for care: cross sectional analysis of the 2001 US National Household Travel Survey. BMC Health Serv Res 2007;7: Goodman DC, Klerman LV, Johnson KA, Chang CH, Marth N. Geographic access to family planning facilities and the risk of unintended and teenage pregnancy. Matern Child Health J 2007;11: Klipstein S, Regan M, Ryley DA, Goldman MB, Alper MM, Reindollar RH. One last chance for pregnancy: a review of 2,705 in vitro fertilization cycles initiated in women age 40 years and above. Fertil Steril 2005;84: Sloter E, Nath J, Eskenazi B, Wyrobek AJ. Effects of male age on the frequencies of germinal and heritable chromosomal abnormalities in humans and rodents. Fertil Steril 2004;81: Fisher ES. Medical care is more always better? N Engl J Med 2003;349: Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med 2003;138: Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med 2003;138: Fertility and Sterility â 755

12 756 Nangia et al. Access to ART in the United s Vol. 93, No. 3, February 2010 APPENDIX 1 Demographic and ART Resource Allocation by. Abbreviation Males Females Years (men 20-49, female 20-44) Male (all ages) of Male years Female (all ages) of Female years of years (male and female) Number of ART Centers Males per ART Center Females Years Arkansas AR 555, ,413 1,021,661 1,304,693 43% 1,368,707 34% 2,673,400 38% 1 555, ,413 1,021,661 California CA 7,864,781 6,383,867 14,248,648 16,874,892 47% 16,996,756 38% 33,871,648 42% , , ,789 Connecticut CT 726, ,215 1,344,132 1,649,319 44% 1,756,246 35% 3,405,565 39% 6 121, , ,022 Hawaii HI 275, , , ,671 45% 602,866 36% 1,211,537 41% 4 68,956 53, ,719 Illinois IL 2,764,631 2,311,899 5,076,530 6,080,336 45% 6,338,957 36% 12,419,293 41% , , ,751 Maryland MD 1,154,126 1,015,775 2,169,901 2,557,794 45% 2,738,692 37% 5,296,486 41% 7 164, , ,986 Massachusetts MA 1,401,892 1,217,199 2,619,091 3,058,816 46% 3,290,281 37% 6,349,097 41% 8 175, , ,386 Montana MT 189, , , ,480 42% 452,715 33% 902,195 38% New Jersey NJ 1,842,668 1,559,402 3,402,070 4,082,813 45% 4,331,537 36% 8,414,350 40% 19 96,983 82, ,056 New York NY 4,137,459 3,588,005 7,725,464 9,146,748 45% 9,829,709 37% 18,976,457 41% , , ,220 Ohio OH 2,421,965 2,043,225 4,465,190 5,512,262 44% 5,840,878 35% 11,353,140 39% , , ,099 Rhode Island RI 224, , , ,635 45% 544,684 36% 1,048,319 40% 1 224, , ,151 Texas TX 4,774,475 3,951,306 8,725,781 10,352,910 46% 10,498,910 38% 20,851,820 42% , , ,859 West Virginia WV 378, , , ,170 43% 929,174 34% 1,808,344 38% 1 378, , ,564 Not 8 Alabama AL 937, ,716 1,748,501 2,146,504 44% 2,300,596 35% 4,447,100 39% 5 187, , ,700 Alaska AK 153, , , ,112 47% 302,820 39% 626,932 43% Arizona AZ 1,130, ,520 2,037,807 2,561,057 44% 2,569,575 35% 5,130,632 40% ,029 90, ,781 Colorado CO 1,049, ,393 1,874,094 2,165,983 48% 2,135,278 39% 4,301,261 44% 7 149, , ,728 Delaware DE 168, , , ,541 44% 403,059 36% 783,600 40% 1 168, , ,606 District of DC 136, , , ,366 51% 302,693 41% 572,059 45% 4 34,031 30,971 65,002 Columbia Florida FL 3,296,219 2,731,501 6,027,720 7,797,715 42% 8,184,663 33% 15,982,378 38% , , ,109 Georgia GA 1,912,062 1,611,447 3,523,509 4,027,113 47% 4,159,340 39% 8,186,453 43% 7 273, , ,358 Idaho ID 279, , , ,660 43% 645,293 35% 1,293,953 39% 1 279, , ,685 Indiana IN 1,331,850 1,103,245 2,435,095 2,982,474 45% 3,098,011 36% 6,080,485 40% , , ,510 Iowa IA 618, ,570 1,119,282 1,435,515 43% 1,490,809 34% 2,926,324 38% 2 309, , ,641 Kansas KS 584, ,632 1,055,915 1,328,474 44% 1,359,944 35% 2,688,418 39% 5 116,857 94, ,183 Kentucky KY 891, ,119 1,638,757 1,975,368 45% 2,066,401 36% 4,041,769 41% 1 891, ,119 1,638,757 Louisiana LA 946, ,380 1,772,314 2,162,903 44% 2,306,073 36% 4,468,976 40% 5 189, , ,463 Maine ME 266, , , ,309 43% 654,614 34% 1,274,923 38% 1 266, , ,492 Michigan MI 2,163,591 1,804,264 3,967,855 4,873,095 44% 5,065,349 36% 9,938,444 40% , , ,220 Minnesota MN 1,103, ,814 2,003,604 2,435,631 45% 2,483,848 36% 4,919,479 41% 5 220, , ,721 Mississippi MS 592, ,422 1,113,156 1,373,554 43% 1,471,104 35% 2,844,658 39% 1 592, ,422 1,113,156 Missouri MO 1,185,486 1,003,987 2,189,473 2,720,177 44% 2,875,034 35% 5,595,211 39% 7 169, , ,782 Nebraska NE 369, , , ,351 44% 867,912 35% 1,711,263 39% 2 184, , ,244 Nevada NV 467, , ,718 1,018,051 46% 980,206 37% 1,998,257 42% 4 116,787 90, ,430 Nangia. Access to ART in the United s. Fertil Steril 2010.

13 Fertility and Sterility â 757 APPENDIX 1 Continued. Abbreviation Males Females Years (men 20-49, female 20-44) Male (all ages) of Male years Female (all ages) of Female years of years (male and female) Number of ART Centers Males per ART Center Females Years New NH 272, , , ,687 45% 628,099 36% 1,235,786 40% 1 272, , ,907 Hampshire New Mexico NM 380, , , ,317 43% 924,729 35% 1,819,046 39% 1 380, , ,080 North NC 1,835,102 1,520,659 3,355,761 3,942,695 47% 4,106,618 37% 8,049,313 42% 9 203, , ,862 Carolina North ND 140, , , ,524 44% 321,676 34% 642,200 39% 1 140, , ,745 Dakota Oklahoma OK 737, ,342 1,341,408 1,695,895 43% 1,754,759 34% 3,450,654 39% 3 245, , ,136 Oregon OR 759, ,152 1,362,436 1,696,550 45% 1,724,849 35% 3,421,399 40% 3 253, , ,145 Pennsylvania PA 2,559,608 2,143,845 4,703,453 5,929,663 43% 6,351,391 34% 12,281,054 38% , , ,674 South SC 866, ,870 1,606,792 1,948,929 44% 2,063,083 36% 4,012,012 40% 4 216, , ,698 Carolina South SD 159, , , ,558 42% 380,286 34% 754,844 38% 1 159, , ,608 Dakota Tennessee TN 1,248,146 1,058,052 2,306,198 2,770,275 45% 2,919,008 36% 5,689,283 41% 7 178, , ,457 Utah UT 499, , ,804 1,119,031 45% 1,114,138 38% 2,233,169 41% 2 249, , ,902 Vermont VT 130, , , ,337 44% 310,490 35% 608,827 39% 1 130, , ,861 Virginia VA 1,621,455 1,353,362 2,974,817 3,471,895 47% 3,606,620 38% 7,078,515 42% , , ,901 Washington WA 1,346,822 1,085,089 2,431,911 2,934,300 46% 2,959,821 37% 5,894,121 41% 8 168, , ,989 Wisconsin WI 1,180, ,098 2,139,603 2,649,041 45% 2,714,634 35% 5,363,675 40% 7 168, , ,658 Wyoming WY 108,206 84, , ,374 44% 245,408 34% 493,782 39% Nangia. Access to ART in the United s. Fertil Steril 2010.

14 758 Nangia et al. Access to ART in the United s Vol. 93, No. 3, February 2010 APPENDIX 2 Male and Female Years Covered by ART Centers by. Women y status Living within 60 min of an ART center in state state living within 60 min of ART ART ART by by state s ART state s ART Arkansas AR 175, ,413 38% 159,540 34% 15,807 3% 0 0% California CA 5,805,435 6,383,867 91% 5,798,249 91% 7,603 0% 417 0% Connecticut CT 616, , % 607,867 98% 598,832 97% % Hawaii HI 158, ,052 74% 158,930 74% 0 0% 0 0% Illinois IL 1,920,291 2,311,899 83% 1,800,067 78% 231,568 10% 111,344 5% Maryland MD 941,538 1,015,775 93% 919,952 91% 910,628 90% % Massachusetts MA 1,186,900 1,217,199 98% 1,178,357 97% 925,714 76% % Montana MT 0 150,863 0% 0 0% 0 0% 0 0% New Jersey NJ 1,547,711 1,559,402 99% 1,547,423 99% 1,515,191 97% % New York NY 3,315,441 3,588,005 92% 3,299,859 92% 2,431,229 68% % Ohio OH 1,808,379 2,043,225 89% 1,789,855 88% 131,400 6% 112,876 6% Rhode Island RI 194, , % 194, % 156,088 80% 156,088 80% Texas TX 2,832,213 3,951,306 72% 2,809,681 71% 22,532 1% 0 0% West Virginia WV 79, ,811 25% 50,907 16% 28,578 9% 0 0% Not mandated Alabama AL 371, ,716 46% 362,377 45% 54,361 7% 45,181 6% Alaska AK 0 117,561 0% 0 0% 0 0% 0 0% Arizona AZ 749, ,520 83% 749,391 83% 223 0% 0 0% Colorado CO 699, ,393 85% 699,605 85% 0 0% 0 0% Delaware DE 114, ,936 79% 114,722 79% 101,108 69% % District of Columbia DC 123, , % 123, % 123, % % Florida FL 2,513,739 2,731,501 92% 2,513,739 92% 41,573 2% 41,573 2% Georgia GA 1,175,547 1,611,447 73% 1,110,892 69% 78,898 5% 14,243 1% Idaho ID 114, ,144 51% 94,503 42% 20,324 9% 0 0% Indiana IN 851,403 1,103,245 77% 635,606 58% 223,449 20% 7,652 1% Iowa IA 267, ,570 53% 241,865 48% 25,879 5% 133 0% Kansas KS 293, ,632 62% 293,855 62% 161,405 34% 161,405 34% Kentucky KY 344, ,119 46% 212,978 29% 134,810 18% 3,749 1% Louisiana LA 608, ,380 74% 608,413 74% 203 0% 0 0% Maine ME 122, ,972 55% 122,163 55% 5,473 2% 5,473 2% Michigan MI 1,461,333 1,804,264 81% 1,457,792 81% 346,879 19% 343,338 19% Minnesota MN 686, ,814 76% 666,617 74% 19,498 2% 0 0% Nangia. Access to ART in the United s. Fertil Steril 2010.

15 Fertility and Sterility â 759 APPENDIX 2 Continued. Women y status Living within 60 min of an ART center in state state living within 60 min of ART ART ART by by state s ART state s ART Mississippi MS 213, ,422 41% 124,111 24% 89,302 17% 0 0% Missouri MO 665,193 1,003,987 66% 658,884 66% 221,784 22% 215,475 21% Nebraska NE 182, ,471 61% 182,894 61% 0 0% 0 0% Nevada NV 335, ,572 92% 335,081 92% 0 0% 0 0% New Hampshire NH 178, ,570 79% 35,810 16% 151,255 67% 8,249 4% New Mexico NM 186, ,360 58% 154,565 48% 32,311 10% 0 0% North Carolina NC 1,092,937 1,520,659 72% 1,044,301 69% 51,340 3% 2,704 0% North Dakota ND 30, ,516 28% 30,880 28% 0 0% 0 0% Oklahoma OK 406, ,342 67% 406,390 67% 392 0% 0 0% Oregon OR 360, ,152 60% 357,457 59% 3,463 1% 0 0% Pennsylvania PA 1,804,808 2,143,845 84% 1,764,737 82% 1,208,378 56% % South Carolina SC 571, ,870 77% 515,443 70% 102,560 14% 46,688 6% South Dakota SD 45, ,545 36% 45,989 36% 0 0% 0 0% Tennessee TN 873,115 1,058,052 83% 873,115 83% 0 0% 0 0% Utah UT 344, ,145 82% 344,824 82% 0 0% 0 0% Vermont VT 87, ,328 81% 62,369 58% 29,368 27% 4,444 4% Virginia VA 1,059,978 1,353,362 78% 1,040,241 77% 449,359 33% % Washington WA 875,946 1,085,089 81% 797,572 74% 79,964 7% 1,590 0% Wisconsin WI 708, ,098 74% 681,055 71% 329,910 34% 302,196 32% Wyoming WY 14,377 84,519 17% 0 0% 14,377 17% 0 0% Men y status Living within 60 min of an ART center population living within 60 min of an ART center ART ART by by state and Arkansas AR 204, ,248 37% 185,590 33% 18,498 3% 0 0% California CA 7,077,549 7,864,781 90% 7,066,966 90% 11,207 0% 624 0% Nangia. Access to ART in the United s. Fertil Steril 2010.

16 760 Nangia et al. Access to ART in the United s Vol. 93, No. 3, February 2010 APPENDIX 2 Continued. Men y status Living within 60 min of an ART center population living within 60 min of an ART center ART ART by by state and Connecticut CT 726, , % 715,575 98% 704,466 97% % Hawaii HI 204, ,823 74% 204,808 74% 0 0% 0 0% Illinois IL 2,270,778 2,764,631 82% 2,127,401 77% 281,137 10% 137,760 5% Maryland MD 1,062,003 1,154,126 92% 1,036,195 90% 1,019,592 88% % Massachusetts MA 1,366,219 1,401,892 97% 1,355,936 97% 1,058,751 76% % Montana MT 0 189,643 0% 0 0% 0 0% 0 0% New Jersey NJ 1,828,463 1,842,668 99% 1,828,064 99% 1,789,783 97% % New York NY 3,780,411 4,137,459 91% 3,761,820 91% 2,719,352 66% % Ohio OH 2,129,865 2,421,965 88% 2,107,466 87% 154,958 6% 132,559 5% Rhode Island RI 223, , % 223, % 178,468 80% 178,468 80% Texas TX 3,393,874 4,774,475 71% 3,367,529 71% 26,345 1% 0 0% West Virginia WV 96, ,753 25% 62,625 17% 33,936 9% 0 0% Not mandated Alabama AL 426, ,785 45% 415,179 44% 61,051 7% 50,006 5% Alaska AK 0 153,803 0% 0 0% 0 0% 0 0% Arizona AZ 931,591 1,130,287 82% 931,315 82% 276 0% 0 0% Colorado CO 877,822 1,049,701 84% 877,822 84% 0 0% 0 0% Delaware DE 131, ,670 78% 131,310 78% 116,411 69% % District of Columbia DC 136, , % 136, % 136, % % Florida FL 3,013,224 3,296,219 91% 3,013,224 91% 47,989 1% 47,989 1% Georgia GA 1,385,161 1,912,062 72% 1,304,210 68% 98,032 5% 17,081 1% Idaho ID 143, ,541 51% 119,073 43% 24,565 9% 0 0% Indiana IN 1,020,788 1,331,850 77% 761,227 57% 269,158 20% 9,597 1% Iowa IA 324, ,712 52% 292,460 47% 32,247 5% 190 0% Kansas KS 357, ,283 61% 357,688 61% 194,415 33% 194,415 33% Kentucky KY 409, ,638 46% 252,207 28% 161,783 18% 4,607 1% Louisiana LA 683, ,934 72% 683,336 72% 248 0% 0 0% Maine ME 144, ,520 54% 144,108 54% 6,745 3% 6,745 3% Michigan MI 1,734,027 2,163,591 80% 1,729,514 80% 415,014 19% 410,501 19% Minnesota MN 825,340 1,103,790 75% 801,469 73% 23,871 2% 0 0% Mississippi MS 242, ,734 41% 137,188 23% 105,785 18% 0 0% Missouri MO 776,717 1,185,486 66% 769,303 65% 261,547 22% 254,133 21% Nangia. Access to ART in the United s. Fertil Steril 2010.