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1 The Supply of and Demand for Assisted Reproductive Technologies in the United States: Clinic and Population Based Data, *Elizabeth Hervey Stephen, Ph.D., Georgetown University Anjani Chandra, Ph.D., CDC/National Center for Health Statistics Rosalind Berkowitz King, Ph.D., Eunice Kennedy Shriver National Institute for Child Health and Human Development Presented at the IUSSP meeting, Busan, South Korea Session 012 Infertility: addressing its causes and providing treatment August 27, 2013, 8:30-10:00 a.m. Room 201, Convention Hall, 2 nd floor * contact info: stepheel@georgetown.edu; The findings and conclusions in this paper are those of the authors and do not necessarily represent the official position of the organizations at which they are employed. DRAFT: PLEASE DO NOT CITE OR QUOTE WITHOUT PERMISSION OF AUTHORS

2 ABSTRACT Although assisted reproductive technologies (ART) represent a very small proportion of overall infertility service use in the United States, they drive much of the public s perception about access to and use of medical services to have a child. We examine trends and individual-level correlates for use of medical services to have a child, using data from two sources. The first source is fertility clinic data collected by the United States Centers for Disease Control and Prevention/Society for Assisted Reproductive Technology (CDC/SART) from and preliminary data for The second data source is the 1995, 2002, and National Surveys of Family Growth (NSFG), each a U.S.-nationally representative, cross-sectional survey of women years of age and each conducted by the CDC s National Center for Health Statistics. This dual-data approach allows us to determine trends in the demand for infertility services at the national level and to explore diagnoses, medical treatment and outcomes at the clinic level. Findings from the two data sources show an increase in the utilization of ART over this time period, a decrease in tubal factor and an increase in diminished ovarian reserve as patient diagnoses. Age and parity are found to be very strong correlates of utilization of ART services. 1

3 The Supply of and Demand for Assisted Reproductive Technologies in the United States: Clinic and Population Based Data, The overall percentage of women aged in the United States who have ever used infertility services increased from 9 percent in 1982 to 15 percent in 1995, then in 2002 declined to 12 percent, and remained at that level in The number and percentage of women utilizing assisted reproductive technologies (ART) has increased consistently over this time period; in 2009, 1.4 percent of all births in the United States were a result of in vitro fertilization and related techniques. 2 Previous analyses have shown that women who make use of medical help for infertility tend to be a highly select group, which may reflect the fact that women of lower socioeconomic status are less likely to have adequate health insurance coverage and other financial resources to afford the necessary diagnostic or treatment services. 3 We anticipate that women who utilize ART are an even more select group given the expense and duration of treatment, and limited insurance coverage for ART. Our goal in this paper is to provide a better understanding of the supply and demand of infertility service use in the United States. We use data from the Centers for Disease 1 Centers for Disease Control and Prevention, Key Statistics from the National Survey of Family Growth, downloaded July 31, 2013.; Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility, Family Planning, and Reproductive Health of US Women: Data from the 2002 National Survey of Family Growth. Vital and Health Statistics 2005; 23(25). Hyattsville, MD: National Center for Health Statistics; 2 Sunderam, S, DM Kissin, L Flowers, JE Anderson, SG Folger, DJ Jamieson, WD Barfield. Assisted Reproductive Technology Surveillance United States, Morbidity and Mortality Weekly Report (MMWR) Surveillance Summaries, November 2, 2012 / 61(SS7); Chandra and EH Stephen, Infertility service use among U.S. women: 1995 and 2002, Fertility and Sterility 93(3): Greil AL, McQuillan J, Shreffler KM, Johnson, KM, Slauson-Blevins KS. Race-ethnicity and medical services for infertility: stratified reproduction in a population-based sample of U.S. women. Journal of Health and Social Behavior 2011; 52(4): Huddleston HG, Cedars MI, Sohn SH, Giudice LC, Fujimoto VY. Racial and ethnic disparities in reproductive endocrinology and infertility. American Journal of Obstetrics and Gynecology 2010 May; 202(5): Missmer SA, Seifer DB, Jain T. Cultural factors contributing to health care disparities among patients with infertility in Midwestern United States. Fertility and Sterility 2011 May;95(6): Nachtigall RD. International disparities in access to infertility services. Fertility and Sterility 2006 Apr;85(4):871-5; Staniec JFO, Webb NJ. Utilization of infertility services: How much does money matter? Health Services Research 2007; 42:3, Part 1: ; Vahratian A. Utilization of fertility-related services in the United States Fertility and Sterility 90(4):

4 Control and Prevention/Society of Assisted Reproductive Technology (CDC/SART) to look at the supply of services through trends in diagnoses, procedures, and outcomes of reported ART cycles from and the National Survey of Family Growth (1995, 2002, and ) to investigate nationally representative individual-level data on the use of infertility services. By utilizing data from two sources, our analyses illuminate the nationallevel trends in ART treatments and outcomes, as well as the characteristics of women who have sought infertility treatment. METHODS CDC/SART Data: The first set of analyses use published and unpublished data from the CDC. The Fertility Clinic Success Rate and Certification Act (FCSRCA, or Public Law ) passed in 1992 mandates that all ART clinics report success rate data to the federal government in a standardized manner. From 1996 to 2003 CDC partnered with the SART to obtain data from fertility medical centers located in the United States (and its territories) regarding ART cycles including patient medical history and infertility diagnoses, clinical information pertaining to the ART procedure, and information regarding resultant pregnancies and births, as well as limited demographic information on the patient. Starting in 2004, CDC has partnered with Westat, Inc. to obtain the same data through what is known as the National ART Surveillance System (NASS), a web-based data collection system developed by CDC. In spite of the federal mandate, not all clinics report data. Across the years approximately 90 percent of all clinics reported data representing approximately 95 2

5 percent of all cycles. The data file contains one record per ART procedure performed; consequently, multiple procedures from a single patient are not linked. 4 The medical director of each clinic verifies the accuracy of success rates. The CDC samples reporting clinics each year to validate the data. Site visits are made to clinics where medical records are reviewed for a sample of the patients. 5 Clinic-based data allow us to determine trends at the national level of the methods of ART that are being used--such as in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), and zygote intrafallopian transfer ZIFT)--in addition to diagnoses, numbers of cycles and resulting live births. Data for cycles and outcomes are available from The diagnoses categories changed in 1999 from earlier years, so data from are used for that portion of this analysis. Infertility diagnoses are given for one factor in one partner or multiple factors in one or both partners. If multiple factors exist then those factors are not detailed: tubal factor --- the woman's fallopian tubes are blocked or damaged, causing difficulty for the egg to be fertilized or for an embryo to travel to the uterus; ovulatory dysfunction --- the ovaries are not producing eggs normally; such dysfunctions include polycystic ovarian syndrome and multiple ovarian cysts; diminished ovarian reserve --- the ability of the ovary to produce eggs is reduced; reasons include congenital, medical, or surgical causes or advanced age; endometriosis --- tissue similar to the uterine lining is growing in abnormal locations in the abdominal cavity; this condition can affect both fertilization of the egg and embryo implantation; uterine factor --- a structural or functional disorder of the uterus is resulting in reduced fertility; male factor --- a low sperm count or problems with sperm function are causing difficulty for a sperm to fertilize an egg under normal conditions; other causes of infertility --- immunologic problems or chromosomal abnormalities, cancer chemotherapy, or serious illnesses; unexplained cause --- no cause of infertility was detected in either partner; 4 Wright, VC, LA Schieve, MA Reynolds, G Jeng, D Kisin Assisted Reproductive Surveillance United States, MMWR 53(SS01): 1-20, April Centers for Disease Control. National ART Surveillance. Accessed June 5,

6 multiple factors, female --- diagnosis of one or more female cause; or multiple factors, male and female --- diagnosis of one or more female cause and male factor infertility. 6 NSFG Data: The demand portion of the analysis is based on data from the 1995, 2002, and National Surveys of Family Growth, conducted by the CDC s National Center for Health Statistics ( Each of these surveys is a multistage probability-based survey that is representative of the national household population of women aged in the United States, and includes oversamples of Hispanics, Blacks, and those aged Further details on the methodology and design of the NSFG have been published elsewhere. 7 All analyses presented in our paper are based on weighted data, using the fully adjusted, post-stratified case weights, and variances are estimated using SAS version 9.2 Survey procedures to account for the complex survey design features of the NSFG ( In keeping with the methods in earlier NSFG-based studies of infertility services, we use age 22 as a lower bound, as this reasonably allows for all individuals in the analysis to have potentially completed college and formed initial unions (cohabitations/marriages). 8 Using data from the NSFG, Manning et al. found that the median age at first union for women was 22.2 years; median age at first marriage was 26.5 years and first cohabitation 6 Wright, VC, J Chang, G Jeng, M Macaluso. Assisted Reproductive Technology Surveillance--United States 2005, MMWR Surveillance Summaries, June 20, 2008, 57(SS05); Lepkowski J, Mosher W, Davis K, Groves RM, van Hoewyk J, Willem J. National Survey of Family Growth, Cycle 6: Sample Design, Weighting, Imputation, and Variance Estimation. Vital and Health Statistics 2006; 2(142). Hyattsville, MD: National Center for Health Statistics. 8 Copen CE, Daniels K, Vespa J, Mosher WD First Marriages in the United States: Data From the National Survey of Family Growth. National Health Statistics Report. No. 49. Hyattsville, MD: National Center for Health Statistics; Copen CE, Daniels K, Mosher WD First Premarital Cohabitation in the United States: National Survey of Family Growth. National Health Statistics Reports, No. 64. Hyattsville, MD: National Center for Health Statistics; Goodwin P, McGill B, Chandra A Who marries and when? Age at first marriage in the United States: NCHS data brief, no 19. Hyattsville, MD: National Center for Health Statistics. 4

7 was 21.8 years. 9 The lower age restriction also improves the reliability of reports of two key variables in this analysis: household income measured as a percent of poverty level and current fertility problems. 10 We restrict our sample to all women aged who have ever used medical help to get pregnant; our sample does not include women who used only miscarriage prevention services, although some analyses of infertility services do include both types of medical help. NSFG Analysis plan: The dependent variable for our logistic analysis is a binary variable indicating whether the woman ever used ART versus only using other types of medical help to get pregnant, which could include advice, infertility testing, artificial insemination (including intrauterine or intracervical insemination); surgery for blocked tubes, endometriosis, fibroids; or ovulation-inducing drugs (without any ART or insemination component). We limited our analysis to those women who ever used medical help to get pregnant for two reasons. First, we wanted to look at the importance of private health insurance to cover such costs and that question was only asked of women who reported using medical help to get pregnant. Second, we focus on distinguishing women who used ART from those who used other less-costly forms of medical help to get pregnant. Based on bivariate associations with this dependent variable, variables were chosen for binary logistic regression modeling. Survey year is included with 1995 as the reference category. The correlates of service use we included in the analysis are: age, parity, education, marital/cohabitation status, income, race and Hispanic origin, private health insurance to 9 Manning, Wendy D., Susan L. Brown, and Krista K. Payne Two Decades of Stability and Change in Age at First Union Framework. Paper presented at the annual meeting of the Population Association of America, New Orleans, LA, April 12, Chandra A, CE Copen, Stephen EH. Infertility and impaired fecundity in the United States, : Data from the National Survey of Family Growth, 2013, National Health Statistics Reports, no. 67, Hyattsville, MD: National Center for Health Statistics. 5

8 cover the costs of medical help to get pregnant, whether the respondent ever had tubal surgery, and whether the woman has current fertility problems. Age and parity are shown as a combined term, with a reference category of parous women years of age. Age is shown in 5-year categories, except for the youngest age group (22-29) since there are fewer women below age 30 who report or are aware of fertility impairments. Parity is dichotomized as 0 for nulliparous women and 1 for women with one or more births, which allows us to distinguish those who used services prior to any live births. Marital/cohabitation status at interview includes informal union status, as well as whether a woman is currently married, with the latter group as the reference group. This distinction allows us to determine if current cohabitors use ART at the same levels as married women or if they are more similar to other unmarried women. Education and poverty level income are dichotomous variables, with break points based on previous research showing significant relationships with use of infertility services. Education is dichotomized at a Bachelor s (4-year) degree or higher. Household income is dichomotized at 400 percent of poverty level income or higher, which was equivalent to $39,732 for a two-person household in 1995 and $58,408 for a two-person household in The race/ethnicity variable is defined as Hispanic, non-hispanic White, non- Hispanic Black and non-hispanic other, with non-hispanic whites as the reference category. 11 Baugher, Eleanor and Leatha Lamison-White. Poverty in the United States: Current Population Reports P60-194, U.S. Goernment Printing Office, Washington, DC, DeNavas-Walt, Carmen, Bernadette D. Proctor, and Jessica C. Smith, Income, Poverty, and Health Insurance Coverage in the United States: Current Population Reports, P60-239, U.S. Government Printing Office, Washington, DC, Appendix B, 6

9 The variable that we utilize for insurance coverage is whether the respondent had private insurance coverage to cover the medical costs for getting pregnant. This question was asked in all three NSFG surveys included in this analysis. The tubal surgery variable is included as a proxy variable for tubal factor infertility, which has traditionally been a primary indication for ART. Respondents who report that they have had tubal surgery are coded as yes; no is the reference category for the logistic model. Thus, the coefficient will represent the effect of the condition most directly and specifically indicating a medical need for ART. The final variable included in the logistic analysis is a composite variable indicating current fertility problems. This variable is coded yes if the woman has either 12-month infertility or impaired fecundity, which are the two standard measures of fertility problems defined by the NSFG. Twelve-month infertility is defined for married or cohabiting women only, and indicates they have had no pregnancy in at least 12 consecutive months of unprotected intercourse with their husband or partner. Impaired fecundity, the second NSFG-based measure of fertility problems, is defined for all women regardless of relationship status, and encompasses problems with pregnancy loss as well as with conception. Trends for these two separate measures of fertility problems have been published elsewhere Chandra A, Copen CE and Stephen EH. Infertility and impaired fecundity in the United States, : Data from the National Survey of Family Growth, 2013, National Health Statistics Reports, no. 67, Hyattsville, MD: National Center for Health Statistics; Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility, Family Planning, and Reproductive Health of US Women: Data from the 2002 National Survey of Family Growth. Vital and Health Statistics 2005; 23(25). Hyattsville, MD: National Center for Health Statistics; Chandra A, Mosher WD. The demography of infertility and the use of medical care for infertility. Infertility and Reproductive Medicine Clinics of North America 1993; 52(2): ; Chandra A, Stephen EH. Impaired fecundity in the United States: Fam Plann Perspect 1998 ; 30(1):34-42.Mosher WD, Pratt WF. Fecundity and infertility in the United States, Advance Data from Vital and Health Statistics # 192. Hyattsville, MD: National Center for Health Statistics,

10 We utilize logistic regression to estimate the adjusted odds ratios associated with these covariates and the use of ART services using a pooled data set for 1995, 2002, and The pooled dataset allows us to assess the net effect of time period on the odds of ever having used ART after controlling for any compositional changes in the population. Strengths and limitations of the analysis: The primary strength of this analysis is that it utilizes two data sources to get a snapshot of the supply and demand for ART. The NSFG analysis allows us to make robust comparisons of service use over time and across subpopulations. The NSFG is limited in its upper age range; we realize that women and their spouses/partners use services and have children beyond the age of 44. Also, the NSFG s cross-sectional design and limited detail on service use makes it difficult to establish temporal sequencing of specific service use and births that may result. This issue of temporal sequencing is also challenging for interpretation of characteristics measured at time of interview, such as parity and marital/cohabitation status. Individual level characteristics are generally measured at time of interview, which may not correspond to those characteristics at the time of service receipt. In addition, dates and other relevant details of infertility service use are not collected with sufficient specificity in the NSFG to relate overall service use of use of specific treatments to the timing of births. For the NSFG analysis we first present a table of overall utilization of medical services, followed by the logistic regression results. 8

11 Supply of Services: the CDC/SART data RESULTS Figure 1 shows the aggregate number of cycles started for all reporting clinics, as well as the live birth deliveries and live births for The live births exceed the deliveries because of the high rate of multiples among ART births; for instance in 2009, 47.4 percent of all ART births were twins or higher order multiples. 14 The number of cycles increased from 64,583 in 1996 to 147,260 in Live birth deliveries and births tripled in this same period of time: from 14,538 live birth deliveries in 1996 to 47,090 in 2010, and 20,870 births in 1996 to 61,564 in The increases in the late 1990s for all three measures slowed in the late 2000s, with a plateau effect from 2008 to There are two at times competing aspects of ART that are captured by these data. One is the maximization of a live birth delivery, and the second is the maximization of singleton births. Because of the concern over adverse birth outcomes for multiple-births, a healthy singleton birth is the ideal outcome for an ART procedure. However because treatments are expensive and often are not covered by insurance plans, one approach to increase the potential success of any one cycle leading to a live birth is to transfer multiple embryos during an in vitro fertilization (IVF) procedure. Assisted hatching techniques that have also been used to increase the effectiveness of ART have been potentially linked to the incidence of monozygotic twins, but research is still inconclusive. 15 Transferring two 13 Centers for Disease Control and Prevention. Analyses of the National ART Surveillance System (NASS) data. Written communication with the Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, August Sunderam, S, DM Kissin, L Flowers, JE Anderson, SG Folger, DJ Jamieson, WD Barfield. Assisted Reproductive Technology Surveillance United States, Morbidity and Mortality Weekly Report (MMWR) Surveillance Summaries, November 2, 2012 / 61(SS7); Das, S, D Blake, C Fahrquhar, and MM Seig Assisted Hatching on assisted conception (IVF and ICSI). Cochrane Database Syst Rev, April 15(2). 9

12 embryos is associated with a more than three-fold increase in the birth rate but more than a16-fold increase in the twin birth rate. 16 As the percentage of multiple births increased among ART births, however, and the percentage of low birthweight babies increased, the guidelines on the ideal number of embryos transferred were revised four times between 2004 and 2009 by the American Society of Reproductive Medicine. 17 In 2011 the ASRM Practice Committee declared that the most direct way to limit the risk of multiple gestations from ART is to transfer single embryos. 18 The two pie charts shown in Figure 2 highlight the difference in practice of embryo transfer from 1996 to 2010 where the mode decreased from 4+ embryos (62 percent) in 1996 to 2 embryos (53 percent) in The differences in transfer of 1 or 2 embryos is stark; in percent of transfers were of 1 or 2 embryos and by 2010 over two-thirds (68 percent) of transfers were wof 1 or 2 embryos. Table 1 shows the patient diagnosis for 1999 and Data on intermediary years are available but for the most part, there were very few changes. We highlight the major differences among diagnoses. Of note is the decline in tubal factors from 16 percent in 1999 to 7 percent in The only diagnosis that has increased over this period of time is diminished ovarian reserve (DOR), which has slightly more than doubled from 7 percent in 1999 to 15 percent in Henne, MB and Bundorf MK. The effects of competition on assisted reproductive technology outcomes. Fertil Steril 2010;93: The Practice Committee of the Society for Assisted Reproductive Technology, the American Society for Reproductive Medicine. Guidelines on the number of embryos transferred. Fertil Steril 2004;82(Suppl 1):1 2; The Practice Committee of the Society for Assisted Reproductive Technology, the American Society for Reproductive Medicine. Guidelines on the number of embryos transferred. Fertil Steril 2006;86(Suppl 5):S51 2; The Practice Committee of the Society for Assisted Reproductive Technology, the American Society for Reproductive Medicine. Guidelines on the number of embryos transferred. Fertil Steril 2008;90(Suppl 3):S163 4; The Practice Committee of the Society for Assisted Reproductive Technology, the American Society for Reproductive Medicine. Guidelines on the number of embryos transferred. Fertil Steril 2009;92: The Practice Committee of the American Society for Reproductive Medicine. Multiple gestation associated with infertility therapy: an ASRM Practice Committee Opinion. Fertil Steril 2012;97:

13 In order to determine if delayed childbearing could be one reason for that increase we examined the number of all cycles by patients age, the number of cycles by age for patients with a DOR diagnosis, and the number of cycles by age for patients with a DOR diagnosis who used a donor oocyte. As seen in Table 2, 22 percent of the cycles in 1999 were for women aged 40 and older; in 2010, 27 percent of the cycles were for women in the oldest reproductive ages. Although the number of cycles of patients with DOR more than tripled from 1999 to 2010 (13,003 cycles to 41,710), the age pattern remained remarkably stable over the time period. In 1999, 61 percent of the cycles were to a patient aged 40 or older; in 2010 it was 58 percent. Another refinement was to look at the age pattern of patients with DOR who use donor oocytes. Although the number of cycles more than doubled in this time period (from 5,911 to 13,190) the age pattern remained similar between 1999 and 2010, with 72 percent of the cycles among women aged 40 and older in 1999 and 76 percent in Although the age pattern for these cycles does not change appreciably during the 11-year time-span, it is evident that the cycles for women with DOR are concentrated in the older ages with approximately three out of five cycles for women aged 40 and older. The age differential is even more pronounced for women with DOR who use donor oocytes with approximately 75 percent of those cycles for women aged 40 and older. We now turn to the individual level data in the NSFG to determine population trends in the utilization of ART and other medical help to get pregnant. 11

14 Demand for Services: NSFG Data The population-based percentages of women aged reporting ever use of specific types of infertility services are shown in Table 3, as well as the percentage of women who ever sought medical help to get pregnant. Women could report using multiple services. The percentage of women aged who have ever used ART was 0.1 percent in 1995 and 0.6 percent in In absolute numbers this is an increase from about 50,000 aged in 1995 to 280,000 women in Although ART remains a small percentage of overall infertility service use among women 22-44, the increase may reflect more options that are available to patients: more refined techniques with higher success rates, greater variety of payment plan options, increased number and geographic distribution of clinics, and more insurance companies that cover ART. Similarly in the CDC/SART data, we observed the five-fold increase in ART cycles performed over this time period, while the number of facilities reporting data increased from 315 in 1996 to 443 in When the sample is limited to women aged who had used medical services to get pregnant, the percentage who ever had ART increased from 1.0 percent in 1995 to 5.2 percent in The percentage of women who had surgery or treatment for blocked tubes decreased from 18.0 percent in 1995 to 10.1 percent in , which mirrors the findings from the CDC/SART data of the tubal factor diagnoses that had decreased from 16 percent in 1999 to 7 percent in The other notable trend in the CDC/SART diagnosis data was the increase in the percentage of women with diminished ovarian reserve, which is much more difficult to isolate in the service use data from NSFG unless we assume that women with diminished ovarian reserve would most likely use IVF and related services. Table 4 shows the adjusted odds ratios for the logistic analysis modeling ever-use of ART relative to all other medical help to get pregnant. Parity and age are very strong 12

15 correlates of ART ever-use. Nulliparous women aged are 21 times more likely to utilize ART than parous women aged 22-29, with nulliparous women aged and nearly 13 times more likely to use ART. Among women with at least one child, women aged were 9 times as likely to use ART and women aged nearly 12 times as likely to use ART as parous women aged While significant in bivariate analyses, marital/cohabitation status, poverty level income, race/hispanic origin, and private insurance coverage for medical costs to get pregnant are not significant in the multivariate model. Women with less than a bachelor s degree were less than half as likely to have utilized ART service as women with at least a bachelor s degree. Women who have had tubal surgery are 4 times as likely and women with a current fertility problem are twice as likely to have received ART services than their reference groups. Of interest is the survey year variable, which mirrors trends in ART cycles from the ART Registry. Women in 2002 were 3.8 times more likely to have used ART and women in were over 7 times more likely to have used ART than women in DISCUSSION The strength in this analysis is the utilization of two data sources to examine both the supply and utilization of ART services. The two data sets should be seen as complementary; each data set has its strengths and weaknesses. The data from the CDC/SART registry allow us to see trends at the national level, based on clinic data. However, the CDC/SART data use cycles rather than women, so we cannot make any population-based estimates for women or couples, and the registry data include limited demographic characteristics. Another limitation of the CDC/SART data is that 13

16 approximately 90 percent--but not 100 percent of the clinics--report data each year, although it is estimated that the reporting clinics represent 95 percent of the ART procedures in any given year. The NSFG data provide nationally representative data on women aged so we are able to make population-based estimates of how many women have ever used specific services, including ART services, rather than the number of cycles as in the CDC/SART data. But the NSFG data are restricted to women 44 years of age and younger; we realize that women over that age may utilize ART services and would be included in the CDC/SART data. On a positive note, because of the consistency of measures in the NSFG surveys over time, we were able to pool the 1995, 2002, and data sets to have a large enough sample for a multivariate analysis of ART service use at the individual level. The trends in the CDC/SART data echo through the NSFG data. The number of clinics included the CDC/SART report increased from 301 in 1996 to 443 in 2010 a 47 percent increase while the numbers of cycles more than doubled between 1996 and 2010, and the number of live birth deliveries and births tripled in that same time period. We cannot compare the NSFG numbers directly to the CDC/SART increases since the NSFG are for women and for ever-use rather than being reported on an annual basis, but the percentage of all women aged who have ever used ART increased over six-fold from 1995 to When we narrow the analysis to women in the same age range who had ever used medical services to get pregnant, we find that the increase was five-fold in the same time period. Our multivariate analysis of the odds of having used ART highlights the importance of parity and age, as well as educational attainment, experience with tubal surgery, and whether the respondent has current fertility problems. Of particular interest is that the variable for survey year is highly significant, which indicates that there has been an increase 14

17 in the odds of ART use since 1995, net of the effects of individual-level characteristics. Additionally, the association with current fertility problems is interesting because many of these respondents are reporting retrospectively on past treatments, some of which resulted in live births. Further analyses could explore whether these women were disproportionately unsuccessful in their treatment experience or were successful yet continue to meet the definition of these fertility impairments at time of interview. These two data sets document the increased number of clinics and the correlates of ART users in the United States over the past two decades. As a result of more and/or more refined treatment ART options available to women/couples, live birth delivery and births have increased three-fold over the same time period that the number of cycles increased two-fold. The increased demand for services could be a result of a number of factors including delayed childbearing and/or a perception of an increase in success rates of ART. We saw clear evidence in the logistic analysis that age and parity are major factors for utilizing ART procedures, with nulliparous women aged having the highest odds of using ART (relative to only other types of medical help to get pregnant) in comparison with women aged with a child. Although we had expected that having private health insurance (for medical costs for getting pregnant) would be significant, it was not significant after controlling for the other variables among women who did receive some form of medical help to get pregnant. On the other hand, survey year was highly significant, which indicates that women in were seven times as likely to have utilized ART as women in There are some findings from this research that will require additional analyses. For instance, while we do not have data in the two sources that perfectly match in terms of diagnoses, there is evidence in both of a decrease in tubal factor infertility. One possibility 15

18 suggested by this decline is that the increase in reported Chlamydia rates at the national level may result in earlier treatment leading to fewer long-term complications that might result in infertility. Likewise we had expected that the increase in diminished ovarian reserve noted in the CDC/SART data was indicative of delayed childbearing, which is evident over the past several decades in the United States, 19 and which has contributed to a larger population seeking to become pregnant in their late 30s and 40s when fecundity is decreasing. 20 However, we did not find any obvious changes in the cycles by age of patients, even when we refine the sample to women with DOR and who used donor oocytes. Another possibility for the increase in the diagnosis is more refined testing for the detection of diminished ovarian reserve and/or earlier testing of women who are seeking to become pregnant. Although there are unanswered questions, this analysis highlights the increasing demand for and supply of ART. An understanding of both clinic-level and individual-level data is critical in order to have a more complete picture of access to this specialized form of medical care. 19 Mathews, TJ and BE Hamilton Delayed Childbearing: More Women are Having Their First Child Later in Life. NCHS Data Brief, No. 21, August Sharara, FI, RT Scott, Jr., and DM Seifer The Detection of Diminished Ovarian Reserve in Infertile Women. Am J Obstet Gynecol 179:

19 ACKNOWLEDGEMENTS The East-West Center provided research space for the first author to conduct this research; Georgetown University provided funding. The National Center for Chronic Disease Prevention and Health Promotion of the CDC provided unpublished data. Sookyung Koo assisted with graphical presentation. 0

20 Figure 1. Cycles, live birth deliveries and births: Cycles Live Birth Deliveries Births Source: Centers for Disease Control and Prevention, Analyses of the National ART Surveillance System (NASS) data. Written communication with the Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, August

21 Figure 2. Percentage distribution of embryos transferred in ART procedures: 1996 and

22 Table 1. Percentage of patient diagnoses for all fertility clinics reporting data to the Centers for Disease Control: 1999 and 2010 Diagnosis Year Tubal factor 16 7 Ovulatory dysfunction 5 7 Diminished ovarian reserve 7 15 Endometriosis 7 4 Uterine factor 1 1 Male factor Other factor 7 7 Unknown factor 9 12 Multiple factors: Female factors only Female & male factors Number of clinics reporting Number of cycles 87, ,260 SOURCE: ART Report, CDC/SART, National Summary 3

23 Table 2. Percentage distribution by broad age group of all cycles, cycles for women with a diminished ovarian reserve diagnosis, and cycles for women with a diminished ovarian reserve diagnosis who used donor oocytes: 1999 and 2010 All cycles <= Total Number , ,260 DOR diagnosis DOR diagnosis, with donor oocytes , , , ,190 Source: Centers for Disease Control and Prevention, Analyses of the National ART Surveillance System (NASS) data. Written communication with the Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, August

24 Table 3. Percentage of women aged who have ever used infertility services and percentage of women aged who sought medical help to get pregnant by type of service, United States: 1995 and NSFG Infertility services Women Women who sought medical help to get pregnant Total Medical help to get pregnant Advice Infertility testing (male or female) Female testing Male testing Ovulation drugs Surgery or treatment for blocked tubes Artificial insemination (incl. intrauterine) Assisted reproductive technology Note: Women could report as many services that they ever used, thus the columns do not add to

25 Table 4. Adjusted odds ratios for utilizing ART procedures among women aged who ever used medical help to get pregnant, United States: 1995, 2002, NSFG Characteristic Adjusted odds ratio (95% confidence interval) Parity and age 0 births/22-29 years 1.32 ( ) 0 births/30-34 years ( )* 0 births/35-39 years ( )** 0 births/40-44 years ( )* 1 or more births/22-29 years (reference) or more births/30-34 years 3.97 ( ) 1 or more births/35-39 years 9.36 ( )* 1 or more births/40-44 years ( )* Marital or cohabiting status Currently married (reference) 1.0 Currently cohabiting 0.15 ( ) Not currently married or cohabiting 0.94 ( ) Education Less than a bachelor's degree 0.43 ( )** Bachelor's degree or higher (reference) 1.0 Private insurance coverage to cover medical costs for getting pregnant Yes 1.06 ( ) No (reference) 1.0 Percent of poverty level Less than 400 percent of poverty level 0.75 ( ) 400 percent or higher (reference) 1.0 Survey year 1995 (reference) ( )** ( )** 6

26 Ever had tubal surgery Yes 4.27 ( )** No (reference) 1.0 Race and ethnicity Hispanic 0.87 ( ) Non-Hispanic Black 0.64 ( ) Non-Hispanic Other 0.78 ( ) Non-Hispanic White (reference) 1.0 Current fertility problem Yes 2.23 ( )* No (reference) 1.0 Model summary Unweighted n Approximate chi-square (df) ** (19) * p < 0.05, ** p <