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                              Fact Sheet: In Vitro Fertilization (IVF) Use Across the United States
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**FOR IMMEDIATE RELEASE March 13, 2024**

        **Contact:
            HHS Press Office 
              202-690-6343media@hhs.gov**

          Fact Sheet: In Vitro Fertilization (IVF) Use Across the United States
    
    

      **KEY POINTS**

Infertility affects millions of Americans in the United States at some point in their life.
	Difficulty conceiving can be caused by a variety of factors such as age, health conditions, and for couples who are same sex or individuals without a partner and cannot otherwise conceive.  In addition, some couples experience unexplained infertility where tests reveal no obvious causes of infertility.
	Fertility treatments, including assisted reproductive technology (ART) procedures such as in vitro fertilization (IVF), allow those who experience infertility a potential path to expand their families.
	IVF represents greater than 99% of ART procedures performed and is an important fertility treatment option because it can help individuals to conceive who may not be able to using other fertility treatment methods.
	In 2021, 86,146 infants born (or 2.3% of all infants born in the U.S.) were conceived through the use of ART.
	IVF enables individuals who use fertility preservation services to save their eggs, sperm, or reproductive tissues to have children at a later time.
	In 2018, over 69% of the 120,000 individuals of reproductive age diagnosed with cancer required fertility preservation procedures and services, now considered a standard of care.
	Use of ART occurs across the country.  The top ten states with the most births using ART in 2021 were California, New York, Texas, New Jersey, Illinois, Massachusetts, Florida, Pennsylvania, Virginia and Georgia.**Many Individuals Experience Infertility and Rely on In Vitro Fertilization to Become Pregnant**

Infertility is a common challenge affecting millions of Americans in the United States and can have important implications for individuals’ well-being.  According to the most recent National Survey of Family Growth, approximately 9% of married women*
 aged 15 to 49 years old are estimated to experience some form of infertility.1
  An earlier version of the survey estimated that approximately 9% of men aged 15 to 44 years old experience some form of infertility.2
  As a result of experiencing challenges to conceive, an estimated 1 in 8 women between the ages of 15 and 49 years old have received infertility services in their lifetime.3
  In addition to infertility challenges, same sex couples and those who are single but desire to have a child may also pursue fertility assistance.  In 2021, approximately 86,146 infants were born using assisted reproductive technology (ART).4
  ART refers to all fertility treatments which involve handling either eggs or embryos.  More specifically, the ART process includes the surgical retrieval of a woman’s eggs from her ovaries (and freezing them for future use, if applicable), followed by combining the eggs with sperm in a laboratory to create an embryo, and then either returning the embryo to the woman’s body, freezing it for later use, or donating to another gestational carrier.†
  The most common form of ART is in vitro fertilization (IVF), in which embryos are first created from the combined eggs and sperm and then either transferred into the woman’s uterus or frozen for potential later use, which are later transferred to a woman’s uterus.  IVF accounts for over 99% of ART procedures performed in the U.S.5

**Causes of and Risk Factors for Infertility**

Both men and women can have conditions that contribute to infertility.  Causes and risk factors of infertility vary between women and men, though in some cases remain unknown (Table 1 in Appendix).  Infertility in men is most often evaluated by a semen analysis to identify any potential abnormalities of the sperm such as low sperm count, low sperm mobility, or sperm quality issues.  Male fertility factors were a primary reason for pursuing ART in nearly 30% of cases in 2021.  Infertility among women can be more complex as conditions impacting multiple reproductive organs (ovaries, fallopian tubes, uterus) can lead to infertility.  The most common causes of infertility among women seeking ART are diminished ovarian reserves (27%), ovulation issues (14%), and tubal factors (10%).6
  In addition, health conditions, genetic factors, and contributing risk factors affecting both men and women, such as older age, unhealthy weight, and substance use can increase the risk of infertility (Figure 1).7

**Figure 1. Contributing risk factors for infertility among women and men in the United States**

Figure 1:  This figure displays a Ven diagram of contributing risk factors for infertility for women and men.  Those risk factors that affect both women and men are listed where the two circles overlap and include age, smoking, excessive alcohol use, and being overweight or obese.  Risk factors that only apply to women include being underweight, extreme weight gain or loss, and excessive physical or emotional stress resulting in absent periods.  Risk factors that only apply to men include excessive drugs use, exposure to testosterone, radiation, or certain medications, frequent exposure of tests to high temperatures, and exposure to environmental toxins.

**Source:** Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health. Infertility. Accessed at https://www.cdc.gov/reproductivehealth/infertility/ on Feb 28, 2024.

**Why Do Many Americans Rely on In Vitro Fertilization as a Safe and Effective Method to Become Pregnant?**

**Infertility Treatment Pathways**

There are a variety of treatment options for infertility, including medication, surgery, intrauterine insemination (IUI), or ART,‡
 such as IVF.  The method of treatment often depends on the specific factors contributing to, and the duration of, infertility, age of the female, and the individual or couple’s preference after receiving counseling on each treatment option’s success rates, risks, and benefits.  The first step in determining which treatment might be most appropriate is to identify the clinical cause(s) of infertility through diagnostic procedures such as laboratory testing, semen analysis, and/or reproductive organ imaging studies and procedures.  When a likely cause of infertility has been identified, treatment options are able to be specifically targeted.  Some conditions, such as abnormal thyroid hormone levels, can be corrected with medication, while other conditions such as fibroids in the uterine cavity may require a surgical intervention.8
  However, if medication and other non-invasive procedures or surgery (if applicable) are unable to achieve a successful pregnancy, more sophisticated fertility assistance procedures such as IUI, ART, and surrogacy may be pursued.  In some cases, a combination of these treatments is required.

In the case of ART, reasons for ART use remain varied (Table 2 in Appendix) and multiple §
 are often needed to successfully conceive.  As a result, these procedures can be costly.  For instance, costs for a single cycle of IVF have recently been estimated to range from $15,000 to $20,000 and can exceed $30,000.9
  Given the average number of cycles that are needed to become pregnant from IVF is 2.5, this means that the average cost of IVF to conceive successfully can easily exceed $40,000.10
,11
,12
  A survey of fertility clinics in California reported average out-of-pocket costs of $24,000 per IVF cycle ($61,000 per successful outcome) and $38,000 per IVF cycle with a donor egg ($73,000 per successful outcome).13

IVF treatment is often not covered by insurance, so the cost of treatment can pose a significant access challenge for lower income individuals.  The majority of states (29 states) do not require private insurance to cover any fertility services.  Select services are required in 21 states and 15 states include IVF coverage mandates.14
 Further, these state mandates do not apply to self-insured plans, which include 61% of workers.15
 Medicaid coverage of fertility diagnosis or treatment is optional for states and coverage varies from state to state.  Some states, like New York and Utah, choose to cover diagnosis and treatment of fertility services through Medicaid, while other states only cover diagnosis.16

**Why Many People Rely on In Vitro Fertilization and the****Importance of Fertility Preservation Services**

Individuals may choose to use IVF for a variety of reasons, including that they are not yet ready to have a child but want to preserve their fertility options for the future.  For instance, this could be done prior to receiving certain treatments for cancer, sickle cell anemia, or lupus, which can cause infertility.  In the case where an individual is diagnosed with cancer during their reproductive years, cancer treatments including chemotherapy, radiation, and surgery can damage eggs and sperm, reproductive organs, impact endocrine functioning and result in birth defects in the person’s future children.17
  In 2018, more than 120,000 patients diagnosed with cancer were of reproductive age (between 15 and 44 years old) and it is estimated that over 69% of these patients were in need of fertility preservation procedures and services, which is now considered a standard of care.18
,19

A large proportion of all ART cycles involve freezing egg or embryos.  In 2021, nearly 41% of ART cycles (167,689 cycles) were egg or embryo banking cycles in which all resulting eggs or embryos were frozen for future use.20
  Across all age groups, around 80% of treatment cycles involving ART procedures used frozen embryos, rather than having an immediate transfer (Table 3 in Appendix).

**Health Outcomes Related to Assisted Reproductive Technology Procedures**

ART procedures have been available in the US since 1981 and research suggests**
 that ART is a relatively safe procedure. Overall, adverse outcomes are rare and much of the risk associated with ART outcomes is explained by the higher proportion of multiple births††
 in the ART population, which have become less common.21

Approximately 12.5% of infants conceived through ART are multiples compared to 3.2% of all infants in the overall birth population.  The higher proportion of multiple births in the ART infant population accounts for a high proportion of low birthweight infants (14.7% compared to 8.5%) and preterm births (19.7% compared to 10.5%).  Compared to risks for multiple births, the risks to both mother and child are lower for singleton births.‡‡
,22
,23

Risks for the mother during an ART pregnancy include higher levels of hypertension, placental complications, hemorrhage, preterm delivery, the need for a Cesarean section, and in rare cases ovarian hyperstimulation syndrome (OHSS).24
,25
  Most cases are mild, but severe OHSS, which is rare (accounting for about 2% of OHSS cases26
), can cause serious complications including blood clots, kidney failure, severe electrolyte imbalance, and severe fluid buildup in the chest or abdomen.27

The majority of children conceived through the use of ART are born without birth defects and any increased risk due to IVF is minimal.28
,29

Among the health conditions that have been examined in children born through IVF, are intellectual disability, cerebral palsy, autism,  and childhood cancer.  Evidence suggests that there is little to no difference in the risk of an intellectual disability or childhood cancer in infants born using IVF.30
,31
,32
A recent meta-analysis found that singleton children born through IVF had a slight increased risk of developing cerebral palsy and similar risk of developing autism after accounting for sociodemographic factors.33
,34

**Utilization of Infertility Treatments**

Between 2012 and 2021, ART use has more than doubled and the number of infants born who were conceived through ART has increased by 50%. In 2021, an estimated 2.3% of all infants born in the United States were conceived using ART.  Approximately 413,776 ART cycles were performed at 453 reporting clinics resulting in 112,088 pregnancies in the United States.35
  Of these pregnancies, 86,146 ART-conceived infants were born in 2021.36

The proportion of live births using ART increases with the mother’s age (Figure 2).  Of women aged 40-45 with live births in 2023, 9% involved the use of ART, whereas for women aged 45 years and older, ART was utilized in nearly one-third of live births.  ART use also varies geographically across the U.S.  States with the highest number of infants born with the use of ART each year include California with over 11,000 infants, New York (almost 9,000 infants), Texas (over 7,000 infants), and New Jersey and Illinois with around 5,000 infants (Figure 3 and Table 4).  Among women using ART, the majority did not have other living children (55%).

**Figure 2. Percentage of all live births conceived through the use of ART by mother’s age, 2023**

Figure 2: This figure displays a bar chart with the percentage of all live births conceived through the use of assistive reproductive technology (ART) by mother’s age.  The overall percentage of live births with ART is 1.8%.  Among mothers less than 30 years old, 0.3% of live births involve the use ART.  Mother’s age categories 30-34, 35-39, 40-44, and 45 and older correspond to 1.8%, 4.1%, 8.9%, and 31.2% of live births involving ART respectively.

**Source:** Centers for Disease Control and Prevention, National Center for Health Statistics.  National Vital Statistics System, Provisional Natality on CDC WONDER Online
Database.  Data are from the Natality Records 2023 through Last Month, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program.  Accessed at http://wonder.cdc.gov/natality-expanded-provisional.html on Feb 28, 2024.**Note:** ART use has been found to be underreported in natality records.

**Figure 3. Map of infants conceived through the use of ART by State, 2021**

Figure 3: This figure displays a bar chart with the percentage of all live births conceived through the use of assistive reproductive technology (ART) by mother’s race and education.  The overall percentage of live births involving ART is 1.8%.  For each mother’s race category, 0.4% of American Indian or Alaska Native live births, 4.4% of Asian live births involve ART, 0.8% of Black live births, 0.5% of Native Hawaiian or Other Pacific Islander live births, 1.9% of White live births, and 1.4% of live births from a mother with more than one race.  For each mother’s education category, 0.4% of mothers with high school or less education had a live birth involving ART, 1.1% of mothers with some college or an associates degree, 2.9% with a bachelor’s degree, 4.9% with a master’s degree, 6.4% with a doctorate or professional degree, and 3.3% with unknown or not stated education.

**Source:** Sunderam S, Zhang Y, Jewett A, Mardovich S, Kissin DM. State-Specific Assisted Reproductive Technology Surveillance, United States: 2021 Data Brief. Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2023.

**APPENDIX**

**Table 1. Causes of infertility among women and men in the United States**

Causes of Infertility among Women
			Causes of Infertility among MenDisruption of ovarian function presence or absence of ovulation and effects of ovarian ‘age’)
				Polycystic ovary syndrome (PCOS), menopause, diminished ovarian reserve, functional hypothalamic amenorrhea, improper function of hypothalamus or pituitary glands, premature ovarian insufficiency
				Fallopian tube obstruction
				Risk factors include history of pelvic infection, ruptured appendix, gonorrhea, chlamydia, endometriosis, or prior abdominal surgery)
				Physical characteristics of the uterus
				Fibroids, intrauterine adhesions, endometrial polyps, adenomyosis, congenital uterine anomalies
			Disruption of testicular or ejaculatory function
				Varicocele
					Trauma
					Heavy alcohol, smoking, illicit drug or anabolic steroid use
					Cancer treatment
					Medical conditions (diabetes, cystic fibrosis, certain autoimmune disorders, certain types of infections)
				Hormonal disorders
				Improper function of the hypothalamus or pituitary glands
					May include benign and malignant (cancerous) pituitary tumors, congenital adrenal hyperplasia, exposure to too much estrogen or testosterone, Cushing’s syndrome, and chronic use of medications such as glucocorticoids
				Genetic disorders
				Klinefelter’s syndrome, Y-chromosome microdeletion, myotonic dystrophy**Source:** Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health. Infertility.  Accessed at https://www.cdc.gov/reproductivehealth/infertility/  on Feb 28, 2024.

**Table 2. Reasons for seeking ART in the United States, in 2021*******

Reasons for seeking ART**Egg or embryo banking**
			40.9%**Other factor**
			30.0%**Male factor**
			27.8%**Diminished ovarian reserve**
			26.9%**Preimplantation genetic testing**
			16.6%**Ovulatory dysfunction**
			14.3%**Unexplained factor**
			10.5%**Tubal factor**
			10.4%**Endometriosis**
			6.5%**Recurrent pregnancy loss**
			6.3%**Uterine factor**
			5.8%**Gestational carrier**
			1.4%*National data based on 413,776 ART cycles in 2021.
Note: Percentages add to over 100% because more than one reason can be reported for each ART cycle.**Source:** Centers for Disease Control and Prevention. 2021 Assisted Reproductive Technology Fertility Clinic  and National Summary Report. US Dept of Health and Human Services; 2023. Accessed from Report-ART-Fertility-Clinic-National-Summary-H.pdf (cdc.gov)

**Table 3****. ART use in the United States, in 2021**

Age of patient (years)
			Percentage of those who used ART in 2021*
			Percentage of ART cycles in which patients used their own eggs/embryos*
			Percentage of ART cycles in which patients used donor eggs/embryos*
			Percentage of transfers used frozen embryosa**Less than35**
			36.2%
			58.9%
			2.3%
			84.0%**35-37**
			23.4%
			56.0%
			3.0%
			86.1%**38-40**
			20.7%
			51.9%
			5.1%
			84.6%**Over40**
			19.7%
			39.1%
			21.8%
			79.8%*** National data based on 413,776 ART cycles.****aNational data based on 202,054 ART cycles in which at least one embryo was transferred.****ART: Assisted Reproductive Technology**

**Source:** Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health. Assisted Reproductive Technology (ART) Data, Patient and Cycle Characteristics.  Accessed at Assisted Reproductive Technology (ART) Data: Clinic | DRH | CDC on Feb 28, 2024.

**Table 4. Number of infants conceived through the use of ART in 2021 by State**

Patient’s reporting area of residencea
			Total number of infants bornb
			Number of ART infants bornc
			Proportion of ART infants among all infants, %**Alabama**
			58,054
			340
			0.6**Alaska**
			9,367
			92
			1.0**Arizona**
			77,916
			1,319
			1.7**Arkansas**
			35,965
			258
			0.7**California**
			420,608
			11,392
			2.7**Colorado**
			62,949
			1,781
			2.8**Connecticut**
			35,670
			1,584
			4.4**Delaware**
			10,482
			274
			2.6**District of Columbia**
			8,660
			504
			5.8**Florida**
			216,260
			3,692
			1.7**Georgia**
			124,073
			2,321
			1.9**Hawaii**
			15,620
			375
			2.4**Idaho**
			22,427
			384
			1.7**Illinois**
			132,189
			4,791
			3.6**Indiana**
			79,946
			1,115
			1.4**Iowa**
			36,835
			823
			2.2**Kansas**
			34,705
			518
			1.5**Kentucky**
			52,214
			629
			1.2**Louisiana**
			57,437
			712
			1.2**Maine**
			12006
			242
			2.0**Maryland**
			68,285
			2,311
			3.4**Massachusetts**
			69,137
			3,717
			5.4**Michigan**
			104,980
			2,015
			1.9**Minnesota**
			64,425
			1,670
			2.6**Mississippi**
			35,156
			274
			0.8**Missouri**
			69,453
			1,132
			1.6**Montana**
			11,231
			166
			1.5**Nebraska**
			24,609
			409
			1.7**Nevada**
			33,686
			689
			2.0**New Hampshire**
			12,625
			447
			3.5**New Jersey**
			101,497
			5,106
			5.0**New Mexico**
			21,391
			195
			0.9**New York**
			210,742
			8,707
			4.1**North Carolina**
			120,466
			2,294
			1.9**North Dakota**
			10,112
			138
			1.4**Ohio**
			129,791
			2,226
			1.7**Oklahoma**
			48,410
			471
			1.0**Oregon**
			40,914
			908
			2.2**Pennsylvania**
			132,622
			3,167
			2.4**Puerto Rico**
			19,304
			84
			0.4**Rhode Island**
			10,464
			256
			2.4**South Carolina**
			57,185
			949
			1.7**South Dakota**
			11,369
			115
			1.0**Tennessee**
			81,717
			1,025
			1.3**Texas**
			373,594
			7,315
			2.0**Utah**
			46,712
			1173
			2.5**Vermont**
			5,384
			159
			3.0**Virginia**
			95,825
			2,383
			2.5**Washington**
			83,911
			2,181
			2.6**West Virginia**
			17,198
			175
			1.0**Wisconsin**
			61,781
			1,050
			1.7**Wyoming**
			6,237
			93
			1.5**Total**
			3,683,596
			86,146
			2.3**a** State of residence as reported by patient. In cases of missing patient’s residence data (1.8%), state was assigned as the location where the ART procedure was performed.bUS births exclude births to non-US residents. Source: CDC, Natality public use file and CD-ROM. Hyattsville, MD, National Center for Health Statistics.cIncludes infants conceived from ART procedures performed in 2020 and born in 2021 and infants conceived from ART procedures performed in 2021 and born in 2021. ART births exclude births to non-US residents.
ART: Assisted Reproductive Technology

**Source:** Sunderam S, Zhang Y, Jewett A, Mardovich S, Kissin DM. State-Specific Assisted Reproductive Technology 
Surveillance, United States: 2021 Data Brief. Centers for Disease Control and Prevention, US Dept of Health 
And Human Services; 2023. Accessed from: State-Specific-ART-Surveillance-2021-Data-Brief-H.pdf (cdc.gov)

**Figure 4. Percentage of all live births conceived through the use of ART by mother’s race and education, 2023**

Figure 4: This figure is a map of U.S. states shaded according to the number of infants conceived through the use of assistive reproductive technology (ART) in the state. States with increasingly dark shades of blue have more infants born with the use of ART. All state values are presented in Table 4 of the Appendix.

**Source:** Centers for Disease Control and Prevention, National Center for Health Statistics.  National Vital Statistics System, Provisional Natality on CDC WONDER Online
Database.  Data are from the Natality Records 2023 through Last Month, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program.  Accessed at http://wonder.cdc.gov/natality-expanded-provisional.html on Feb 28, 2024.**Note:** ART use has been found to be underreported in natality records.


*. Sex is self-identified in the National Survey of Family Growth.  While the current fact sheet generally refers to women, the content of this brief is inclusive of every person giving birth, irrespective of gender identity or demographic background. back to note *
                      1. Centers for Disease Control and Prevention, National Center for Health Statistics.  Key Statistics from the National Survey of Family Growth – I Listing (cdc.gov) back to note 1
                      2. Chandra, A., Copen, C.E., & Stephen, E.H. (2013). Infertility and Impaired Fecundity in the United States, 1982-2010: Data from the National Survey of Family Growth. National Health Statistics Reports, 67, 1-19. Retrieved February 7, 2018, from https://www.cdc.gov/nchs/data/nhsr/nhsr067.pdf (PDF 328 KB) back to note 2
                      3. Centers for Disease Control and Prevention, National Center for Health Statistics.  Key Statistics from the National Survey of Family Growth – I ListingInfertility Data. Accessed from FastStats - Infertility (cdc.gov) NSFG - Listing I - Key Statistics from the National Survey of Family Growth (cdc.gov) back to note 3
                      4. Sunderam S, Zhang Y, Jewett A, Mardovich S, Kissin DM. State-Specific Assisted Reproductive Technology Surveillance, United States: 2021 Data Brief. Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2023 back to note 4
                      †. A gestational carrier (also called a gestational surrogate) is a woman who agrees to carry a developing embryo created from another woman's egg. back to note †
                      5. Sunderam S, Kissin DM, Zhang Y, Jewett A, Boulet SL, Warner L, Kroelinger CD, Barfield WD. Assisted Reproductive Technology Surveillance - United States, 2018. MMWR Surveill Summ. 2022 Feb 18;71(4):1-19. doi: 10.15585/mmwr.ss7104a1. back to note 5
                      6. Centers for Disease Control and Prevention. 2021 Assisted Reproductive Technology Fertility Clinic and National Summary Report. US Dept of Health and Human Services; 2023. Accessed from Report-ART-Fertility-Clinic-National-Summary-H.pdf (cdc.gov) back to note 6
                      7. Infertility | CDC back to note 7
                      ‡. ART also includes intracytoplasmic sperm injection, zygote intrafallopian transfer, tubal embryo transfer, and gamete intrafallopian transfer. back to note ‡
                      8. Coverage and Use of Fertility Services in the U.S. | KFF back to note 8
                      §. ART cycles include any process in which (1) an ART procedure is performed, (2) a woman has undergone ovarian stimulation or monitoring with the intent of having an ART procedure, or (3) frozen embryos have been thawed with the intent of transferring them to a woman. back to note §
                      9. How Much Does IVF Cost In 2024? – Forbes Health back to note 9
                      10. Smith ADAC, Tilling K, Nelson SM, Lawlor DA. Live-Birth Rate Associated With Repeat In Vitro Fertilization Treatment Cycles. JAMA. 2015 Dec 22-29;314(24):2654-2662. doi: 10.1001/jama.2015.17296. PMID: 26717030; PMCID: PMC4934614. back to note 10
                      11. How Many IVF Cycles Should I Plan For? - Reproductive Resource Center Kansas City IVF (rrc.com) back to note 11
                      12. IVF Success Rates By Age - ELITE IVF - Global IVF Clinic (elite-ivf.com) back to note 12
                      13. Coverage and Use of Fertility Services in the U.S. | KFF back to note 13
                      14. Insurance Coverage by State | RESOLVE: The National Infertility Association back to note 14
                      15. Coverage and Use of Fertility Services in the U.S. | KFF back to note 15
                      16. Coverage and Use of Fertility Services in the U.S. | KFF back to note 16
                      17. American Cancer Society - Female Fertility and Cancer. Preserving Fertility in Females with Cancer | American Cancer Society back to note 17
                      18. Jiang C, Yabroff KR, Hill MJ, Han X. Dobbs v Jackson and access to fertility care among newly diagnosed adolescents and young adults with cancer in the USA. Lancet Oncol. 2022 Oct;23(10):1240-1243. doi: 10.1016/S1470-2045(22)00562-9. Erratum in: Lancet Oncol. 2022 Nov;23(11):e492. PMID: 36174616. back to note 18
                      19. Aaa Kutluk Oktay et al., Fertility Preservation in Patients With Cancer: ASCO Clinical Practice Guideline Update. JCO 36, 1994-2001(2018). DOI:10.1200/JCO.2018.78.1914 back to note 19
                      20. Report-ART-Fertility-Clinic-National-Summary-H.pdf (cdc.gov) back to note 20
                      **. Assessing risk in ART is challenging because numbers are small and it is hard to disentangle the degree to which outcomes are tied to environmental factors, factors associated with underlying infertility, and risks associated with the ART process itself. back to note **
                      ††. Fertility treatments, both fertility medicines and IVF, can lead to a pregnancy with multiples, which can increase both the maternal and fetal risk for complications during the pregnancy, such as preterm birth and developmental abnormalities. back to note ††
                      21. Yu H, Liang Z, Cai R. *et al.* Association of adverse birth outcomes with in vitro fertilization after controlling infertility factors based on a singleton live birth cohort. *Sci Rep* **12**, 4528 (2022). https://doi.org/10.1038/s41598-022-08707-x back to note 21
                      ‡‡. Low birth weight among singletons was 8.8% among ART-conceived infants and 6.9% among all infants born. back to note ‡‡
                      22. Sunderam S, Zhang Y, Jewett A, Mardovich S, Kissin DM. State-Specific Assisted Reproductive Technology Surveillance, United States: 2021 Data Brief. Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2023. back to note 22
                      23. Guidance on the limits to the number of embryos to transfer: a committee opinion. American Society for Reproductive Medicine. Fertility and Sterility Vol. 116, No 3. September 2021. Accessed on 28 February 2024 from https://www.asrm.org/practice-guidance/practice-committee-documents/guidance-on-the-limits-to-the-number-of-embryos-to-transfer-a---committee-opinion-2021 back to note 23
                      24. Graham ME, Jelin A, Hoon AH Jr, Wilms Floet AM, Levey E, Graham EM. Assisted reproductive technology: Short- and long-term outcomes. Dev Med Child Neurol. 2023 Jan;65(1):38-49. doi: 10.1111/dmcn.15332. Epub 2022 Jul 18. PMID: 35851656; PMCID: PMC9809323. back to note 24
                      25. Schirmer DA, Kulkarni AD, Zhang Y, Kawwass JF, Boulet SL, Kissin DM. Ovarian hyperstimulation syndrome after assisted reproductive technologies: trends, predictors, and pregnancy outcomes. Fertility and Sterility. 2020 Sep;114(3):567-578. back to note 25
                      26. Namavar Jahromi B MD, Parsanezhad ME MD, Shomali Z MD, Bakhshai P MD, Alborzi M MD, Moin Vaziri N MD PhD, Anvar Z PhD. Ovarian Hyperstimulation Syndrome: A Narrative Review of Its Pathophysiology, Risk Factors, Prevention, Classification, and Management. Iran J Med Sci. 2018 May;43(3):248-260. PMID: 29892142; PMCID: PMC5993897 back to note 26
                      27. https://www.mountsinai.org/health-library/diseases-conditions/ovarian-hyperstimulation-syndrome back to note 27
                      28. Lu Y, Liu L, Zhang P, Sun Y, Ma C, Li Y. Risk of birth defects in children conceived with assisted reproductive technology: A meta-analysis. Medicine (Baltimore). 2022 Dec 30;101(52):e32405. doi: 10.1097/MD.0000000000032405. PMID: 36596016; PMCID: PMC9803464. back to note 28
                      29. Sullivan-Pyke CS, Senapati S, Mainigi MA, Barnhart KT. In Vitro fertilization and adverse obstetric and perinatal outcomes. Semin Perinatol. 2017 Oct;41(6):345-353. doi: 10.1053/j.semperi.2017.07.001. Epub 2017 Aug 14. PMID: 28818301; PMCID: PMC5951714. back to note 29
                      30. Kim HR, Jung YH, Kim SY, Choi CW. Neurodevelopmental outcomes of preterm infants with very low birth weight conceived with the assistance of in vitro fertilization. *Fertility and Sterility* [Internet]. 2022. Jun;117(6):1214‐1222. Available from: 10.1016/j.fertnstert.2022.03.006 back to note 30
                      31. Spaan M, van den Belt‐Dusebout AW, van den Heuvel‐Eibrink MM, Hauptmann M, Lambalk CB, Burger CW, et al. Risk of cancer in children and young adults conceived by assisted reproductive technology. Hum Reprod. 2019. Apr 1;34(4):740–50. back to note 31
                      32. Hargreave M, Jensen A, Hansen MK, Dehlendorff C, Winther JF, Schmiegelow K, Kjær SK. Association Between Fertility Treatment and Cancer Risk in Children. JAMA. 2019 Dec 10;322(22):2203-2210. doi: 10.1001/jama.2019.18037. PMID: 31821431; PMCID: PMC7081748. back to note 32
                      33. Cavero-Ibiricu A, Canelas-Fernandez J, Gomez-Acebo, I et al. Association between Assisted Reproductive Technology and Cerebral Palsy, A Meta-Analysis. Pedneur. 2023 Dec 29. 2023DOI:https://doi.org/10.1016/j.pediatrneurol.2023.12.019 back to note 33
                      34. https://www.cdc.gov/ncbddd/autism/features/artandasd.html back to note 34
                      35. Assisted Reproductive Technology (ART) DataAssisted Reproductive Health Data: Clinic | DRH | CDC back to note 35
                      36. Report-ART-Fertility-Clinic-National-Summary-H.pdf (cdc.gov) back to note 36
  

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