02555625985N Engl J MedN. Engl. J. Med.The New England journal of medicine0028-47931533-440624988584460703210.1056/NEJMc1404371HHSPA729009ArticleMonitoring Health Outcomes of Assisted Reproductive TechnologyKissinDmitry M.M.D., M.P.H.dkissin@cdc.govJamiesonDenise J.M.D., M.P.H.BarfieldWanda D.M.D., M.P.H.Centers for Disease Control and Prevention, Atlanta, GA71020153720141510201537119193TO THE EDITOR

During the past 35 years, assisted reproductive technology has been transformed from a miracle to a standard and common part of medical practice. Although this technology is believed to be safe and has resulted in more than 5 million infants born globally, rapid technological progress leading to treatment modifications makes it important to continually monitor the safety of assisted reproductive technology for the rapidly growing population of users of the technology and infants conceived with its use.

Although many countries have national registries to monitor the use and effectiveness of assisted reproductive technology, they are typically not designed to collect data beyond delivery. In the United States, the Centers for Disease Control and Prevention (CDC) maintains the National ART (Assisted Reproductive Technology) Surveillance System (NASS), which collects limited information about treatment outcome (live birth data are limited to plurality, infant sex, birth weight, and gestational age). Studying the long-term health outcomes of assisted reproductive technology is difficult owing to the relative infrequency of both the exposure to it and the outcomes of interest (e.g., birth defects, cancer, and developmental disorders) and to the sensitive nature of the fertility treatments. Our knowledge of the long-term effect of assisted reproductive technology on maternal and child health is thus quite limited.1

To better understand the effect of assisted reproductive technology on maternal and child health and to improve state-based surveillance, in 2001 the CDC’s Division of Reproductive Health initiated linkage of the NASS data with Massachusetts birth-certificate data. This small pilot project has since grown into the States Monitoring ART (SMART) Collaborative, which includes Massachusetts, Michigan, Florida, and Connecticut, with creative integration of existing surveillance systems and registries (e.g., hospital-discharge, birth-defects, and cancer registries) and broad collaboration among the federal government, state health departments, universities, and professional societies.2 The SMART Collaborative serves as a platform for researchers to study the short- and long-term outcomes of assisted reproductive technology, drawing from the large sample of infants conceived with the use of this technology. The collaborative is also used for state-based monitoring of one of the most serious and costly adverse consequences of assisted reproductive technology — preterm births, which are estimated to result in a societal economic burden of more than $1.3 billion annually (Table 1).3,4

The field of assisted reproductive technology would benefit from closer monitoring of its safety. The renewed emphasis on patient safety in the United States5 calls for developing new tools or adapting old ones to identify the problem, to address the problem, and to measure progress. The integration of existing surveillance systems and registries could create an efficient infrastructure for conducting both important population-based, patient-centered research on the outcomes of assisted reproductive technology and state-based public health surveillance aimed at protecting maternal and child health.

The findings and conclusions in this letter are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.

TalaulikarVSArulkumaranSMaternal, perinatal and long-term outcomes after assisted reproductive techniques (ART): implications for clinical practiceEur J Obstet Gynecol Reprod Biol201317013923759305MneimnehASBouletSLSunderamSStates Monitoring Assisted Reproductive Technology (SMART) Collaborative: data collection, linkage, dissemination, and useJ Womens Health (Larchmt)201322571723829183SunderamSKissinDMCrawfordSAssisted reproductive technology surveillance — United States, 2010MMWR Surveill Summ20136212424304902Societal costs of preterm birthBehrmanREButlerASPreterm birth: causes, consequences, and preventionWashington, DCNational Academies Press200712AspdenPCorriganJMWolcottJEricksonSMPatient safety: achieving a new standard for careWashington, DCNational Academies Press2004

Infants, Preterm Infants, and the Societal Economic Burden of Preterm Births Conceived through Assisted Reproductive Technology in the United States (2010).*

State, District, or TerritoryInfants Conceived through Assisted Reproductive Technology
Total No. of InfantsNo. of Preterm InfantsSocietal Economic Burden Associated with Preterm Infants2013 $
California7,5402,573158,800,414
New York6,2582,008123,929,744
Texas4,3471,998123,312,564
New Jersey3,8031,42087,639,560
Illinois3,7751,32581,776,350
Massachusetts3,4801,03563,878,130
Florida2,40299461,347,692
Pennsylvania2,16275446,535,372
Virginia1,93168342,153,394
Maryland1,85660237,154,236
Ohio1,51254233,451,156
Michigan1,46052732,525,386
North Carolina1,45555734,376,926
Connecticut1,40446328,575,434
Georgia1,39055234,068,336
Washington1,31844227,279,356
Minnesota1,05035321,786,454
Colorado99441725,736,406
Arizona92137423,082,532
Indiana70530819,009,144
Missouri67228917,836,502
Wisconsin56821513,269,370
Oregon56021213,084,216
Iowa54119912,281,882
Utah52223714,627,166
South Carolina52122613,948,268
Nevada47923614,565,448
Tennessee45816710,306,906
Kentucky45318711,541,266
Louisiana41517610,862,368
Oklahoma36917010,492,060
Alabama3681489,134,264
District of Columbia3371036,356,954
Kansas3151167,159,288
New Hampshire288684,196,824
Idaho2441126,912,416
Rhode Island239804,937,440
Hawaii2361116,850,698
New Mexico229895,492,902
Nebraska210945,801,492
Delaware204563,456,208
Arkansas203694,258,542
Mississippi163664,073,388
West Virginia124422,592,156
Montana105422,592,156
Other states and territories53320112,405,318
Total59,11921,6381,335,454,084

The state, district, or territory indicates the place of patient residency; in cases of missing residency data (4%), we used the place in which the assisted-reproductive-technology procedure was performed; states or territories with fewer than 100 infants conceived through assisted reproductive technology were included in the category for other states and territories. Data on all infants and preterm infants conceived through assisted reproductive technology are from Sunderam et al.3 Calculations of societal economic burden were based on an assumption of an average burden of $51,600 ($61,718 in 2013 U.S. dollars) per infant born preterm, in accordance with calculations from the Institute of Medicine.4