Embryo transfer practices and multiple births resulting from assisted reproductive technology: an opportunity for prevention Dmitry M. Kissin, M.D.,

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Embryo transfer practices and multiple births resulting from assisted reproductive technology: an opportunity for prevention Dmitry M. Kissin, M.D., M.P.H., Aniket D. Kulkarni, M.B.B.S., M.P.H., Allison Mneimneh, M.P.H., Lee Warner, Ph.D., M.P.H., Sheree L. Boulet, Dr.P.H., M.P.H., Sara Crawford, Ph.D., Denise J. Jamieson, M.D., M.P.H. Fertility and Sterility Volume 103, Issue 4, Pages 954-961 (April 2015) DOI: 10.1016/j.fertnstert.2014.12.127 Copyright © 2015 Terms and Conditions

Figure 1 Number of multiple births by type of assisted reproductive technology (ART) cycle and plurality, National ART Surveillance System (NASS), United States, 2012. Fertility and Sterility 2015 103, 954-961DOI: (10.1016/j.fertnstert.2014.12.127) Copyright © 2015 Terms and Conditions

Figure 2 Number of transfers resulting in multiple births by patient's age and number of embryos transferred among patients using fresh embryos from autologous oocytes, United States, 2012. (A, B) Favorable prognosis patients (first assisted reproductive technology [ART] cycle and extra embryo(s) cryopreserved) using (A) blastocyst stage (days 5–6) and (B) cleavage stage (days 2–3) embryos. (C, D) Average prognosis patients ([1] first ART cycle and no extra embryo(s) cryopreserved, [2] previous ART cycle(s), no previous live birth(s), but extra embryo(s) cryopreserved, or [3] previous ART cycle(s) and previous live birth(s)) using (C) blastocyst stage (days 5–6) and (D) cleavage stage (days 2–3) embryos. (E, F) Less favorable prognosis patients (previous ART cycle(s), no previous live birth(s), and no extra embryo(s) cryopreserved) using (E) blastocyst stage (days 5–6) and (F) cleavage stage (days 2–3) embryos. Numbers 1 through 4 are not shown due to confidentiality requirements to suppress small cell tabulations. ∗Indicates acceptable number of embryos to transfer according to 2009 American Society for Reproductive Medicine (ASRM) and the Society for Assisted Reproductive Technology (SART) Guidelines on Number of Embryos Transferred (12). Fertility and Sterility 2015 103, 954-961DOI: (10.1016/j.fertnstert.2014.12.127) Copyright © 2015 Terms and Conditions

Figure 3 Number of transfers resulting in multiple births among (A) patients using donor oocytes and (B) patients using frozen/thawed embryos from autologous oocytes by number of embryos transferred, embryo state (fresh and frozen/thawed), embryo stage at transfer (for fresh cycles only), and patient age (for nondonor cycles only), United States, 2012. Numbers 1 through 4 are not shown due to confidentiality requirements to suppress small cell tabulations. ∗Indicates acceptable number of embryos to transfer according to 2009 American Society for Reproductive Medicine (ASRM) and the Society for Assisted Reproductive Technology (SART) Guidelines on Number of Embryos Transferred (for fresh cycles only) (12). Fertility and Sterility 2015 103, 954-961DOI: (10.1016/j.fertnstert.2014.12.127) Copyright © 2015 Terms and Conditions