We appreciate the important considerations raised by Blumenthal and Lerma regarding our | recent publication.1 | We agree that continuation is an important programmatic outcome. | However, intrauterine device (IUD) reinsertion after expulsion may not be feasible for all | women owing to cost, insurance coverage, or logistical barriers. Therefore, expulsion is an | essential contributor to continuation, and these data may inform patient-centered counseling. | To provide information pertinent to U.S. practice, we included data on copper and | levonorgestrel IUDs that were ever available in the United States, rather than those included | in a recent review.2 | We agree that certain factors (eg, insertion technique and health care | provider experience) may influence expulsion risk; however, these factors were not | consistently reported by studies and therefore not included in our analysis. | We based our timing categories of postpartum IUD placement on U.S. Medical Eligibility | Criteria for Contraceptive Use recommendations.3 | The majority of data are reported by these | categories, and studies examining the early postpartum period (more than 10 minutes after | placental delivery to less than 4 weeks postpartum) did not provide sufficient data to | separate expulsion rates into additional time periods. Ideally, future studies will describe | outcomes, including uptake, expulsions, and continuation, associated with placements in the | delivery room, during the hospital stay, or at an early postpartum visit to better inform | postpartum contraception care and programs. Nonetheless, postpartum IUD placement is | safe at any time and can be provided based on the woman’s preference.

BACKGROUND: Current influenza vaccine effectiveness (VE) improvement efforts focus on minimizing egg adaptation mutations during manufacture. This study compared immune response of two FDA-approved quadrivalent inactivated influenza vaccines in an unblinded randomized controlled trial. METHODS: Participants were 144 community dwelling, healthy children/adolescents aged 4-20 years, randomized 1:1 in blocks of 4 to a vaccine grown in cell culture (ccIIV4 [Flucelvax(R)]; n = 85); or in egg medium (IIV4 [Fluzone (R)]; n = 83). Blood was drawn at day 0 prevaccination and at day 28 (19-35 days) post vaccination. Hemagglutination inhibition (HI) assays against A/H1N1 and both B strains and microneutralization (MN) assays against egg-based and cell-based A/H3N2 strains were conducted. The primary outcome measure was seroconversion (day 28/day 0 titer ratio >/= 4 with day 28 titer >/= 40). Secondary outcomes were elevated titers (day 28 HI titer >/= 1:110), geometric mean titers (GMTs) and mean fold rise (MFR) in titers. Outcomes were compared for 74 ccIIV4 recipients and 70 IIV4 recipients, and for those vaccinated and unvaccinated the previous year. Only the HI and MN laboratory analysis team was blinded to group assignment. RESULTS: In this racially diverse (81% non-white) group of children with a median age of 14 years, baseline demographics did not differ between vaccine groups. At day 0, half or more in each vaccine group had elevated HI or MN titers. Low seroconversion rates (14%-35%) were found; they did not differ between groups. Among 2018-19 ccIIV4 recipients, those unvaccinated in the previous season showed significantly higher MFR against A/H1N1 and A/H3N2 cell-grown virus than the previously vaccinated. Similar results were found for MFR against B/Victoria among 2018-2019 IIV4 recipients. CONCLUSION: In mostly older children with high baseline titers, no differences in seroconversion or other measures of antibody titers were found between ccIIV4 and IIV4 recipients against egg- and cell-grown influenza vaccine viruses. CLINICAL TRIALS NO: NCT03614975.

OBJECTIVES: To provide updated and more detailed pooled IUD expulsion rates and expulsion risk estimates among women with postpartum IUD placement by timing of insertion, delivery type, and IUD type to inform current IUD insertion practices in the United States. DATA SOURCES: We searched PubMed, Cochrane Library, and ClinicalTrials.gov through June 2019. STUDY ELIGIBILITY CRITERIA: We included all studies, of any study design, that examined postpartum placement of Copper T380A (copper) or Levonorgestrel (LNG)-containing IUDs that reported counts of expulsion. STUDY APPRAISAL AND SYNTHESIS METHODS: We evaluated IUD expulsion among women receiving postpartum IUDs in the 'immediate' (within 10 minutes), 'early inpatient' (greater than 10 minutes to less than 72 hours), 'early outpatient' (72 hours to less than 4 weeks) and interval (4 weeks or greater) time periods after delivery. We assessed study quality using the U.S. Preventive Services Task Force evidence grading system. We calculated pooled absolute rates of partial and complete IUD expulsion separately and estimated adjusted relative risks by the timing of postpartum placement, delivery type and IUD type using log-binomial multivariable regression. RESULTS: We identified 48 level I to II-3 studies of poor to good quality that reported a total of 7,661 IUD placements. Complete IUD expulsion rates varied by timing of placement: 10.2% (range 0.0-26.7) for immediate, 13.2% (3.5-46.7) for early inpatient, 0% for early outpatient, and 1.8% (0.0-4.8) for interval placements. Complete IUD expulsion rates also varied by delivery type: 14.8% (range 4.8-43.1) for vaginal and 3.8% (0.0-21.1) for cesarean deliveries. Among immediate postpartum vaginal placements, the expulsion rate for LNG-IUDs was 27.4% (18.8-45.2) and 12.4% (4.8-43.1) for copper IUDs. Compared with interval placement, immediate and early postpartum placements (inpatient and outpatient combined) were associated with greater risk of complete expulsions (adjusted RR (aRR), 8.33; 95% CI, 4.32-16.08 and aRR, 5.27; 95% CI, 2.56-10.85, respectively). Among immediate postpartum placements, risk of expulsion was greater for placement after vaginal compared with cesarean deliveries (aRR, 4.57; 95% CI, 3.49-5.99). Among immediate placements at the time of vaginal delivery, LNG-IUDs were associated with a greater risk of expulsion compared with copper IUDs (aRR, 1.90; 95% CI, 1.36-2.65). CONCLUSION: While IUD expulsion rates vary by timing of placement, type, and mode of delivery, IUD insertion can take place at any time. Understanding the risk of IUD expulsion at each time period will enable women to make an informed choice about when to initiate an IUD in the postpartum period based on her own goals and preferences.

OBJECTIVE: To estimate the absolute and relative risk of venous thromboembolism (VTE) among women who initiate depot medroxyprogesterone acetate (DMPA) immediately postpartum compared with those who do not initiate hormonal contraception. METHODS: The IBM MarketScan Commercial Claims and Encounters databases were used to identify delivery hospitalizations among women aged 15-44 years during 2005 through 2014. Diagnosis, procedure, and drug codes were used to identify contraception, VTE, and potential confounding chronic or pregnancy-related conditions. Women who initiated DMPA during days 0 through 7 postpartum were compared with women who did not initiate hormonal contraception during days 0 through 7 postpartum. Women were followed from date of delivery through 12 weeks postpartum for the occurrence of VTE, with censoring at hormonal contraception initiation or prescription, hysterectomy, sterilization, or inpatient death. The incidence rate of VTE and 95% CIs were calculated within each group and the incidence rate ratio was calculated comparing the two groups. RESULTS: The unadjusted VTE incidence rate through 12 weeks postpartum was 0.42/10,000 women-days in the immediate postpartum DMPA group (34 events among 11,159 women contributing 805,999 days of follow-up) and 0.15/10,000 women-days in the control group (3,107 events among 3,102,011 women contributing 206,180,811 days of follow-up). The incidence rate ratio for VTE was 2.87 (95% CI 2.05-4.03) among women in the immediate postpartum DMPA group compared with women in the control group, adjusting for age alone. After adjusting for age and pregnancy-related and chronic conditions, the adjusted incidence rate ratio for VTE was 1.94 (95% CI 1.38-2.72) among women in the immediate postpartum DMPA group compared with women in the control group. CONCLUSION: Initiation of DMPA immediately postpartum is associated with a low incidence but an increased relative risk of VTE compared with nonuse of hormonal contraception.

OBJECTIVE: To estimate expulsion rates among women with postpartum intrauterine device (IUD) placement by timing of insertion, IUD type, and delivery method. DATA SOURCES: We searched PubMed, Cochrane Library, and ClinicalTrials.gov from 1974 to May 2018. METHODS OF STUDY SELECTION: We searched databases for any published studies that examined postpartum placement of a copper IUD or levonorgestrel intrauterine system and reported counts of expulsions. We assessed study quality using the U.S. Preventive Services Task Force evidence grading system. We calculated pooled absolute rates of IUD expulsion and estimated adjusted relative risks (RRs) for timing of postpartum placement, delivery method, and IUD type using log-binomial multivariable regression model. TABULATION, INTEGRATION, AND RESULTS: We identified 48 level I to II-3 studies of poor to good quality. Pooled rates of expulsion varied by timing of IUD placement, ranging from 1.9% with interval placements (4 weeks postpartum or greater), 10.0% for immediate placements (10 minutes or less after placental delivery), and 29.7% for early placements (greater than 10 minutes to less than 4 weeks postpartum). Immediate and early postpartum placements were associated with increased risk of expulsion compared with interval placement (adjusted RR 7.63, 95% CI 4.31-13.51; adjusted RR 6.17, 95% CI 3.19-11.93, respectively). Postpartum placement less than 4 weeks after vaginal delivery was associated with an increased risk of expulsion compared with cesarean delivery (adjusted RR 5.19, 95% CI 3.85-6.99). Analysis of expulsion rates at less than 4 weeks postpartum also indicated that the levonorgestrel intrauterine system was associated with a higher risk of expulsion (adjusted RR 1.91, 95% CI 1.50-2.43) compared with CuT380A. CONCLUSION: Postpartum IUD expulsion rates vary by timing of placement, delivery method, and IUD type. These results can aid in counseling women to make an informed choice about when to initiate their IUD and to help institutions implement postpartum contraception programs.

OBJECTIVE: To assess the characteristics of IVF cycles for which preimplantation genetic diagnosis (PGD) was used and to evaluate indications for PGD and treatment outcomes associated with this procedure as compared with cycles without PGD with the data from the U.S. National ART Surveillance System. DESIGN: Retrospective cohort study. SETTING: None. PATIENT(S): Fresh autologous cycles that involved transfer of at least one embryo at blastocyst when available. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): PGD indications and age-specific reproductive outcomes. RESULT(S): There were a total of 97,069 non-PGD cycles and 9,833 PGD cycles: 55.6% were performed for aneuploidy screening (PGD Aneuploidy), 29.1% for other reasons (PGD Other), and 15.3% for genetic testing (PGD Genetic). In comparison to non-PGD cycles, PGD Aneuploidy cycles showed a decreased odds of miscarriage among women 35-37 years (adjusted odds ratio [aOR] 0.62; 95% CI, 0.45-0.87) and women >37 years (aOR 0.55; 95% CI, 0.43-0.70); and an increased odds of clinical pregnancy (aOR 1.18; 95% CI, 1.05-1.34), live-birth delivery (aOR 1.43; 95% CI, 1.26-1.62), and multiple-birth delivery (aOR 1.98; 95% CI, 1.52-2.57) among women >37 years. CONCLUSION(S): Aneuploidy screening was the most common indication for PGD. Use of PGD was not observed to be associated with an increased odds of clinical pregnancy or live birth for women <35 years. PGD for aneuploidy was associated with a decreased odds of miscarriage for women >35 years, but an increased odds of a live-birth and a multiple live-birth delivery among women >37 years.

OBJECTIVE: To examine the associations between hormonal contraceptive use and measures of HIV disease progression and antiretroviral treatment (ART) effectiveness. STUDY DESIGN: A prospective cohort study of women with prevalent HIV infection in St Petersburg, Russia was conducted. After contraceptive counseling, participants chose to use combined oral contraceptives (COCs), depot-medroxyprogesterone acetate (DMPA), a copper intrauterine device (IUD), or male condoms for pregnancy prevention. Among participants not using ART at enrollment, we used multivariate Cox regression to assess the association between current (time-varying) contraceptive use and disease progression, measured by the primary composite outcome of CD4 decline to <350 cells/mm3, ART initiation, or death. Among participants using ART at enrollment, we used linear mixed models to estimate the predicted mean CD4 change at select time points by contraceptive method. RESULTS: During a total of 5,233 months follow-up among participants not using ART with enrollment CD4 ≥350 cells/mm3 (n=315), 97 experienced disease progression. Neither current use of COCs (adjusted hazard ratio [aHR] 0.91, 95% confidence interval [CI] 0.56-1.48) nor DMPA (aHR 1.28, 95% CI 0.71-2.31) was associated with a statistically significant increased risk for disease progression compared with use of non-hormonal methods (IUD or condoms). Among participants using ART at enrollment (n=77), we found no statistically significant differences in the predicted mean changes in CD4 cell count comparing current use of COCs (P=0.1) or DMPA (P=0.3) with non-hormonal methods. CONCLUSION: Hormonal contraceptive use was not significantly associated with measures of HIV disease progression or ART effectiveness among women with prevalent HIV infection. IMPLICATIONS: Hormonal contraceptive use was not significantly associated with measures of HIV disease progression or ART effectiveness among women with prevalent HIV infection.

Advances in sequencing technologies have facilitated concurrent testing for many disorders, and the results generated may provide information about a patient's health that is unrelated to the clinical indication, commonly referred to as incidental findings. This is a paradigm shift from traditional genetic testing in which testing and reporting are tailored to a patient's specific clinical condition. Clinical laboratories and physicians are wrestling with this increased complexity in genomic testing and reporting of the incidental findings to patients. An enormous amount of discussion has taken place since the release of a set of recommendations from the American College of Medical Genetics and Genomics. This discussion has largely focused on the content of the incidental findings, but the laboratory perspective and patient autonomy have been overlooked. This report by the Association of Molecular Pathology workgroup discusses the pros and cons of next-generation sequencing technology, potential benefits, and harms for reporting of incidental findings, including the effect on both the laboratory and the patient, and compares those with other areas of medicine. The importance of genetic counseling to preserve patient autonomy is also reviewed. The discussion and recommendations presented by the workgroup underline the need for continued research and discussion among all stakeholders to improve our understanding of the effect of different policies on patients, providers, and laboratories.

BACKGROUND: Bleeding irregularities, such as intermenstrual spotting or heavy or prolonged menstrual bleeding, are common among copper-containing intrauterine device (Cu-IUD) users and are one of the leading reasons for method discontinuation. This review evaluates the evidence for effective therapeutic and preventive treatments for bleeding irregularities during Cu-IUD use. STUDY DESIGN: We searched the PubMed database for peer-reviewed articles that were published in any language from inception of the database through March 2012 and were relevant to treatments for irregular bleeding during Cu-IUD use. We used standard abstract forms and grading systems to summarize and assess the quality of the evidence. RESULTS: From 1470 articles, we identified 17 articles that met our inclusion criteria. Evidence from two studies of poor quality demonstrated that antifibrinolytic agents or nonsteroidal anti-inflammatory drugs (NSAIDs) have been used for intermenstrual bleeding or spotting among a small number of Cu-IUD users with mixed results. Evidence from 10 studies of fair to poor quality suggested that some NSAIDs may significantly reduce menstrual blood loss or bleeding duration among Cu-IUD users with heavy or prolonged menstrual bleeding. Antifibrinolytic drugs or antidiuretics may also help reduce blood loss. High-dose aspirin was shown to increase blood loss among those with baseline menorrhagia. Evidence from five studies of fair to poor quality suggested that bleeding irregularities among new Cu-IUD users may be prevented with NSAIDs, although one large study of good quality suggested that prophylactic treatment with ibuprofen does not affect continuation of Cu-IUD use. Evidence from two studies of fair to poor quality suggested that antifibrinolytic agents might be helpful in preventing heavy or prolonged menstrual bleeding among new Cu-IUD users. CONCLUSIONS: Limited evidence suggests that NSAIDs may be effective treatments for bleeding irregularities associated with Cu-IUD use; antifibrinolytic agents and antidiuretics have also been studied as possible treatments in a small number of subjects, but their safety has not been well documented. NSAIDs and antifibrinolytics may also prevent bleeding irregularities among new CU-IUD users. Preventive NSAID use, however, does not impact Cu-IUD continuation.

BACKGROUND: The emergence of the pandemic H1N1 influenza strain in 2009 reinforced the need for improved influenza surveillance efforts. A previously described influenza typing assay that utilizes RT-PCR coupled to electro-spray ionization mass spectrometry (ESI-MS) played an early role in the discovery of the pandemic H1N1 influenza strain, and has potential application for monitoring viral genetic diversity in ongoing influenza surveillance efforts. OBJECTIVES: To determine the analytical sensitivity of RT-PCR/ESI-MS influenza typing assay for identifying the pandemic H1N1 strain and describe its ability to assess viral genetic diversity. STUDY DESIGN: Two sets of pandemic H1N1 samples, 190 collected between April and June of 2009, and 69 collected between October 2009 and January 2010, were processed by the RT-PCR/ESI-MS influenza typing assay, and the spectral results were compared to reference laboratory results and historical sequencing data from the Nucleotide Database of the National Center for Biotechnology Information (NCBI). RESULTS: Strain typing concordance with reference standard testing was 100% in both sample sets, and the assay demonstrated a significant increase in influenza genetic diversity, from 10.5% non-wildtype genotypes in early samples to 69.9% in late samples (P<0.001). An NCBI search demonstrated a similar increase, from 13.4% to 45.2% (P<0.001). CONCLUSIONS: This comparison of early versus late influenza samples analyzed by RT-PCR/ESI-MS demonstrates the influenza typing assay's ability as a universal influenza detection platform to provide high-fidelity pH1N1 strain identification over time, despite increasing genetic diversity in the circulating virus. The genotyping data can also be leveraged for high-throughput influenza surveillance.

PURPOSE: To describe the trend of Acanthamoeba keratitis case reports following an outbreak and the recall of a multipurpose contact lens disinfection solution. Acanthamoeba keratitis is a serious eye infection caused by the free-living amoeba Acanthamoeba that primarily affects contact lens users. METHODS: A convenience sample of 13 ophthalmology centers and laboratories in the USA, provided annual numbers of Acanthamoeba keratitis cases diagnosed between 1999-2009 and monthly numbers of cases diagnosed between 2007-2009. Data on ophthalmic preparations of anti-Acanthamoeba therapies were collected from a national compounding pharmacy. RESULTS: Data from sentinel site ophthalmology centers and laboratories revealed that the yearly number of cases gradually increased from 22 in 1999 to 43 in 2003, with a marked increase beginning in 2004 (93 cases) that continued through 2007 (170 cases; p < 0.0001). The outbreak identified from these sentinel sites resulted in the recall of a contact lens disinfecting solution. There was a statistically significant (p ≤ 0.0001) decrease in monthly cases reported from 28 cases in June 2007 (following the recall) to seven cases in June 2008, followed by an increase (p = 0.0004) in reported cases thereafter; cases have remained higher than pre-outbreak levels. A similar trend was seen in prescriptions for Acanthamoeba keratitis chemotherapy. Cases were significantly more likely to be reported during summer than during other seasons. CONCLUSION: The persistently elevated number of reported cases supports the need to understand the risk factors and environmental exposures associated with Acanthamoeba keratitis. Further prevention efforts are needed to reduce the number of cases occurring among contact lens wearers.

BACKGROUND: While evidence on the association between oral contraceptive (OC) use and breast cancer generally suggests little or no increased risk, the question of whether breast cancer risk varies by OC formulation remains controversial. Few studies have examined this issue because large samples and extensive OC histories are required. STUDY DESIGN: We used data from a multicenter, population-based, case-control investigation. Women aged 35-64 years were interviewed. To explore the association between OC formulation and breast cancer risk, we used conditional logistic regression to derive adjusted odds ratios, and we used likelihood ratio tests for heterogeneity to assess whether breast cancer risk varied by OC formulation. Key OC exposure variables were ever use, current or former use, duration of use and time since last use. To strengthen inferences about specific formulations, we restricted most analyses to the 2282 women with breast cancer and the 2424 women without breast cancer who reported no OC use or exclusive use of one OC. RESULTS: Thirty-eight formulations were reported by the 2674 women who used one OC; most OC formulations were used by only a few women. We conducted multivariable analyses on the 10 formulations that were each used by at least 50 women and conducted supplemental analyses on selected formulations of interest based on recent research. Breast cancer risk did not vary significantly by OC formulation, and no formulation was associated with a significantly increased breast cancer risk. CONCLUSIONS: These results add to the small body of literature on the relationship between OC formulation and breast cancer. Our data are reassuring in that, among women 35-64 years of age, we found no evidence that specific OC formulations increase breast cancer risk.

BACKGROUND: Diallyl sulfide (DAS) has been shown to have a preventive effect against various cancers. AIMS AND OBJECTIVES: We evaluated the protective effects of DAS in regression of ultraviolet B (UVB)-induced skin tumor formation in SKH-1 hairless mice and its underlying early molecular biomarkers. METHODS: We examined the efficacy of DAS in UVB light-induced skin lesion in SKH-1 hairless mice and the associated molecular events. RESULTS: Mice irradiated with UVB at 180 mJ/cm(2) twice per week elicited 100% tumor incidence at 20 weeks. The topical application of DAS before UVB irradiation caused a delay in tumor appearance, multiplicity, and size. The topical application of DAS before and immediately after a single UVB irradiation (180 mJ/cm(2) ) resulted in a significant decrease in UVB-induced thymine dimer-positive cells, expression of proliferative cell nuclear antigen (PCNA), terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling, and apoptotic sunburn cells, together with an increase in p53 and p21/Cip1-positive cell population in the epidermis. Simultaneously, DAS also significantly inhibited nuclear factor-kappaB (NF-kappaB), cyclooxygenase-2 (COX-2), prostaglandin E2 (PGE2), and nitric oxide (NO) levels. CONCLUSIONS: The protective effect of DAS against photocarcinogenesis is accompanied by the down-regulation of cell-proliferative controls, involving thymine dimer, PCNA, apoptosis, transcription factors NF-kappaB, and of inflammatory responses involving COX-2, PGE2, and NO, and up-regulation of p53, p21/Cip1 to prevent DNA damage and facilitate DNA repair.

PROBLEM/CONDITION: Assisted Reproductive Technology (ART) includes fertility treatments in which both eggs and sperm are handled in the laboratory (i.e., in vitro fertilization and related procedures).Patients who undergo ART procedures are more likely to deliver multiple-birth infants than women who conceive naturally. Multiple births are associated with increased risk for mothers and infants (e.g., pregnancy complications, premature delivery, low-birthweight infants, and long-term disability among infants). This report presents the most recent national data and state-specific results. REPORTING PERIOD COVERED: 2006. DESCRIPTION OF SYSTEM: In 1996, CDC initiated data collection regarding ART procedures performed in the United States, as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (FCSRCA) (Public Law 102-493 [October 24, 1992]). Beginning with 2004, CDC has contracted with Westat, Inc., a statistical survey research organization, to obtain data from ART medical centers in the United States. Westat, Inc., maintains the National ART Surveillance System (NASS), CDC's web-based data collection system. RESULTS: In 2006, a total of 138,198 ART procedures were reported to CDC. These procedures resulted in 41,343 live-birth deliveries, and 54,656 infants. ART procedures are categorized into four major procedure types: procedures that used embryos from freshly fertilized eggs (fresh embryos) from the patient's eggs (72%); procedures that used thawed embryos from the patient's eggs (16%); procedures that used fresh embryos from donor eggs (8%); and procedures that used thawed embryos from donor eggs (4%). Overall, 44% of ART transfer procedures resulted in a pregnancy, and 36% in a live-birth delivery (delivery of one or more live-born infants). Live-birth rates were generally higher among ART procedures that used fresh embryos from donor eggs (54%) than among other types. The highest numbers of ART procedures were performed among residents of California (18,886); New York (13,259); Illinois (9,594); New Jersey (9,237); and Massachusetts (8,305). All five states reported the highest number of live-birth deliveries as a result of ART. Of 54,656 infants born through ART, 48% were multiple-birth deliveries. The risk for a multiple-birth delivery was highest for women who underwent ART transfer procedures that used fresh embryos from either donor eggs (39%) or their own eggs (31%). Approximately 1% of U.S. infants born in 2006 were conceived through ART. Those infants accounted for 18% of multiple births nationwide. Approximately 9% of ART singletons, 57% of ART twins, and 96% of ART triplets or higher-order multiples were low birthweight. Similarly, 14% of ART singletons, 65% of ART twins, and 97% of ART triplets or higher-order multiples were born preterm. INTERPRETATION: Whether an ART procedure resulted in a pregnancy and live-birth delivery varied, according to different patient and treatment factors. ART poses a major risk for multiple births associated with adverse maternal and infant outcomes (e.g., placenta previa, preterm delivery, cesarean delivery, low birthweight, and infant mortality). This risk varied according to the patient's age, the type of ART procedure performed, the number of embryos available for transfer to the uterus, the number transferred, and the day of transfer (day 3 or 5). PUBLIC HEALTH ACTIONS: ART-related multiple births represent a sizable proportion of all multiple births nationwide and in selected states. To minimize the adverse maternal and child health effects associated with multiple pregnancies, ongoing efforts to limit the number of embryos transferred in each ART procedure should be continued and strengthened. Adverse maternal and infant outcomes (e.g., low birthweight and preterm delivery) associated with ART treatment choices should be explained thoroughly when counseling patients considering ART.