Original Research ajog.

org

OBSTETRICS
Fertility treatment use and breastfeeding outcomes
Chloe M. Barrera, MPH; Jennifer F. Kawwass, MD; Sheree L. Boulet, DrPH; Jennifer M. Nelson, MD, MPH; Cria G. Perrine, PhD

BACKGROUND: About 15% of women aged 15e44 years in the RESULTS: Mode of conception was not associated with breastfeeding
United States experience infertility. Factors associated with infertility and outcomes when comparing women who conceived spontaneously to
fertility treatments may also be associated with lactation difficulties. women who conceived using any fertility treatment. The odds of
Limited data exist examining the impact of infertility or mode of conception breastfeeding at 8 weeks were lower among women who conceived
on breastfeeding outcomes. using ART, after adjusting for basic demographic covariates (adjusted
OBJECTIVE: The objectives of this study were to report breastfeeding odds ratio [aOR], 0.71; 95% confidence interval [CI], 0.52e0.97) and
outcomes (initiation and duration at 8 weeks) among women who additionally adjusting for maternal health conditions (aOR, 0.68; 95%
conceived spontaneously compared to women who conceived using CI, 0.49e0.93), but this difference was no longer significant after
fertility treatments (assisted reproductive technology [ART], intrauterine adjusting for plurality and preterm birth (aOR, 0.74; 95% CI,
insemination, or fertility-enhancing drugs). 0.54e1.02).
MATERIALS AND METHODS: Maternal-reported data from 4 states CONCLUSION: This study suggests that mothers who conceive
from the 2012e2015 Pregnancy Risk Assessment and Monitoring System using ART may breastfeed for shorter durations than mothers who
(PRAMS) were used to explore use of fertility treatment and breastfeeding conceive spontaneously, partially mediated by an increased
initiation and continuation at 8 weeks (n ¼ 15,615). Data were weighted to likelihood of multiples and infants born preterm. Studies are needed to
represent all women delivering live births within each state; SAS survey elucidate these associations and to understand the intentions and
procedures were used to account for PRAMS complex survey design. barriers to breastfeeding among women who conceive with the help of
Stepwise, multivariable logistic regression, adjusted for maternal de- ART.
mographics, parity, plurality, mode of delivery, preterm birth, and maternal
pre-pregnancy health conditions, was used to quantify the associations Key words: assisted reproductive technology, breastfeeding, fertility
between fertility treatment use and breastfeeding. treatment

T he American Academy of Pediatrics

(AAP) recommends exclusive
breastfeeding for about the first 6
can be treated with fertility-enhancing
drugs, intrauterine insemination (IUI),
or assisted reproductive technology
In addition, both singleton and multiple
birth infants conceived through fertility
treatment are at increased risk for being
months of life.1 Despite 83% of infants (ART), which includes treatments in born premature or small for gestational
in the United States initiating breast- which eggs or embryos are handled in age.9e11 All of these characteristics asso-
feeding, only 25% meet this recom- the laboratory for the purpose of estab- ciated with fertility treatment have been
mendation.2 Increasing breastfeeding lishing a pregnancy. In the United States, associated with lactation difficulties.12 In
rates to improve the health of mothers over 99% of ART procedures involve addition, poor maternal mental and
and infants and to meet national rec- in vitro fertilization (IVF).6 emotional health has been found to have
ommendations requires an understand- It is unclear whether and to what de- a negative impact on breastfeeding,3 and
ing of populations who may be at risk for gree fertility treatments may be associated women who undergo fertility treatments
experiencing lactation difficulties. One with breastfeeding outcomes, in part often experience unique stresses and
such population is women who experi- because women who conceive with the anxieties.13 Finally, breast milk produc-
ence infertility,3 defined as the inability help of fertility treatment are often char- tion has been found to be lower among
to conceive within 1 year of well-timed acterized by factors that have been asso- mothers who give birth to infants
unprotected intercourse.4 In the United ciated with both positive and negative conceived through fertility treatment.14
States, it is estimated that about 15% of breastfeeding outcomes. Women who Several studies have been conducted in
nonpregnant, sexually active women conceive with the help of fertility treat- developed countries aimed at exploring
aged 15e44 who are not using contra- ment tend to be older, more educated, of the relationship between fertility treat-
ception and are trying to become preg- higher income status, and nonsmokers,7 ments and breastfeeding outcomes;
nant experience infertility.5 Infertility all of which have previously been associ- however, these studies have yielded
ated with being significantly more likely inconsistent results.13,15e18 To our
to initiate breastfeeding.8 knowledge, only 1 study in the United
Cite this article as: Barrera CM, Kawwass JF, Boulet SL, Conception through fertility treatment States has looked at the association be-
et al. Fertility treatment use and breastfeeding outcomes. is associated with giving birth to twins or tween mode of conception and breast-
Am J Obstet Gynecol 2019;XX:x.ex-x-ex.
other higher-order multiples, and a feeding outcomes, and that study was
0002-9378/$36.00 higher likelihood of cesarean deliveries, conducted in a single state.19 The aims of
ª 2018 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ajog.2018.11.1100
maternal hemorrhage, pregnancy-related our study were to examine breastfeeding
hypertension, and gestational diabetes.9 initiation and continuation (at 8 weeks)

MONTH 2019 American Journal of Obstetrics & Gynecology 1.e1

Original Research OBSTETRICS ajog.org

spontaneous conceptions; these women

AJOG at a Glance were not asked about receipt of fertility
Why was this study conducted? treatment. Women who were trying to
This secondary data analysis was conducted to assess whether women who conceive were asked, “Did you take any
conceive with fertility treatment have different breastfeeding outcomes than fertility drugs or receive any medical
women who conceive spontaneously. procedures from a doctor, nurse, or
other healthcare worker to help you get
Key findings pregnant with your new baby?” (yes/no).
Although initiation rates were comparable between women who conceived with Those who responded “yes” were then
and without any fertility treatment, results of this study suggest that women who asked, “Did you use any of the following
conceive with the help of assisted reproductive technology may breastfeed for fertility treatments during the month
shorter durations than women who conceive spontaneously. that you got pregnant with your new
baby?” This was a “check all that apply”
What does this add to what is known? question. Answer choices included
This study is unique in the size of the population and in the resultant ability to “Fertility-enhancing drugs prescribed by
stratify women by the type of fertility treatment received. a doctor,” “Artificial insemination or
intrauterine insemination,” “Assisted
reproductive technology,” “Other medi-
(1) among women who conceived using additional questionnaires, followed by up cal treatment” (with a free text field
any fertility treatment, and (2) by type of to 15 attempted telephone calls. prompting respondents to “Please tell
fertility treatments used, specifically The PRAMS questionnaire includes us: _____”), and “I wasn’t using fertility
among women who conceived using core questions that are asked by all states, treatments during the month that I got
ART, IUI, or fertility-enhancing drugs standard questions developed and pre- pregnant with my new baby.”
compared to women who conceived tested by the CDC from which states can To categorize type of fertility treatment
spontaneously. choose to include or not include, and received, we created a hierarchical classi-
questions developed by states. Thus, fication according to the highest treatment
Materials and Methods each state has a unique PRAMS ques- intensity used: (1) women who conceived
Data source and study sample tionnaire. This study uses data from with the help of ART, either alone (n ¼
This study uses data from the Pregnancy Phase 7 (2012e2015) PRAMS from 311) or combined with any other treat-
Risk Assessment and Monitoring System Massachusetts, Maryland, New York, ment (n ¼ 228), were placed in the ART
(PRAMS), a cross-sectional surveillance and Utah. These 4 states were the only group; (2) women who conceived with the
system that provides state-specific pop- states that included standard questions help of intrauterine insemination only
ulation-based data on maternal behav- to assess receipt of any fertility treat- (n ¼ 36) or combined with fertility-
iors before, during, and after ment, as well as the type of fertility enhancing drugs (n ¼ 153) were placed
pregnancies that result in live births. treatment that a woman received. For the in the intrauterine insemination group;
PRAMS is administered by the Centers release of Phase 7 data, PRAMS had a (3) women who conceived only with the
for Disease Control and Prevention minimum survey response rate help of fertility-enhancing drugs pre-
(CDC) in collaboration with state health threshold of at least 60%.6 scribed by a doctor were placed in the
departments.16 The PRAMS protocol Data were available for 19,657 women fertility-enhancing drugs group (n ¼
was approved by the CDC’s Institutional from the 4 states. Women who reported 328); and (4) women who conceived
Review Board, and participating states their infant was not alive (n ¼ 219) or spontaneously (n ¼ 14,559) (women who
approved the study analysis plan. Each was not living with them (n ¼ 97), and were not trying to get pregnant, women
questionnaire is linked to the child’s teenage mothers (<20 years, n ¼ 1238) who answered “no” to having taken
birth certificate, so the PRAMS analytic were not eligible for this analysis. Among fertility drugs, and women who responded
dataset contains both maternal re- the 18,135 women who were eligible, that they were not using fertility treat-
sponses and selected state vital statistics 17,190 had data on our predictors and ments during the month in which they got
data. (Detailed PRAMS methodology outcomes of interest. We excluded the pregnant with their new baby). Responses
can be found at: www.cdc.gov/prams/ 1,574 women who were missing covari- to the open-ended “Other medical treat-
methodology.htm.) ate data, resulting in an analytic sample ment” option were recoded as ART,
In brief, each participating state sam- of 15,615 participants. intrauterine insemination, fertility-
ples 1300 to 3400 women every year from enhancing drugs, or no treatment, based
live birth certificate registries. The pri- Measures on the written responses.
mary means of data collection is a single, Our exposure of interest was women’s Our outcomes of interest were
self-administered questionnaire mailed to reported use of fertility treatment. The breastfeeding initiation (based on any
women 2e4 months after giving birth. pregnancies of women who were not breastfeeding, yes/no) and any breast-
Nonrespondents are mailed up to 2 trying to get pregnant were considered feeding at 8 weeks (based on the reported

1.e2 American Journal of Obstetrics & Gynecology MONTH 2019

ajog.org OBSTETRICS Original Research

number of weeks/months that mothers

TABLE 1
breastfed or pumped milk). Mothers
Comparison of selected demographic characteristics by mode of conception
were asked, “Did you ever breastfeed or
among women participating in PRAMS, 2012e2015 (n [ 9041)
pump breast milk to feed to your new
Mode of conception baby after delivery, even for a short
period of time?” (yes/no). Those who
Spontaneous Fertility treatment
responded “yes” were asked “Are you
(n ¼ 14,559) (n ¼ 1,056) currently breastfeeding or feeding
Variable %a %a P valueb pumped milk to your new baby?” (yes/
Maternal age (y) <.0001 no); of which, those who responded
“no” were asked, “How many weeks or
20e24 19.2 3.2
months did you breastfeed or pump milk
25e29 30.6 17.9 to feed your baby?” For our sample, no
30e34 31.8 38.6 mothers completed a survey before 8
35 18.4 40.3 weeks, so any mother who answered that
she was still breastfeeding was put in the
Maternal race/ethnicity <.0001
any breastfeeding at 8 weeks group.
Non-Hispanic white 65.2 78.7 We accounted for covariates including
Non-Hispanic black 12.7 3.9 maternal age (20e24, 25e29, 30e34,
Hispanic 13.7 6.0 35 years), maternal race/ethnicity
(non-Hispanic white, non-Hispanic
Asian 5.7 8.8
black, Hispanic, Asian, other), maternal
Other 2.6 2.6 education (less than high school, high
Maternal education <.0001 school, more than high school), maternal
Less than high school 8.6 2.3 pre-pregnancy body mass index (BMI;
<18.5, 18.5e24.9, 25.0e29.9, 30 kg/m2),
High school graduate 19.1 8.0
marital status (married, other), partici-
More than high school 72.3 89.7 pation in the Special Supplemental
Maternal BMI (kg/m2) 0.075 Nutrition Program for Women, Infants,
Underweight, <18.5 3.7 2.3 and Children (WIC) during pregnancy
(yes/no), maternal smoking status during
Normal, 18.5e24.9 50.9 56.0
pregnancy (smoker, nonsmoker), parity
Overweight, 25.0-29.9 24.1 21.6 (primiparous, multiparous), plurality
Has obesity, 30 21.3 20.1 (singleton, multiples), vaginal delivery
Married <.0001 (yes/no), preterm birth (gestational age
<37 weeks), and maternal pre-pregnancy
Yes 68.5 94.4
health conditions including whether or
No 31.5 5.6 not a woman was diagnosed by a doctor
WIC during pregnancy <.0001 or nurse with type 1 or type 2 diabetes
Yes 35.6 7.5 (not the same as gestational diabetes),
high blood pressure or hypertension,
No 64.4 92.5
and/or depression before getting preg-
Smoked during pregnancy <.0001 nant. The above maternal health variables
Yes 7.4 1.1 were included because they were likely to
No 92.6 98.9
be associated with fertility and breast-
feeding outcomes. With the exception of
Multiparous <.0001 WIC and the medical conditions diag-
Yes 62.6 47.5 nosed before pregnancy (PRAMS ques-
No 37.4 52.5 tionnaire variables), all other covariates
were from the birth certificate.
Plurality <.0001
Singleton 98.7 86.7 Statistical analysis
Multiples 1.3 13.3 We used c2 tests to describe differences
Barrera et al. Fertility treatment and breastfeeding. Am J Obstet Gynecol 2019. (continued) in demographic and birth characteristics
by mode of conception. We then

MONTH 2019 American Journal of Obstetrics & Gynecology 1.e3

Original Research OBSTETRICS ajog.org

for covariates (Table 2). When exam-

TABLE 1 ining specific types of fertility treatment,
Comparison of selected demographic characteristics by mode of conception in unadjusted analysis, the odds of ever
among women participating in PRAMS, 2012e2015 (n [ 9041) (continued) breastfeeding were higher among
Mode of conception women who used IUI and fertility-
enhancing drugs compared to women
Spontaneous Fertility treatment
who conceived spontaneously, but these
(n ¼ 14,559) (n ¼ 1,056) relationships were no longer significant
Variable %a %a P valueb after adjusting for covariates. The odds
Vaginal delivery <.0001 of breastfeeding at 8 weeks were signifi-
cantly different between those who
Yes 67.2 55.5
conceived by fertility-enhancing drugs
No 32.8 44.5 and those who conceived spontaneously
Preterm birth <.0001 in unadjusted analyses but not after
Gestational age <37 wk 7.2 16.0 adjusting for covariates (Table 2). The
odds of breastfeeding at 8 weeks was
Gestational age 37 wk 92.8 84.0
lower among women who conceived
Maternal pre-pregnancy health condition 0.021 using ART than among women who
Yes 13.6 10.2 conceived spontaneously in model 1
No 86.4 89.8 (adjusted odds ratio [aOR], 0.71; 95%
confidence interval [CI], 0.52e0.97) and
BMI, body mass index; PRAMS, Pregnancy Risk Assessment and Monitoring System; WIC, Special Supplemental Nutrition
Program for Women, Infants, and Children. model 2 (aOR, 0.68; 95% CI,
a
Weighted prevalence; b Comparison of spontaneous conception and fertility treatment. 0.49e0.93); however, this difference was
Barrera et al. Fertility treatment and breastfeeding. Am J Obstet Gynecol 2019. no longer significant in model 3 (aOR,
0.74; 95% CI, 0.54e1.02) (Table 2).

described breastfeeding outcomes by SAS version 9.4 survey procedures for all Comment
specific type of fertility treatment. We statistical analyses.21 Although breastfeeding rates appeared
used bivariable and stepwise multivari- to be higher among women who received
able logistic regression models to assess Results fertility treatment, differences were not
the odds of ever breastfeeding and Of the 15,615 women included in the significant after adjusting for covariates.
breastfeeding at 8 weeks among women analysis, 5.8% (n ¼ 1,056) conceived Breastfeeding rates may have appeared
who conceived with any fertility treat- with the use of fertility treatment. higher in the unadjusted analyses
ment and by specific type of fertility Women who conceived with fertility because women receiving fertility treat-
treatment, compared to women who treatment were more likely to be older, ment tended to be older, more educated,
conceived spontaneously. Model 1 non-Hispanic white, married, and more married, and with higher income, all
included maternal age, maternal race/ educated, to have given birth to multi- factors known to be associated with an
ethnicity, maternal education, marital ples, and to have given birth to a preterm increased likelihood of breastfeeding.
status, WIC status, parity, and mode of infant (all P < .01), compared with The only association that was significant
delivery. Model 2 included these vari- women who conceived spontaneously. in any of the adjusted models was
ables plus maternal health conditions Women who conceived with fertility women who conceived with the help of
(maternal BMI, smoking status during treatments were less likely than women ART having a reduced odds of breast-
pregnancy, and maternal pre-pregnancy with spontaneous conceptions to be feeding at 8 weeks. This association
health history), and model 3 included participating in WIC, to smoke during became nonsignificant in the final
all previously mentioned covariates as pregnancy, to be multiparous, to deliver model, suggesting that the effect of ART
well as plurality and preterm birth. via vaginal delivery, and to have pre- on breastfeeding duration may be
We assessed our models for collin- pregnancy health conditions (all P < mediated by the increased likelihood of
earity using the %COLLIN_2011 macro, .03) (Table 1). multiple births and infants born
and we assessed our models for an Women who conceived with the help preterm.
interaction with plurality; neither was of any fertility treatment were more Some of the characteristics that are
detected.20 likely to ever breastfeed and to be associated with both use of fertility
All estimates are weighted to represent breastfeeding at 8 weeks than women treatment and non-initiation and
all women delivering live births within who conceived spontaneously in unad- shorter duration of breastfeeding may be
each state, adjusting for sampling design, justed analyses, but these relationships mitigated by a strong desire to breastfeed
noncoverage, and nonresponse. We used were no longer significant after adjusting that is unique to women who undergo

1.e4 American Journal of Obstetrics & Gynecology MONTH 2019

ajog.org OBSTETRICS Original Research

fertility treatment. A study that exam-

ined the breastfeeding experiences of

0.75e1.72
0.40e1.19

0.66e4.25

0.95e5.01

0.71e1.14
0.54e1.02

0.63e1.73

0.73e1.57
95% CI new mothers who conceived with the use
— of fertility treatments found that these

—
mothers expressed internal pressure
Model 3

because they believed that it was their

1.00
1.13
0.69

1.67

2.18
1.00
0.90
0.74

1.04

1.07
aOR

only chance to breastfeed, and they

believed that it was the one natural thing
that they should be able to do.17 They

a
0.74e1.68
0.41e1.16

0.65e4.19

0.95e4.98

0.68e1.07
0.49e0.93

0.61e1.65

0.72e1.54
expressed the feeling that not breast-
95% CI

feeding meant failing at motherhood.22

—

— Another study had similar findings, and

Model 2

the authors reported that women who

a
1.00
1.11
0.69

1.65

2.17
1.00
0.85
0.68

1.01

1.05
aOR

conceived through fertility treatment

Prevalence and odds of breastfeeding (ever and at 8 weeks) by conception method, PRAMS 2012e2015 (n [ 15,615)

were determined to breastfeed to coun-

teract the need for fertility treatment
a
0.76e1.75
0.42e1.19

0.65e4.29

0.99e5.55

0.69e1.09
0.52e0.97

0.58e1.58

0.72e1.61
intervention.23
95% CI

CI, confidence interval; OR, odds ratio; PRAMS, Pregnancy Risk Assessment and Monitoring System; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.
Few previous studies have examined
breastfeeding outcomes following
—

fertility treatments, and of those that

Model 1

have, results are conflicting.13,15e18 One

a
1.00
1.15
0.70

1.67

2.35
1.00
0.86
0.71

0.96

1.08
aOR

Canadian study compared women who

used any type of fertility treatment to
Model 2 includes all covariates in model 1, plus maternal body mass index, smoking status during pregnancy, and maternal pre-pregnancy health history.
1.30e2.86a

1.17e7.03a

1.58e7.43a

1.11e2.23a

women who conceived spontaneously

0.77e2.14

1.12e1.71
0.89e1.64

0.94e2.55

and found no significant differences be-

95% CI

tween groups in terms of breastfeeding

—

Model 1 is adjusted for maternal age, maternal race/ethnicity, maternal education, marital status, WIC status, parity, and mode of delivery.
Unadjusted

initiation, duration at 4 months, or

breastfeeding difficulties.17 Another Ca-
1.93a

2.86a

3.43a

1.57a
1.00

1.29

1.00
1.38
1.21

1.55

nadian retrospective cohort study found

OR

that the odds of breastfeeding exclusively

at hospital discharge were significantly
% Breastfeeding

higher among mothers who conceived

without reproductive assistance.18 A
study from New York found women who
88.2
93.5
90.6

95.6

96.3
69.6
76.0
73.4

78.0

78.3

conceived with the help of fertility

treatments were more likely to be
breastfeeding at 4 months but less likely
1056

1056
14,559

14,559
539

189

328

539

189

328

to be breastfeeding at 12 months than

Barrera et al. Fertility treatment and breastfeeding. Am J Obstet Gynecol 2019.

women who conceived spontaneously.19

n

Model 3 includes all covariates in model 2, plus plurality, and preterm birth.

This study also asked women who were

Fertility-enhancing drugs

Fertility-enhancing drugs

not breastfeeding at 4 months why they

Artificial or intrauterine

Artificial or intrauterine
Assisted reproductive

Assisted reproductive

had stopped; women who conceived

Any fertility treatment

Any fertility treatment

Mode of conception

with the use of fertility treatments were

more likely to say they stopped “due to
insemination

insemination
technology

technology
Spontaneous

Spontaneous

an inability to establish a milk supply”

than women who conceived spontane-
ously.19 Further research regarding
fertility treatments and an ability to
establish an adequate milk supply may
Breastfeeding at 8 wk

help elucidate a better understanding of

Statistically significant.

whether certain underlying fertility di-

Ever breastfed

agnoses are associated with a patho-

TABLE 2

physiologic limitation on breast milk

production.
Our study found that women who
a

conceived with ART did not differ in

MONTH 2019 American Journal of Obstetrics & Gynecology 1.e5

Original Research OBSTETRICS ajog.org

breastfeeding initiation from women undergoing fertility treatment for other among expectant mothers. Matern Child Health
who conceived spontaneously, but they reasons, such as male partner fertility J 2016;20:993–1000.
3. Evans A, Marinelli KA, Taylor JS. ABM clinical
may be less likely to be breastfeeding at 8 issues or not having a male partner. protocol #2: Guidelines for hospital discharge of
weeks. A study of an Australian pro- Because of the hierarchical groupings of the breastfeeding term newborn and mother:
spective cohort found that women who fertility treatment type received, we are “the going home protocol,” revised 2014.
conceived with the use of ART were unable to conclude whether a specific Breastfeed Med 2014;9:3–8.
significantly more likely to initiate treatment or a combination of treat- 4. Centers for Disease Control and Prevention.
Contraindications to breastfeeding or feeding
breastfeeding but significantly less like to ments may have an impact on breast- expressed breast milk to infants [updated
be breastfeeding exclusively at 3 months feeding. In addition, PRAMS data are March 21, 2018]. Available at:. https://www.
compared to women who conceived based on maternal report and cannot be cdc.gov/breastfeeding/breastfeeding-special-
spontaneously.13 verified by in-facility observation or circumstances/Contraindications-to-breastfeeding.
Women in our study who conceived medical chart review. PRAMS data also html. Accessed June 28, 2018.
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than women who conceived spontane- breastfeeding intention and duration of estimated by the current duration approach and
ously to give birth to multiples (13.3% vs stay in the neonatal intensive care unit, a traditional constructed approach. Fertil Steri
1.3%, P < .0001), to give birth to a pre- which could affect breastfeeding 2013;99:1324–31.
term infant (16.0% vs 7.2%, P <.0001), continuation. Finally, because only 4 6. Joint Commission Health Care Quality Data
Download. Available at:. http://www.
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(44.5% vs 32.8%, P < .0001). We treatment that could be included in this 2018.
adjusted for these factors in our final analysis, results of this study are not 7. Duwe KN, Reefhuis J, Honein MA,
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may have difficulty continuing to that provides us with data representative Grummer-Strawn LM. Factors associated with
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