Psychosocial risks associated with multiple births resulting from assisted reproduction

Exploring the Link Between Parental Sociodemographic Characteristics and Multiple Births: Insights from National Birth Data in Japan, 1995-2020

This present study investigated the parental characteristics of multiple births using national birth data in Japan. This study included birth data from Vital Statistics: Occupational and Industrial Aspects every five fiscal years from 1995 to 2020. The multiple birth rates were defined as the number of live-birth deliveries with multiple fetuses (e.g., twins, triplets) per total live-birth deliveries. Parental ages, nationalities, occupations and household occupation (occupation of the top earner of the household) were considered as parental characteristics. The multiple birth rates were calculated based on parental characteristics for each year, and a log-binomial regression model was used to assess the association between parental characteristics and multiple births. The multiple birth rate for Japanese mothers consistently exceeded that for non-Japanese mothers over the years, and the rate increased progressively from manual workers to lower non-manual workers and then to upper non-manual workers for both maternal and paternal occupations. The regression results indicated that the risk ratio (RR) for multiple births among non-Japanese mothers was significantly lower than that among Japanese mothers. Moreover, concerning household occupation, the RRs of self-employed individuals, full-time employees at smaller companies, others, and the unemployed were significantly lower than those of full-time employees at larger companies. Furthermore, the RRs of lower non-manual and manual workers were significantly lower than those of upper non-manual workers in maternal and paternal occupations. The results suggested an association between multiple births and parental socioeconomic status in Japan.

[Embryo reduction in twin pregnancy on maternal request: A French practice study]

INTRODUCTION

In France, embryo reduction is controversial in twin pregnancy, especially when there is no underlying pathology. The objective of this study was to establish the status of this practice in France and to depict the ethical issues around this problematic.

STUDY DESIGN

A questionnaire drafted by Maternal and Fetal Medicine physicians and family planning teams of the University Hospital from Strasbourg was distributed to the 48 French Multidisciplinary Prenatal Diagnosis Centers, among which 28 answered (58,3%).

RESULTS

Embryo reduction in twin pregnancy on maternal request has already challenged 71% of the centers; 29% have performed such a reduction. The overall position of the centers to these requests is negative (3.1/10), with very mixed levels of in-team agreement. The main arguments against this practice are that twin pregnancy is not a pathology, that embryo reduction exposes to the risk of loosing the entire pregnancy, the feeling of being held hostage with the alternative of abortion of the whole pregnancy, and the lack of legal framing. On the contrary, the arguments in favor of the reduction are: that the reduction can avoid an abortion, that this type of reduction can be related to a partial abortion, that it responds to women's rights and that mental health is an integral part of women's health.

CONCLUSION

There is no consensus about how to respond to patients requesting for embryo reduction in twin pregnancy. However, the majority of Centers have been confronted with it and it would be necessary to open the debate on this problem and the ethical questions it raises.

Is the mental health of couples with twins more at risk? Results from an Italian cohort study

Introduction

Our retrospective study aimed to investigate whether parents of twins encounter heightened psychological and emotional distress one year after childbirth, in comparison to parents of singletons within an Italian cohort.

Methods

Exclusion criteria included multiparity, preterm birth, congenital anomalies, stillbirth, >2 fetus pregnancies, and pre-existing maternal mental health disorders. Out of the 300 couples (600 parents) invited to participate, 286 parents (158 mothers, 128 fathers) successfully completed a self-administered survey. We analyzed three scores separately for mothers and fathers, differentiating between singleton and twin pregnancies: the Edinburgh Postnatal Depression Scale (EPDS) score, the State and Trait Anxiety Inventory (STAI)-Y1 score, and the STAI-Y2 score.

Results

Logistic models were used to assess the influence of age, BMI, marital status, education, and employment on the three binary scores (EPDS, STAI-Y1, and STAI-Y2), revealing no significant differences in absolute scores between parents of singletons and twins. Paired analysis revealed significantly higher EPDS (mean increase: 3.8, SD: 6.5), STAI-Y1 (mean increase: 5.4, SD: 12.5), and STAI-Y2 (mean increase: 4.5, SD: 12.4) scores for mothers (p < 0.0001). Approximately 10% of women and 8% of men reported suicidal thoughts.

Discussion

Contrary to expectations, no substantial psychological differences emerged between parents of twins and singletons. Adjusting for confounders through univariate analysis maintained nonsignificant trends. Nevertheless, caution in interpretation is warranted due to strict inclusion criteria favoring twin pregnancies with better outcomes. Unintended bias could have resulted from routine psychological support offered to mothers of twins in our clinic. This presents an important framework for future research, including randomized controlled trials comparing parents of multiples with psychological support to those without.Finally, the elevated prevalence of depression symptoms and suicidal thoughts in our cohort underscores the importance of mental health during pregnancy and early parenting. We advocate for the screening of parents for postpartum depression and various psychological conditions, encompassing a spectrum of anxiety disorders. Those at elevated risk of mental distress should be proactively offered appropriate support.

Recurrence risk and risk factors for monozygotic twin and triplet birth in over 65,000 single-embryo transfers

PURPOSE

To determine the recurrence risk and risk factors for monozygotic splitting after elective single-embryo transfers (eSET).

METHODS

A retrospective cohort study was performed investigating 65,664 eSET cycles that resulted in a clinical pregnancy as reported in the Society for Assisted Reproductive Technology (SART) Clinical Outcomes Reporting System (CORS) between 2004 and 2017. Monozygosity was defined as more than one fetal heart tone by the first-trimester ultrasound and concordant sex at live birth. The primary outcome was recurrence risk, with recurrence defined as one patient having two or more cycles of eSET resulting in monozygotic multiples. The secondary objective was to identify factors associated with smonozygotic splitting, using a multivariable logistic regression model and a stepwise purposeful model selection.

RESULTS

There were 1355 (2.05%) pregnancies that resulted in two or more fetal heart tones after SET, including 840 monozygotic twins and triplets at birth. Recurrence occurred in two cases-0.0001% of patients with multiple eSET cycles. One case resulted from embryos created from a single cohort with intracytoplasmic sperm injection (ICSI), assisted hatching (AH), and blastocyst transfers. The second case resulted from donor egg embryos with ICSI and blastocyst transfers. Risk factors associated with monozygotic live birth were blastocyst transfer (OR 1.23, 95% CI 1.04-1.47, P = 0.0176) and AH (OR 1.23, 95% CI 1.05-1.44, P = 0.0081).

CONCLUSION

Recurrence of monozygotic live births in eSET was very rare. Blastocyst transfer and AH were confirmed to be risk factors for monozygotic live births, while ICSI, PGT, and FET do not appear to be associated.

Artificial intelligence model to predict pregnancy and multiple pregnancy risk following in vitro fertilization-embryo transfer (IVF-ET)

OBJECTIVE

To decrease multiple pregnancy risk and sustain optimal pregnancy chance by choosing suitable number of embryos during transfer, this study aims to construct artificial intelligence models to predict the pregnancy outcome and multiple pregnancy risk after IVF-ET.

MATERIALS AND METHODS

From Jan 2010 to Dec 2019, 1507 fresh embryo transfer cycles contained 20 features were obtained. After eliminating incomplete records, 949 treatment cycles were included in the pregnancy model dataset and 380 cycles in the twin pregnancy model dataset. Six machine learning algorithms were used for model building based on the dataset which 70% of the dataset were randomly selected for training and 30% for validation. Model performances were quantified with the area under the receiver operating characteristic curve (AUC), accuracy, specificity, and sensitivity.

RESULTS

Models built with XGBoost performed best. The pregnancy prediction model produced accuracy of 0.716, sensitivity of 0.711, specificity of 0.719, and AUC of 0.787. The multiple pregnancy prediction model produced accuracy of 0.711, sensitivity of 0.649, specificity of 0.740, and AUC of 0.732.

CONCLUSIONS

The AI models provide reliable outcome prediction and could be a promising method to decrease multiple pregnancy risk after IVF-ET.

Qualitative Investigation into Pre- and Post-Natal Experience of Parents of Triplets

Although parents of triplets experience substantial mental distress, research about this increasing population has primarily focused on physical health risks of triplets and mothers, failing to capture the subjective wellbeing of parents. Accordingly, this study aimed to understand first-hand experience of parents of triplets, using thematic analysis of semi-structured interviews participated by eight parents (four couples: Age M = 48.63, SD = 10.61 years). Six themes were identified: (1) Negative and (2) Positive experiences of raising triplets prenatally and postnatally, (3) Social, psychological, and material support, (4) Experiences and challenges specific to mothers and (5) fathers, and (6) Advice for future parents. These themes suggest that being reassured and accepting support from others are particularly essential in reducing stress and anxiety. Self-compassion interventions were recommended to support the wellbeing of parents of triplets. Our findings will help parents of triplets, their social circles, and healthcare workers to develop effective approaches to reduce the mental health difficulties that this under-researched population experiences.

Three or less? Decision making for or against selective reduction and psychological outcome in forty women with a triplet pregnancy

OBJECTIVES

The aim of the study was to investigate decision making for or against multifetal pregnancy reduction (MFPR) and psychological outcome in women with a triplet pregnancy.

METHODS

We investigated medical and sociodemographic variables and characteristics of the decision process for or against MFPR in forty women with triplet pregnancies who had either undergone MFPR (MFPR-group: N = 10) or had delivered triplets (triplet-group: N = 30). Moreover, emotional experiences of the reduction procedure were assessed. Psychological outcome was measured using the Beck Depression inventory (BDI) and the 36-Item Short Form Health Survey (SF-36).

RESULTS

Women of the MFPR-group had a higher gestational age at delivery (p = 0.001), shorter NICU stay (p = 0.001), higher educational level (p = 0.010), more frequently utilized psychological counseling during the decision process (p = 0.016), rated their gynecologist as more helpful for the decision (p = 0.045), required more time for their decision (p = 0.016), and were more likely to be in paid employment at follow-up (p = 0.041) than women of the triplet-group. MFPR was experienced as stressful (90%) or terrifying (10%). At 3.2 (±2.2) years after delivery, the vast majority of women in both groups were free from clinically relevant depression.

CONCLUSIONS

MFPR, though associated with emotional distress related to the procedure, results in a satisfactory psychological outcome in the majority of women. The decision for or against MFPR may be related to sociodemographic (such as educational) variables, which further supports the concept of framing in medical decision making. Having triplets most probably is associated with multiple (e.g. social or economic) consequences that may remain poorly investigated.

Triplet pregnancy: What do we tell the prospective parents

Experience managing triplet pregnancies has increased over the past few decades as the incidence has changed related to assisted reproductive practices. Physicians caring for women carrying triplets cannot predict an individual outcome or pregnancy course but must educate patients about the challenges related to these high risk pregnancies. Obstetric providers can describe the wide range of risks associated with triplet gestations, and the general plan for management, but ultimately parents must make decisions with potentially lifelong consequences. Here, we present the diagnostic criteria, common complications, and management options for triplet pregnancies, to help obstetricians counsel patients on the medical and psychosocial consequences of triplet pregnancy, potential complications, and multifetal reduction.

Early styles of interaction in mother-twin infant dyads and maternal mental health

Transition to parenthood is considered a critical process for mothers of twins. There are, however, few studies on the subject. This study aims to evaluate the differences between mother-twin infant dyads and mother-singleton infant dyads with regard to maternal depression, anxiety, parenting stress, and the quality of mother-infant interaction. Mothers of twin infants (N = 40) were compared to mothers of singletons (N = 72). At infant 3 months, maternal depression, anxiety, and parenting stress were assessed via a questionnaire and styles of interaction with the Care-Index. The results indicated that mothers of twins (vs mothers of singletons) had significantly higher state anxiety and higher scores on the Difficult Child Scale of the Parenting Stress Index at infant 3 months. No significant differences between the two groups were found with regard to maternal depression. Mothers of twins had significantly lower sensitivity and were more unresponsive than mothers of singletons. Twin infants had significantly more difficult and compliant behaviours than singleton infants. Assisted reproductive treatment (ART) and prematurity had no effect on any of the examined variables. State anxiety was shown to partially mediate the relationship between twin parenthood and maternal sensitivity and to completely mediate the relationship between twin parenthood and infant difficult style. Maternal unresponsiveness was shown to be exclusively linked to being the parent of twins. The study shows that twin parenthood has a significant effect on maternal mental health and on the quality of mother-infant interaction and highlights the importance of early prevention programmes for twin parents.

Reduction of multiple pregnancy: Counselling and techniques

The incidence of multiple births has risen in the last few decades. This rise is mainly due to the widespread use of assisted reproduction techniques mainly as a result of increasing maternal age at conception. Twin and higher-order multiple pregnancies are associated with increased risk of perinatal, as well as maternal, mortality and morbidity compared to singleton pregnancies. There can also be psychosocial and socioeconomic implications for women and their families. In this chapter, we aim to discuss the risks associated with multiple pregnancies, the pros and cons of fetal reduction, the current techniques used in clinical practice, and how to approach counselling parents, enabling them to make informed decisions.

Comparing pregnancy outcomes and loss rates in elective twin pregnancy reduction with ongoing twin gestations in a large contemporary cohort

BACKGROUND

As compared with singleton gestations, twin pregnancies are associated with a significantly higher risk of preterm birth and maternal complications as well as fetal and neonatal morbidity and mortality. Multifetal pregnancy reduction is a technique developed in the 1980s to reduce the fetal number in higher-order multiple pregnancies to reduce the risk of adverse pregnancy outcomes, most importantly preterm birth.

OBJECTIVE

The objective of the study was to compare pregnancy outcomes and loss rates in elective twin pregnancy reduction to ongoing twin gestations in a large contemporary cohort.

STUDY DESIGN

This was a retrospective review of dichorionic diamniotic twin gestations that underwent first-trimester ultrasound at our institution from January 2008 to September 2016. Planned elective 2-to-1 multifetal pregnancy reductions at less than 15 weeks' gestation were compared with ongoing dichorionic diamniotic twin gestations. Data were collected via chart review. Demographics between 2-to-1 reduced singletons and ongoing twins were assessed using a Student t test or a Wilcoxon rank-sum test, as appropriate, for continuous variables and χ² or Fisher exact tests, as appropriate, for categorical variables. Univariable and multivariable logistic regressions were used to compare pregnancy outcomes between ongoing twins and reduced singletons adjusting for maternal age, body mass index, race, in vitro fertilization, use of chorionic villus sampling, prior term birth, and prior preterm birth.

RESULTS

Of 1070 dichorionic diamniotic twin pregnancies identified, completed follow-up data were available and analyzed for 855 patients (79.9%). Among those, 250 (29.2%) were 2-to-1 singletons and 605 (70.8%) were ongoing twins. Reduced singleton patients were slightly older, more likely white, and had lower body mass index. They were also more likely to have undergone in vitro fertilization (63.6% vs 48.8%), had chorionic villus sampling (92% vs 37.5%), and had prior term births (54% vs 35.7%). Compared with 2-to-1 singletons, the adjusted odds of having preterm delivery at 37 weeks for ongoing twins were 5.62 times (95% confidence interval, 3.67-8.61; P < .001) and 2.22 times (95% confidence interval, 1.20-4.11; P < .001) at 34 weeks. While intrauterine growth restriction, placental abruption, and gestational diabetes were not significant, ongoing twins were more likely to have a cesarean delivery (odds ratio, 5.53, 95% confidence interval, 3.60-8.49; P < .001) and preeclampsia (odds ratio, 3.33, 95% confidence interval, 1.60-6.96; P < .001) after adjusting for maternal characteristics. There were also significant differences between groups for preterm premature rupture of membranes and low birthweight at less than the fifth and 10th percentiles. Total pregnancy loss (at 24 and 20 weeks) was similar between singleton and ongoing twins (4% vs 2.5%, P = .23, and 3.6% vs 1.7%, P = .09 for respective weeks). There were no significant differences in the rate of unintended pregnancy loss (2.4% vs 2.3%; P = .94) and the rate of intrauterine fetal death greater than 24 weeks (1.2% vs 0.7%; P = .43) in reduced singleton versus ongoing twin group, respectively.

CONCLUSION

In our study, patients who elected to reduce to a singleton pregnancy had a higher gestational age of delivery and lower rates of preterm birth and pregnancy complications without an increased risk of pregnancy loss.

Being a mother of preterm multiples in the context of socioeconomic disadvantage: perceived stress and psychological symptoms

OBJECTIVE

This study aimed to examine the differences between mothers of preterm multiples and mothers of preterm singletons regarding perceived stress and maternal psychological symptoms, and to explore the putative adverse amplified effect of socioeconomic disadvantage.

METHOD

Ninety-five mothers of 1-year-olds born preterm participated in this cross-sectional study. Data collection was carried out in two public hospitals from Northern Portugal. To assess maternal perceived daily stress and psychological symptoms, mothers completed two questionnaires. Mothers reported on socioeconomic factors, including family poverty, parent unemployment, and low education, and two groups of family socioeconomic disadvantage were created. A child medical risk index was calculated.

RESULTS

Results indicated that mothers of preterm multiples reported higher levels of stress than mothers of preterm singletons. Moreover, and specifically regarding psychological functioning, mothers of preterm multiples reported more symptoms than mothers of preterm singletons, but only when living in a context of socioeconomic adversity.

CONCLUSIONS

The results of the present study have important implications for practice. Mothers of preterm multiples are at higher risk to present mental health difficulties, in comparison to mothers of singletons, especially when exposed to socioeconomic adversities. The development of psychosocial intervention programs and public policies are of decisive importance in helping mothers of multiples adjust to parenthood.

Twins conceived using IVF: a follow-up of the family environment and psychosocial adjustment in adolescence

STUDY QUESTION

Compared to families with IVF singletons, what are parental depressive, parent-adolescent interaction and adolescent adjustment outcomes in families with 11-17-year-old IVF twins?

SUMMARY ANSWER

No differences were detected for any measured outcome between families with 11-17-year-old IVF twins and those with IVF singletons, despite high statistical power.

WHAT IS KNOWN ALREADY

When IVF twins are younger than 5-years-old, parents tend to have more mental health difficulties and poorer parent-child interactions relative to IVF singletons. By middle childhood, these differences may no longer exist and available studies with middle childhood-aged IVF twins challenge the expected long-term implications of the early concerns. IVF twins may even have more optimum adjustment than IVF singletons in middle childhood.

STUDY DESIGN, SIZE, DURATION

Study of 280, 11-17-year-old IVF children (n = 122 twins and n = 158 singletons) from 195 families at a US reproductive endocrinology clinic.

PARTICIPANTS/MATERIALS, SETTING, METHOD

At Wave 1, clinic patients with an IVF child born between 1998 and 2004 were invited to participate in an online survey. In this follow-up study, mothers and fathers provided information on each of their 11-17-year-old IVF adolescents.

MAIN RESULTS AND THE ROLE OF CHANCE

There were no differences between 11- and 17-year-old IVF twins and IVF singletons in parent depressive symptoms, parent-adolescent interactions or adolescent adjustment outcomes.

LIMITATIONS REASONS FOR CAUTION

Although the family demographics are representative of IVF patients, participants were drawn from one US clinic.

WIDER IMPLICATIONS OF THE FINDINGS

Study results provide reassurance that by adolescence IVF twins and their families function as well as IVF singletons and their families.

STUDY FUNDING/COMPETING INTERESTS

University of Minnesota (UMN) Agriculture Experiment Station (MN-52-107), UMN Grant-in-Aid of Research, Artistry and Scholarship, UMN College of Education and Human Development Research Development Investment Grant, UMN Women's Philosophic Leadership Circle Award, UMN Eva Miller Endowed Fellowship. The authors have no conflicts of interest to declare.

Promoting the use of elective single embryo transfer in clinical practice

Background

The transfer of multiple embryos after in vitro fertilization (IVF) increases the risk of twins and higher-order births. Multiple births are associated with significant health risks and maternal and neonatal complications, as well as physical, emotional, and financial stresses that can strain families and increase the incidence of depression and anxiety disorders in parents. Elective single embryo transfer (eSET) is among the most effective methods to reduce the risk of multiple births with IVF.

Main body

Current societal guidelines recommend eSET for patients <35 years of age with a good prognosis, yet even this approach is not widely applied. Many patients and clinicians have been reluctant to adopt eSET due to studies reporting higher live birth rates with the transfer of two or more embryos rather than eSET. Additional barriers to eSET include risk of treatment dropout after embryo transfer failure, patient preference for twins, a lack of knowledge about the risks and complications associated with multiple births, and the high costs of multiple IVF cycles. This review provides a comprehensive summary of strategies to increase the rate of eSET, including personalized counseling, access to educational information regarding the risks of multiple pregnancies and births, financial incentives, and tools to help predict the chances of IVF success. The use of comprehensive chromosomal screening to improve embryo selection has been shown to improve eSET outcomes and may increase acceptance of eSET.

Conclusions

eSET is an effective method for reducing multiple pregnancies resulting from IVF. Although several factors may impede the adoption of eSET, there are a number of strategies and tools that may encourage the more widespread adoption of eSET in clinical practice.

Maternal psychosocial consequences of twins and multiple births following assisted and natural conception: a meta-analysis

The aim of this meta-analysis is to provide new evidence on the effects on maternal health of multiple births due to assisted reproductive technology (ART). A bibliographic search was undertaken using PubMed, PsycINFO, CINAHL and Science Direct. Data extraction was completed using Cochrane Review recommendations, and the review was performed following PRISMA and MOOSE guidelines. Meta-analytic data were analysed using random effects models. Eight papers (2993 mothers) were included. Mothers of ART multiple births were significantly more likely to experience depression (standardized mean difference [SMD] d = 0.198, 95% CI 0.050 - 0.345, z = 2.623, P = 0.009; heterogeneity I(2) = 36.47%), and stress (SMD d = 0.177, 95% CI 0.049 - 0.305, P = 0.007; heterogeneity I(2) = 0.01%) than mothers of ART singletons. No difference in psychosocial distress (combined stress and depression) (SMD d = 0.371, 95% CI -0.153 - 0.895; I(2) = 86.962%, P = 0.001) or depression (d = 0.152, 95% CI -0.179 - 0.483: z = 0.901; I(2) = 36.918%) were found between mothers of ART and naturally conceived multiple births. In conclusion, mothers of ART multiple births were significantly more likely to have depression and stress than mothers of ART singletons, but were no different from mothers of naturally conceived multiples.

Raising multiples: mental health of mothers and fathers in early parenthood

The rate of twin and higher-order gestation births has risen dramatically in recent decades in the United States as well as other Western countries. Although the obstetrical and neonatal risks of multiple gestation pregnancies are well-documented, much less is known regarding the mental health impact on parents of multiples during the perinatal and early parenthood period. Given that parents of multiples face greater functional demands, as well as other pressures (financial, medical) this population may be at risk for heightened distress. We conducted a systematic review of quantitative, English language studies that assessed mental health outcomes of parents of multiples during pregnancy, in the first postpartum year, and in the period of early parenthood, including depression, anxiety, stress, and related constructs. Twenty-seven articles published between 1989 and 2014 met selection criteria and were included in the review. Studies utilized a wide range of methods and outcome constructs, often making comparisons difficult. Although some studies found no differences, most investigations that compared mental health outcomes in parents of multiples versus parents of singletons found that parents of multiples experience heightened symptoms of depression, anxiety, and parenting stress. We discuss gaps in the existing body of literature on parental mental health related to multiple gestation birth and conclude by discussing the need for novel intervention strategies to meet the needs of this growing population. Parents of multiples may experience worse mental health outcomes than parents of singletons. More research is needed, and future work should explore potential treatment and support options.

Twins conceived using assisted reproduction: parent mental health, family relationships and child adjustment at middle childhood

STUDY QUESTION

Compared with singletons, what is the parent mental health, parent-child and couple relationship satisfaction, and child adjustment of 6- to 12-year-old assisted reproduction technology (ART) twins and their families?

SUMMARY ANSWER

There are no differences between 6- and 12-year-old ART twin and singleton families in parent mental health or family relationships; however, twins had significantly fewer behavior and attention problems than singletons in middle childhood.

WHAT IS KNOWN ALREADY

When ART twins are younger than 5 years old, parents have more mental health difficulties and poorer parent-child relationship quality, and no differences have been found in ART twin and singletons' psychosocial adjustment. However, studies have only examined the implications of ART twin status in families with infant and toddler aged children.

STUDY DESIGN, SIZE, DURATION

A cross-sectional study of 300 6-12-year-old ART children (n = 124 twins and n = 176 singletons) from 206 families at a reproductive endocrinology clinic in the USA.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Patients from one clinic with a child born between 1998 and 2004 were invited to participate in an online survey (82% recruitment rate). Participants provided information on each 6- to 12-year-old ART child in the family, and responded to questions on parent mental health, family relationships and child adjustment.

MAIN RESULTS AND THE ROLE OF CHANCE

There were no differences in parent mental health or family relationships in families with 6- to 12-year-old ART twins versus singletons. However, twins (M = 2.40, SE = 0.35) had significantly fewer behavior problems than singletons (M = 3.47, SE = 0.36; F(1, 201) = 4.54, b = 1.08, P < 0.05). Twins (M = 1.86, SD = 0.23) also had fewer attention problems than singletons (M = 2.64, SD = 0.23; F(1, 156) = 5.75, b = 0.78, P < 0.05). Results also suggest that full-term twins had significantly fewer attention problems (M = 1.37, SE = 0.33; F(1, 222) = 2.65, P = 0.05) than premature twins (M = 2.32, SE = 0.32, b = 0.95, P < 0.05), full-term singletons (M = 2.25, SE = 0.21, b = 0.88, P < 0.05) and premature singletons (M = 2.84, SE = 0.49, b = 1.47, P = 0.01). There were no significant differences between the other groups.

LIMITATIONS, REASONS FOR CAUTION

Although the response rate is high (82%) and family demographics are representative of US ART patients, patients are from one US clinic. Responses also are from one family member and may be subject to social desirability biases. Additionally, our data did not include identification of monozygotic and dizygotic twins.

WIDER IMPLICATIONS OF THE FINDINGS

Studies on infant and toddler ART twins suggest these families have parents with more mental health difficulties and lower parent-child relationship quality than singleton families. This study indicates the negative effects of twin status may have ameliorated by middle childhood, and twins may even have more optimum psychosocial adjustment than singletons in this developmental period.

STUDY FUNDING/COMPETING INTERESTS

This research is based on a collaborative research effort supported by University of Minnesota Agriculture Experiment Station Project Number MN-52-107, a University of Minnesota Grant-in-Aid of Research, Artistry and Scholarship grant, a University of Minnesota College of Education and Human Development Research Development Investment Grant and the M. Janice Hogan Fellowship. The authors of this article have no commercial or corporate interests to declare.

Families with twins - a systematic review

Parenthood is among the developmental transitions that set major challenges for contemporary families. When there is a twin pregnancy, those challenges increase. Our aims in this study are understanding the parental experience in families with twins and identifying the factors which condition parental experience in such families. It is a literature review focusing on studies published between 2000 and 2012 based on reference data. The articles were analyzed considering the aims, participants, phases of data collection, tools used; and results achieved regarding the dimensions involved in parenting experiences faced by parents of twins. In the 19 studies identified, maternity was the main focus of research. Women with twin children showed lower scores on well-being, higher stress risks, exhaustion and depression. The experience of these families was different, more demanding and complex than singletons' parents. Understanding of this matter becomes crucial to contributing to better health for families.

Day 3 ET, single blastocyst transfer (SBT) or frozen-thawed embryo transfer (FET): which is preferable for high responder patients in IVF/ICSI cycles?

PURPOSE

To compare the clinical outcomes after day 3 embryo transfer, day 5 single blastocyst transfer (SBT) and frozen-thawed embryo transfer (FET) in high responder patients (>15 retrieved oocytes) undergoing IVF/ICSI treatment.

METHODS

A retrospective analysis of three embryo transfer strategies for the high responder patients in IVF/ICSI cycles. The 1041 high responder patients diagnosed as primary infertility with more than 15 oocytes retrieved were recruited in Day 3 ET group, 308 patients with more than 15 oocytes retrieved first transferred with one blastocyst in SBT group and 425 patients with more than 15 oocytes retrieved in fresh cycle, first transferred with one frozen-thawed blastocyst were assigned in FET group.

RESULTS

In the high responder patients, the clinical pregnancy rate after day 5 SBT was significantly lower than that of day 3 ET (43.18% VS 57.16%, p < 0.05). In addition, the clinical pregnant rate and implantation rate of FET cycles were significantly higher than SBT cycles (59.06% vs. 43.18% and 64.70% vs. 47.40%, p < 0.05). The multiple pregnancy rate in FET cycles was markedly lower than that of day 3 ET (2.35% VS 34.97%, p < 0.05).

CONCLUSIONS

FET was the preferable strategy for the high responder patients in IVF/ICSI cycles to obtain both desirable clinical outcome and lower multiple pregnancy rates.

Maternal and perinatal outcomes in spontaneous versus assisted conception twin pregnancies

OBJECTIVE

To compare maternal and perinatal outcomes in twin pregnancies conceived via assisted reproductive techniques (ART) compared with spontaneous twin pregnancies.

STUDY DESIGN

This retrospective study examined 345 dichorionic, di-amniotic twin pregnancies (207 conceived spontaneously and 138 conceived via ART), delivered between January 2007 and June 2011 at the San Pietro Fatebenefratelli Hospital, Rome, a tertiary medical centre. Maternal and perinatal outcomes were compared. A multiple logistic regression analysis was performed to calculate risk estimates as odds ratios (OR) adjusted for maternal age, parity and systemic diseases. Patient data were obtained from a computerized database and analyzed using Statistical Package for the Social Sciences Version 17.

RESULTS

Gestational age and birth weight were lower in the ART group, and preterm delivery, gestational diabetes and placental abruption were higher in the ART group compared with the spontaneous conception group. The incidence rates of respiratory complications, patent ductus arteriosus and admission to the neonatal intensive care unit were higher among ART newborns. Length of hospital stay for mothers and newborns was longer in the ART group. No differences in mode of delivery, Apgar score at 5min, congenital anomalies, perinatal mortality, and other considered pregnancy and neonatal complications were found between the two groups. Multivariate analysis adjusted for maternal age, parity and systemic diseases revealed that only the rates of placental abruption [OR 7.45, 95% confidence interval (CI) 2.05-26.98] and patent ductus arteriosus (OR 3.39, 95% CI 1.01-11.46) were significantly higher for the ART group.

CONCLUSIONS

Twin pregnancies conceived via ART are at greater risk of poorer outcomes than spontaneous twin pregnancies. This may be related to the type of conception and specific negative features of subfertile patients undergoing infertility treatment.

Second try: who returns for additional assisted reproductive technology treatment and the effect of a prior assisted reproductive technology birth

OBJECTIVE

To evaluate the effect of a prior assisted reproductive technology (ART) live birth on subsequent live-birth rates.

DESIGN

Historical cohort study.

SETTING

Clinic-based data.

PATIENT(S)

The study population included 297,635 women with 549,278 cycles from 2004 to 2010 from the Society for Assisted Reproductive Technology Clinic Outcome Reporting System. Try 1 refers to ART cycles up to and including the first live birth, try 2 to ART cycles after a first live birth.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Live-birth rates by cycle number, try number, and oocyte source.

RESULT(S)

Younger women at try 1 are more likely to return for try 2. Women returning for try 2 were more likely to have had an ART singleton versus multiple birth (33.2% after a try 1 singleton versus 8.1% after twins and 4.9% after triplets) and were less likely to have a diagnosis of diminished ovarian reserve or tubal factors. Live-birth rates were significantly higher for try 2 compared with try 1 for autologous fresh cycles, averaging 7.7 percentage points higher over five cycles. Live-birth rates were not significantly different for try 2 versus try 1 with thawed autologous cycles or either fresh or thawed donor cycles.

CONCLUSION(S)

These results indicate that when fresh autologous oocytes can be used, live-birth rates per cycle are significantly greater after a prior history of an ART live birth.

ACOG Committee opinion no. 553: multifetal pregnancy reduction

Fertility treatments have contributed significantly to the increase in multifetal pregnancies. The first approach to the problem of multifetal pregnancies should be prevention, and strategies to limit multifetal pregnancies, especially high-order multifetal pregnancies, should be practiced by all physicians who treat women for infertility. Incorporating the ethical frameworks presented in this Committee Opinion will help physicians counsel and guide patients when making decisions regarding multifetal pregnancy reduction. In cases of high-order multifetal pregnancies, counseling should include the availability of multifetal pregnancy reduction. Fellows should be knowledgeable about the medical risks of multifetal pregnancy, the possible medical benefits of multifetal pregnancy reduction, and the complex ethical issues inherent in decisions regarding the use of multifetal pregnancy reduction. Physicians should not be required to act in ways that conflict with their value systems but should be prepared to react in a professional and ethical manner to patient requests for both information and intervention.

Fatal child maltreatment associated with multiple births in Japan: nationwide data between July 2003 and March 2011

OBJECTIVES

The purpose of the present study is to clarify the impact of multiple births in fatal child maltreatment (child death due to maltreatment).

METHODS

The national annual reports on fatal child maltreatment, which contain all cases from July 2003 to March 2011, published by the Ministry of Health, Labor and Welfare of Japan, were used as the initial sources of information. Parent-child murder-suicide cases were excluded from the analyses. Multiple births, teenage pregnancy and low-birthweight were regarded as the exposed groups. The relative risks (RRs) and their 95 % confidence intervals (CIs) were estimated using the data from the above reports and vital statistics. These analyses were performed both including and excluding missing values.

RESULTS

Among 437 fatal child maltreatment cases, 14 multiple births from 13 families were identified. The RRs of multiple births per individual were 1.8 (95 % CI 1.0-3.0) when including missing values and 2.7 (95 % CI 1.5-4.8) when excluding missing values. The RRs of multiple births per family were 3.6 (95 % CI 2.1-6.2) when including missing values and 4.9 (95 % CI 2.7-9.0) when excluding missing values. The RR tended to be much lower than the RR of teenage pregnancy (RR 12.9 or 22.2), but slightly higher than the RR of low-birthweight (RR 1.4 or 2.9).

CONCLUSIONS

Families with multiple births had elevated risk for fatal child maltreatment both per individual and per family unit. Health providers should be aware that multiple pregnancies/births may place significant stress on families and should provide appropriate support and intervention.

Parenting Stress, Social Support, and Mother-Child Interactions in Families of Multiple and Singleton Preterm Toddlers

The study investigated family support as a buffer of stress in 153 mothers and preterm toddlers. Data were collected regarding maternal depressive symptoms, parenting stress, and family support; infant health; and videotaped mother-child interactions. Although more parenting stress related to less optimal child play, only information support functioned as a protective factor. Information support predicted positive play under high, but not low, maternal stress. Mothers of multiples reported more parenting stress than mothers of singletons.

Comparative study of the psychosocial risks associated with families with multiple births resulting from assisted reproductive technology (ART) and without ART

OBJECTIVE

To determine whether the psychosocial risks associated with multiple births are increased as a consequence of the use of assisted reproductive technology (ART) in comparison with those not resulting from ART.

DESIGN

Cross-sectional study.

SETTING

Fertility units of a university hospital and a private hospital.

PATIENT(S)

Parents of single children and multiples (twins and triplets) between 6 months and 4 years of age (n = 636) were divided into two groups: those who conceived through ART (n = 265) and those who conceived through non-ART (n = 371).

INTERVENTION(S)

Administration of six scales, in office or by mail.

MAIN OUTCOME MEASURE(S)

Measurement scales of material necessities, social stigma, marital satisfaction, perceived stress, depression, quality of life, and their subscales.

RESULT(S)

The analysis of variance, Student's t-test, and χ(2)-test were applied. No effect was observed based on the use of ART in the psychosocial variables studied. Significant differences were obtained between the groups of single (SB) and multiple births (MB) with respect to material necessities, social stigma, marital satisfaction, depression, and quality of life.

CONCLUSION(S)

Having more than one child per birth, whether resulting from the use of ART or not, increases psychosocial risks for the parents. Assisted reproduction centers should include this information with the obstetric and neonatal risks, stressing the advantages of having one child per birth. Psychosocial risks are not increased as a result of having used ART, but the goal of avoiding the repeated use of ART does influence the desire to transfer the maximum number of embryos possible. Psychological counseling should be included before initiating ART, as well as when a multiple pregnancy is confirmed.

[Parents of multiple births after assisted conception]

BACKGROUND

A major criticism is the increase in multiple pregnancies after ART in the past 30 years and the associated fetal and maternal risks.

MATERIAL

Few studies examined the psychosocial risks of the parents of multiple births after ART, for example psychology adjustment, parenting stress, education problems, anxiety, depression, relationship problems or social isolation.

RESULTS

The research confirms the psychosocial characteristics after multiple births. In the early postpartum period there is increased risk of depressive disorders. Mothers of twins after ART show a limitation of their psychosocial well-being compared to mothers of singles after ART.

DISCUSSION

Higher expectations of parenthood during pregnancy, less sufficiency coping strategies, and consequently, greater parental stress show twin mothers after ART in comparison to twin mothers after nature conception. An interdisciplinary postpartum care services makes sense. However, clinicians should keep attention to potential psychosocial burden of a multiple birth.

Comparing patients' and clinicians' perceptions of elective single embryo transfer using the attitudes to a twin IVF pregnancy scale (ATIPS)

BACKGROUND

This study evaluated a questionnaire originally developed for use with health professionals to explore and compare patients' and clinicians' perceptions of elective single embryo transfer and twin births.

METHODS

IVF clinicians and patients attending an independent Fertility clinic were surveyed using the Attitudes to a twin birth scale (ATIPS) comprising two subscales: attitudes to twins (A-Twin) and attitudes to elective single embryo transfer (A-SET). After refinement total sample scores showed both subscales were reliable with Cronbach's alpha >0.8 and item-total correlations >0.35.

RESULTS

Questionnaires were completed by 100 female IVF patients and 17 IVF clinicians. A-Twin subscale scores indicated neither the IVF clinicians nor female IVF patients demonstrated very positive attitudes to a twin birth although the IVF female patients were more in favour (t = 5.29, n = 117, p = <0.001). Responses suggest both groups would benefit from increased information about the risks of a twin birth for the baby. First cycle IVF female patients were significantly more positive about eSET (z = 3.94, n = 100, p =  <0.001). Clinicians perceive both their colleagues' and female patients' negativity towards eSET; suggesting a role for education.

CONCLUSIONS

This study found the ATIPS to be a reliable measure which could be useful in evaluating interventions to promote single embryo transfer.

One consequence of infertility treatment: multifetal pregnancy

This article discusses the issue of multifetal pregnancy as a result of fertility treatments. Pregnancies with multiple gestations are associated with serious infant and maternal health risks as well as psychological distress and significant financial consequences, and are a far too common consequence of infertility treatments such as assisted reproductive technology (ART) and ovulation induction drugs. Women with multifetal pregnancies are at a higher risk for multiple pregnancy complications and maternal morbidity/mortality as well as stress, depression, and anxiety disorders, especially when there is the threat of a loss of one or more fetuses. The rise in rates of multifetal gestation and the accompanying increased risk to both mother and fetuses have led the American Society for Reproductive Medicine and the Society for Assisted Reproductive Technology to develop guidelines to limit the number of transferred embryos during in vitro fertilization. Nurses who work with infertile women are in a position to educate them about the risks, benefits, and alternatives associated with ARTs and multifetal pregnancies, and should endeavor to learn as much as possible about this topic.

As relações entre a satisfação conjugal e as habilidades sociais percebidas no cônjuge

As relações entre habilidades sociais percebidas pelo cônjuge e satisfação conjugal foram investigadas. Cinquenta casais (n=100), com idades entre 29 a 69 anos e tempo de união entre sete e 38 anos, responderam à Escala de Satisfação Conjugal, ao Inventário de Habilidades Sociais Conjugais e ao Questionário de Empatia Conjugal. A análise de regressão múltipla apontou forte relação entre a empatia do cônjuge e a satisfação conjugal, seguida pela expressão de sentimentos e defesa dos próprios direitos. O número de filhos se correlacionou inversamente com a satisfação e as mulheres foram percebidas como mais empáticas. As habilidades sociais, especialmente a empatia, parecem ser facilitadores da satisfação conjugal. Recomenda-se o desenvolvimento dessas habilidades no tratamento de casais em crise.

Relationship and parenthood in IVF couples with twin and singleton pregnancies compared with spontaneous singleton primiparous couples—a prospective 5-year follow-up study

OBJECTIVE

To analyze relationship and parenthood in IVF twin couples, IVF singleton couples, and spontaneously pregnant primiparous couples.

SETTING

Southeast region of Sweden.

DESIGN

Prospective case-control study.

PATIENT(S)

In total, 24 women and men who became pregnant with twins, consecutively, and expected their first child in 1997-98 were studied. A control IVF group of 94 singleton primiparous IVF couples were used. A group of spontaneous primiparous pregnant women were selected out of the total pregnant population as a control group.

MAIN OUTCOME MEASURE(S)

Relationship and parenthood measured by questionnaires and interviews.

RESULT(S)

The IVF singleton couples were most stable in their relationship during the whole study period, and the IVF twin parents also seemed more stable and satisfied compared with the control group of spontaneous conception couples. In the control group, 88% had a second child during the study period. In the singleton IVF group the corresponding number was 9%, and none of the twin parents had another child during the study period.

CONCLUSION(S)

We conclude that the stresses associated with IVF treatment and becoming first-time parents of twins did not have a negative impact on the couples' appreciation of their relationship and parenthood as stated by both men and women.

Maternal risk factors for potential maltreatment deaths among healthy singleton and twin infants

Our aim was to evaluate the risk of death among healthy infants due to maltreatment, using national linked vital statistics data. The study population included all nonanomalous, full-term (> or = 37 weeks), non-low birthweight (> 2500 grams) infants born between 1995 and 2000 and their linked death certificates: 18,673,439 singleton pregnancies (36,864 deaths) and 77,800 twin pregnancies (356 pregnancies with a death). The underlying cause of death was characterized as due to maltreatment, sudden infant death syndrome (SIDS), and other causes, based on ICD-9 and ICD-10 codes, and modeled by maternal age using multinomial logistic regression; mothers aged 25 to 29 were the reference group. The highest risk for infant mortality was among the youngest mothers for maltreatment (AOR 2.45 and 1.95 for singleton mothers < 20 and aged 20 to 24, respectively; AOR 4.34 and 2.25 for twin mothers < 20 and aged 20 to 24, respectively). The risk of death overall and for each category was modeled by maternal age < 20, aged 20 to 24, and > or = 25, with and without the father's age present on the birth certificate, with mothers > or = 25 and father's age present as the reference group. All risks of death were significantly increased for mothers younger than age 25, with the highest risks among the youngest mothers and missing father's age. The pattern for twins was similar, with elevated risks among younger mothers with or without father's age present on the birth certificate. These results add to the body of knowledge regarding risk factors for infant mortality among healthy singletons and twins.

Towards the elective replacement of a single embryo (eSET) in the United Kingdom

In the UK, the live birth rate after IVF in women aged less than 36 is >25%. The multiple birth rates in these women are excessive (20% to 25%). The perinatal mortality rate is increased significantly with IVF twins and triplets (8/1000 singletons, 20/1000 twins and 34/1000 triplets). Multiple pregnancies and births significantly increase the risks to the mother and the children, adversely affect family life and are economically disadvantageous to the couple and the wider community. The elective transfer of a single fresh embryo, followed if necessary by a single thawed embryo, in women at high risk of a multiple birth does not reduce the live birth rate and all but prevents the conception of twins and triplets.

Contemporary risks of maternal morbidity and adverse outcomes with increasing maternal age and plurality

OBJECTIVE

To evaluate the risks of pregnancy complications and adverse outcomes associated with increasing maternal age and higher plurality.

DESIGN

Population-based, historic cohort study.

SETTING

US birth certificates and infant death certificates.

PATIENT(S)

Live births of > or =20 weeks gestation between 1995-2000: 22,991,306 singleton, 316,696 twin, and 12,193 triplet pregnancies.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Pregnancy-associated hypertension, incompetent cervix, tocolysis, premature rupture of membranes, excessive bleeding at delivery, delivery <29 weeks, and infant death.

RESULT(S)

Compared to singletons, the risks for all adverse outcomes among multiple pregnancies were significantly elevated, and were highest for tocolysis, delivery <29 weeks, and infant mortality. Within pluralities, increasing maternal age was associated with significantly higher risks of pregnancy-associated hypertension, excessive bleeding, and incompetent cervix, but for twin and triplet pregnancies, significantly lower risks for tocolysis (ages > or =40, singleton adjusted odds ratio [AOR] 0.97, twin AOR 0.67, triplet AOR 0.72), delivery <29 weeks (ages > or =40, singleton AOR 1.55, twin AOR 0.72, triplet AOR 0.52), and infant mortality (ages > or =40, singleton AOR 1.34, twin AOR 0.71, triplet AOR 0.42).

CONCLUSION(S)

Older maternal age and higher plurality are each associated with increasing risks for many pregnancy complications, but with significantly lower risks of tocolysis, early preterm birth, and infant mortality.

A mandatory single blastocyst transfer policy with educational campaign in a United States IVF program reduces multiple gestation rates without sacrificing pregnancy rates

OBJECTIVE

To reduce the twin rate in our IVF program.

DESIGN

A prospective educational study of infertile couples; a retrospective review of IVF outcomes before vs. after mandatory single embryo transfer (mSBT) policy change.

SETTING

University-based infertility center.

PATIENT(S)

One hundred ten of 120 consecutive new infertile couples completed the educational study. Outcomes of all embryo transfers (n = 693) performed 17 months before and 17 months after mSBT were evaluated.

INTERVENTION(S)

A 1-page educational summary of comparative risks of twins vs. singletons to maternal and child health.

MAIN OUTCOME MEASURE(S)

Knowledge of twin risks and desired number of embryos transferred before and after education. Pregnancy rates, number of embryos transferred, and multiple-gestation rates before and after mSBT policy.

RESULT(S)

After education, knowledge of twin risks improved and a significant number of subjects changed their desired outcome to a lower gestational number. There was no change in ongoing pregnancy rates with blastocyst transfer before and after mSBT (63% vs. 58%; NS). Program-wide number of embryos transferred (2.1 +/- 0.6 vs. 1.9 +/- 0.7) and multiple-gestation rates (35% vs. 19%) decreased significantly while pregnancy rates were maintained.

CONCLUSION(S)

Simple educational materials can improve knowledge of twin pregnancy risks and affect decision making. In high-risk patients, mSBT results in pregnancy rates similar to two-blastocyst transfer, with decreased twin rates.

Guidelines for the number of embryos to transfer following in vitro fertilization

OBJECTIVE

To review the effect of the number of embryos transferred on the outcome of in vitro fertilization (IVF), to provide guidelines on the number of embryos to transfer in IVF-embryo transfer (ET) in order to optimize healthy live births and minimize multiple pregnancies.

OPTIONS

Rates of live birth, clinical pregnancy, and multiple pregnancy or birth by number of embryos transferred are compared.

OUTCOMES

Clinical pregnancy, multiple pregnancy, and live birth rates.

EVIDENCE

The Cochrane Library and MEDLINE were searched for English language articles from 1990 to April 2006. Search terms included embryo transfer (ET), assisted reproduction, in vitro fertilization (IVF), ntracytoplasmic sperm injection (ICSI), multiple pregnancy, and multiple gestation. Additional references were identified through hand searches of bibliographies of identified articles.

VALUES

Available evidence was reviewed by the Reproductive Endocrinology and Infertility Committee and the Maternal-Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada and the Board of the Canadian Fertility and Andrology Society, and was qualified using the Evaluation of Evidence Guidelines developed by the Canadian Task Force on the Periodic Health Exam.

BENEFITS, HARMS, AND COSTS

This guideline is intended to minimize the occurrence of multifetal gestation, particularly high-order multiples (HOM), while maintaining acceptable overall pregnancy and live birth rates following IVF-ET.