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

ESHRE guideline: number of embryos to transfer during IVF/ICSI†

STUDY QUESTION

Which clinical and embryological factors should be considered to apply double embryo transfer (DET) instead of elective single embryo transfer (eSET)?

SUMMARY ANSWER

No clinical or embryological factor per se justifies a recommendation of DET instead of eSET in IVF/ICSI.

WHAT IS KNOWN ALREADY

DET is correlated with a higher rate of multiple pregnancy, leading to a subsequent increase in complications for both mother and babies. These complications include preterm birth, low birthweight, and other perinatal adverse outcomes. To mitigate the risks associated with multiple pregnancy, eSET is recommended by international and national professional organizations as the preferred approach in ART.

STUDY DESIGN, SIZE, DURATION

The guideline was developed according to the structured methodology for development and update of ESHRE guidelines. Literature searches were performed in PUBMED/MEDLINE and Cochrane databases, and relevant papers published up to May 2023, written in English, were included. Live birth rate, cumulative live birth rate, and multiple pregnancy rate were considered as critical outcomes.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Based on the collected evidence, recommendations were discussed until a consensus was reached within the Guideline Development Group (GDG). A stakeholder review was organized after the guideline draft was finalized. The final version was approved by the GDG and the ESHRE Executive Committee.

MAIN RESULTS AND THE ROLE OF CHANCE

The guideline provides 35 recommendations on the medical and non-medical risks associated with multiple pregnancies and on the clinical and embryological factors to be considered when deciding on the number of embryos to transfer. These recommendations include 25 evidence-based recommendations, of which 24 were formulated as strong recommendations and one as conditional, and 10 good practice points. Of the evidence-based recommendations, seven (28%) were supported by moderate-quality evidence. The remaining recommendations were supported by low (three recommendations; 12%), or very low-quality evidence (15 recommendations; 60%). Owing to the lack of evidence-based research, the guideline also clearly mentions recommendations for future studies.

LIMITATIONS, REASONS FOR CAUTION

The guideline assessed different factors one by one based on existing evidence. However, in real life, clinicians' decisions are based on several prognostic factors related to each patient's case. Furthermore, the evidence from randomized controlled trials is too scarce to formulate high-quality evidence-based recommendations.

WIDER IMPLICATIONS OF THE FINDINGS

The guideline provides health professionals with clear advice on best practice in the decision-making process during IVF/ICSI, based on the best evidence currently available, and recommendations on relevant information that should be communicated to patients. In addition, a list of research recommendations is provided to stimulate further studies in the field.

STUDY FUNDING/COMPETING INTEREST(S)

The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, the literature searches, and the dissemination of the guideline. The guideline group members did not receive payment. DPB declared receiving honoraria for lectures from Merck, Ferring, and Gedeon Richter. She is a member of ESHRE EXCO, and the Mediterranean Society for reproductive medicine and the president of the Croatian Society for Gynaecological Endocrinology and Reproductive Medicine. CDG is the past Chair of the ESHRE EIM Consortium and a paid deputy member of the Editorial board of Human Reproduction. IR declared receiving reimbursement from ESHRE and EDCD for attending meetings. She holds an unpaid leadership role in OBBCSSR, ECDC Sohonet, and AER. KAR-W declared receiving grants for clinical researchers and funding provision to the institution from the Swedish Cancer Society (200170F), the Senior Clinical Investigator Award, Radiumhemmets Forskningsfonder (Dnr: 201313), Stockholm County Council FoU (FoUI-953912) and Karolinska Institutet (Dnr 2020-01963), NovoNordisk, Merck and Ferring Pharmaceuticals. She received consulting fees from the Swedish Ministry of Health and Welfare. She received honoraria from Roche, Pfizer, and Organon for chairmanship and lectures. She received support from Organon for attending meetings. She participated in advisory boards for Merck, Nordic countries, and Ferring. She declared receiving time-lapse equipment and grants with payment to institution for pre-clinical research from Merck pharmaceuticals and from Ferring. SS-R received research funding from Roche Diagnostics, Organon/MSD, Theramex, and Gedeo-Richter. He received consulting fees from Organon/MSD, Ferring Pharmaceuticals, and Merck Serono. He declared receiving honoraria for lectures from Ferring Pharmaceuticals, Besins, Organon/MSD, Theramex, and Gedeon Richter. He received support for attending Gedeon Richter meetings and participated in the Data Safety Monitoring Board of the T-TRANSPORT trial. He is the Deputy of ESHRE SQART special interest group. He holds stock options in IVI Lisboa and received equipment and other services from Roche Diagnostics and Ferring Pharmaceuticals. KT declared receiving payment for honoraria for giving lectures from Merck Serono and Organon. She is member of the safety advisory board of EDQM. She holds a leadership role in the ICCBBA board of directors. ZV received reimbursement from ESHRE for attending meetings. She also received research grants from ESHRE and Juhani Aaltonen Foundation. She is the coordinator of EHSRE SQART special interest group. The other authors have no conflicts of interest to declare.

DISCLAIMER

This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose (full disclaimer available at https://www.eshre.eu/Guidelines-and-Legal).

Exploring the lived experiences of women with multiple gestations in Iran: a phenomenological study

BACKGROUND

Multiple gestations present numerous physical, psychological, social, and economic challenges for women. Understanding the problem-solving experiences of pregnant women carrying multiple can be invaluable. This study aimed to explore the experiences of Iranian women with multiple gestations.

METHODS

This descriptive phenomenological study utilized purposive sampling and continued until data saturation. Data collection involved in-depth semi-structured interviews, with analysis performed using Colaizzi's 7-step method. MAXQDA software was employed for data management.

RESULTS

This study involved 12 women with multiple gestations. The average age of the participants was 33.76 ± 6.22 years, and 9 were pregnant with triplets. The data were categorized into four primary themes: the paradox of emotions, the pregnancy prison, immersion in fear, and the crystallization of maternal love, encompassing 17 sub-themes.

CONCLUSION

Pregnant women with multiple gestations undergo various changes and experience conflicting emotions. Enhancing their ability to adapt to and accept numerous pregnancies can be achieved through supportive, personalized, and family-centered care, along with improvements and revisions in care policies for multiple gestations.

Potential impact on using aspirin as the primary prevention of adverse pregnancy outcomes in twins conceived using ART

With the development of assisted reproductive technology, the number of twin pregnancies is increasing year by year. Given the increased risk of pregnancy complications associated with twin pregnancies, and the fact that these babies are rare and difficult to obtain through assisted reproductive technology, clinicians urgently require finding effective and safe drugs to improve pregnancy outcomes. Low-dose aspirin can not only promote placental blood supply, but also effectively anti-inflammatory. Whether Low-dose aspirin can effectively reduce the risk of pregnancy complications in this special group needs to be clarified. We therefore retrospectively analyzed 665 twin pregnancies from assisted reproduction technology, grouped according to aspirin use, and followed pregnancy outcomes to assess bleeding risk. Low-dose aspirin was found to be effective in preventing preeclampsia without a significant risk of bleeding. However, aspirin does not prevent specific complication in twin pregnancies and seems to have a better preventive effect only when the mother is under 30, which should alarm clinicians should not blindly using aspirin in this particular group.

Online mindfulness-based intervention for women with pregnancy distress: A randomized controlled trial

BACKGROUND

Pregnancy distress among childbearing women is common and can negatively affect both mother and infant. Mindfulness-based interventions (MBIs) may have a positive effect on pregnancy distress but randomized controlled trials with sufficient power are lacking. The current study examined the effectiveness of an online self-guided MBI in pregnant women with pregnancy distress.

METHODS

Pregnant women with elevated pregnancy distress levels at 12 weeks of pregnancy, measured with the Edinburgh Depression Scale (EDS) and Tilburg Pregnancy Distress Scale negative affect (TPDS-NA), were randomized into an intervention group (online MBI, N = 109) or control group (care as usual, N = 110). The primary outcome was the change in pregnancy distress post-intervention and at eight-weeks-follow-up. Secondary outcomes were mindfulness skills (Three Facet Mindfulness Questionnaire-Short Form), rumination (Rumination-Reflection Questionnaire), and self-compassion (Self-Compassion Scale-Short Form) at post-intervention and follow-up in the intervention group.

RESULTS

Significant improvements were found in pregnancy distress scores, but no significant differences between intervention and control group appeared. The MBI group showed improvements in mindfulness skills, rumination, and self-compassion.

LIMITATIONS

Low adherence to the intervention and assessment of secondary outcome measures in the intervention group only.

CONCLUSIONS

An intervention trial with one of the largest samples (N = 219) provided no evidence of a significant effect of an online self-guided MBI in distressed pregnant women. An online MBI may be associated with an improvement in mindfulness skills, rumination, and self-compassion. Future research should address the effectiveness of MBI's with different formats (online and group-based combined) and examine a possible delayed effect.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03917745, registered on 4 March 2019.

Exposure to bisphenols, parabens and phthalates during pregnancy and postpartum anxiety and depression symptoms: Evidence from women with twin pregnancies

BACKGROUND

Women are vulnerable to suffer from the common mental disorders like anxiety and depression during the postpartum period. Exposure to bisphenols, parabens, and phthalates has been linked to anxiety and depression symptoms in the general population. However, little is known about their impacts on postpartum women.

OBJECTIVE

To evaluate the effects of individual and joint exposure to 11 nonpersistent chemicals during pregnancy on postpartum anxiety and depression.

METHODS

Among 278 mothers from the Wuhan Twin Birth Cohort (WTBC), bisphenols, parabens, and phthalate metabolites were measured in maternal urine samples from each trimester. Self-rating Anxiety Scale (SAS) and Edinburgh Postnatal Depression Scale (EPDS) were administrated at early pregnancy and 1 month and 6 months postpartum to determine anxiety and depression symptoms, respectively. Associations between urinary chemical biomarkers (individual or mixtures) and anxiety and depression symptoms were estimated using multiple informant model and quantile-based g-computation.

RESULTS

With adjustment for confounders, one quartile increase in the overall chemical mixture (bisphenols, parabens and phthalate metabolites) during the second trimester was associated with 1.03-point (95% CI: 0.07, 1.99, P = 0.036) higher EPDS score at 1 month postpartum, in which bisphenol A (BPA) and bisphenol F (BPF) contributed the most to the positive association. Consistent effects were also observed in the multiple informant models. We found that second-trimester BPA and BPF exposure individually showed the strongest and significant associations with anxiety and depression symptoms, and some of associations differed across trimesters (P_{trimester-int} < 0.05).

CONCLUSIONS

Second-trimester nonpersistent chemical exposure was associated with increased postpartum anxiety and depression symptoms.

Multiple Gestations and Assisted Reproductive Technologies: Qualitative Study of the Discourse of Health Professionals in Spain

Multiple gestations have become an increasing phenomenon that has impacted public health globally, largely due to the application of assisted reproductive technologies. The objective of this work was to find out the discourse that the health professionals involved in its follow-up have in our context. For this, a qualitative methodology was chosen, with semi-structured interviews recorded in audio, prior authorisation, and transcribed verbatim. It was based on a script designed for this purpose, with the following analysis categories: the current trend of multiple gestations, impact, and follow-up. The content analysis was based on the experiences, knowledge, and perceptions of the professionals interviewed. Professionals stated that the current socioeconomic and legal context hinders a single embryo transfer policy that decreases multiple gestation rates. They emphasised the importance of the psychic impact of such gestations on the couple, on the mother in particular, as well as the economic effect on families, health, and society in general. They expressed the need to create specific protocols to assist these gestations. Midwives, in particular, demanded that the health administration recognise and support the differentiated care they perform with this type of gestation. Work on specific models is needed to adequately size the impact of multiple gestations, as well as to generate social health policies that lead to co-responsible reconciliation measures that favour women having one pregnancy at a time.

Single-embryo transfer: a key strategy to reduce the risk for multiple pregnancy in assisted human reproduction

In the early days of assisted reproductive technology (ART), the main target was achieving gestation. Success rates were low, and multiple embryo transfers became common practice, with multiple pregnancies being 20 times higher than in natural conception. Multiple pregnancy is associated with a higher risk of complications for the mother and the baby than a singleton pregnancy. Added to healthcare costs, multiple pregnancy also involves other costs and psychosocial risks, with a high social and health costs. At present, success rates of assisted human reproduction (AHR) have improved dramatically, partially due to advances in laboratory techniques such as culture of blastocyst-stage embryos and vitrification. Additionally, there is a wide range of counseling, health and economic policies that have demonstrated being effective in increasing single-embryo transfer (SET) practices and reducing multiple pregnancies, which ensures satisfactory success rates. Therefore, single-embryo transfer emerges as the approach of choice for AHR to result in a full-term healthy newborn.

Mothering Twins During the First Year of Life: A Metaphor Analysis

This secondary qualitative analysis identified metaphorical expressions mothers of twins used to describe their first year caring for their infants. Data from the primary grounded theory study were reanalyzed using metaphor identification procedure and revealed eight metaphors: blur, life on hold, being an orchestrator, being a juggler, being an equalizer, being a quick-change artist, being a milk factory, and open invitation. These metaphors give clinicians an insider's view of the struggle's mothers of twins experience during the first year after birth. Being attentive to the metaphors mothers used can provide a unique approach to helping them. Lactation consultants are key to providing much needed support for mothers who are breastfeeding twins.

Association between delivering live-born twins and acute psychiatric illness within 1 year of delivery

BACKGROUND

Having twins is associated with more depressive symptoms than having singletons. However, the association between having twins and psychiatric morbidity requiring emergency department visit or inpatient hospitalization is less well known.

OBJECTIVE

This study aimed to determine whether women have higher risk of having a psychiatric diagnosis at an emergency department visit or inpatient admission in the year after having twins vs singletons.

STUDY DESIGN

This retrospective cohort study used International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedure codes within the Florida State Inpatient Database and State Emergency Department Database, which have an encrypted identifier allowing nearly all inpatient and emergency department encounters statewide to be linked to the medical record. The first delivery of Florida residents at the age of 13 to 55 years from 2005 to 2014 was included, regardless of parity; women with International Classification of Diseases, Ninth Revision, Clinical Modification coding for psychiatric illness or substance misuse during pregnancy or for stillbirth or higher-order gestations were excluded. The exposure was an International Classification of Diseases, Ninth Revision, Clinical Modification code during delivery hospitalization of live-born twins. The primary outcome was an International Classification of Diseases, Ninth Revision, Clinical Modification code during an emergency department encounter or inpatient admission within 1 year of delivery for a psychiatric morbidity composite (suicide attempt, depression, anxiety, posttraumatic stress disorder, psychosis, acute stress reaction, or adjustment disorder). The secondary outcome was drug or alcohol use or dependence within 1 year of delivery. We compared outcomes after delivery of live-born twins with singletons using multivariable logistic regression adjusting for sociodemographic and medical factors. We tested for interactions between independent variables in the primary model and conducted sensitivity analyses stratifying women by insurance type and presence of severe intrapartum morbidity or medical comorbidities.

RESULTS

A total of 17,365 women who had live-born twins and 1,058,880 who had singletons were included. Within 1 year of birth, 1.6% of women delivering twins (n=270) and 1.6% of women delivering singletons (n=17,236) had an emergency department encounter or inpatient admission coded for psychiatric morbidity (adjusted odds ratio, 1.00; 95% confidence interval, 0.88-1.14). Coding for drug or alcohol use or dependence in an emergency department encounter or inpatient admission in the year after twin vs singleton delivery was also similar (n=96 [0.6%] vs n=6222 [0.6%]; adjusted odds ratio, 1.11; 95% confidence interval, 0.91-1.36). However, women with public health insurance were more likely to be coded for drug or alcohol use or dependence after twin than singleton delivery (n=75 [1.2%] vs n=4858 [1.0%]; adjusted odds ratio, 1.27; 95% confidence interval, 1.01-1.60). Women with ≥1 medical comorbidity, severe maternal morbidity, or low income also had an increased risk of psychiatric morbidity after twin delivery (comorbidities, n=7438 [42.8%]; adjusted odds ratio, 1.30; 95% confidence interval, 1.25-1.34; severe maternal morbidity, n=940 [5.4%]; adjusted odds ratio, 1.65; 95% confidence interval, 1.49-1.81; lowest income quartile, n=4409 [26.8%]; adjusted odds ratio, 1.31; 95% confidence interval, 1.23-1.40; second-lowest income quartile, n=4770 [29.0%]; adjusted odds ratio, 1.34; 95% confidence interval, 1.26-1.43).

CONCLUSION

Overall, diagnostic codes for psychiatric illness or substance misuse in emergency department visits or hospital admissions in the year after twin vs singleton delivery are similar. However, women with who are low income or have public health insurance, comorbidities, or severe maternal morbidity are at an increased risk of postpartum psychiatric morbidity after twin vs singleton delivery.

Assisted reproductive technologies are slightly associated with maternal lack of affection toward the newborn: The Japan Environment and Children's Study

AIM

To evaluate the association between use of assisted reproductive technology (ART) and mother-to-infant bonding.

METHODS

Using nationwide birth cohort study with periodical follow-ups for mothers and children during pregnancy and at 1 year after delivery, mothers were classified following three groups; infertility group with ART: 2792 mothers; infertility group with non-ART treatment (ovulation induction and intrauterine insemination): 3835 mothers and unaided pregnancy group: 78 726 mothers. Data on maternal and child health as well as basic characteristics were collected via medical records and self-administered questionnaires. The Japanese version of Mother-to-Infant Bonding Scale was used to evaluate maternal bonding style. To evaluate the association between ART and maternal bonding toward babies, multivariate analysis was used with adjustment for potential confounders such as babies' sex, socio-economic status and history of maternal mental disorders.

RESULTS

Multivariate logistic regression analysis indicated that ART was slightly but significantly associated with an increased risk of maternal lack of affection toward their newborn (adjusted odds ratio 1.10, 95% confidence interval 1.02-1.20), while non-ART was significantly associated with both maternal lack of affection and anger/rejection toward the newborn. No substantial association was observed between ART and overall Mother-to-Infant Bonding Scale score (adjusted odds ratio 1.03, 95% confidence interval 0.94-1.12). Very slight negative correlations were observed between poor mother-to-infant bonding and good infant mental and physical development at both 6 months and 1 year.

CONCLUSION

ART may exert a negative influence on maternal emotion after delivery, but this does not have strong correlation with child development evaluated by mothers.

An integrative literature review of psychosocial factors in the transition to parenthood following non-donor-assisted reproduction compared with spontaneously conceiving couples

The paper reports an integrative literature review of research into the psychosocial factors which shape the transition to parenthood in couples following non-donor in vitro fertilization in comparison with those conceiving spontaneously. Nineteen papers of non-donor IVF and SC mothers and fathers were included. Differences between groups were reported for a range of psychosocial measures during the transition from pregnancy to parenthood including: the control couples feel they have over their lives (locus of control), parental adjustment and child behaviour, parental stress, parental investment in the child, self-esteem and self-efficacy, greater levels of protectiveness (separation anxiety) towards child, marital and family functioning, family alliance, marital satisfaction and communication, as well as anxiety, indirect aggression and lowered respect for the child. We have conceptualised these differences as three substantive themes which reflect psychosocial factors shaping transition to parenthood in parents after non-donor AR: namely social support, relationships and emotional well-being, which are in turn influenced by gender differences. These findings have implications for health care professionals' assessment of individual couples' support needs.

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.