Maternal and perinatal outcomes in twin pregnancies following assisted reproduction: a systematic review and meta-analysis involving 802 462 pregnancies
Authors: Marleen Shemoon , Kodithuwakku Wasana , Nandasena Ruvini , Mohideen Shezoon , Allotey John , Fernández-García Silvia , Gaetano-Gil Andrea , Ruiz-Calvo Gabriel , Aquilina Joseph , Khalil Asma , Bhide Priya , Zamora Javier , Thangaratinam Shakila 
Published: February 2024

Abstract

BACKGROUND
ART is associated with higher rates of twin pregnancies than singleton pregnancies. Whether twin pregnancies conceived following ART have additional maternal and neonatal complications compared with non-ART twin pregnancies is not known.

OBJECTIVE AND RATIONALE
The objective was to quantify the risk of adverse maternal and perinatal outcomes among twin pregnancies conceived following ART compared with non-ART and natural conception. Existing reviews vary in the reported outcomes, with many studies including triplet pregnancies in the study population. Therefore, we aimed to perform an up-to-date review with an in-depth analysis of maternal and perinatal outcomes limited to twin pregnancies.

SEARCH METHODS
We searched electronic databases MEDLINE and EMBASE from January 1990 to May 2023 without language restrictions. All cohort studies reporting maternal and perinatal outcomes following ART compared with non-ART twin pregnancies and natural conception were included. Case–control studies, case reports, case series, animal studies, and in vitro studies were excluded. The Newcastle–Ottawa Scale was used to assess the methodological quality of the studies. Using random-effects meta-analysis, the estimates were pooled and the findings were reported as odds ratios (OR) with 95% CI.

OUTCOMES
We included 111 studies (802 462 pregnancies). Twin pregnancies conceived following ART were at higher risk of preterm birth at &lt;34 weeks (OR 1.33, 95% CI 1.14–1.56, 29 studies, I2 = 73%), &lt;37 weeks (OR 1.26, 95% CI 1.19–1.33, 70 studies, I2 = 76%), hypertensive disorders in pregnancy (OR 1.29, 95% CI 1.14–1.46, 59 studies, I2 = 87%), gestational diabetes mellitus (OR 1.61, 95% CI 1.48–1.75, 51 studies, I2 = 65%), and caesarean delivery (OR 1.80, 95% CI 1.65–1.97, 70 studies, I2 = 89%) compared with non-ART twins. The risks for the above maternal outcomes were also increased in the ART group compared with natural conception. Of the perinatal outcomes, ART twins were at significantly increased risk of congenital malformations (OR 1.17, 95% CI 1.05–1.30, 39 studies, I2 = 59%), birthweight discordance (&gt;25% (OR 1.31, 95% CI 1.05–1.63, 7 studies, I2 = 0%)), respiratory distress syndrome (OR 1.32, 95% CI 1.09–1.60, 16 studies, I2 = 61%), and neonatal intensive care unit admission (OR 1.24, 95% CI 1.14–1.35, 32 studies, I2 = 87%) compared with non-ART twins. When comparing ART with natural conception, the risk of respiratory distress syndrome, intensive care admissions, and birthweight discordance &gt;25% was higher among the ART group. Perinatal complications, such as stillbirth (OR 0.83, 95% CI 0.70–0.99, 33 studies, I2 = 49%), small for gestational age &lt;10th centile (OR 0.90, 95% CI 0.85–0.95, 26 studies, I2 = 36%), and twin–twin transfusion syndrome (OR 0.45, 95% CI 0.25–0.82, 9 studies, I2 = 25%), were reduced in twin pregnancies conceived with ART versus those without ART. The above perinatal complications were also fewer amongst the ART group than natural conception.

WIDER IMPLICATIONS
ART twin pregnancies are associated with higher maternal complications than non-ART pregnancies and natural conception, with varied perinatal outcomes. Women seeking ART should be counselled about the increased risks of ART twin pregnancies and should be closely monitored in pregnancy for complications. We recommend exercising caution when interpreting the study findings owing to the study’s limitations.