Observed Mother- and Father-Child Interaction Differences in Families with Medically Assisted Reproduction-Conceived Twins and Singletons

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).

Adolescent attachment to parents and peers in singletons and twins born with assisted and natural conception

STUDY QUESTION

Does adolescent attachment to parents and peers differ between singletons and twins born with ART or natural conception (NC)?

SUMMARY ANSWER

Adolescent attachment anxiety with the father was higher among NC singletons than among ART and NC twins, whereas attachment avoidance with the father was higher in ART singletons than in NC singletons and NC twins. No differences were found in attachment to the mother, best friend or romantic partner.

WHAT IS KNOWN ALREADY

Most studies have not found differences between ART and NC singletons in parent–adolescent relationships, but twin relationships may be more at risk. No previous study has examined all four groups in the same study, or specifically looked at attachment relationships.

STUDY DESIGN, SIZE, DURATION

This was an 18-year, prospective and controlled longitudinal study with families of 496 ART singletons, 101 ART twin pairs, 476 NC singletons and 22 NC twin pairs. Families were recruited during the second trimester of pregnancy; the ART group was recruited from five infertility clinics in Finland and the control group was recruited from a hospital outpatient clinic during a routine visit.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Mothers and fathers gave background information for this study during pregnancy, and during the child’s first year and early school age (7–8 years). For the ART group, infertility characteristics and prenatal medical information was also obtained from the patient registry of the infertility clinics. Children (originally 50% girls) filled in electronic questionnaires related to their attachment to mother, father, best friend and romantic partner (Experiences in Close Relationships—Relationship Structures) at 17–19 years of age.

MAIN RESULTS AND THE ROLE OF CHANCE

Adolescent attachment anxiety to father was higher in NC singletons than in ART twins, P = 0.004 and marginally higher than in NC twins, P = 0.06. Adolescent attachment avoidance to father was higher in ART singletons than in NC singletons, P = 0.006 and marginally higher than in NC twins, P = 0.055.

LIMITATIONS, REASONS FOR CAUTION

The sample size was small especially in the NC twin group and there was drop-out over the 18-year time period, especially among boys and families with lower parental education level. The study only included native Finnish-speaking families. The results could differ in a more diverse population. ART singletons were younger and had fewer siblings than ART twins and NC children, and ART and NC twins had more newborn health risks than ART and NC singletons.

WIDER IMPLICATIONS OF THE FINDINGS

The study adds to a growing body of evidence that neither ART treatments nor being a twin places mother–child relationships or peer relationships at long-term risk. However, in our study, which was the first to examine both ART and twinhood simultaneously, we found that there may be more problems in father–adolescent relationships, but only in ART singletons and only related to attachment avoidance. Our findings suggest that men, as well as women, should receive enough support in pre- and peri-natal health care during and after infertility treatments.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by Academy of Finland (grant number 2501308988), the Juho Vainio Foundation and the Finnish Cultural Foundation. The authors report no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

The Recorded Interaction Task: A Validation Study of a New Observational Tool to Assess Mother-Infant Bonding

INTRODUCTION

Mother-infant bonding describes the early emotional connectedness between a mother and her infant. The quality of the mother-infant bond early in life is related to the subsequent quality of the child's attachment, the quality of further mother-infant interactions, and various other social outcomes across the child's life span. The Recorded Interaction Task (RIT) was developed to assess mother-infant bonding using observational methods in a naturalistic but standardized setting, thus addressing shortcomings of previous self-report tools. The RIT focusses on the common interaction between mother and infant (aged 2 to 5 months old), during a diaper (nappy) change. The interaction is video recorded and later assessed. The RIT must be validated before it can be used to assess mother-infant bonding in future research or in clinical practice.

METHODS

Face and content validity of the RIT were assessed by a panel of 6 experts in bonding and assessment of maternal and infant behavior. The RIT and self-reported Postpartum Bonding Questionnaire (PBQ) were administered to 15 mother-infant dyads with the correlation between their scores used to assess convergent validity.

RESULTS

Acceptable face and content validity of the RIT was demonstrated. A weak correlation between the RIT and PBQ (r = -0.13) and their subscales (r = -0.22) were observed. A strong correlation between the RIT maternal behavior and infant behavior subscales was recorded (r = 0.69).

DISCUSSION

The RIT appears to be a viable tool for the observational assessment of mother-infant bonding. Reliability testing and piloting will be required before the RIT can be used in future research or clinical practice.

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.

Twins' and Singletons' Linguistic Environment: A Systematic Review

Background: Among twins, lower linguistic skills emerged when compared with singletons. Considering the association found between parental linguistic input and children's language development, exploring the differences between twins and singletons' linguistic environments could find variables that are potentially associated with the lower linguistic skills of twins.

Aim: The current systematic review aims to analyze and systematize the existing literature focused on the comparison of twins' and singletons' linguistic environments within their first 3 years of life. Methodological issues (i.e., the procedure used to assess the linguistic environment, the coding of the linguistic environment's features, the computational method employed to assess the parental linguistic input, and participant characteristics) and differences found among twins and singletons regarding their linguistic environment (i.e., linguistic input quantity, linguistic input complexity, linguistic features of child-directed speech, parental responsiveness, and directiveness, joint attention, and book reading) were highlighted.

Method: The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement was followed. Eligible studies were searched through EBSCO, PubMed, and Web of Science. From this search, 1,347 study results emerged, and 8 studies were included.

Results: To our knowledge, this is the first systematic review focused on the comparison of twins' and singletons' linguistic environments. Differences between the groups were found in all of the included studies. Data against twins were generally identified regarding all the considered linguistic environment's features. However, conflicting results within and between the included studies emerged, mainly according to the computational method employed (i.e., twin moms value, twin direct dyadic value, twin direct dyadic + both value, and input directed toward both children simultaneously).

Conclusion: The disadvantaged linguistic environment of twins is likely due to limited parental resources and demands associated with the management of two children of the same age. However, the limited and conflicting data found did not allow for a firm conclusion to be drawn on the differences in the twins' and singletons' linguistic environments. Further studies on the topic are needed.