Growth of twins conceived using assisted reproductive treatments up to 5 years old: a national growth cohort

Fiskani J. M. Kondowe, Peter Clayton, Matthew Gittins, Stephen W. D'Souza, Daniel R. Brison, Stephen A. Roberts

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Study question: Do twins conceived through assisted reproductive treatments (ART) grow differently from naturally conceived (NC) twins in early life?
Summary answer: Assessments at 6-8 weeks old and at school entry show that ART twins conceived from frozen embryo transfer (FET) grow faster than both NC twins and ART twins conceived from fresh embryo transfer (ET).
What is known already: Singletons born from fresh ET grow more slowly in utero and in the first few weeks of life but then show postnatal catch-up growth by school age, compared to NC and FET babies. Evidence on early child growth of ART twins relative to NC twins is inconsistent; most studies are small and do not distinguish FET from fresh ET cycles.
Study design, size, duration: This cohort study included 13,528 live-born twin babies conceived by ART (fresh ET: 2792, FET: 556) and NC (10,180) between 1991 and 2009 in Scotland. The data was obtained by linking HFEA ART register data to the Scottish Morbidity Record (SMR02) and Scottish child health program datasets. Outcome data were collected at birth, 6-8 weeks (first assessment), and school entry (4-7 years old) assessments. The primary outcome was growth, measured by weight at the three assessment points. Secondary outcomes were length (at birth and 6-8 weeks) or height (at school entry), BMI, occipital circumference, gestational age at birth, newborn intensive care unit (NICU) admission and growth rates (between birth and 6-8 weeks and between 6-8 weeks and school entry).
Participants/materials, setting, methods: All twins in the linked dataset (born between 1991 and 2009) with growth data were included in the analysis. To determine outcome differences between fresh ET, FET and NC twins, linear mixed models (or analogous logistic regression models) were used to explore the outcomes of interest. All models were adjusted for available confounders: gestational age/child age, gender, maternal age and smoking, Scottish Index of Multiple Deprivation, year of treatment, parity, ICSI, and embryo transfer stage.
Main results and the role of chance: In the primary birth weight models, the average birth weight of fresh ET twins was lower [-35g; 95%CI(-53, -16)g] than NC controls, while FET twins were heavier [71g;95%CI(33,110)g] than NC controls and heavier [106g; 95%CI(65,146)g] than fresh ET twins. However, the difference between FET and NC twins was not significant when considering only full-term twins (≥37 weeks gestation) [26g; 95% CI (-30, 82)g], while it was significantly higher in preterm twins [126g; 95% CI (73, 179)g]. Growth rates did not differ significantly for the three groups from birth to 6-8 weeks. However, FET twins grew significantly faster from 6-8 weeks than NC (by 2.2g/week) and fresh ET twins (by 2.1g/week). By school entry, FET twins were 614g [95%CI(158,1070)g] and 581g [95%CI(100,1063)g] heavier than NC and fresh ET twins, respectively. Length/height and occipital frontal circumference did not differ significantly at any time point.
Limitations, reasons for caution: Although the differences between ART and NC reflect the true ART effects, these effects are likely to be mediated partly through the different prevalence of mono/dizygotic twins in the two groups. We could not explore the mediating effect of zygosity due to the unavailability of data. The confounding variables included in the study were limited to those available in the datasets.
Wider implications of the findings: Live-born twins from FET cycles are heavier at birth, grow faster than their fresh ET and NC counterparts and are still heavier at school entry. This differs from that observed in singletons from the same cohort, where babies in the three conception groups had similar weights by school entry age. The results are reassuring on known differences in FET versus fresh ET and NC twin outcomes. However, FET twins grow faster and are consistently 66 larger, and more ART twins depict catch-up growth. These may lead to an increased risk profile for non-communicable diseases in later life. As such, these twin outcomes require careful evaluation using more recent and comprehensive cohorts.
Original languageEnglish
JournalHuman reproduction (Oxford, England)
Early online date10 Feb 2023
Publication statusE-pub ahead of print - 10 Feb 2023


  • assisted reproduction
  • birth weight
  • child growth
  • twins
  • catch-up growth
  • catch-down growth


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