Objective: To determine the effect of perinatal and neonatal risk factors on retinopathy of prematurity (ROP) and to examine the association of fertility treatments on the risk for ROP in very low birth weight (VLBW) preterm twins. Methods: The population-based observational study consisted of VLBW twins born at 24–29 weeks gestational age (GA). Data from the Israel national database (1995–2020) were applied. Univariate and multivariable logistic regression using the General Estimating Equation were used for assessment of risk factors. Results: The study population comprised 4092 infants of whom 2374 (58%) were conceived following fertility treatments. ROP was diagnosed in 851 (20.8%) infants. The odds for ROP approximately doubled with each week decrease in GA: at 24 weeks, Odds Ratio (OR) 58.00 (95% confidence interval (CI) 31.83–105.68); 25 weeks, OR 25.88 (95% CI 16.76–39.96); 26 weeks, OR 12.69 (95% CI 8.84–18.22) compared to 29 weeks GA. Each decrease in one birthweight z-score was associated with 1.82-fold increased risk for ROP (OR, 1.82, 95% CI 1.59–2.08). Infertility treatments were not associated with ROP. Neonatal morbidities significantly associated with ROP were surgical necrotizing enterocolitis (NEC) (OR, 2.04, 95% CI 1.31–3.19); surgically treated patent ductus arteriosus (PDA) (OR, 1.63, 95% CI 1.12–2.37); sepsis (OR, 1.43, 95% CI 1.20–1.71) and bronchopulmonary dysplasia (OR, 1.52, 95% CI 1.22–1.90). Conclusion: Among preterm VLBW twins, poor intrauterine growth and surgical interventions for NEC and PDA were associated with high odds for ROP. This study does not support an association of fertility treatments with increased risk for ROP.