A 34-year-old woman with 4 years of primary infertility (resulting from male-factor infertility) underwent IVF treatment at our clinic after several failed intrauterine inseminations. A mild stimulation protocol was performed using clomiphene and human menopausal gonadotropin (HMG; 150 units every other day; HMG150; Ferring Pharmaceuticals, Tokyo, Japan) []. Oocyte maturation was triggered using 1000 IU of human chorionic gonadotropin (hCG) (HCG 10000 U for injection; Fujipharma, Toyama-shi, Toyama). Nine mature oocytes were collected, of which 7 were fertilized via intracytoplasmic sperm injection (ICSI) and cultured for 3 days. Embryo transfer was performed during the next cycle due to the endometrial thickness. Three day-3 embryos were cryopreserved. During the next cycle, a frozen-thawed embryo transfer was performed and she became pregnant. She delivered a healthy baby at 40 weeks of gestation.\nWanting another child, she requested a frozen embryo transfer when she was 39 years old. The endometrium was prepared with hormone replacement therapy (HRT). The two remaining embryos were of poor grade (Veeck’s classification: 9 cells grade 4 and 8 cells grade 4, respectively) and were transferred using assisted hatching under transabdominal ultrasound (US). Luteal progesterone support was administered for 2 weeks. The woman successfully conceived, as confirmed by an hCG level of 450 IU/L on day 11 post-transfer (4 weeks 0 days). HRT was continued and a transvaginal US was performed on day 18 post-transfer (5 weeks 0 days). There were two gestational sacs (GSs) with dizygotic twins suspected. On day 32 post-transfer (7 weeks 0 days), an US showed two GSs with three fetuses, and a dizygotic trichorionic triamniotic triplet pregnancy was suspected (Fig. ). On day 48 post-transfer (9 weeks 2 days), the heartbeat of one of the monozygotic twin fetuses had stopped, resulting in a dichorionic diamniotic twin pregnancy. The subsequent pregnancy course went well, and a healthy boy and girl were delivered by elective caesarean section at 36 weeks 5 days of gestation.
The patient was a 41-year-old woman who complained of secondary infertility for 3 years related to male-factor infertility. She had a regular menstrual cycle and all routine analyses for infertility were unremarkable. She underwent IVF treatment. A mild stimulation protocol was followed for 9 days, with clomiphene and HMG (150 units every other day; HMG150; Ferring Pharmaceuticals, Tokyo, Japan) []. Thirty-five hours before egg collection, we administered 1000 IU of hCG (HCG 10000 U for injection; Fujipharma, Toyama-shi, Toyama). Six mature oocytes were collected, all of which were fertilized using ICSI, yielding 4 viable embryos on day 3 (Veeck’s classification: 10 cells grade 2, 9 cells grade 2, 8 cells grade 2, and 9 cells grade 3, respectively). Transfer was performed during the next cycle due to the endometrium thickness. A single day-3 embryo (Veeck’s classification: 10 cells grade 2) was transferred during an HRT cycle, but the transfer was not successful. In the following cycle, the culture was extended from a day-3 embryo to a day-5 blastocyst. The endometrium was prepared with HRT and two embryos (among the three remaining cleavage stage embryos) were grown to blastocysts. Assisted hatching was performed, and 2 blastocysts (Gardner’s classification: 5CB and 3CC, respectively) were transferred under transabdominal US guidance. Luteal progesterone support was given for 2 weeks. The serum hCG level was 520 IU/L on day 9 post-transfer (4 weeks 0 days). Transvaginal US performed at 5 weeks, 0-days gestation showed 2 GSs inside the uterus. At 7 weeks 0-days gestation, 3 fetal heart beats were detected and a dichorionic triamniotic triplet pregnancy (dichorionic monoamniotic twin + single) was suspected (Fig. ). After being informed of the maternal and fetal risks, the patient decided to proceed with selective reduction, hoping to obtain a single pregnancy. At 9 weeks 2-days gestation, reduction was successfully performed. The subsequent pregnancy course went well and the remaining single fetus was vaginally delivered without any problems at 38 weeks 0 days.