A 32-year-old female with a history of polycystic ovary (PCO) underwent a third intracytoplasmic sperm injection (ICSI) attempt. On the first ICSI cycle, she achieved biochemical pregnancy. Her second ICSI attempt resulted in first trimester miscarriage. Before starting the third ICSI cycle, her elevated prolactin was corrected by one weekly 0.5 mg tablet of Dostinex (cabergoline, Pfizer Inc). She received 50 microgram thyroxine daily. Her thyroid-stimulating hormone (TSH), physical examination, and hysterosalpingogram (hSG) were normal. The partner had normal semen parameters. The ovarian stimulation was initiated on day-three of the cycle with 150 IU Gonal–F (recombinant follitropin alfa, Merck Biopharma, MA, USA) for six days with a dose increase to 225 IU for another two days. From day eight to 11 of the cycle, 0.25 mg daily injection of gonadotrophin-releasing hormone (GnRH) antagonist, Cetrotide (cetrorelix acetate, Merck Biopharma) was administered. Final oocyte maturation was achieved by a single injection of 10,000 IU of human chorionic gonadotropin (hCG). The oocytes were retrieved 36 hours post hCG injection.\nAt retrieval, 13 oocytes were collected: three metaphase II (MII), seven germinal vesicle (GV) and three empty zona. Oocytes denudation, semen processing, ICSI and culture were performed using standard protocols. Only three MII oocytes were injected. A fertilization check 18 hours post ICSI revealed two normally fertilized oocytes and the third had only one pronucleus. On day-three post retrieval, two embryos—six cells grade two and seven cells grade two were transferred under transabdominal ultrasound guidance. Assisted hatching was performed on both transferred embryos. Luteal support was provided by Cyclogest pessaries (L.D.Collins and CO, UK).\nThe first pregnancy test two weeks post embryo transfer had an hCG level of 2714 mIU/mL which increased to 26862 mIU/mL six days later. An ultrasound scan at five weeks revealed four intrauterine gestational sacs (Figure ). Later, a monochorionic pregnancy with four distinct gestational sacs and three embryos with cardiac activity was confirmed. The measurements for sacs one–four were 1.96 x 0.676, 1.70 x 0.83, 1.33 x 0.794, and 0.541 x 0.451 cm, respectively. A minor bleed 9 x 7 x 7 mm was noted on the anterio-lateral of sac one. The heart activity was noted in sacs one, two, and three but not in sac four.\nAnother ultrasound scan at seven weeks and two days confirmed triplet pregnancy with heart rates 145, 154, and 150 BPM for sacs one, two, and three, respectively. No fetal pole or yolk sac was noted in sac four. The crown-rump lengths (CRL) at eight weeks, six days were 2.35, 2.35, and 2.06 cm and heart rates were 173, 178, and 183 BPM for sacs one, two, and three, respectively. The risks of monozygotic pregnancies, medical abortion, and selective embryo reduction were extensively discussed with the couple. This patient had experienced spontaneous abortion at 16 weeks in a previous pregnancy, therefore cervical cerclage was offered.\nThe couple accepted fetal reduction and cervical cerclage. At 10 weeks and two days, twin viable pregnancy was confirmed with CRL 3.45 and 3.28 cm and heart activity 164 and 160 BPM, respectively for sac one and two.\nA 23 x 5 mm subchorionic bleed was noted posterio-lateral of sac two. The remnants of the reduced fetal sac were still noted measuring 28 x 15 mm. Estimated fetal weights for sac one and two at 12 weeks and six days were 57 and 70 g, respectively. Amniotic fluid volumes were adequate. The healthy twin boys were vaginally delivered after 36 weeks gestation.
A 32-year-old nulligravida Asian female visited the Sendai Art Clinic with primary infertility, including anovulation for the past 2 years. She was diagnosed with PCOS according to the Rotterdam ESHRE/ASRM consensus criteria []. Hysterosalpingography showed bilateral tubal patency and no defects of uterine cavity. Her husband’s semen analysis showed normozoospermia, based on the 2010 World Health Organization criteria. After she had failed to achieve pregnancy following several courses of ovulation induction with clomiphene citrate or gonadotrophin injections, she opted for IVM treatment to retrieve germinal vesicle (GV) oocytes for in vitro culture. Informed consent was provided.\nShe was initiated on an IVM-in vitro fertilization (IVF) protocol on day 6 of a spontaneous menstrual cycle and given 4 days of 75 IU recombinant FSH (Gonal-F, Serono Japan, Tokyo, Japan). She was repetitively evaluated on days 6 and 8 of the menstrual cycle by transvaginal ultrasound scans. When the leading follicle size was less than 12 mm, 5000 IU of urinary human chorionic gonadotropin (hCG) (gonatropin, ASKA Pharmaceutical Co., Ltd., Tokyo, Japan) was administered and oocyte retrieval was carried out 34 h after hCG triggering. The collection and culture of immature oocytes were performed as previously described [].\nFifteen GV stage immature oocytes were retrieved and incubated for 26 h in IVM culture medium (MediCult IVM medium, ORIGIO Japan, Yokohama, Japan) supplemented with recombinant FSH 75 mIU/ml (Gonal-F, Serono Japan, Tokyo, Japan), hCG 100 mIU/ml (gonatropin, ASKA Pharmaceutical Co., Ltd., Tokyo, Japan), and 10% patient’s inactivated serum. The oocytes were then denuded from the cumulus cells. Eleven mature oocytes were obtained and subjected to ICSI with fresh sperm (Fig. ). Zygotes were cultured in culture medium (Universal IVF, ORIGIO Japan, Yokohama, Japan), and fertilization was judged 16–18 h after ICSI for the appearance of two distinct pronuclei and two polar bodies. Nine (81.8%) oocytes were fertilized. Fertilized zygotes were transferred into culture medium (IVC-1, In Vitro Care, MD, Frederick, USA) and all embryos developed to blastocysts on day 5 (one middle expanding blastocyst and early blastocysts) and were cryopreserved by vitrification.\nFor the preparation of the endometrium, transcutaneous estradiol (Estrana TAPE 0.72 mg, Hisamitsu Pharmaceutical, Tokyo, Japan; four sheets every 2 days) was administered on day of the hormone replacement therapy (HRT). The endometrial lining was evaluated on days 12–14 of the HRT cycle and the endometrial thickness needed to be a minimum of 8 mm. A vaginal progesterone suppository (Luteum, Aska pharmacy, Tokyo, Japan; 2 tablets everyday) was administered when the endometrial thickness achieved was greater than 8 mm. The transcutaneous estradiol and vaginal progesterone suppository were continued until 9 weeks of gestation. A single frozen-thawed blastocyst (Gardner’s classification:4 BC) (Fig. ) was transferred under transvaginal ultrasound guidance on day 5 after vaginal progesterone suppository was administered. Two weeks after blastocyst transfer, the patient’s serum hCG concentration was 2194 IU/L and pregnancy was confirmed. Transvaginal ultrasound performed at 5 weeks and 0 days of gestation showed 2 gestational sacs inside the uterus. At 8 weeks 2 days gestation, 3 fetal heart beats were detected and a dichorionic triamniotic triplet pregnancy was observed by ultrasound (Fig. ). The subsequent pregnancy course went well until 28 weeks 5 days when she was admitted to the maternal fetus intensive care unit for fetal growth restriction. She received prenatal steroids for fetal lung maturation and intravenous magnesium sulfate for tocolysis until the delivery. At 33 weeks 4 days, three baby girls were delivered by an elective Caesarean section. Their weight and APGAR scores at 1 min and 5 min were 1852 g, 8–8, 1817 g, 7–8, and 1495 g, 8–9, respectively. Histological examination of the placenta confirmed monochorionicity. The babies remained in the neonatology unit without morbidity and were discharged 4 weeks after birth.