A 29-year-old woman with 2 years of primary infertility resulting from male factor infertility (oligoasthenospermia) and abnormal karyotype [45,XY, rob [, ] (q10;q10)] underwent PGD-ICSI treatment at the Center for Reproductive Medicine, Renji Hospital, Shanghai. During her first ART treatment cycle, stimulation was performed with daily administration of 150 units of recombinant follicle stimulating hormone (rFSH) (N.V.Organon, Netherlands) according to a standardised long protocol with Triptorelin 0.05 mg daily downregulation (Ferring, Germany). Following hCG trigger, 17 oocytes were collected, of which eight cleavage stage embryos were biopsied. Following fluorescent in situ hybridization (FISH), two normal euploid embryos were diagnosed, of which one was selected for transfer. The embryo selected had undergone single cell biopsy at the 10 cell stage and was subsequently transferred on day 4.\nThe woman successfully conceived, as confirmed by a hCG level of 2610 IU/L on day 15 post-transfer. Routine two-dimensional (2D) transvaginal ultrasound (US) by a reproductive medicine specialist on day 29 following transfer reported a single gestational sac (37 × 21 × 37 mm) with three yolk sacs and three foetal poles, all with heart beats. The TVU was repeated by the same doctor on day 35 post-transfer reporting a single gestational sac (52 × 19 × 40mm) with three viable foetuses with crown rump lengths (CRL) of 10.5, 8.1 and 10.0 mm. The couple was informed about the increased maternal and foetal risks with this condition and were counselled about the possibility of a foetal reduction procedure.\nAfter consideration, the couple decided to undergo foetal reduction at the prenatal diagnosis centre (PDC) of the First Maternal and Infant Hospital of Shanghai. At 13 + 2 weeks of the pregnancy, an abdominal US was performed by a foetal medicine specialist in fact revealed the presence of a MCQA pregnancy with four equal sized viable foetuses (CRL of 82, 83, 82 and 82 mm), all with nuchal translucency measurements within normal range. The woman subsequently underwent selective foetal reduction via use of radiofrequency ablation on two occasions, at 16 + 3 and 17 + 4 weeks of gestation. In the absence of any definitive evidence, reduction of only one foetus at a time was performed, with the assumption that it may reduce the risk of miscarriage in the remaining foetuses. The procedures were uncomplicated, and two healthy twin girls were delivered by elective Caesarean Section at 35 + 6 weeks of gestation, weighing 2060 and 1985 g. The placental specimen along with the two selectively reduced foetuses confirmed a MCQA pregnancy (Fig. ).
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.