A 34-year-old lady with 7 years of secondary infertility due to tubal factor underwent conventional IVF treatment at the University ART unit, Prince of Wales Hospital, Hong Kong. She had a previous first trimester miscarriage in 2007 and a right ectopic pregnancy in 2008, at which time she had a salpingectomy. Subsequent investigations including a laparoscopy confirmed blockage of the contralateral tube and evidence of endometriosis. During her first ART cycle, stimulation was performed with daily administration of 225 units of human menopausal gonadotrophin (hMG) (Serono, Aubonne/Switzerland) according to a standardised antagonist protocol with Ganirelix 0.25 mg downregulation (Merck Serono, Germany). Following hCG trigger, 14 mature oocytes were collected, of which 12 were fertilised, yielding 6 viable blastocysts (i.e. Gardner grading of BB grading or above) on day 5. No assisted hatching was performed, and a single expanding blastocyst (i.e. increasing blastocoel cavity with thinning of the zona pellucida and differentiation of the inner cell mass) was transferred to the patient on day 5. The remaining blastocysts were all cryopreserved following appropriate consent.\nThe woman successfully conceived, as confirmed by an hCG level of 154 IU/L on day 9 post-transfer. Routine 2D transvaginal US 23 days following transfer was suspicious of monochorionic twin or triplet pregnancy; therefore, a 3D US was performed on the same day demonstrating clearly a single gestational sac with three yolk sacs and three foetal poles (CRL of 4.5, 3.1 and 3.0 mm) (Fig. ). On day 36 following transfer, 3D US confirmed a MCTA pregnancy (Fig. ). The couple was informed appropriately regarding the increased maternal and foetal risks of higher order monozygotic gestations and was counselled regarding the possibility of a foetal reduction procedure.\nAfter being reviewed by the foetal medicine team of the Prince of Wales Hospital, an US at 11 + 5 weeks showed all three CRLs of the triplets to be within normal range, although the nuchal translucency was increased in one of the triplets (3.6 mm versus 2.3 and 1.2 for the other two). The couple subsequently decided to proceed with selective foetal reduction via use of radiofrequency ablation, which was successfully performed for the triplet with the thickest nuchal translucency at 14 + 1 weeks of gestation. The procedure was uncomplicated, and the remaining twins are well at the time of writing this article.
An IVF cycle was planned for a 29-year-old nulligravida patient with unexplained infertility. Prior to this, she had one failed intrauterine insemination (IUI) and three failed IUI cycles with clomiphene citrate. The stimulation was performed with recombinant FSH and hMG using a short protocol with GnRH antagonist. Fourteen oocytes were aspirated during follicular puncture. Seven oocytes were fertilized and cultured. The cultured embryos were of relatively poor quality and the grading of the three embryos selected for transfer on day 3 was 6-cell, grade C; 4-cell, grade B; 4-cell grade C []. About 4 weeks later, three intrauterine gestational sacs were noted by transvaginal ultrasound (). At 7 weeks of gestation, a quintuplet pregnancy with monozygotic (monochorionic, triamniotic) triplets and dizygotic (dichorioinc diamniotic) twins was sonographically confirmed (). All five embryos demonstrated cardiac activity and were concordant. The patient was counseled and referred for selective fetal reduction of the monochorionic triamniotic triplets. This was performed without complications on the 12th week of her pregnancy. Amniocentesis of the triplets during fetal reduction showed normal chromosomes (46, XX) and no structural abnormalities. The pregnancy was subsequently complicated by preterm labor followed by emergency cesarean delivery due to nonreassuring fetal tracing resulting in delivery of healthy female and male babies at 30 weeks of gestation. Both babies were born in 2006 and are currently doing well.