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 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.