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.
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.