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.
A 29-year-old woman presented with secondary infertility of 3-year duration. The couple was married for 6 years with regular menstrual cycles and normal husband's semen analysis. Her reproductive history included an ectopic pregnancy for which she had undergone the right salpingectomy and a missed miscarriage at 8 weeks pregnancy in the past. She had 4 failed intrauterine insemination cycles and was then planned for IVF in view of tubal factor.\nShe was started on the standard antagonist protocol and stimulated with 150 iu of recombinant follicle-stimulating hormone (rFSH; Gonal-F, Merck Serono, Geneva, Switzerland) and 75 iu of HMG-HP (Menopur, Ferring Pharmaceuticals, Sweden) daily. GnRH antagonist was started on day 6 of stimulation and administered daily till the day of human chorionic gonadotropin (hCG). Egg retrieval was performed 35 h after administration of 250 ug of recombinant hCG (rhCG; Ovitrelle, Merck Serono) and 16 oocytes were retrieved. The 15 metaphase II oocytes were subjected to conventional IVF since semen parameters were normal. 14 oocytes fertilized and after 5 days of in vitro culture (Vitrolife G1.3, Göteborg, Sweden), 6 blastocysts were obtained. Two top quality blastocysts (4AA, 2AA) were transferred, and 4 were cryopreserved. She received standard luteal support with vaginal progesterone gel (Crinone gel 8%, Merck Serono). A positive beta hCG was obtained 14 days after embryo transfer. Ultrasound performed at 5 weeks of pregnancy showed a single gestational sac. At 7 weeks of gestation, ultrasound revealed MCTA triplets with three yolk sacs and three fetal poles with cardiac activity in each [Figures and ]. In view of monochorionic gestation, she was offered fetal reduction by selective cord ligation at 16 weeks. Despite counseling about increased chances of antenatal complications with triplets, the couple chose to continue pregnancy without fetal reduction. She had an uneventful pregnancy till 17 weeks gestation after which she developed preterm premature rupture of membranes and cord prolapse. Her pregnancy was terminated using medical management.