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.
The patient was a 41-year-old woman who complained of secondary infertility for 3 years related to male-factor infertility. She had a regular menstrual cycle and all routine analyses for infertility were unremarkable. She underwent IVF treatment. A mild stimulation protocol was followed for 9 days, with clomiphene and HMG (150 units every other day; HMG150; Ferring Pharmaceuticals, Tokyo, Japan) []. Thirty-five hours before egg collection, we administered 1000 IU of hCG (HCG 10000 U for injection; Fujipharma, Toyama-shi, Toyama). Six mature oocytes were collected, all of which were fertilized using ICSI, yielding 4 viable embryos on day 3 (Veeck’s classification: 10 cells grade 2, 9 cells grade 2, 8 cells grade 2, and 9 cells grade 3, respectively). Transfer was performed during the next cycle due to the endometrium thickness. A single day-3 embryo (Veeck’s classification: 10 cells grade 2) was transferred during an HRT cycle, but the transfer was not successful. In the following cycle, the culture was extended from a day-3 embryo to a day-5 blastocyst. The endometrium was prepared with HRT and two embryos (among the three remaining cleavage stage embryos) were grown to blastocysts. Assisted hatching was performed, and 2 blastocysts (Gardner’s classification: 5CB and 3CC, respectively) were transferred under transabdominal US guidance. Luteal progesterone support was given for 2 weeks. The serum hCG level was 520 IU/L on day 9 post-transfer (4 weeks 0 days). Transvaginal US performed at 5 weeks, 0-days gestation showed 2 GSs inside the uterus. At 7 weeks 0-days gestation, 3 fetal heart beats were detected and a dichorionic triamniotic triplet pregnancy (dichorionic monoamniotic twin + single) was suspected (Fig. ). After being informed of the maternal and fetal risks, the patient decided to proceed with selective reduction, hoping to obtain a single pregnancy. At 9 weeks 2-days gestation, reduction was successfully performed. The subsequent pregnancy course went well and the remaining single fetus was vaginally delivered without any problems at 38 weeks 0 days.