A 32-year-old female with a history of polycystic ovary (PCO) underwent a third intracytoplasmic sperm injection (ICSI) attempt. On the first ICSI cycle, she achieved biochemical pregnancy. Her second ICSI attempt resulted in first trimester miscarriage. Before starting the third ICSI cycle, her elevated prolactin was corrected by one weekly 0.5 mg tablet of Dostinex (cabergoline, Pfizer Inc). She received 50 microgram thyroxine daily. Her thyroid-stimulating hormone (TSH), physical examination, and hysterosalpingogram (hSG) were normal. The partner had normal semen parameters. The ovarian stimulation was initiated on day-three of the cycle with 150 IU Gonal–F (recombinant follitropin alfa, Merck Biopharma, MA, USA) for six days with a dose increase to 225 IU for another two days. From day eight to 11 of the cycle, 0.25 mg daily injection of gonadotrophin-releasing hormone (GnRH) antagonist, Cetrotide (cetrorelix acetate, Merck Biopharma) was administered. Final oocyte maturation was achieved by a single injection of 10,000 IU of human chorionic gonadotropin (hCG). The oocytes were retrieved 36 hours post hCG injection.\nAt retrieval, 13 oocytes were collected: three metaphase II (MII), seven germinal vesicle (GV) and three empty zona. Oocytes denudation, semen processing, ICSI and culture were performed using standard protocols. Only three MII oocytes were injected. A fertilization check 18 hours post ICSI revealed two normally fertilized oocytes and the third had only one pronucleus. On day-three post retrieval, two embryos—six cells grade two and seven cells grade two were transferred under transabdominal ultrasound guidance. Assisted hatching was performed on both transferred embryos. Luteal support was provided by Cyclogest pessaries (L.D.Collins and CO, UK).\nThe first pregnancy test two weeks post embryo transfer had an hCG level of 2714 mIU/mL which increased to 26862 mIU/mL six days later. An ultrasound scan at five weeks revealed four intrauterine gestational sacs (Figure ). Later, a monochorionic pregnancy with four distinct gestational sacs and three embryos with cardiac activity was confirmed. The measurements for sacs one–four were 1.96 x 0.676, 1.70 x 0.83, 1.33 x 0.794, and 0.541 x 0.451 cm, respectively. A minor bleed 9 x 7 x 7 mm was noted on the anterio-lateral of sac one. The heart activity was noted in sacs one, two, and three but not in sac four.\nAnother ultrasound scan at seven weeks and two days confirmed triplet pregnancy with heart rates 145, 154, and 150 BPM for sacs one, two, and three, respectively. No fetal pole or yolk sac was noted in sac four. The crown-rump lengths (CRL) at eight weeks, six days were 2.35, 2.35, and 2.06 cm and heart rates were 173, 178, and 183 BPM for sacs one, two, and three, respectively. The risks of monozygotic pregnancies, medical abortion, and selective embryo reduction were extensively discussed with the couple. This patient had experienced spontaneous abortion at 16 weeks in a previous pregnancy, therefore cervical cerclage was offered.\nThe couple accepted fetal reduction and cervical cerclage. At 10 weeks and two days, twin viable pregnancy was confirmed with CRL 3.45 and 3.28 cm and heart activity 164 and 160 BPM, respectively for sac one and two.\nA 23 x 5 mm subchorionic bleed was noted posterio-lateral of sac two. The remnants of the reduced fetal sac were still noted measuring 28 x 15 mm. Estimated fetal weights for sac one and two at 12 weeks and six days were 57 and 70 g, respectively. Amniotic fluid volumes were adequate. The healthy twin boys were vaginally delivered after 36 weeks gestation.
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.