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.
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.