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.
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.