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.
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.