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.
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.