This article has Open Peer Review reports available.
Monochorionic-triamniotic triplet pregnancy after intracytoplasmic sperm injection, assisted hatching, and two-embryo transfer: first reported case following IVF
© Ghulmiyyah et al; licensee BioMed Central Ltd. 2003
Received: 05 July 2003
Accepted: 08 August 2003
Published: 08 August 2003
We present a case of monochorionic-triamniotic pregnancy that developed after embryo transfer following in vitro fertilization (IVF).
After controlled ovarian hyperstimulation and transvaginal retrieval of 22 metaphase II oocytes, fertilization was accomplished with intracytoplasmic sperm injection (ICSI). Assisted embryo hatching was performed, and two embryos were transferred in utero. One non-transferred blastocyst was cryopreserved.
Fourteen days post-transfer, serum hCG level was 423 mIU/ml and subsequent transvaginal ultrasound revealed a single intrauterine gestational sac with three separate amnion compartments. Three distinct foci of cardiac motion were detected and the diagnosis was revised to monochorionic-triamniotic triplet pregnancy. Antenatal management included cerclage placement at 19 weeks gestation and hospital admission at 28 weeks gestation due to mild preeclampsia. Three viable female infants were delivered via cesarean at 30 5/7 weeks gestation.
The incidence of triplet delivery in humans is approximately 1:6400, and such pregnancies are classified as high-risk for reasons described in this report. We also outline an obstetric management strategy designed to optimize outcomes. The roles of IVF, ICSI, assisted embryo hatching and associated laboratory culture conditions on the subsequent development of monozygotic/monochorionic pregnancy remain controversial. As demonstrated here, even when two-embryo transfer is employed after IVF the statistical probability of monozygotic multiple gestation cannot be reduced to zero. We encourage discussion of this possibility during informed consent for the advanced reproductive technologies.
Keywordstriplet pregnancy / IVF / monochorionic / cerclage / outcome
Although the developmental mechanisms responsible monozygotic mutiple gestation are poorly characterized, some laboratory procedures altering the zona pellucida (e.g., ICSI and assisted embryo hatching) have been proposed as important. In this report, we describe the first known case of monochorionic-triamniotic triplets after IVF, an unusual physiological event requiring the sequence of two properly timed, distinct embryo splitting events.
A 21 year-old Caucasian nulligravida presented with her partner for assessment and treatment of primary male factor infertility of 24 months duration. Both were in good general health and the female's past gynecological history was unremarkable. The wife smoked approximately 1/2 pack of cigarettes daily, and used alcohol only rarely. Her only regular medication was a prenatal vitamin. Physical exam revealed no abnormality; BMI was 20 kg/m2. Her blood type was O positive. Cervical cytology and laboratory tests results were all normal, and saline hysterography identified no intracavitary defects. The patient had never used ovulation induction agents or periovulatory hCG.
The partner was a non-smoker and took no regular medications. He had commissioned no pregnancies in a prior marriage, and had been diagnosed with azoospermia four years earlier. Urological evaluation found no anatomical abnormality. Karyotype was normal 46, XY and Y-chromosome microdeletion analysis via polymerase chain reaction method was negative for any known mutation. Obstructive azoospermia (rete testes obliteration) had been diagnosed after exploratory scrotal surgery four years before presentation. The couple declined intrauterine insemination with anonymous donor sperm for personal reasons. Given the male factor infertility diagnosis necessitating intracytoplasmic injection (ICSI), the couple elected in vitro fertilization utilizing surgically retrieved spermatozoa. Full informed consent was obtained, including a discussion of multiple gestation risk.
Following pituitary downregulation with intranasal nafarelin acetate (0.4 mg/d), controlled ovarian hyperstimulation commenced using a combined FSH+hMG protocol. Subcutaneous hCG was administered on stimulation day 11, when serum estradiol was 2110 pg/ml. Twenty-two oocytes were retrieved via ultrasound-guided transvaginal needle aspiration, undertaken in parallel with spermatozoa collection via testicular biopsy (both procedures performed under intravenous sedation). Utilizing ICSI, 10 oocytes advanced to the 2pn stage. Two embryos (8 and 9-cell stage) were transferred fresh on post-fertilization day three after assisted hatching via acid Tyrode's method. One blastocyst was cryopreserved. Serum hCG was 423 mIU/ml two weeks after embryo transfer.
At 28 weeks' gestation, the patient was readmitted to hospital for mild preeclampsia with a blood pressure of 140/80. To promote fetal lung maturity, betamethasone (12 mg × 2 doses) was administered via intramuscular injection. The patient had no focal neurological signs and ALT and AST were elevated (97 and 121 u/l, respectively). Liver function tests normalized soon after admission. Platelet count was 157,000 and protein (325 mg) was present in 24 h urine collection. Multifetal biophysical profiles were performed every 48 h with reassuring results. At 305/7 weeks' gestation, serum uric acid was 7.8 mg/dl, platelets had fallen to 115,000, and the patient began to experience visual scotomata. Based on these findings consistent with worsening preeclampsia, the patient underwent a primary low-transverse cesarean delivery (estimated blood loss = 1,000 ml) resulting in the births of three viable female infants (1475, 1021, and 1021 g); one vertex and two breech presentations. Apgar scores were and 8/9, 9/9, and 8/9, respectively. A single three-umbilical cord placenta (weight = 639 g) was delivered without complication, and each umbilical cord was morphologically normal. The patient was discharged home after seven days in good condition, and two of the triplets were discharged home three weeks later. The other infant was discharged home at eight weeks age due to necrotizing enterocolitis that required surgery for intestinal obstruction. At six months follow-up, mother and babies continue to do well.
Previous investigators [2–4] have suggested at least three factors could modulate development of monozygotic multiple gestations in the setting of the advanced reproductive technologies: ovulation induction per se, certain IVF culture conditions, and zona pellucida architecture/micromanipulation. As these three variables commonly occur together, multiple regression analysis to quantify the individual contribution of each intervention has proven difficult. The potential impact of such iatrogenic influences on monozygotic gestations is reviewed elsewhere . Whether or not spontaneous embryo splitting or duplication might occur as another mechanism by which monozygotic/monochorionic multiplets develop remains controversial. Although rare, the de novo appearance of multiple inner-cell mass within a single embryo has been documented both in animals [6, 7] and humans .
Intrapartum and neonatal challenges of triplet pregnancy include a higher risk of respiratory distress  and a known association between intratriplet birthweight discordance and overall neonatal mortality . A recent Japanese study  revealed improved perinatal mortality rates among triplets over the interval 1980–1998, but birthweight <2000 g persisted as a poor prognostic indicator of outcome throughout the study period. While the societal cost of multiple births has proven more difficult to study, previous work has shown depression and divorce rates to be higher among parents of multiple births compared to those who have only singleton deliveries [12, 13].
Epidemiologists have rightly called attention to the problem of higher-order multiple births when a larger number of embryos are transferred , and some authors have suggested that a reduction in multiple gestations can only be obtained by transfer of one embryo after IVF . However, this monozygotic/monochorionic triplet pregnancy occurred in the context of a single blastocyst implantation after day three transfer of two embryos with IVF, a practice we regard as clinically conservative.
While the largest published series of monozygotic twin sets from one center found the frequency of monozygotic twinning not statistically different between zona manipulated and zona intact subgroups , summary research collected from multiple institutions (and embracing an even larger pooled sample) has offered a contrasting view . Indeed, it must be acknowledged that our present report describes a triplet conception and delivery following both ICSI and assisted embryo hatching. Yet whether these zona manipulations were causative or merely associative interventions cannot be fully determined from available data. Further observational studies will be necessary to characterize more completely the physiology of monozygotic/monochorionic multiple pregnancy.
The exact mechanism of monozygotic mutiple gestation is still poorly characterized. Procedures that modify the zona pellucida (e.g., ICSI and assisted embryo hatching) have been suggested as important in the monozygotic multiple gestation hypothesis, yet a definitive relationship between any clinical intervention during IVF and the subsequent development of multiple monozygotic gestation remains speculative. Nevertheless, even when the number of embryos transferred is limited, the potential for spontaneous embryo duplication escapes prediction. Accordingly, counseling should disclose such information during informed consent and offer a full opportunity to discuss number of embryos to transfer.
LMG was resident physician associated with the case and drafted the manuscript. MP was chief medical attending. MJT was senior embryologist responsible for cell culture and assisted fertilization. JHZ was the lead obstetrician and primary surgeon at delivery. DPE was consulting perinatologist. ESS conceived of the research, directed the resident, and coordinated manuscript revisions.
Written consent was obtained from the patient for publication of this manuscript.
- Bulmer MG: The Biology of Twinning in Man. Clarendon Press, Oxford. 1970Google Scholar
- Edwards RG, Mettler L, Walters D: Identical twins and in vitro fertilization. J In Vitro Fert Embryo Transfer. 1986, 3: 114-7.View ArticleGoogle Scholar
- Derom C, Vleitinck R, Derom R, van den Bergh H, Thiery M: Increased monozygotic twinning rate after ovulation induction. Lancet. 1987, 30: 1236-8. 10.1016/S0140-6736(87)92688-2.View ArticleGoogle Scholar
- Alikani M, Noyes N, Cohen J, Rosenwaks Z: Monozygotic twinning in the human is associated with the zona pellucida architecture. Hum Reprod. 1994, 9: 1318-21.PubMedGoogle Scholar
- Sills ES, Moomjy M, Zaninovic N, Veeck LL, McGee M, Palermo GD, Rosenwaks Z: Human zona pellucida micromanipulation and monozygotic twinning frequency after IVF. Hum Reprod. 2000, 15: 890-5. 10.1093/humrep/15.4.890.View ArticlePubMedGoogle Scholar
- Chida S: Monozygous double inner cell masses in mouse blastocysts following fertilization in vitro and in vivo. J In Vitro Fert Embryo Transf. 1990, 7: 177-9.View ArticlePubMedGoogle Scholar
- Ozdzenski W, Szczesny E, Tarkowski AK: Postimplantation development of mouse blastocysts with two separate inner cell masses. Arch Gynecol Obstet. 1997, 195: 467-71.Google Scholar
- Sills ES, Tucker MJ, Palermo GD: Assisted reproductive technologies and monozygous twins: implications for future study and clinical practice. Twin Res. 2000, 3: 217-23.View ArticlePubMedGoogle Scholar
- Shinwell ES, Blickstein I, Lusky A, Reichman B: Excess risk of mortality in very low birthweight triplets: a national, population based study. Arch Dis Child Fetal Neonatal Ed. 2003, 88: F36-40. 10.1136/fn.88.1.F36.View ArticlePubMedPubMed CentralGoogle Scholar
- Jacobs AR, Demissie K, Jain NJ, Kinzler WL: Birth weight discordance and adverse fetal and neonatal outcome among triplets in the United States. Obstet Gynecol. 2003, 101 (5 pt 1): 909-14. 10.1016/S0029-7844(02)03080-6.PubMedGoogle Scholar
- Imaizumi Y: Perinatal mortality in triplet births in Japan: time trends and factors influencing mortality. Twin Res. 2003, 6: 1-6. 10.1375/136905203762687825.View ArticlePubMedGoogle Scholar
- Nielsen J: Parents of twins have a specifically higher divorce rate. Sygeplejersken. 1986, 86: 21-PubMedGoogle Scholar
- Garel M, Salobir C, Blondel B: Psychological consequences of having triplets: a 4-year follow-up study. Fertil Steril. 1997, 67: 1162-5. 10.1016/S0015-0282(97)81457-4.View ArticlePubMedGoogle Scholar
- Schieve LA, Peterson HB, Meikles SF, Jeng G, Danel I, Burnett NM, Wilcox LS: Live-birth rate and multiple-birth rate risk using in vitro fertilization. JAMA. 1999, 282: 1832-8. 10.1001/jama.282.19.1832.View ArticlePubMedGoogle Scholar
- De Neubourg D, Gerris J, Van Royen E, Mangelschots K, Valkenburg M: Prevention of twin pregnancy after IVF/ICSI using embryo transfer. Verh K Acad Geneeskd Belg. 2002, 64: 361-70.PubMedGoogle Scholar
- Schieve LA, Miekle SF, Perterson HB, Jeng G, Burnett NM, Wilcox LS: Does assisted hatching pose a risk for monozygotic twinning in pregnancies conceived through in vitro fertilization?. Fertil Steril. 2000, 74: 288-94. 10.1016/S0015-0282(00)00602-6.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2393/3/4/prepub
This article is published under license to BioMed Central Ltd. This is an Open Access article: verbatim copying and redistribution of this article are permitted in all media for any purpose, provided this notice is preserved along with the article's original URL.