1 Department of Obstetrics and Gynecology, Atlanta Medical Center, 2 Georgia Reproductive Specialists LLC, 3 Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Atlanta Medical Center, Atlanta, Georgia, and 4 Cornell Institute for Reproductive Medicine, Weill Medical College of Cornell University, New York, NY, USA
5 To whom correspondence should be addressed at: Suite 270, 5445 Meridian Mark Road, Atlanta, Georgia 30342, USA. e-mail: dr.sills@ivf.com
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Abstract |
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Key words: delivery/IVF/monozygotic/quadramniotic/twins
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Case report |
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The patient had already received four unsuccessful ovulation induction cycles with clomiphene (100 mg/day for 5 days) before referral. We estimated ovarian reserve as reported previously (Perloe et al., 2000), with cycle day 3 serum FSH and estradiol (E2) levels at 6.3 mIU/ml and 35.4 pg/ml respectively. All other laboratory tests including thyroid stimulating hormone and serum prolactin were normal. The provisional diagnosis of unexplained infertility was made and the couple requested IVF. The initial IVF cycle resulted in the transfer of three embryos (3, 7 and 9 cells/embryo); neither ICSI nor assisted embryo hatching (AH) was done. No pregnancy was established.
After 5 months, a second IVF cycle including mid-luteal pituitary down-regulation with GnRH agonist, and controlled ovarian hyperstimulation using a combined FSH + hMG protocol (Sills et al., 1998) was commenced. Following a 9 day follicular recruitment phase, the patients terminal serum E2 was 2950 pg/ml. Thirteen oocytes were retrieved via transvaginal sonogram-guided needle aspiration, and all advanced to the 2 pronuclei (PN) stage after ICSI (Palermo et al., 1992
). AH was accomplished with acid Tyrodes solution (Tucker et al., 1994
). On post-fertilization day 3, four embryos (7, 7, 7 and 8 cells/embryo) were transferred using a co-axial Frydman catheter (Laboratoire CCD, Paris, France) under transabdominal sonographic guidance. Embryo morphology was compromised by moderate fragmentation (1522%); some blastomere irregularity/asymmetry was also noted. The patient received 10 mg diazepam p.o. 1 h before transfer. None of the non-transferred embryos was considered suitable for cryopreservation. On the evening of embryo transfer, supplementary progesterone was administered transmucosally (Sills et al., 2002
). When measured 14 days post-transfer, the serum hCG value was 753 mIU/ml. The patient returned to our centre at 35 days gestation and transvaginal sonogram (probe frequency = 6.0 mHz; SDU 400+; Shimadzu Corporation, Kyoto, Japan) revealed slightly enlarged ovaries, grossly normal adnexa and two symmetrical intrauterine gestational sacs. Each sac appeared to contain one conceptus, with crownrump lengths of 7 and 8 mm. Cardiac activity was noted in both gestational sacs, with rates confirmed by B-mode Doppler pulse at 126 and 131/min.
Follow-up evaluation performed 1 week later (by the same physician using the same equipment) again identified two intrauterine gestational sacs. However, at this point each sac now contained two distinct fetal poles (Figure 1). Four foci of cardiac activity were present (rates = 166, 157, 162 and 166/min). Based on sonographic findings, the diagnosis was revised to quadruplet pregnancy and perinatology consultation confirmed a quadramniotic-dichorionic gestation. The couple was counselled extensively on the maternal and neonatal risks associated with quadruplet pregnancy, as well as multifetal reduction techniques.
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The obstetrical course was unremarkable until week 27, when a targeted sonogram identified a subtle left hydronephrosis in one twin. Oligohydramnios was absent. At week 33 of pregnancy, biophysical profile score for both twins was 8/8 and the placenta was grade 1. Fetal biometrics confirmed appropriate growth for twin A, but twin B was borderline small for gestational age. No sonographic evidence of pathological vascular anastomosis between the twins was evident. At 36 weeks gestation, presentation was vertex/vertex and the patient underwent induction of labour. An uncomplicated vaginal twin delivery occurred within 24 h. The weights at birth were 2495 and 2239 g. For both twins, 1 and 5 min Apgar scores were 8 and 7 respectively. Inspection of the single placenta confirmed monozygosity. Mother and twins were discharged home in good condition on post-partum day 2 and were continuing to do well 3 months later (see Note added at proof).
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Discussion |
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MZ twins account for 0.4% of all births (Bulmer, 1970
), and early studies found MZ twinning frequency independent of race, age, parity or family history. However, other investigators (Harvey et al., 1977
; Shapiro et al., 1978
) have suggested that MZ twinning may be affected by an inheritable component. The roles of ovulation induction, in-vitro culture conditions, and zona pellucida tampering in the MZ twinning process also remain controversial and have been reviewed elsewhere (Sills et al., 2000b
; Schachter et al., 2001
).
Our patient elected to undergo multifetal reduction after she considered the risks associated with higher order multiple gestation. The possibility of a spontaneous reduction was also discussed (Dickey et al., 2002) but the couple found expectant management unacceptable. In such settings, the role of supportive counselling cannot be overstated (Garel et al., 1995
). The reassuring chromosomal status present in one MZ twin pair via CVS and FISH analysis reflects current recommendations for genetic testing before multifetal reduction is performed (Eddleman et al., 2000
). While the overall pregnancy loss rate after multifetal reduction is influenced by operator experience (Evans et al., 1993
), most referral centres have sufficient proficiency with the procedure to make the risk acceptable.
Several investigators have called attention to the increased incidence of higher-order multiple gestations following IVF, but such outcomes are almost always related to the number of embryos transferred rather than physiological twinning events. Nevertheless, exceptional cases have been documented. A trizygotic quadruplet pregnancy after IVF and transfer of only three embryos (Biljan et al., 1995) illustrates the need to consider natural twinning events in assisted reproductive settings. Another report of quadrichorionic-quadruplet pregnancy (after IVF with implantation of two transferred embryos) found two additional gestational sacs from a concurrent unassisted conception (Milki et al., 2001
). These reports underscore the principle that multiple gestations established after IVF require early and precise sonographic characterization (Timor-Tritsch et al., 1997
).
In the current report, we describe an IVF patient with two normal intrauterine gestational sacs, both of which appear to have split between days 35 and 42 of gestation. Such a quadramniotic-dichorionic membrane configuration is thought to require embryo splitting between post-fertilization days 4 and 8an early microscopic event that could easily be missed at the time of the initial sonogram. In any case, formal documentation of quadruplet pregnancy consisting of two simultaneous sets of MZ twins (calculated probability 0.4x0.4 = 0.16%) is unprecedented in humans. Whether or not this outcome was in some way influenced by AH or ICSI (both of which were performed in this case) cannot be known with certainty. If particular AH methods are associated with higher twinning frequency then this would represent yet another unknown.
It is acknowledged that this double MZ twin-quadruplet pregnancy after AH and ICSI appears congruent with some studies where a connection between MZ twinning and zona pellucida tampering was hypothesized (Sheiner et al., 2001; Tarlatzis et al., 2002
). However, a larger series of more than 1900 IVF cycles including 23 MZ twin sets reported no significant increase in MZ twinning after AH, ICSI or frozen embryo transfer (Sills et al., 2000a
). How to reconcile our anecdotal report of double monozygosity after AH and ICSI with these conflicting observations is an unanswered challenge inviting continued research. The possibility of spontaneous MZ twinning, while still a remote risk, should be included in IVF patient counselling until more is known.
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Note added at proof |
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References |
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Submitted on August 6, 2002; accepted on October 3, 2002.