Concurrent IVF and spontaneous conception resulting in a quadruplet pregnancy

Case report

A.A. Milki1,4, M.D. Hinckley1, F.C. Grumet2 and U. Chitkara3

1 Department of Gynecology and Obstetrics, 2 Department of Pathology and 3 Department of Gynecology and Obstetrics, Stanford University, Stanford, CA 94305 USA


    Abstract
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 Abstract
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 Case Report
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Blastocyst transfer of just one or two embryos has been used to help limit the number of high-order gestations. In this case report we describe the occurrence of a quadruplet pregnancy after the transfer of only two blastocysts during IVF. Sonographic examination showed four fetuses and what appeared to be quadriamniotic/quadrichorionic sacs, suggesting that a concomitant spontaneous conception had occurred. Definite confirmation of zygosity was obtained by genetic testing using DNA microsatellite polymorphism determinations after the birth of one boy and three girls at 32 weeks gestation. Although this event has not been reported previously, the possibility of its occurrence should be kept in mind. IVF patients with patent Fallopian tubes should be cautioned against intercourse late in their controlled ovarian stimulation, especially if they would decline multifetal reduction.

Key words: blastocyst/IVF/multifetal reduction/quadruplet/spontaneous conception


    Introduction
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 Abstract
 Introduction
 Case Report
 Discussion:
 References:
 
Although an overall spontaneous conception rate of 10–20% has been reported in infertile patients subsequent to IVF attempts, the probability of a spontaneous pregnancy in any given cycle is very small in this population (Vardon et al., 1995Go; Shimizu et al., 1999Go; Hennelly et al., 2000Go). When IVF patients are cautioned against intercourse near the time of oocyte retrieval, it is primarily to avoid trauma to hyperstimulated ovaries as well as to optimize sperm parameters, rather than to prevent a simultaneous pregnancy. We are unaware of any reports describing concurrent conception from intercourse and IVF in the same cycle. The case presented here illustrates such an occurrence.


    Case Report
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 Abstract
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 Case Report
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A 35-year-old nulliparous woman with 3 years of infertility was referred to our centre for IVF. She had undergone an infertility work-up after attempting to conceive naturally for 1 year. She had a normal hormonal profile, normal hysterosalpingogram, and mild endometriosis was found and treated at laparoscopy. Her husband's semen analysis was normal. They had failed six cycles of clomiphene–intra-uterine insemination (IUI) and six cycles of gonadotrophins–IUI. Before initiating IVF, they were counselled about the possibility of a high-order gestation and the option of a multifetal reduction. The couple stated that they would not undergo a multifetal reduction.

The patient underwent gonadotrophin-releasing hormone down-regulation followed by controlled ovarian hyperstimulation with FSH/human menopausal gonadotrophin. The couple admitted to having intercourse 5 days prior to the retrieval where 24 oocytes were recovered and inseminated, resulting in 18 zygotes. These were cultured in P1 medium containing 10% synthetic serum substitute (SSS, Irvine Scientific) until day 3. Embryos were then transferred to blastocyst medium (Irvine Scientific) + 10% SSS until day 5. Extended culture yielded 8 blastocysts. Two expanded blastocysts with a well-defined inner cell mass and trophectoderm were transferred on day 5, and the remaining 6 blastocysts were frozen.

The patient conceived and an ultrasound scan at 7 weeks gestation showed a quadruplet pregnancy with what appeared to be thick dividing membranes and a lambda sign between all four sacs. Subsequent ultrasound examinations throughout her gestation showed good interval growth of all four fetuses. She delivered three girls and one boy at 32 weeks gestation by elective Caesarean section. Baby A (boy) and baby B (girl) had separate placentas, whereas the placentas of baby C (girl) and baby D (girl) were fused. To further determine the zygosity, cord blood samples of each baby were tested for DNA short tandem repeat polymorphisms at 8 microsatellite loci (Scharf et al., 1995Go). The loci SE33, HUMTH01, HUMvWA31/A, D21S11, CSF1PO, and D7S796 were genetically informative and showed the boy and one girl to be fraternal, and the other two girls to be identical (Figure 1Go). Pathological examination of the placentas revealed no evidence of vascular anastomoses between the placentas of baby C and baby D, and histological section of the dividing membrane was consistent with a diamniotic, dichorionic membrane. These findings, along with evidence from the DNA studies, suggest that babies C and D were derived from a single zygote in which division occurred before implantation. All babies had an uneventful neonatal course and were discharged home within 10 weeks of delivery.



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Figure 1. Chromatogram tracing showing sample patterns of microsatellite alleles for each of six family members tested. The three microsatellite loci tested are listed at the top of the figure. The scale for allele sizing (in base pairs) is shown along the bottom of the figure. In each lane, the first peak on the far left and the last, double peak on the far right are size markers. Infants C and D had identical patterns whereas infants A and B were each unique; all alleles followed expected distribution for co-dominant Mendelian inheritance. Similar results were observed (data not shown) for the remaining informative microsatellite loci tested: HUMTho1, D21S11, CSF1PO and D7S796. The probability that infants C and D would have such identical patterns by chance alone (i.e. would not be monozygotic) is <6x10–5.

 

    Discussion:
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 Abstract
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 Case Report
 Discussion:
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High-order multiple births are a known occurrence with ovulation induction, even in the context of IVF where the desire to increase the success rate per cycle often leads to the transfer of more than two embryos. To control this complication, many countries legislate the number of embryos allowed for transfer, while other countries have voluntary professional guidelines suggesting numbers that are acceptable to eliminate nearly all triplet pregnancies (American Society for Reproductive Medicine, 1999Go; Jones and Schnorr, 2001Go). A singleton pregnancy is the ideal outcome in IVF, but twin gestations are less hazardous than higher order multiple births and may present an acceptable risk level. While a conception with more than twins is medically undesirable for any patient, avoiding high-order gestations is even more of a priority for patients who are unwilling to have multifetal reduction.

Although it is still debated whether blastocyst transfer improves pregnancy rates, blastocyst culture may help facilitate the selection of the best two embryos to eliminate triplet or greater gestations while maintaining an optimal pregnancy rate (Milki et al., 1999Go, 2000aGo,2000bGo). Blastocyst transfer is now routinely used in our programme to help limit the number of embryos transferred in patients at risk. Indeed it was carefully planned for this couple, with the expectation that the gestation would not exceed twins. There is, however, the rare exception where monozygotic splitting can occur with a resultant higher number than twins. We have previously reported a 4% incidence of monozygotic twinning with blastocyst transfer in a multi-centred study (Behr et al., 1999Go, 2000Go). As expected, these pregnancies are monochorionic, since with blastocyst transfer, embryo splitting occurs on or beyond day 5 after the inner cell mass has developed and cells destined to become chorion have already differentiated (Cunningham, 1997). In this patient with quadruplets, it would appear that the two transferred blastocysts led to fraternal twins, and a spontaneous conception with embryo splitting in vivo by day 4 resulted in identical twins. However, a recent case report showed early ultrasound findings of a trichorionic/triamniotic pregnancy resulting from the transfer of two blastocysts in a woman with bilateral salpingectomies. One of the blastocysts had herniated in vitro through a small hole in the zona pellucida and formed two half blastocysts of similar size, connected by a narrow bridge, with both inner cell mass and trophectoderm components ( Langendonckt et al., 2000Go). With this case in mind, it is possible that the monozygotic twins in our patient could have resulted from one blastocyst splitting. Even if that were true, at least one fetus would have been conceived spontaneously, which is incontestable based on the genetic testing.

Concurrent spontaneous conception with IVF is possible as some oocytes can be missed in patients with numerous follicles, despite careful attempts at harvesting all oocytes. Most IVF practitioners have on occasion recovered additional oocytes from the cul de sac when they suction the serosanguinous fluid at the end of the retrieval. Furthermore, sperm survival from intercourse may be prolonged in the presence of copious cervical mucus as seen with high levels of oestrogen in stimulated cycles. Even in non-stimulated cycles, the estimated probability of conception was reported at 0.10 when intercourse occurs 5 days prior to ovulation in a healthy population (Wilcox et al., 1995Go). Based on the case presented here, it may be prudent to caution IVF patients against unprotected intercourse after the initial days of controlled ovarian hyperstimulation if they have patent Fallopian tubes, normal semen parameters, and particularly if they will not consider multifetal reduction in the event of conception of a high-order multiple pregnancy.


    Notes
 
4 To whom correspondence should be addressed at: 300 Pasteur Drive HH #333, Dept Gyn/OB, Stanford University School of Medicine, Stanford, CA 94065, USA. E-mail: milki4{at}aol.com Back


    References:
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 Abstract
 Introduction
 Case Report
 Discussion:
 References:
 
American Society for Reproductive Medicine (1999) Guidelines on number of embryos transferred. American Society for Reproductive Medicine, Birmingham, Alabama.

Behr, B., Fisch, J.D., Milki, A.A. et al. (1999) Blastocyst transfer is associated with an increased incidence of monozygotic twinning. Hum. Reprod., 14 (Suppl.), 181

Behr, B., Fisch, J.D., Racowsky, C. et al. (2000) Blastocyst-ET and monozygotic twinning. J. Assist. Reprod. Gen., 17, 349–351.[ISI][Medline]

Cunningham, F.G., MacDonald, P.C., Gant, N.E. et al. (1997) Multifetal Pregnancy. In Williams Obstetrics, 20th edn, Appleton and Lange, Stamford, pp. 862–864.

Hennelly, B., Harrison, R.F., Kelly, J. et al. (2000) Spontaneous conception after a successful attempt at in vitro fertilization/intracytoplasmic sperm injection. Fertil. Steril., 73, 774–778.[ISI][Medline]

Jones, H.W. Jr and Schnorr, J.A. (2001) Multiple Pregnancy: a call for action. Fertil. Steril., 75, 11–13.[ISI][Medline]

Langendonckt, A., Wyns, C., Godin, P.A. et al. (2000) Atypical hatching of a human blastocyst leading to monozygotic twinning: a case report. Fertil. Steril., 74, 1047–1050.

Milki, A.A., Fisch, J.D. and Behr, B. (1999) Two-blastocyst transfer has similar pregnancy rates and a decreased multiple gestation rate compared with three-blastocyst transfer. Fertil. Steril., 72, 225–228.[ISI][Medline]

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Milki, A.A., Hinckley, M.D. and Behr, B. (2000b) Three is a crowd with blastocyst transfer. Fertil. Steril. (Suppl.), 73, 158.

Scharf, S.F., Smith, A.G., Hansen, J.A. et al. (1995) Quantitative determination of bone marrow transplant engraftment using fluorescent polymerase chain reaction primers for human identity markers. Blood, 85, 1954–1963.[Abstract/Free Full Text]

Shimizu, Y., Kodama, H., Fukuda, J. et al. (1999) Spontaneous conception after the births of infants conceived through in vitro fertilization treatment. Fertil. Steril., 71, 35–39.[ISI][Medline]

Vardon, D., Burban, C., Collomb, J. et al. (1995) Spontaneous pregnancies in couples after failed or successful in vitro fertilization. J. Gynecol. Obstet. Biol. Reprod. (Paris), 24, 811–815.[Medline]

Wilcox, A.J., Weinberg, C.R. and Baird, D.D. (1995) Timing of sexual intercourse in relation to ovulation—effects on the probability of conception, survival of the pregnancy, and sex of the baby. N. Engl. J. Med., 333, 1517–1521.[Abstract/Free Full Text]

Submitted on March 16, 2001; accepted on August 2, 2001.