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Monochorionic-triamniotic triplet pregnancy after intracytoplasmic sperm injection, assisted hatching, and two-embryo transfer: first reported case following IVF.

Ghulmiyyah LM, Perloe M, Tucker MJ, Zimmermann JH, Eller DP, Sills ES - BMC Pregnancy Childbirth (2003)

Bottom Line: We also outline an obstetric management strategy designed to optimize outcomes.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.

View Article: PubMed Central - HTML - PubMed

Affiliation: Georgia Reproductive Specialists LLC/Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Atlanta Medical Center; Atlanta Medical Center; Atlanta, Georgia USA. dr.sills@ivf.com

ABSTRACT
BACKGROUND: We present a case of monochorionic-triamniotic pregnancy that developed after embryo transfer following in vitro fertilization (IVF). METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

No MeSH data available.


Related in: MedlinePlus

Derom's developmental hypothesis (1987) of multiple births as a function of embryo fission (splitting) events and blastocyst implantation. Delivery outcomes assume 100% implantation. The incidence of human MZ triplets (black box) is estimated at 1:6400 deliveries. DZ = dizygotic MZ = monozygotic.
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Figure 2: Derom's developmental hypothesis (1987) of multiple births as a function of embryo fission (splitting) events and blastocyst implantation. Delivery outcomes assume 100% implantation. The incidence of human MZ triplets (black box) is estimated at 1:6400 deliveries. DZ = dizygotic MZ = monozygotic.

Mentions: Monozygotic twinning is thought to occur in 0.42% of all deliveries [1]. Not surprisingly triplet pregnancy in general accounts for even fewer births (1:6400), and the monochorionic triplet subset may occur only once in 100,000 births. Monozygotic multiple gestations occur when a single fertilized ovum splits into genetically identical embryos (Figure 2). Exactly when this division occurs governs the configuration of chorion and amnion compartments, with later fission resulting in development of progressively greater shared tissue elements among conceptuses. While zygosity refers to the number of source zygotes comprising the gestational set (with profound life-long implications for a sibling cohort), the precise anatomical characterization of chorion and amnion for any multiple gestation is more important in intrapartum risk assessment and obstetrical management. Depending on time of embryo splitting, monozygotic multiplets may have separate chorions or placentas, yet monochorionic gestations must always develop in a monozygous context. Based on this relationship, the number of placentas correlates with embryo number for multizygotic gestations, while monochorionic multiplets without mosaicism must be uniformly classified as monozygotic. Here we present the first known case of monochorionic-triamniotic triplets after IVF, a highly unusual occurrence necessitating a sequence of two properly timed, distinct embryo splitting events.


Monochorionic-triamniotic triplet pregnancy after intracytoplasmic sperm injection, assisted hatching, and two-embryo transfer: first reported case following IVF.

Ghulmiyyah LM, Perloe M, Tucker MJ, Zimmermann JH, Eller DP, Sills ES - BMC Pregnancy Childbirth (2003)

Derom's developmental hypothesis (1987) of multiple births as a function of embryo fission (splitting) events and blastocyst implantation. Delivery outcomes assume 100% implantation. The incidence of human MZ triplets (black box) is estimated at 1:6400 deliveries. DZ = dizygotic MZ = monozygotic.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC184457&req=5

Figure 2: Derom's developmental hypothesis (1987) of multiple births as a function of embryo fission (splitting) events and blastocyst implantation. Delivery outcomes assume 100% implantation. The incidence of human MZ triplets (black box) is estimated at 1:6400 deliveries. DZ = dizygotic MZ = monozygotic.
Mentions: Monozygotic twinning is thought to occur in 0.42% of all deliveries [1]. Not surprisingly triplet pregnancy in general accounts for even fewer births (1:6400), and the monochorionic triplet subset may occur only once in 100,000 births. Monozygotic multiple gestations occur when a single fertilized ovum splits into genetically identical embryos (Figure 2). Exactly when this division occurs governs the configuration of chorion and amnion compartments, with later fission resulting in development of progressively greater shared tissue elements among conceptuses. While zygosity refers to the number of source zygotes comprising the gestational set (with profound life-long implications for a sibling cohort), the precise anatomical characterization of chorion and amnion for any multiple gestation is more important in intrapartum risk assessment and obstetrical management. Depending on time of embryo splitting, monozygotic multiplets may have separate chorions or placentas, yet monochorionic gestations must always develop in a monozygous context. Based on this relationship, the number of placentas correlates with embryo number for multizygotic gestations, while monochorionic multiplets without mosaicism must be uniformly classified as monozygotic. Here we present the first known case of monochorionic-triamniotic triplets after IVF, a highly unusual occurrence necessitating a sequence of two properly timed, distinct embryo splitting events.

Bottom Line: We also outline an obstetric management strategy designed to optimize outcomes.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.

View Article: PubMed Central - HTML - PubMed

Affiliation: Georgia Reproductive Specialists LLC/Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Atlanta Medical Center; Atlanta Medical Center; Atlanta, Georgia USA. dr.sills@ivf.com

ABSTRACT
BACKGROUND: We present a case of monochorionic-triamniotic pregnancy that developed after embryo transfer following in vitro fertilization (IVF). METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

No MeSH data available.


Related in: MedlinePlus