Monochorionic triplet and monoamniotic twins gestation after intracytoplasmic sperm injection and laser-assisted hatching

Objective: To report on a patient with a quintuplet pregnancy consisting of a monochorionic triamnionic triplet pregnancy and one case of monoamniotic twins after intracytoplasmic sperm injection (ICSI), laser-assisted hatching, and day 4 embryo transfer. Case Report: A 34-year-old woman who underwent ICSI due to male infertility. She underwent standard controlled ovarian hyperstimulation. Retrieved oocytes were fertilized in vitro, and 3 embryos were transferred on day 4 after laser-assisted hatching. Transvaginal ultrasound revealed a monoamniotic twin pregnancy and a monochorionic-triamniotic triplet pregnancy. A second ultrasound, 1 week later, showed three distinct foci of cardiac motion in one sac, while the sac of the monoamniotic twins had one embryo with heart beat. After extensive counseling with perinatologists about pregnancy complications, the patient elected to performed fetal reduction on the third sac. A healthy male infant was delivered by Caesarean section at 38 weeks of gestation. Conclusions: The exact mechanism of monozygotic multiple 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 in vitro fertilization and the subsequent development of multiple monozygotic gestation remains speculative.