We report, to our knowledge, on the first case of 2 sets of monozygotic twins co-existing with a singleton pregnancy resulting from transfer of three cleaved embryos in an IVF /ICSI patient. Monozygosity was diagnosed in this case as the number of fetuses (five) exceeded the number of embryos replaced (three). It is very unlikely that one or two fetuses could have resulted from a spontaneously fertilized unrecovered oocyte as the couple fully denied any intercourse around the time of IVF/embryo transfer. Moreover, out of the three sacs, there were two monochrionic monoamniotic twins.
Despite nondirective pre-conception counseling regarding fetal and maternal complications of multiple births, the couple insisted on having 3 embryos replaced. There is no legislation in Jordan limiting the number of embryos to be transferred. The medical team did not succeed to convince the couple to accept transferring one or two embryos only, in fact they were still keen to have 3 embryos replaced even though the team gave them the option to leave their embryos to the blastocyst stage. Had the couple received information regarding embryos splitting and the potential complications associated with MZT, they probably would have accepted to have only one or two embryos at most. This case should discourage the transfer of more than one embryo even in cleavage stage transfer particularly when embryos derived from younger oocytes. We therefore call on all countries to set a legal limit on the number of embryos transferred in a single cycle
A study compared IVF and ICSI and found a significantly higher rate of monozygotic twins only after ICSI and blastocyst transfer (8.9 versus 0%; 5.9 versus 0%).[9] Mostly this is due to disruption of the mucopolysaccharide architecture of the zona pellucida. [10] Other investigators found that younger maternal age is associated with monozygotic twinning. [11] This case has therefore two risk factors which adds further support to the necessity of counseling such patients re embryo splitting in utero.
Feticide was first described in 1978 by Alberg, who performed intracardiac puncture of the fetal heart of a fetus affected by Hurler's syndrome. [12] Nonetheless, feticide gained more popularity in the last two decades to ameliorate the adverse sequelae of high order multiple pregnancies resulting from assisted reproductive technologies as in this case. Although it is debatable whether feticide is appropriate for triplets, it is generally accepted in cases of quintuplets due to the higher fetal loss rates. Our couple were counseled on the potential risks and benefits of fetal reduction to twins, or to a singleton. It was their autonomous decision to undergo reduction to twins. As both twins were monochorionic, intracardiac potassium chloride could not be used and cardiac puncture and aspiration was used instead.