Embryo Reduction in Dichorionic Triplets to Dichorionic Twins by Intrafetal Laser

Abstract

Objective: To describe a new technique for embryo reduction (ER) in dichorionic triplet (DCT) pregnancies. Methods: In 22 DCT pregnancies, ER to dichorionic twins was carried out at 11.3-13.9 weeks' gestation by ultrasound-guided laser ablation of the pelvic vessels of one of the monochorionic twins. Results: Intrafetal laser was successfully carried out in all cases, but ultrasound examination within 2 weeks of the procedure demonstrated that the co-twin had died in 11 cases and was alive in the other 11. In the dichorionic group there was one miscarriage at 23 weeks due to cervical incompetence and in the other 10 cases there were two live births at a median gestational age of 35.0 (range 32.2-37.1) weeks. In the 11 cases where both monochorionic fetuses died the separate triplet was live born at a median gestation of 38.0 (range 32.2-40.5) weeks. Conclusions: In the management of DCT pregnancies, ER to dichorionic twins by intrafetal laser is an additional option to the traditional ones of expectant management, ER by intrafetal injection of potassium chloride (KCl) to monochorionic twins or ER by KCl to singleton.

Intrafetal laser ablation for embryo reduction from dichorionic triplets to dichorionic twins

“…We have proposed a new approach for ER of DC triplet pregnancies to DC twins by ultrasound‐guided laser ablation of the pelvic vessels of one of the monochorionic twins. In a series of 22 DC triplet pregnancies undergoing intrafetal laser, ultrasound examination within 2 weeks of the procedure demonstrated that the cotwin had died in 11 cases and was alive in the other 11; in the DC group there was one miscarriage at 23 weeks and in the other 10 cases there were two live births at a median gestational age of 35 weeks, whereas in the 11 cases in which both monochorionic fetuses died, the separate triplet was liveborn at a median gestation of 38 weeks.…”

Pregnancy outcomes of dichorionic triamniotic triplet pregnancies after in vitro fertilization-embryo transfer : multifoetal pregnancy reduction versus expectant management

“…In addition, acute haemorrhage of the surviving twin may occur soon after the death of the co-twin through placental vascular anastomoses, with consequent death or neurodevelopmental impairment [34,35]. Relatively new vascular occlusive techniques have enabled the possibility of reducing a triplet pregnancy containing MC twins to a DC twin pregnancy [3,36,37]. Some studies have reported the efficiency of this new technique in women with MC twins; however, it potentially increases the risk of technique-associated complications and the rate of intrauterine demise of the retained co-twin [3,34,36].…”

“…Relatively new vascular occlusive techniques have enabled the possibility of reducing a triplet pregnancy containing MC twins to a DC twin pregnancy [3,36,37]. Some studies have reported the efficiency of this new technique in women with MC twins; however, it potentially increases the risk of technique-associated complications and the rate of intrauterine demise of the retained co-twin [3,34,36]. Chaveeva P et al [38] reported 61 DC triplet pregnancies that were reduced to DC twin pregnancies by intrafoetal laser ablation; although reduction resulted in a relatively lower miscarriage rate (3%), 45.9% of the cases of co-twin miscarriage within the subsequent 2 weeks were likely due to incomplete vascular occlusion and 9 retrograde haemorrhage of the survivor through placental vascular anastomoses into the dead cotwin.…”

Expectant management versus multifetal pregnancy reduction in higher order multiple pregnancies containing a monochorionic pair and a review of the literature

“…More recently, reduction to two fetuses by reducing one of the monochorionic pair and retaining dichorionic twins has been proposed [23,24]. The techniques described include aspiration of embryonic parts at 6-8 week [23] or intrafetal interstitial laser ablation at 11-14 weeks [24].…”

“…The techniques described include aspiration of embryonic parts at 6-8 week [23] or intrafetal interstitial laser ablation at 11-14 weeks [24]. The latter might be a concept, especially for complications in the monochorionic pair evident as early as in the first trimester even if the death of the monochorionic co-twin was observed in 50 % of cases 2 weeks later [24].…”