FERTILITY AND STERILITY威

VOL. 77, NO. 1, JANUARY 2002

Copyright ©2002 American Society for Reproductive Medicine
Published by Elsevier Science Inc.
Printed on acid-free paper in U.S.A.

Evidence of early placental vascular

anastomosis during selective embryo
reduction in monozygotic twins
François Olivennes, M.D., Ph.D., Severin Doumerc, M.D., Marie-Victoire Senat, M.D.,
François Audibert, M.D., Renato Fanchin, M.D., and René Frydman, M.D.
Service de Gynécologie-Obstétrique, Hôpital Antoine Béclère, Clamart, France

Objective: To describe selective embryo reduction of two triplet pregnancies with a monozygotic twin.
Design: Case reports.
Setting: Infertility unit of a Department of Obstetrics and Gynecology.
Patient(s): Two patients treated with IVF-ET who had triplet pregnancies.
Intervention(s): Selective embryo reduction of monozygotic twins.
Main Outcome Measure(s): Fetal heart beat.
Result(s): During intracardiac injection of potassium chloride plus midazolam in one of the monozygotic
twin fetuses, we observed an immediate diminution of the cardiac pulse rate of the second twin. This
phenomenon was observed in both patients.
Conclusion(s): These observations clearly indicate the presence of vascular anastomosis between the two
fetuses of these monozygotic twins. Thus, use of toxic substance to reduce one of the two fetuses of a
monozygotic twin pregnancy is contraindicated. In cases of triplets that include a monozygotic twin, it is safest
to interrupt the evolution of the twin if selective reduction is desired. (Fertil Steril威 2002;77:183– 4. ©2002
by American Society for Reproductive Medicine.)
Key Words: Monozygotic twin, embryo reduction, IVF-ET

Received April 11, 2001;
revised and accepted July
10, 2001.
Reprint requests: François
Olivennes, M.D., Ph.D.,
Service de Gynécologie-
Obstétrique, Hôpital
Antoine Béclère, 157, rue
de la Porte de Trivaux,
92141 Clamart Cedex,
France (FAX: 33-1-45-37-
49-80).
0015-0282/02/$22.00
PII S0015-0282(01)02942-9
Multiple pregnancies are the major compli-
cation of IVF-ET. Twins represent up to 25%
of all the pregnancies obtained after IVF-ET.
Most of these twins are dizygotic because they
developed after multiple embryo transfer.
However, monozygotic twins occur after IVF-
ET, and their incidence is reported to be in-
creasing (1). In multiple pregnancies of higher
order than twins, selective embryo reduction
has been proposed to reduce the incidence of
perinatal adverse outcome (2).
We present two cases in which selective
embryo reduction was proposed. These two
patients had triplet pregnancies in which
monozygotic twins were diagnosed by early
ultrasonography.
CASE REPORTS
The two cases were observed over 14
months in the infertility unit of a department of
obstetrics and gynecology. The patients, who
were 32 and 34 years of age, had tubal infer-
tility requiring IVF-ET. They underwent con-
trolled ovarian stimulation with a combination
of GnRH agonists and gonadotrophins. Ovula-
tion was induced with hCG. Oocyte retrieval
was performed under neuroleptanalgesia. Em-
bryo transfers were performed 48 hours later.
Three embryos were transferred in both pa-
tients. In one patient, assisted hatching was
performed in all the transferred embryos be-
cause of repeated implantation failure.
Pregnancies were detected by early ␤-hCG
measurement 12 days after embryo transfer.
Early ultrasonography was proposed 4 weeks
after embryo transfer. A triplet pregnancy was
observed in each patient, and at 7 weeks of
pregnancy, the presence of diamniotic mono-
chorionic twins was established.
Selective embryo reduction was proposed to
both patients, as is done in all cases of triplet
pregnancy at our institution. Psychological

183
counseling is also offered. Our custom is to propose reduc-
tion of triplets pregnancies to twins; in this circumstance,
however, the selective reduction of one embryo only would
have meant leaving the monozygotic twins, with an in-
creased risk for obstetric complications, or selectively inter-
rupting the development of one monozygotic twin, with
unknown effects on the second one. It was therefore pro-
posed that the triplet pregnancy be reduced to a single
pregnancy by interrupting development of the monozygotic
twins.
The outpatient procedure was performed after informed
consent was obtained from both patients. Selective embryo
reduction was done under transabdominal ultrasonographic
guidance at 8 weeks of pregnancy.
Careful decontamination of the abdomen was performed
with iodine. A needle was inserted into the amniotic sac
through the abdomen and the uterus, and intracardiac injec-
tion of potassium chloride and midazolam (Hypnovel;
Roche, Neuilly, France) was performed on one of the
monozygotic fetuses. During injection of the first monozy-
gotic twin, an immediate reduction of the cardiac pulse
frequency of the second one was clearly observed.
In the first case, the cardiac pulse of the second twin
decreased from 170 beats/min to 30 beats/min, and the fetus
was temporary immobilized. In the second case, the cardiac
pulse of the second twin decreased from 150 beats/min to 50
beats/min, and the fetus retained some attenuated movement.
In both cases, we repeated the procedure on the second twin
to decrease the overall time of the procedure. Therefore, we
could not observe the long-term effects of the fetoplacental
circulation of the drugs. In both cases, the procedure did not
affect the cardiac pulse of the third fetus.
The two pregnancies were uneventful and had a favorable
outcome. The patients delivered healthy children at 35 and
37 weeks of gestation.
DISCUSSION
There are two types of placenta in twin pregnancies.
Dichorionic twin placenta develops from the simultaneous
implantation of two embryos, whereas monochorionic pla-
centa originates from a single blastocyst. Diamniotic mono-
chorionic twins are the most common sort of monozygotic
twins.
The two placentas have different types of vascular anas-
tomoses: artery to artery, vein to vein, and artery to vein.
184 Olivennes et al. Early vascular anastomosis in monozygotic twins
These anastomoses are involved in the twin transfusion
syndrome (3). This syndrome is one of the major causes of
the excessive mortality rate among twins; without interven-
tion, it is lethal to 90% of twins when diagnosed before 26
weeks. We observed clinical manifestations of vascular
anastomoses between 8 and 9 weeks of gestation. The effect
of the injected drugs was not related to diffusion through the
amniotic membrane, because reduced cardiac pulse is not
observed when triplet pregnancies without monozygotic
twins are reduced to twins.
These observations have implications for selective em-
bryo reduction. It seems dangerous to reduce a triplet preg-
nancy to twins by selectively terminating one of the monozy-
gotic twins by intravascular drug injection. Some
investigators have proposed that selective embryo reduction
can be achieved by simple aspiration of the cardiac blood at
an early stage, with no drug injection (Dr. A. Hazout, un-
published data). These procedures have not been reported in
monozygotic twins. Passage of a toxic substance from the
dead fetus to the living one is possible and is suspected to
have adverse effects (4).
In conclusion, our observations indicate the existence of
early vascular anastomoses in monochorionic diamniotic
twins. These findings have two implications. First, use of a
toxic substance in one monozygotic twin is contraindicated
because vascular passage of the substance may harm the
second one. In cases of large anastomoses, the transit time
during fetal transfusion may be only 1 minute, and we
observed an effect on the second fetus in less than 30
seconds. In addition, these findings may lead to new research
on management of the twin transfusion syndrome. Manage-
ment of this syndrome may include interruption of these
anastomoses (5). Early detection of vascular anastomosis by
Doppler ultrasonography has been described, and an inter-
vention could be designed and studied.
References
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4. Geva E, Lerner-Geva L, Stavorovsky Z, Modan B, Freedman L, Amit A,
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Vol. 77, No. 1, January 2002