A multiple male and female pregnancy in a patient with stage IV endometriosis undergoing single embryo transfer after IVF-ICSI

A primary challenge in assisted reproductive treatment (ART) is the risk of multiple pregnancies. Current practice emphasizes single embryo transfer (SET) to minimize complications. This report presents a rare case: a dizygotic twin pregnancy (male and female) following SET and IVF-ICSI in a patient with advanced endometriosis and bilateral tubal occlusion. The 36-years-old patient presented with two years of infertility and suspected advanced endometriosis with mild to moderate symptoms. Examination showed a firm, irregular uterus, enlarged adnexa, and ultrasound revealed heterogeneous uterine echogenicity with adenomyosis. Uterine mobility was restricted, ovaries were immobile. The right ovary contained multiple endometriomas (up to 25 mm), while the left had a large endometrioma (64 mm, increased from 38 mm six months prior). Deep infiltrating endometriosis was suspected in the anterior rectosigmoid. Due to concerns about complications, the patient opted for laparoscopic surgery focusing on reducing ovarian lesion size and removing extra-gastrointestinal adhesions. Surgery confirmed stage IV endometriosis (rASRM). The large ovarian cyst was decompressed, biopsied, adhesions and peritoneal endometriosis were partially excised, and bilateral tubal occlusion was confirmed. The patient was then referred for ART. Ovarian stimulation used a short GnRH antagonist protocol: human menopausal gonadotropin (300 IU) from day 3, ganirelix (0.25 mg subcutaneously) from day 8. After nine days, final follicular maturation was triggered with choriogonadotropin alfa (6500 IU). Five oocytes were retrieved, four fertilized via ICSI, and three developed into high-quality blastocysts. SET was performed. Ten days post-embryotransfer, a positive pregnancy test was obtained. At five weeks, two gestational sacs were visualized; at eight weeks, a diamniotic, dichorionic twin pregnancy was confirmed. The pregnancy progressed uneventfully, managed according to protocols for such pregnancies. A cesarean section at 35 weeks resulted in the delivery of healthy male and female twins. ART increases the risk of monozygotic twinning by approximately 2–3 times. Twin pregnancies carry increased risks, including potentially life-threatening conditions [1, 2]. ART indications include patient age and endometriosis severity however available guidelines vary [3]. Studies suggest that surgical removal of visible endometriosis improves ART outcomes [4]. Simultaneous IVF and spontaneous conception are unlikely, but still possible [5]. The tubal occlusion raises the possibility of an oocyte being dislodged into the fallopian tube during oocyte retrieval. To our knowledge, similar cases in patients with severe endometriosis are undocumented. This case demonstrates the feasibility of successful ART in patients with advanced endometriosis, despite the unusual outcome. Article information and declarations Author contributions Piotr Olcha — ART; Lukasz Nowakowski — initial assessment, surgery; Iwona Radzik — neonatal care; Michal Ciebiera — article revision; Lechoslaw Putowski — article revision. Acknowledgments None. Funding Authors declare no funding. Conflict of interest Authors declare no conflict of interest.