ABSTRACT Blastocyst transfer is advocated to reduce the risk of multiple gestations in pregnancies by assisted reproduction. Nevertheless, there remains the rare inherit possibility of embryo splitting that can result in monozygotic twins leading to high-order multiples. Also, when a patient is found to have a higher gestation than the number of embryos transferred it calls into question the IVF facility’s competency and credibility. The case report presented such a rare phenomenon of embryo splitting and the clinical consequences precipitated from it. In the patient, two blastocysts were transferred 5 days after transvaginal oocyte retrieval. The pregnancy confirming hCG test did not predict high-order multiples in this case. Early ultrasonography documented trichorionic-quadramnionic gestation. Selective reduction of the monochorionic twins was done at 11 weeks. Dichorionic twin gestation continued uneventful until 22 weeks at which point the patient experienced preterm premature rupture of membranes with subsequent delivery. The pathology report confirmed trichorionic-quadramnionic gestation. The mode of splitting was different for the two embryos one leading to monozygotic dichorionic and the other to monozygotic monochorionic. Furthermore, the implantation was also apparently asynchronous with one implanted considerable later than the other. The first β-hCG value seemingly did not represent the entire initial implementation events otherwise the value would be higher carrying the early signal of high-order multiple.
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