Background: Radiofrequency ablation (RFA) is considered as an optional treatment method in complicated monochorionic (MC) twin pregnancies. The purpose of this study is to investigate the main factors of fetal death after such treatment procedure. The study also compares the perinatal outcomes among various groups of indication and gestational age (GA) at procedure. Materials and Methods: This prospective cohort study considers 195 cases of MC multiple pregnancies including one twin with twin-twin transfusion syndrome, selective intrauterine growth restriction, sever anomaly and twin reversed arterial perfusion sequence(TRAP) which underwent selected reduction using RFA from 2016 to 2018 at Yas Hospital, Tehran, Iran. The GA at RFA categorized as 16-19+6 wks., 20-23+6 wks., and 24-28 wks. The analysis of risk factors of fetal death after RFA is based on multivariable logistic regression model. Results: The result of analysis reveals that the rate of co-twin anemia after RFA in anomaly indication was higher than the other indications significantly (p=0. 038) while according to GA categories, it is significantly lower in 20-23+6 weeks. (p=0. 016). Three independent significant factors contributing in fetal death after RFA were co-twin anemia after RFA, TRAP and anomaly indications of RFA and GA at RFA, respectively. Conclusion: The co-twin anemia after RFA was found the most contributing factor of fetal death. As the results showed that the rate of co-twin anemia after RFA is significantly low in 20-23+6 weeks of GA, such GA is suggested for RFA procedure to reduce the fetal death.

Background: Selective reduction of the fetus is one of the therapeutic methods in complicated monochorionic twins. The present study aimed to investigate the success rate and perinatal outcomes of selective reduction using radiofrequency ablation (RFA) in monochorionic multiple pregnancies with a hydropic fetus. Methods: This prospective interventional single-arm study was conducted in a referral hospital from 2017 to 2019. Totally, 27 complicated monochorionic twin and triplet pregnancies underwent RFA to occlude the umbilical vein of the hydropic fetus. The participants were followed until 2 months post-delivery. Procedure success rate, survival rate, gestational age at delivery, and neonatal outcome were evaluated. Results: The umbilical cord in 26 (96. 2%) cases was successfully occluded by RFA with no maternal complications. Live birth was within 75%. The mean ± SD age at delivery was 34. 4 ± 3. 83 weeks. The gestational age at delivery in TTTS (twin-to-twin transfusion syndrome)-induced hydrops was significantly lower than the non-TTTS hydrops group (P = 0. 003). Four cases experienced preterm premature rupture of the membranes (PPROM) before 34 weeks. Of all viable neonates, 8 cases were admitted to the neonatal intensive care unit (NICU). In 2 months follow-up post-delivery, all neonates had normal findings without any adverse outcomes. Conclusion: Selective reduction by RFA in complicated monochorionic pregnancies with a hydropic fetus may be a safe method with a high success rate and 100% neonatal survival. This method may be optimal for feticide in non-TTTS hydropic twins.

Background: Twin pregnancies have a higher risk of preterm labor than singletons. Otherwise, progesterone using to reduce the risk of preterm labor in twin pregnancies remains controversial. Therefore, this study evaluated the effect of intramuscular progesterone to prevent preterm labor in complicated monochorionic diamniotic twin pregnancies after Radiofrequency Ablation (RFA) of one fetus. Methods: Pregnant women with monochorionic diamniotic twin pregnancies of 16 to 26 weeks of gestational age in an academic center were randomly assigned to receive intramuscular 17-hydroxy progesterone caproate weekly until 36 weeks of gestational age after RFA of one fetus and a control group who did not receive intervention after RFA. Demographic and obstetrical characteristics, as well as maternal, fetal and neonatal outcomes were compared between groups. Results: In total, 79 participants were recruited in the study. The mean±SD of gestational age at delivery in case and control groups were 34. 6±3. 8 and 34. 6±5. 1 with no significant difference (p=0. 967). Neonatal outcomes including birth weight (p=0. 870), intensive care unit admission (p=0. 415), premature preterm rupture of membrane (p=0. 115) and pregnancy outcome (live birth, fetal demise or neonatal death) (p=0. 524) were not different either. Indeed, gestational age at delivery was inversely related to cervical length at the time of procedure and maternal body mass index, but these differences were not statistically significant. Also, there was no significant difference in terms of gestational diabetes, which was a worrying complication of 17-hydroxy progesterone caproate. Conclusion: Although 17-hydroxy progesterone caproate seems to be safe with no apparent maternal and neonatal side effects, it does not prolong pregnancy after RFA. Further studies with longer follow up and larger sample size are suggested.

Objectives: This study aimed to investigate the effect of assisted reproductive technology (ART) on both maternal and neonatal outcomes in monochorionic (MC) and dichorionic (DC) twin pregnancies. Methods: This retrospective cohort study was conducted on women with twin pregnancies who delivered at Hafez and Hazrat Zeinab hospitals (affiliated to the Shiraz University of Medical Sciences) from March 2013 to May 2018. Results: In this study, 651 twin pregnancies (122 MC and 529 DC) were analyzed. Among MC twin pregnancies, the adverse maternal and neonatal outcomes were similar between the ART and the spontaneous pregnancies, except for lower 1-minute and 5-minute Apgar scores (5. 3 vs. 7. 2; P = 0. 036 and 6. 4 vs. 8. 5; P = 0. 039, respectively) and a higher fetal death rate in ART group (19% vs. 3. 5%, P = 0. 001). Among the DC twin pregnancies, the risks for pregnancy-related hypertensive disorders, gestational diabetes mellitus, emergency cesarean section and antenatal corticosteroid exposure significantly increased in the ART group (P < 0. 001, P = 0. 002, P = 0. 014, and P = 0. 001, respectively). Furthermore, DC twins showed significantly higher rates of deliveries before the 34 weeks of gestation (44. 8% vs. 31. 0%, P = 0. 002), extremely low birth weight (11. 9% vs. 4. 0%, P < 0. 001), intrauterine fetal growth restriction (29. 3% vs. 13. 5%, P < 0. 001), lower 1-minute (P = 0. 009 for fetus A and P = 0. 003 for fetus B, respectively) and 5-minute (P < 0. 001 for fetus A and P < 0. 001 for fetus B, respectively) Apgar scores, perinatal mortality (14. 4% vs. 6. 9%, P < 0. 001) and congenital anomaly (8. 3% vs. 2. 3%, P = 0. 001) after ART treatment. These results were confirmed by multivariate analysis after adjusting for the baseline variables. Conclusions: Despite the controversial perinatal outcomes in the literature, we found that ART is associated with an increased risk of perinatal morbidity and mortality, particularly in DC twin pregnancies. Therefore, ART twin pregnancies management requires closer surveillance and advanced facilities at tertiary care centers.

By the means of assisted reproductive technologies (ART), such as in vitro fertilization (IVF) and intracyctoplasmic sperm injection techniques (ICSI), more than one million infants have been born throughout the world. One of the interesting happenings in infertility treatment procedures, that needs to be addressed, is the occurrence of multiple pregnancies which is usually seen following the use of ovary stimulating medications, embryo hatching and transference of a high number of embryos for higher success rates. For reducing the chances of this problem and preventing subsequent complications during pregnancy, embryo reduction is employed for two purposes: 1. Embryo reduction in triple or higher pregnancies, for the prevention of fetal and maternal complications and 2. Selective embryo reduction in cases where one or more fetuses have malformations or chromosomal defects. Embryo reduction methods: Dilatation of cervix and suction of one or more fetuses, via transvaginal route, by the help of sonography and transabdominally by the use of sonography. Although medical doctors might not be eager enough to know about embryo reduction in multiple pregnancies, but they have to know about the procedures and be prepared for medical interventions in emergencies, based on ethical and legal principles or on the request of patients. The first step, especially in infertility clinics, is reducing the chances or preventing the occurrence of these instances. Although selective reduction of embryos is ethically and legally accepted, but before any moves taken, offering infertility counseling is essential and it should include the expression of the risks of multiple pregnancies and ethical issues in embryo reduction before the transference of embryo(s) to the uterus, as lack of information on these subjects may lead to more problems afterwards. This study reviews the medical and ethical aspects of the issue and also introduces embryo reduction techniques in multiple pregnancies,in methods employing ovarian stimulating medications and in in vitro fertilization techniques. This method of embryo reduction, will reduce the risks of abortion, premature births, birth of malformed children and fetal demise,otherwise these would be the case if measures are not taken to correct the problem.

In Multipregnancies, The careful control of Number of follicles in stimulation cycles and Number of embryos transferred in ART cycles is so important. Just twin pregnancies are reason for racial death (12- 15%).The risk for CP in twin pregnancies is 8 times more and for Triple is 47 times more than simple ones. Approximately all prenatal problems increase in multiple pregnancies and therefore this kind of pregnancies are considered high risk pregnancies. One of the most issues in prenatal care in Multiple pregnancies is to detect the number of corions that its best detective time is in first trimester by about 100% accuracy. mono Corion pregnancies have more danger for Newborns for example 5 times increase in loss of fetus, 10 times increase in Low birth weight. Mono Corion twin Consequences are as follow: Imbalanced Blood transfer between two fetus, mono amnions twin, death of one fetus in uterus (IUFD), TRAP twins and sucked twins.

Background: Monochorionic diamniotic ,(MCDA) twin pregnancies are considered high‑, risk for several reasons, especially the risk of twin‑, to‑, twin transfusion syndrome ,(TTTS). Renal artery Doppler ,(RAD) is reported as a useful tool for predicting oligohydramnios in singleton pregnancies. We aimed to compare the RAD indices between MCDA twins with and without TTTS. Materials and Methods: In this case–, control study, all pregnant women aged 18–, 38 , years, with gestational age , ≥,  , 18 , weeks, who were referred to two Prenatal Clinics, Alzahra and Beheshti Educational Hospitals, affiliated to Isfahan University of Medical Sciences, Isfahan, Iran, October 2020–, March 2022 were enrolled,the women with MCDA twin pregnancies complicated by TTTS , (case group, n , = , 12) and without TTTS , (control group, n , = , 24). For each twin, biometric analysis, fetal weight, and Doppler study of fetal arteries, including RAD, middle cerebral artery , (MCA), umbilical artery, and ductus venosus were performed. Peak systolic velocity, Pulsatility index , (PI), resistance index , (RI), and systole/diastole , (S/D) were measured for all arteries. Results: The donors of the case group had a lower mean MCA S/D , (4. 48 , ±,  , 1. 89) than the control group , (6. 48 , ±,  , 1. 97) , (P , = , 0. 01) and higher mean umbilical parameters, including PI, RI, and S/D , (P , < , 0. 05). The recipients of the case group had a lower mean renal PI than the control , (P , = , 0. 008) and lower mean MCA PI, RI, and S/D , (P , < , 0. 05). The donor group had a higher mean umbilical RI and S/D than the recipient twin, while the mean fetal weight of the recipient group was higher , (P , < , 0. 05). Conclusion: Comparing the RAD parameters between the twins with and without TTTS in the present study did not identify significant results, which rejected the primary hypothesis. Among all RAD parameters, the only significant difference observed in the present study was the lower RAD PI in RT, which cannot suggest this measurement as a valuable tool for the prediction of TTTS in MCDA twins. Therefore, the results of the present study failed to show the additional value of RAD, compared with the conventional Doppler examination of fetal arteries. Further studies are required to prove this conclusion.

Background: Microwave ablation (MWA) is a newly introduced technique for selective fetal reduction in complicated monochorionic (MC) pregnancies. This study aimed to describe maternal and neonatal outcomes after implementing MWA for selective fetal reduction in complicated MC pregnancies and analyze the procedure’s success rate. Methods: This is a case series of 21 complicated MC pregnancies that underwent MWA in the Fetal-Maternal Center affiliated with Shiraz University of Medical Sciences (Shiraz, Iran) to occlude fetal blood circulation from May 2021 to May 2022. The participants were followed until delivery. Gestational age at the time of the procedure, duration of the procedure, survival rate, procedure-to-delivery time, gestational age at delivery, as well as maternal and neonatal outcomes were evaluated. Results: MWA was successfully performed in all 21 cases. The median (Q1-Q3) gestational age at the time of the procedure was 18 weeks. The fetus’s blood circulation was completely stopped in all cases. The median (Q1-Q3) total ablation time was 4 (3-6) min, and the total ablation voltage was 100 (100-200) W. Fetal loss occurred in 19% (4/21) of cases after MWA. The duration of the surgery showed a significant negative correlation with the surgical outcome (P=0. 012). The overall procedure-to-delivery time was 16 (14. 5-19. 5) weeks, with a survival rate of 81%. The median gestational age at delivery was 34 (30. 5-37. 5) weeks. Among the babies, 70. 6% required admission to the neonatal intensive care unit,however, all survived the neonatal period. No maternal complications were observed. Conclusion: MWA represents a potentially effective alternative modality for selective fetal reduction in complicated MC twin pregnancies. As a newly introduced technique, it is still in its early stages of implementation, and there is a need for reporting and discussing the specific details of its application.

Over the past 25 years the rate of twin and higher - order multifetal birth have increased between 1980 and 2005. The twining rate rose from 18.9 to 32.1 per 1000 live birth.Multifetal gestations are at high risk of fetaland complication such as; growth restricted fetal death, LBW and cerebral palasy. Maternal complications are that also increased such as: preeclampsia, diabetes, maternal death and PROM.Multiple pregnancies are characterized by a significantly higher fetal morbidity and mortality than singleton pregnancies. This places them in the category of high risk pregnancies. Ultrasound Is crucial for the diagnosis of twin. Sonography allows determination of zygosity, chorionicity, amnionicity, placental location, and fetal presentation and the detection of complications such as growth discrepancy, amniotic fluid volum imbalance.Etiology of multifetal gestations:1. Fertilization of two or more oocytes (in two - third of cases)2. Early embryonic splitting of single ovum (in one - third of cases).The role of ultrasound in first trimester:1. Detection of all sac2. Detection of viable embryo in each sac3. Size comparision of embryos (CRL)4. Detection of a vanishing twin5. Determination of chorionicity and amniocity:precise determination of zygocity and chorionicity is the most important step for management of multipie pregnancies6. Early detection of anomaly.The role of ultrasound in second and third trimesters:1. Biometry2. Detection of anomalies3. Invasive testing as indicated4. Amniotic fluid volumes5. Detection of twin-twin transfusion syndrome6. Doppler examinations7. Fetal lie8. Placental location.