A 27 year-old, para 3 lady and her husband presented to our clinic with a one year history of secondary infertility that was labelled as unexplained after confirming normal gonadotrophins levels, hysterosalpingogram, and advanced semen analysis. The couple declined diagnostic laparoscopy and chose to undergo treatment with intrauterine insemination (IUI) after they were counselled about their options of assisted reproductive techniques including IUI and IVF with and without ICSI, and their potential complications including the risk of multiple pregnancy and their potential consequences.
Ovarian stimulation was undertaken with gonadotrophin using a recombinant FSH product (Puregon; Organon, Oss, The Netherlands). The patient overresponded and had developed 13 follicles over the size of 15 mm on stimulation day 13. The couple was counselled to cancel the treatment cycle or switch to IVF provided an LH surge did not occur. The couple chose the latter and ovarian stimulation continued with a higher dose of the same recombinant FSH product after starting a GnRH antagonist (Cetrotide; Serono, Baxter Oncology, Germany). 
When most follicles were in the range of 17 to 22 mm, final oocyte maturation was completed with hCG (Choriomon; IPSA, Lugano, Switzerland). Thirty-six hours later, a vaginal ultrasound-guided oocyte collection was undertaken and a total of 23 oocytes were retrieved. After stripping of the surrounding cumulus oophorus from the oocytes in preparation for ICSI, the embryologist evaluated only 19 oocytes as being mature and each was inseminated by a single sperm. After 18 to 20 hours, 17 oocytes showed pronucleate development and were further evaluated on day 2 and day 3 after oocyte recovery. The remaining 2 unfertilized eggs were discarded.
On day 3, of the 17 embryos, 10 had developed to the 8-cell stage, one to the 7-cell stage, and 6 remained at 2-to-4-cell stage. After extensive counselling, the couple chose to have 3 embryos transferred back to the uterus, understanding the risk of multiple pregnancy and its potential consequences. Three very good quality 8-cell embryos (with grade 3.5 to 4 out of 4) were considered most appropriate for embryo transfer and this was undertaken later that day at around 72 hours after oocyte recovery. Embryo transfer was undertaken without difficulty using Sydney IVF embryo transfer catheter (Catalogue number K-JETS-6019-SIVF, Cook, Limerick, Ireland). The remaining 8 good quality embryos (seven 8-cell and one 7-cell embryos with grade 3 to 3.5 out of 4) underwent cryopreservation using vitrification technique.
On luteal day 18, the patient had a positive pregnancy test with a BhCG level of 747 IU/mL. An ultrasound was performed on luteal day 49, and four intrauterine sacs with embryos each measuring 7 to 10 mm were seen (appropriate for the equivalent gestational age). A normal heartbeat was noted in all embryos. Not surprisingly, the couple was shocked by this news but further discussion and counselling was carried out that day and repeated a week later outlining the possible causes of what have happened, the risks of high order multiple pregnancy, the possible treatment options open to them at that time including selective reduction, the supervision and management of the pregnancy should they choose to continue and the likely options and the gestational age at which delivery might occur. 
At 11 weeks of gestation, the couple was seen and underwent an ultrasound study that confirmed the viability of all four foetuses. Chorionicity was examined by looking at the intersac membranes and they appeared to be trichorionic quadramniotic pregnancy as the dividing membrane between two of the foetuses showed a "T" sign as opposed to a "lambda" sign that was seen in the other dividing membranes between the foetuses. This was expected as it was the most likely explanation for the transformation of those 3 embryos to 4 foetuses. The couple was counselled again about all potential complications of such kind of pregnancy and they were also counselled about the pros and cons and controversies of cervical cerclage and nuchal translucency measurement in high-order multiple pregnancies. They chose not to undergo nuchal translucency measurement as they made up their mind that they will continue this pregnancy no matter what the outcome is. The couple chose to have a cervical cerclage only if all four foetuses remained alive in 2 weeks. At 13 weeks of gestation, and after confirming viability of the 4 foetuses, McDonald cervical cerclage was carried out with no complications. 
The patient was seen every 2 weeks starting at 15 weeks of gestation to rule out the early development of TTTS. A detailed morphology exam (level II ultrasound) showed normal 4 foetuses at 19 weeks of gestation with no major anomalies seen in any of them. At 26 of gestation, the patient had some uterine irritability and two doses of 12 mg betamethasone were given a day a part. Three weeks later, gestational diabetes was ruled out and biophysical profile (BPP) as well as end-diastolic-flow umbilical artery Doppler (EDF-UAD) were started at around 29 weeks of gestation and repeated every 2 weeks. 
At around 33 weeks of gestation, one of the monochorionic foetuses was relatively smaller than the others, with parameters consistent with intrauterine growth restriction (IUGR); however it remained to have normal and concordant amniotic fluid and EDF-UAD. Foetal assessment started to be done on weekly bases in the form of amniotic fluid assessment and EDF-UAD. At 35 weeks and 2 days of gestation, the small foetus remaind to be IUGR, however all four foetuses showed normal interval growth, amniotic fluid, and EDF-UAD. A week later, the patient was found to have a mildly elevated blood pressure (around 142/90 mmHg), but no proteinuria. She was asymptomatic and her investigations including those for HELLP syndrome were normal. Amniotic fluid assessment as well as EDF-UAD of all foetuses continued to be normal with exception to the small foetus that started to have intermittent absent end diastolic flow. 
Given the excellent gestational age reached and the development of those multiple mild complications, delivery was advised and was undertaken by semielective caesarean section the following day at a gestational age of 36 weeks and 3 days. At this, she delivered four healthy infants, three girls and one boy. Their weights were 1785, 1890 grams (gm), for the monochorionic twin, and 2035 and 2225 gm for the other girl and boy, respectively. The APGAR scores at 1 and 5 minutes were 8 and 9, respectively, for all four infants. All four infants were admitted to the Neonatal Intensive Care unit (NICU) for monitoring only. Four hours later, 2 infants were discharged to the normal nursery including the smallest one. The other two were on nasal oxygen cannula (blended oxygen) as they had Transient Tachypnea of Newborn (TTN), but both were discharged to the normal nursery in less than 24 hours. Pathological examination of the placentae confirmed the zygosity of trichorionic quadramniotic quadruplet. All four babies were discharged home with their mother on post-operative day 3. The babies were seen at 2 and 6 months of age for their scheduled immunization shot. All babies were well and with developmental assessment corresponding to their age. Permission was sought and obtained from the couple to publish this report.