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IVF Pregnancy with a “Vanishing Twin”

by Dr. Geoffrey Sher on July 10, 2016

Today, in first world environments where there is ready access to advanced medical technology, many women undergo ultrasound diagnosis of pregnancy as early as 5-6 weeks after their last menstrual period. As a result, multiple pregnancies are often recognized very early on. Serial ultrasound follow-up examinations performed in such cases have shown that often times one of the developing babies subsequently “mysteriously” vanishes while the remaining, surviving conceptus (baby) proceeds to a healthy birth. Since most multiple gestations comprise of twin pregnancies, the term “vanishing twin” has emerged as the term to describe this situation. While in most cases the vanishing of a twin is associated with an innocuous small bleed, this is not invariably the case.In fact, in many cases the disappearance of the conceptus goes undetected without there being any bleeding or other symptoms at all.

The incidence of spontaneous pregnancies resulting in twin births is about 1:80. But what many fail to appreciate is that about one in 10 spontaneous pregnancies start off as twins but as the pregnancy advances into the 1st trimester and beyond, one twin will “vanish” (absorb) while the other will continue as a healthy, unaffected singleton. The incidence of multiple pregnancies increases in women with absent or dysfunctional ovulation, who takes fertility drugs. In fact the incidence of multiple pregnancies in such women under 35 years of age who are treated, treated with Clomiphene and Femara is about 1:20. In similar women using injectible gonadotropin fertility medications the incidence is about 1:4-5, while women (regardless of their ovulatory status) who receive fertility drugs in preparation for IVF (where multiple embryos are usually transferred), the current incidence is about 1:3 to 1:4.

When with a multiple pregnancy, the occurrence of painless mild bleeding is followed by ultrasound evidence that one is “absorbing” or “vanishing” often evokes understandable alarm raising several concerns and questions:

Q : Am I destined to lose both concepti and miscarry?

A: The bleeding results from the absorption of one of the pregnancies and since the vast majority of twin pregnancies have separate and independent placentas; the loss of one will accordingly usually not affect the remaining twin. As long as the bleeding remains mild and she does not experience an increase in cramping and pain over a period of a few days, the pregnancy will probably not be lost. In fact, in the majority of such cases, this is precisely what happens!

Q: How long will I continue to bleed?

A:In most cases unless the remaining conceptus is also abnormal and thus destined to miscarry, the bleeding will remain slight, painless, and will usually stop within a week or so. However, this will depend on when the one twin succumbed. If it occurred late in the first trimester the bleeding could last longer (even for a few weeks) than when the pregnancy is lost earlier. It should be borne in mind however, that the loss of one conceptus (the “vanishing twin”) might not be accompanied by any bleeding at all In effect they might absorbs the one twin without symptoms and with no outward indication of the loss.

Q. How will the loss of one twin affect the surviving one?

Answ: In the majority of cases, the other conceptus usually progresses, unaffected, onto a healthy birth.

Q: Will there be any residual evidence of the “vanished twin” detected at birth?

A: Usually not! Sometimes a small area of scarring or “thickening” of part of the placenta will be seen. However, this will usually only occur in cases where the one conceptus succumbed late in the first trimester (10-12 weeks) or in the 2nd trimester. In rare cases where a baby is lost later in pregnancy. It might not absorb completely and be expelled with birth of the surviving baby (“fetus papyraceus”).

Q: Could the “vanishing” of one twin have been prevented — Did I do something wrong?

Answ: The vanishing twin is neither parents fault. In most cases the conceptus twin is lost because it is chromosomally or genetically abnormal. Since many “vanishing twins” are lost very early in pregnancy, before most women would have undergone a diagnostic ultrasound, most cases go undetected and the woman would have no knowledge that she had been carrying more than one conceptus. In fact as stated above, many more of us begin life as twins than was previously thought.

“Vanishing” concepti can also occur in high order multiple pregnancies (triplets or greater). In such cases the pregnancy could reduce from triplets to twins or even a singleton or even from a higher number downward. Since the incidence of multiple pregnancy as well as high order multiples are most common after IVF where several embryos are often deliberately transferred to the uterus, the incidence of a conceptus “vanishing” is greatest with IVF.

Regardless of the genesis of multiple gestations, individuals and families who experience the “vanishing” of a conceptus will often experience anxiety and even panic when bleeding starts and a sense of relief when it finally and  they learn that the remaining conceptus and the pregnancy have survived. However, in most cases there will inevitably be an accompanying sense of profound loss, sadness and even grief, especially in cases where prior ultrasound examination had spelled the “promise” of a multiple birth.

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  • Eve - February 3, 2018 reply

    my first ultrasound at 5 weeks showed one sac, my second ultrasound at 5 weeks 6 days showed a second sac but MD stated its empty and called the sac a vanishing twin. Is there a possibility medically for the second sac to still grow and i have twins?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 3, 2018 reply

    5-6 weeks is a little early. I would advise repeating the US at 7 weeks.

    Geoff Sher

  • dan - August 4, 2017 reply

    We did IVF & are 10weeks pregant. There was vanishing twin. What are our options for testing for genetic disorders for the fetus that is progressing normally? I’ve read the blood work that would normally be done to test for genetic disorders can give a false positive result due to the vanishing twin. Thank you for any info you can provide.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - August 5, 2017 reply

    Blood work is quite good but in my opinion, CVS now or amniocentesis in a month or so is the way to go!

    Good luck and G-d bless!

    Geoff Sher

  • Betsy palmer - October 21, 2016 reply

    Hello
    I wonder if you can help me. It’s been confirmed that although I started with a twin pregnancy only one of the fetus had a heart beat ( the other one has a fetal pole and appears to have grown from 8mm to 12mm in the last week). The healthy fetus is the right size of 8 weeks 2 days. Is it more likely that the fetus will be absorbed by the body or that I will miscarry? Thank you

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 21, 2016 reply

    It is more likely that the healthy one will survive and develop appropriately.

    Geoff Sher

  • Tracie Futterman-Alvarez - July 29, 2016 reply

    Two things-Is it true that eggs go through a 3-4 month cycle so anything you change (Adding CoQ10, change in diet-more protein to gain weight, change in exercise, acupuncture, etc) will not affect egg quality if you are doing an IVF cycle that next month or two?
    I am 33, with normal AMH and FSH but had one IVF with only One normal blast and it didn’t implant, second IVF, high responder with 14 fertilized but no genetically normal blasts out of 5, and now doing a third IVF with 16 fertilized awaiting day 5 results then PGS results.
    How would you explain poor quality for my age and normal reserve/levels?
    Protocol for IVF 1 was a study, so only stimmed with menopur, then ganerlix, then HCG trigger
    Protocol for ivf 2 and 3 was gonal F/follistim with low dose HCG to stim then ganirelix, then lupron. trigger. This protocol for 2nd and 3rd time got me 17 mature eggs retrieved, then 20 mature retrieved.
    Thanks!!
    Tracie

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - July 29, 2016 reply

    I cannot be sure, but one of the common reasons relates to the protocol used for ovarian stimulation (see below). I would need a great deal more information to comment authoritatively.

    I strongly recommend that you visit http://www.DrGeoffreySherIVF.com. Then go to my Blog and access the “search bar”. Type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.
    • Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • The Fundamental Requirements For Achieving Optimal IVF Success
    • Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
    • Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
    • The “Biological Clock” and how it should Influence the Selection and Design of Ovarian Stimulation Protocols for IVF.
    • A Rational Basis for selecting Controlled Ovarian Stimulation (COS) protocols in women with Diminished Ovarian Reserve (DOR)
    • Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
    • Controlled Ovarian Stimulation (COS) in Older women and Women who have Diminished Ovarian Reserve (DOR): A Rational Basis for Selecting a Stimulation Protocol
    • Optimizing Response to Ovarian Stimulation in Women who Have Compromised Ovarian Response to Ovarian Stimulation in Women who Have Compromised Ovarian Reserve: A Personal Approach.
    • Human Growth Hormone Administration in IVF: Does it Enhances Egg/Embryo Quality and Outcome?
    • The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
    • Blastocyst Embryo Transfers Should be the Standard of Care in IVF
    • Why did my IVF Fail
    • Preimplantation Genetic Testing (PGS) in IVF: It Should be Used Selectively and NOT be Routine.
    • Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
    • PGS in IVF: Are Some Chromosomally abnormal Embryos Capable of Resulting in Normal Babies and Being Wrongly Discarded?
    • PGS and Assessment of Egg/Embryo “competency”: How Method, Timing and Methodology Could Affect Reliability
    • IVF Failure and Implantation Dysfunction:
    • The Role of Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 1-Background
    • Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 2- Making a Diagnosis
    • Immunologic Dysfunction (IID) & Infertility (IID):PART 3-Treatment
    • Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID)
    • Immunologic Implantation Dysfunction: Importance of Meticulous Evaluation and Strategic Management:(Case Report
    • Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID)
    • Intralipid (IL) Administration in IVF: It’s Composition; How it Works; Administration; Side-effects; Reactions and Precautions
    • Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
    • Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • Vaginally Administered Viagra is Often a Highly Effective Treatment to Help Thicken a Thin Uterine Lining
    • Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF
    • How Many Embryos should be transferred: A Critical Decision in IVF.
    • The Role of Nutritional Supplements in Preparing for IVF

    Please call or email Julie Dahan, my patient concierge. She will guide you on how to set up an in-person or Skype consultation with me. You can reach Julie at on her cell phone or via email at any time:
    Julie Dahan

  • Christine - July 26, 2016 reply

    Vanishing twin
    I can’t understand why I have lost one of my twins they said it wasn’t growing but never told me there wasn’t a heart beat I am having another scan in 3 weeks time but I am scared there going to say both have gone

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - July 27, 2016 reply

    Hopefully that will not be the case.

    Good luck!

    Geoff Sher

  • Aydde Hurtado - July 24, 2016 reply

    I has 2 5d frozen embryo transer done on 7/12/16 on 7/21 had my first beta hcg level of 11. On 7/33 my hcg level dropped to 4. My re and staff can only say it’s not a negative and we’ll see you on monday. Can you please explain what’s happening?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - July 24, 2016 reply

    Respectfully, this does not look promising Aydde,

    So sorry!

    Geoff Sher

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