Successful Twin Pregnancy Through ICSI in a 29-Year-Old with Four Failed IUIs, an Arcuate Uterus, and Recurrent Pregnancy Bleeding

A 29-year-old woman married for 10 years came to Dr. Mohit Saraogi at Saraogi Hospital & IRIS IVF Centre, Mumbai in April 2025 after four failed IUI cycles, along with multiple rounds of follicular monitoring and several natural cycles. Evaluation showed she was largely healthy with a slightly reduced egg count, while a hysteroscopy later revealed an arcuate uterus. As an experienced ivf doctor in mumbai, Dr. Mohit Saraogi managed the case with ICSI, a corrective metroplasty, and a fresh Day-5 transfer of two grade B blastocysts. The very first transfer succeeded, resulting in twins. Despite relentless bleeding episodes and a large intrauterine hematoma throughout the pregnancy, the patient was managed conservatively with tocolysis, immunosuppressants, and a cervical cerclage, and went on to deliver healthy term twins, one boy and one girl, each weighing 2 kg.

An arcuate uterus is a mild congenital anomaly in which the top (fundus) of the uterine cavity is slightly indented inward rather than smoothly curved. While it is one of the milder uterine variations, it can still affect where and how an embryo implants and, in some cases, contribute to bleeding and pregnancy loss. In this patient, the arcuate cavity was identified on hysteroscopy and corrected with a minor metroplasty before embryo transfer. The illustration below compares a typical uterine cavity with the arcuate cavity seen in this case.

• Ovarian stimulation started with injectable medication and tracked through follicular monitoring
• Egg retrieval performed; a reasonable number of eggs collected, though egg quality was suboptimal
• Eggs fertilised with the husband’s sperm using ICSI
• Embryos cultured to day 5; growth was slow, yielding two grade B blastocysts
• Diagnostic hysteroscopy performed, revealing an arcuate uterus; a slight metroplasty was done to correct the cavity
• Fresh Day-5 embryo transfer of the two grade B blastocysts performed
• Pregnancy confirmed on the first transfer; twin gestation identified on early scan
• First bleeding episode at 5 to 6 weeks; patient admitted, bleeding controlled with tocolysis and immunosuppressants, and the pregnancy maintained
• Three days later, a heavy bleeding episode with large clots; ultrasound remained normal with both fetal heartbeats present
• A large intrauterine hematoma measuring 5 by 5 cm developed from the repeated bleeding
• A third bleeding episode within a span of 10 days required readmission; the heartbeat remained strong
• At 9 weeks, clots of 4 by 4 cm and 2 by 2 cm were noted behind both babies; bleeding continued but fetal heart rates stayed normal
• Bleeding episodes persisted through 12 weeks, likely related to a weak uterine lining and the lower grade of the embryos
• At 15 weeks, further bleeding occurred and the hematoma increased to around 6 cm; managed conservatively and successfully
• A cervical cerclage (stitch) was placed, along with continued immunosuppressant therapy, to support the pregnancy
• After the cerclage, the patient had only one further bleeding episode, and by 18 weeks the bleeding stopped completely
• The patient delivered healthy twin babies at term, one boy and one girl, each weighing approximately 2 kg

Feedback recorded after the twin delivery at Saraogi Hospital, Mumbai.

• Luteal-phase hormonal support continued after the embryo transfer
• Immunosuppressant therapy maintained to support implantation and reduce the risk of pregnancy loss
• Strict rest advised after the cervical cerclage placement
• Regular monitoring for bleeding episodes and abdominal pain throughout the pregnancy
• Tocolytic therapy administered during bleeding episodes to help maintain the pregnancy
• Serial ultrasound monitoring of both fetal heartbeats and the intrauterine hematoma
• Frequent antenatal visits, with closer monitoring during high-risk phases
• Mother counselled and supported emotionally throughout the high-risk pregnancy
• Both babies delivered healthy at term, with no major neonatal intervention required

DISCLAIMER: This case study is for informational purposes only and does not constitute medical advice. Individual results may vary. Consult a qualified fertility specialist before undergoing any procedure. Patient feedback published with written consent. Patient identity withheld per confidentiality guidelines.