Live Sextuplet Birth After Ovulation Induction in a Patient With Secondary Infertility: A Case Report

High-order multiple pregnancy is an unusual but serious complication of ovulation induction and is associated with significant maternal, fetal, and neonatal risks. While ovulation induction has been commonly used in the management of unexplained infertility, multifetal gestation remains an important iatrogenic outcome despite careful monitoring. In this article, we report a rare case of high-order multiple pregnancy following the induction of clomiphene citrate in a woman with unexplained secondary infertility. A 30-year-old para 1 female patient (eight years long) presented to Tadawi Medical Hospital, Khamis Mushait, Saudi Arabia, seeking pregnancy for secondary infertility. An infertility study confirmed normal hormonal status, bilateral tubal patency on hysterosalpingography, and normal semen analysis of her husband, and a diagnosis of unexplained secondary infertility was made. At the start of the stage, she underwent routine cycle monitoring using timing for intercourse and received folic acid, vitamins, and L-arginine. Induction of ovulation was accomplished by clomiphene citrate 50 mg daily for five days. On day 12, she had mild ovarian hyperstimulation, managed lightly. Initial early pregnancy evaluation showed markedly increased beta-human chorionic gonadotropin levels. Ultrasound revealed five gestational sacs that each harbored a viable fetal pole, pointing towards high-order multifetal gestation. The patient received close antenatal follow-up every two weeks. Fetal reduction was recommended due to the high maternal and perinatal risks; however, she declined. Cervical cerclage at 14 weeks gestation with Mersilene was performed because of the increased risk of cervical insufficiency. She was kept on progesterone support and was placed on dexamethasone for fetal lung maturation at 24 weeks. Serial ultrasounds revealed continuous viability of all fetuses and no gross structural anomalies. Although elective delivery was planned at 30-32 weeks, she developed preterm labor at 28 weeks and underwent cesarean section. Each neonate was born alive and placed in the neonatal intensive care unit for approximately five weeks. A rare situation with an extremely serious management challenge of high-order multiple pregnancy, including the complications post-ovulation induction and management challenges that this case presents. To facilitate these outcomes, it is critical that intensive monitoring, timely intervention, complex management, multidisciplinary effort, as well as neonatal support occur.