the field of assisted reproduction has been a witness to emerging new trends in laboratory techniques since the past two decades . one such arena is preimplantation genetic screening ( pgs ) of embryos . as opposed to genetic diagnosis , which is more specialized and restrictive , simple screening of embryos for chromosomal normalcy is more applicable in conventional clinical practice as a means to significantly improve pregnancy rates in assisted reproductive technology ( art ) programs . it has been well - documented that at least 60% of embryos generated by various laboratory procedures used in conventional in vitro fertilization ( ivf ) protocols are chromosomally incompetent . the errors leading to numerical abnormalities in these embryos are responsible for the current success rates in art . we herewith present a case report where the use of this technique resulted in a successful viable twin birth . the patient was a 28-year - old when she first sought consultation with us in january 2012 , after 1 year and 4 months of marriage . she had married her cousin ( iii consanguinity ) and had regular menstrual cycles but infrequent intercourse owing to vaginismus . her husband 's semen parameters were normal and her hormonal evaluation revealed a high day 2 luteinizing hormone ( lh ) value ( > 8 ) in consecutive cycles . a diagnostic hysterolaparoscopy was performed which revealed a posterior wall fibroid ( < 2 cm ) patent tubes and normal appearing ovaries . she underwent a fenton 's repair in the same sitting and was allowed a period of 6 months to conceive using mild ovarian stimulation with clomiphene and timed intercourse . her hormonal evaluation was done and found to be normal except for a high lh . she was initiated for the long protocol in may 2013 , using injection zoladex 3.6 mg subcutaneously on day 20 ( astrazeneca , london , uk ) for downregulation and gonal - f ( merck serono , india ) with luveris ( merck serono , india ) for ovarian hyperstimulation . nineteen oocytes were obtained of which 11 fertilized and 9 embryos were viable for transfer and freezing . five embryos were frozen , whereas 4 were used for sequential transfer , 2 ( 68 cells ) grade ii on day 3 , and one expanded blastocyst ( iii ) on day 5 . she conceived in this cycle , but it resulted in a preclinical pregnancy . a menstrual regulation was performed in june 2013 . the couple went on a break until august 2013 when they returned for the frozen embryo transfer ( fet ) . she was placed on hormone replacement therapy and had a fet performed on october 7 , 2013 . the chorionic villi obtained by dilatation and curettage were sent for karyotyping , and it revealed trisomy . the cytogeneticist revealed the karyotype of the husband to be normal male with pericentric inversion of chromosome 9 ( 46 , xy , inv ( 9 ) ( p11q13 ) ) . although found in 11.65% of the population , it has been associated with spermatogenic disturbances in men with infertility by the presence of loops or acentric fragments formed during meiosis . this time , they were counseled regarding pgs of embryos along with their conventional art program , and they gave their consent for the same . in march 2014 , she was once again initiated with the long protocol , using injection zoladex ( astrazeneca , london , uk ) for downregulation and recagon ( organon india pvt . ltd . , india ) and human menopausal gonadotropins ( lg life sciences , india ) for ovarian hyperstimulation . we retrieved 22 oocytes by transvaginal aspiration , of which 17 were fertilized using intracytoplasmic sperm injection . fifteen embryos cleaved of which we performed biopsy on 10 of them , which were at least 68 cells or more in cleavage stage on day 3 . out of 10 biopsied embryos [ figures 1 and 2 ] , 5 were normal embryos , 2 were complex abnormal , 1 was an abnormal embryo ( 7 , 9 ) , and 2 had no dna detected in them . only 2 of the 5 normal embryos developed into hatching blastocysts while the rest were arrested . no blastocysts were generated from the remaining biopsied embryos with a blastocyst formation rate of only 20% . the two normal blastocysts [ figures 3 and 4 ] were transferred to the patient on day 5 . her serum beta human chorionic gonadotropin done on the 11 day and 13 day was 427.9 miu / ml and 791.6 miu / ml , respectively . an ultrasound on 38 day revealed a twin intrauterine gestational sac with fetal heart pulsations . she had a prophylactic cervical cerclage on june 30 , 2014 , at 1415 weeks of pregnancy . her level ii antenatal screening at 22 weeks was normal and her antenatal period was also uneventful . she delivered a healthy male and female baby weighing 2.19 kg and 2.26 kg , respectively [ figure 5 ] . we have been performing biopsies since october 2013 for pgs and were very restricted to offering it for patients , selecting only those with repeated failures in art or those with karyotype variations or abnormalities . however , this year , we extended to all affordable patients who would benefit within the first attempt itself to a greater extent than conventional art . since then , we have done 75 cases where 740 embryos were generated . of these the most common errors were complex abnormalities ( multiple chromosomal errors were detected in a single embryo ) . the subsequent miscarriage rate and take home baby rates posttransfer of normal blasts were 26.6% and 73.4% , respectively . more so , it is important to recognize that abnormal embryos do have a blastocyst conversion rate as follows , 40% for trisomy , 21% for polyploidy , and 0% for haploid / monosomic . it is also interesting to note that aneuploidies during the cleavage stage affect the chromosomes 15 , 16 , 21 , and 22 the most and x or y the least . trisomic and monosomic ( aneuploid ) embryos account for at least 10% of pregnancies and for women at advanced age , the incidence may exceed 50% . it becomes imperative to detect these in cases of assisted reproduction when performed for women in older age group who wish to try their own gametes . there is a degree of mosaicism ( 90% normal and 10% abnormal ) , one can expect in embryos which hamper the efficacy and accuracy of pgs . when a report is normal , it means that all nuclei are normal except for 10% which may be tetraploidy . qi et al . reported that 15.6% of blastocyst and embryos biopsied from women with advanced age group were euploid , whereas 84.4% were aneuploid . we are associated with two different laboratories that provide us with array comparative genomic hybridization ( cgh ) and next - generation sequencing ( ngs ) , respectively . although the former has a 99.8% concordance with the latter , ngs is fast emerging as an efficient diagnostic tool . array cgh has enough studies to back its efficacy while ngs although comparable , needs more numbers of cases for validation . the success of pgs is highly dependent on technical competence , embryo culture , and quality and also the presence of mosaicism in preimplantation embryos . in this particular case , the low generation of blastocyst could be due to her antecedent clinical history , but in general as discussed earlier the blastocyst formation rates are much higher in biopsied normal embryos .
we report the first documented successful birth of twins following preimplantation genetic screening ( pgs ) of cleavage stage embryos by array comparative genomic hybridization ( cgh ) technology , in south india . 
 the case was a 28-year - old woman with the previous history of preclinical pregnancy and a miscarriage in two attempted in vitro fertilization cycles . 
 day 3 cleavage stage embryos were generated by conventional long protocol with the use of a gonadotropin - releasing hormone analog and a combination of recombinant folliculotropins and human menopausal gonadotropins . 
 intracytoplasmic sperm injection of oocytes thus obtained was performed , and 10 selected embryos underwent pgs using the array cgh technique . 
 two normal blastocysts were transferred to the patient , and she conceived twins . 
 she delivered at 35 weeks of gestation by elective cesarean on november 19 , 2014 . 
 she delivered a healthy male and female baby weighing 2.19 kg and 2.26 kg , respectively . 
 postnatal evaluation of babies was also normal , and the hospital course was uneventful . 
 pgs has a definitive indication in assisted reproductive technology programs and can be utilized to improve pregnancy rates significantly .