Donald School Journal of Ultrasound in Obstetrics and Gynecology

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VOLUME 15 , ISSUE 2 ( April-June, 2021 ) > List of Articles


Vanishing Twin Syndrome

Maria Carla Monni, Ambra Iuculano, Cristina Peddes, Giovanni Monni

Keywords : First trimester, Multiple pregnancy, Ultrasound, Vanishing twin syndrome

Citation Information : Monni MC, Iuculano A, Peddes C, Monni G. Vanishing Twin Syndrome. Donald School J Ultrasound Obstet Gynecol 2021; 15 (2):134-142.

DOI: 10.5005/jp-journals-10009-1693

License: CC BY-NC 4.0

Published Online: 02-07-2021

Copyright Statement:  Copyright © 2021; Jaypee Brothers Medical Publishers (P) Ltd.


The vanishing twin syndrome (VTS) is defined as a spontaneous demise of one twin or one gestational twin sac in a multiple pregnancy in the first trimester. The incidence of VTS is increased in assisted reproduction techniques (ART) pregnancies, fundamentally due to the increased twin pregnancy rate rather than ART per se. Vanishing twin syndrome seems to be associated with adverse outcomes affecting the remaining survivor both in spontaneously conceived pregnancies and ART pregnancies. Vanishing twin syndrome can influence the measurement of invasive and noninvasive screening techniques. Conclusion: To date, the evidence of the short and long-term effects of VTS on the surviving fetus is discordant. We can reduce its incidence by correcting some predisposing factors. Early detection of VTS and meticulous ultrasound monitoring of the alive twin for the entire pregnancy is mandatory to identify possible adverse obstetric outcomes.

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  1. Levi S. Ultrasonic assessment of the high rate of human multiple pregnancy in the first trimester. J Clin Ultrasound 1976;4(1):3–5. DOI: 10.1002/jcu.1870040104.
  2. La Sala GB, Villani MT, Nicoli A, et al. Effect of the mode of assisted reproductive technology conception on obstetric outcomes for survivors of the vanishing twin syndrome. Fertil Steril 2006;86(1):247–249. DOI: 10.1016/j.fertnstert.2005.11.073.
  3. Sun L, Jiang LX, Chen HZ. Obstetric outcome of vanishing twins syndrome: a systematic review and meta-analysis. Arch Gynecol Obstet 2017;295(3):559–567. DOI: 10.1007/s00404-017-4289-9.
  4. Landy HJ, Keith L. The vanishing twin: a review. Hum Reprod Update 1998;4(2):177–183. DOI: 10.1093/humupd/4.2.177.
  5. Patrizio P, Bianchi V, Lalioti MD, et al. High rate of biological loss in assisted reproduction: it is in the seed, not in the soil. Reprod Biomed Online 2007;14(1):92–95. DOI: 10.1016/s1472-6483(10)60769-9.
  6. Barton SE, Missmer SA, Hornstein MD. Twin pregnancies with a ‘vanished’ embryo: a higher risk multiple gestation group? Hum Reprod 2011;26(10):2750–2753. DOI: 10.1093/humrep/der221.
  7. Greenwold N, Jauniaux E. Collection of villous tissue under ultrasound guidance to improve the cytogenetic study of early pregnancy failure. Hum Reprod 2002;17(2):452–456. DOI: 10.1093/humrep/17.2.452.
  8. Jauniaux E, Van Oppenraaij RH, Burton GJ. Obstetric outcome after early placental complications. Curr Opin Obstet Gynecol 2010;22(6):452–457. DOI: 10.1097/GCO.0b013e3283404e44.
  9. Oloyede OA, Iketubosin F, Bamgbopa K. Spontaneous foetal reduction and early pregnancy complications in multiple pregnancies following in vitro fertilisation. Int J Gynaecol Obstet 2012;119(1):57–60. DOI: 10.1016/j.ijgo.2012.05.021.
  10. Pinborg A, Wennerholm UB, Romundstad LB, et al. Why do singletons conceived after assisted reproduction technology have adverse perinatal outcome? Systematic review and meta-analysis. Hum Reprod Update 2013;19(2):87–104. DOI: 10.1093/humupd/dms044.
  11. Rizzo G, Capponi A, Pietrolucci ME, et al. First trimester placental volume and three dimensional power doppler ultrasonography in type I diabetic pregnancies. Prenat Diagn 2012;32(5):480–484. DOI: 10.1002/pd.3848.
  12. Loeken MR. Advances in understanding the molecular causes of diabetes induced birth defects. J Soc Gynecol Investig 2006;13(1):2–10. DOI: 10.1016/j.jsgi.2005.09.007.
  13. De Sutter O, Bontinck J, Schutysers V, et al. First trimester bleeding and pregnancy outcome in singletons after assisted reproduction. Hum Reprod 2006;21(7):1907–1911. DOI: 10.1093/humrep/del054.
  14. Jauniaux E, Elkazen N, Leroy F, et al. Clinical and morphological aspects of the vanishing twin phenomenon. Obstet Gynecol 1988;72(4):577–581.
  15. Magnus MC, Ghaderi S, Morken NH, et al. Vanishing twin syndrome among ART singletons and pregnancy outcomes. Hum Reprod 2017;32(11):2298–2304. DOI: 10.1093/humrep/dex277.
  16. Depp R, Macones GA, Rosenn MF, et al. Multifoetal pregnancy reduction: evaluation of foetal growth in the remaining twins. Am J Obstet Gynecol 1996;174(4):1233–1238. DOI: 10.1016/s0002-9378(96)70666-x.
  17. Sampson A, de Crespigny LC. Vanishing twins: the frequency of spontaneous foetal reduction of a twin pregnancy. Ultrasound Obstet Gynecol 1992;2(2):107–109. DOI: 10.1046/j.1469-0705.1992.02020107.x.
  18. Gjerris AC, Tabor A, Loft A, et al. First trimester prenatal screening among women pregnant after IVF/ICSI. Hum Reprod Update 2012;18(4):350–359. DOI: 10.1093/humupd/dms010.
  19. Pinborg A, Lidegaard O, la Cour Freiesleben N, et al. Consequences of vanishing twins in IVF/ICSI pregnancies. Hum Reprod 2005;20(10):2821–2829. DOI: 10.1093/humrep/dei142.
  20. Kupka MS, D'Hooghe T, Ferraretti AP, et al. European IVF-monitoring consortium (EIM) European Society of Human Reproduction and Embryology (ESHRE). Hum Reprod 2016;31(2):233–248. DOI: 10.1093/humrep/dev319.
  21. Sunderam S, Kissin DM, Crawford SB, et al. Assisted reproductive technology surveillance, United States, 2012. MMWR Surveill Summ 2015;64(11):1–29. DOI: 10.15585/mmwr.ss6411a1.
  22. Glujovsky D, Blake D, Farquhar C, et al. Cleavage stage versus blastocyst stage embryo transfer in assisted reproductive technology. Cochrane Database Syst Rev 2012;7:CD002118.
  23. Glujovsky D, Farquhar C. Cleavage-stage or blastocyst transfer: what are the benefits and harms? Fertil Steril 2016;106(2):244–250. DOI: 10.1016/j.fertnstert.2016.06.029.
  24. Dyer S, Chambers GM, de Mouzon J, et al. International committee for monitoring assisted reproductive technologies world report: assisted reproductive technology 2008, 2009 and 2010. Hum Reprod 2016;31(7):1588–1609. DOI: 10.1093/humrep/dew082.
  25. Rudnicki M, Vejerslev LO, Junge J. The vanishing twin: morphologic and cytogenetic evaluation of an ultrasonographic phenomenon. Gynecol Obstet Invest 1991;31(3):141–145. DOI: 10.1159/000293133.
  26. Fernando D, Halliday JL, Breheny S, et al. Outcomes of singleton births after blastocyst versus nonblastocyst transfer in assisted reproductive technology. Fertil Steril 2012;97(3):579–584. DOI: 10.1016/j.fertnstert.2011.12.032.
  27. Pereira N, Pryor KP, Petrini AC, et al. Perinatal risks associated with early vanishing twin syndrome following transfer of cleavage- or blastocyst-stage embryos. J Pregnancy 2016;2016:1245210. DOI: 10.1155/2016/1245210.
  28. Márton V, Zádori J, Kozinszky Z, et al. Prevalences and pregnancy outcome of vanishing twin pregnancies achieved by in vitro fertilization versus natural conception. Fertil Steril 2016;106(6):1399–1406. DOI: 10.1016/j.fertnstert.2016.07.1098.
  29. Jauniaux E, Ben-Ami I, Maymon R. Do assisted-reproduction twin pregnancies require additional antenatal care? Reprod Biomed Online 2013;26(2):107–119. DOI: 10.1016/j.rbmo.2012.11.008.
  30. La Sala GB, Nicoli A, Villani MT, et al. Spontaneous embryonic loss rates in twin and singleton pregnancies after transfer of top-versus intermediate-quality embryos. Fertil Steril 2005;84(6):1602–1605. DOI: 10.1016/j.fertnstert.2005.05.045.
  31. Schieve LA, Meikle SF, Ferre C, et al. Low and very low birth weight in infants conceived with use of assisted reproductive technology. N Engl J Med 2002;346(10):731–737. DOI: 10.1056/NEJMoa010806.
  32. Jauniaux E, Farquharson RG, Christiansen OB, et al. Evidence-based guidelines for the investigation and medical treatment of recurrent miscarriage. Hum Reprod 2006;21(9):2216–2222. DOI: 10.1093/humrep/del150.
  33. Zhao J, Zhang Q, Li Y. The effect of endometrial thickness and pattern measured by ultrasonography on pregnancy outcomes during IVF-ET cycles. Reprod Biol Endocrinol 2012;10(1):100. DOI: 10.1186/1477-7827-10-100.
  34. Evron E, Sheiner E, Friger M, et al. Vanishing twin syndrome: is it associated with adverse perinatal outcome? Fertil Steril 2015;103(5):1209–1214. DOI: 10.1016/j.fertnstert.2015.02.009.
  35. Almog B, Levin I, Wagman I, et al. Adverse obstetric outcome for the vanishing twin syndrome. Reprod Biomed Online 2010;20(2):256–260. DOI: 10.1016/j.rbmo.2009.11.015.
  36. Shebl O, Ebner T, Sommergruber M, et al. Birth weight is lower for survivors of the vanishing twin syndrome: a case-control study. Fertil Steril 2008;90(2):310–314. DOI: 10.1016/j.fertnstert.2007.06.048.
  37. Mansour R, Serour G, Aboulghar M, et al. The impact of vanishing fetuses on the outcome of ICSI pregnancies. Fertil Steril 2010;94(6):2430–2432. DOI: 10.1016/j.fertnstert.2010.02.058.
  38. Sun L, Chen Z, Liu J, et al. Obstetric and neonatal outcomes of vanishing twin syndrome. Nan Fang Yi Ke Da Xue Xue Bao 2014;34(10):1537–1540.
  39. Tabanelli C, Ferraretti AP, Feliciani E, et al. Vanishing twins in IVF/ICSI pregnancies: a case-control study. Mol Hum Reprod 2009;24:i130–i131.
  40. Zhou L, Gao X, Wu Y, et al. Analysis of pregnancy outcomes for survivors of the vanishing twin syndrome after in vitro fertilization and embryo transfer. Eur J Obstet Gynecol Reprod Biol 2016;203:35–39. DOI: 10.1016/j.ejogrb.2016.04.014.
  41. Frisell T, Oberg S, Kuja-Halkola R, et al. Sibling comparison designs: bias from non-shared confounders and measurement error. Epidemiology 2012;23(5):713–720. DOI: 10.1097/EDE.0b013e31825fa230.
  42. Oepkes D, Sueters M. Antenatal fetal surveillance in multiple pregnancies. Best Pract Res Clin Obstet Gynaecol 2017;38:59–70. DOI: 10.1016/j.bpobgyn.2016.09.004.
  43. Van Oppenraaij RH, Jauniaux E, Christiansen OB, et al. ESHRE special interest group for early pregnancy (SIGEP). Predicting adverse obstetric outcome after early pregnancy events and complications: a review. Hum Reprod Update 2009;15(4):409–421. DOI: 10.1093/humupd/dmp009.
  44. Chasen ST, Luo G, Perni SC, et al. Are in vitro fertilization pregnancies with early spontaneous reduction high risk? Am J Obstet Gynecol 2006;195(3):814–817. DOI: 10.1016/j.ajog.2006.06.022.
  45. Murray E, Fernandes M, Fazel M, et al. Differential effect of intrauterine growth restriction on childhood neurodevelopment: a systematic review. BJOG 2015;122(8):1062–1072. DOI: 10.1111/1471-0528.13435.
  46. Bass NH, Oliver JB, Srinivasan M. Persistently elevated AFP and ACHE in amniotic fluid from a normal fetus following the demise of its twin. Prenat Diagn 1986;6(1):33–35. DOI: 10.1002/pd.1970060105.
  47. Pinborg A, Lidegaard O, Freisleben N, et al. Vanishing twins: a predictor of small-for-gestational age in IVF singletons. Hum Reprod 2007;22(10):2707–2714. DOI: 10.1093/humrep/dem225.
  48. Shek NW, Hillman SC, Kilby MD. Single-twin demise: pregnancy outcome. Best Pract Res Clin Obstet Gynaecol 2014;28(2):249–263. DOI: 10.1016/j.bpobgyn.2013.11.003.
  49. Hillman SC, Morris RK, Kilby MD. Co-twin prognosis after single fetal death: a systematic review and meta-analysis. Obstet Gynecol 2011;118(4):928–940. DOI: 10.1097/AOG.0b013e31822f129d.
  50. Ong SS, Zamora J, Khan KS, et al. Prognosis for the co-twin following single-twin death: a systematic review. BJOG 2006;113(9):992–998. DOI: 10.1111/j.1471-0528.2006.01027.x.
  51. Dällenbach P, Pelte MF, Irion O. Life-threatening third-trimester hemorrhage following a vanishing twin phenomenon in early pregnancy. Ultrasound Obstet Gynecol 2005;26(2):196–197. DOI: 10.1002/uog.1946discussion 197.
  52. Huang T, Boucher K, Aul R, et al. First and second trimester maternal serum markers in pregnancies with a vanishing twin. Prenat Diagn 2015;35(1):90–96. DOI: 10.1002/pd.4492.
  53. Spencer K, Staboulidou I, Nicolaides KH. First trimester aneuploidy screening in the presence of a vanishing twin: implications for maternal serum markers. Prenat Diagn 2010;30(3):235–240. DOI: 10.1002/pd.2445.
  54. Chasen ST, Perni SC, Predanic M, et al. Does a “vanishing twin” affect first-trimester biochemistry in Down syndrome risk assessment? Am J Obstet Gynecol 2006;195(1):236–239. DOI: 10.1016/j.ajog.2006. 01.044.
  55. Gjerris AC, Loft A, Pinborg A, et al. The effect of a ‘vanishing twin’ on biochemical and ultrasound first trimester screening markers for Down's syndrome in pregnancies conceived by assisted reproductive technology. Hum Reprod 2009;24(1):55–62. DOI: 10.1093/humrep/den362.
  56. Abbas A, Sebire NJ, Johnson M, et al. Maternal serum concentrations of pregnancy associated placental protein A and pregnancy specific B1 glycoprotein in multifetal pregnancies before and after fetal reduction. Hum Reprod 1996;11(4):900–902. DOI: 10.1093/oxfordjournals.humrep.a019275.
  57. Sankaran S, Rozette C, Dean J, et al. Screening in the presence of a vanished twin: nuchal translucency or combined screening test? Prenat Diagn 2011;31(6):600–601. DOI: 10.1002/pd.2735.
  58. Curnow KJ, Wilkins-Haug L, Ryan A, et al. Detection of triploid, molar, and vanishing twin pregnancies by a single-nucleotide polymorphism-based noninvasive prenatal test. Am J Obstet Gynecol 2015;212(1):79.e1-9. DOI: 10.1016/j.ajog.2014.10.012.
  59. Masala M, Saba L, Zoppi MA, et al. Pitfalls in noninvasive fetal RhD and sex determination due to a vanishing twin. Prenat Diagn 2015;35(5):506–508. DOI: 10.1002/pd.4489.
  60. American College of Obstetricians and Gynecologists. Invasive prenatal testing for aneuploidy. ACOG practice bulletin no. 88. Obstet Gynecol 2007;110(6):1459–1467. DOI: 10.1097/01.AOG.0000291570.63450.44.
  61. Manzur A, Goldsman MP, Stone SC, et al. Outcome of triplet pregnancies after assisted reproductive techniques: how frequent are the vanishing embryos? Fertil Steril 1995;63(2):252–257. DOI: 10.1016/s0015-0282(16)57350-6.
  62. Centers for Disease Control and Prevention ASfRM, Technology SfAR. 2010 Assisted reproductive technology national summary report. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention 2012.
  63. Niles KM, Murji A, Chitayat D. Prolonged duration of persistent cell free fetal DNA from a vanishing twin. Ultrasound Obstet Gynecol 2018(4). DOI: 10.1002/uog.19004.
  64. Lathi RB, Gustin SL, Keller J, et al. Reliability of 46, XX results on miscarriage specimens: a review of 1,222 first-trimester miscarriage specimens. Fertil Steril 2013;101(1):178–182. DOI: 10.1016/j.fertnstert.2013.09.031.
  65. Levy B, Sigurjonsson S, Pettersen B, et al. Genomic imbalance in products of conception: single nucleotide polymorphism chromosomal microarray analysis. Obstet Gynecol 2014;124(2 Pt 1):202–209. DOI: 10.1097/AOG.0000000000000325.
  66. Hartwig TS, Ambye L, Sorensen S, et al. Discordant noninvasive prenatal testing (NIPT) - a systematic review. Prenat Diagn 2017;37(6):527–539. DOI: 10.1002/pd.5049.
  67. Yin A, Ng EH, Zhang X, et al. Correlation of maternal plasma total cell-free DNA and fetal DNA levels with short term outcome of first-trimester vaginal bleeding. Hum Reprod 2007;22(6):1736–1743. DOI: 10.1093/humrep/dem058.
  68. Lim JH, Kim MH, Han YJ, et al. Cell-free fetal DNA and cell-free total DNA levels in spontaneous abortion with fetal chromosomal aneuploidy. PLoS ONE 2013;8(2):e56787. DOI: 10.1371/journal.pone.0056787.
  69. Reddy KS, Petersen MB, Antonarakis SE, et al. The vanishing twin: an explanation for discordance between chorionic villus karyotype and fetal phenotype. Pren Diagn 1991;1(9):679–684. DOI: 10.1002/pd.1970110903.
  70. Tharapel AT, Elias S, Shulamm LP, et al. Resorbed co-twin as an explanation for discrepant chorionic villus results: non-mosaic 47,XX, + 16 in villi (direct and culture) with normal (46,XX) amniotic fluid and neonatal blood. Prenat Diagn 1989;9(7):467472. DOI: 10.1002/pd.1970090703.
  71. Ledbetter DH, Martin AO, Verlinsky Y, et al. Cytogenetic results of chorionic villus sampling: high success rate and diagnostic accuracy in the United States collaborative study. Am J Obstet Gynecol 1990;146(2):495–501. DOI: 10.1016/0002-9378(90) 90419-8.
  72. Lloveras E, Lecumberri JM, Pérez C, et al. A female infant with a 46,XX/48,XY+8+10 karyotype in prenatal diagnosis: a ‘vanishing twin’ phenomenon? Prenat Diagn 2001;21(10):896–897. DOI: 10.1002/pd.174.
  73. Barnhart KT, Sammel MD, Rinaudo PF, et al. Symptomatic patients with an early viable intrauterine pregnancy: HCG curves redefined. Obstet Gynecol 2004;104(1):50–55. DOI: 10.1097/01.AOG.0000128174.48843.12.
  74. Morse CB, Sammel MD, Shaunik A, et al. Performance of human chorionic gonadotropin curves in women at risk for ectopic pregnancy: exceptions to the rules. Fertil Steril 2012;97(1):101–106. DOI: 10.1016/j.fertnstert.2011.10.037.
  75. Kelly MP, Molo MW, Maclin VM, et al. Human chorionic gonadotropin rise in normal and vanishing twin pregnancies. Fertil Steril 1991;56(2):221–224. DOI: 10.1016/s0015-0282(16)54475-6.
  76. Brady PC, Correia KF, Missmer SA, et al. Early beta-human chorionic gonadotropin trends in vanishing twin pregnancies. Fertil Steril 2013;100(1):116–121. DOI: 10.1016/j.fertnstert.2013.02.057.
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