First trimester transvaginal embryo reduction is an effective alternative for managing multifetal pregnancy in assisted reproduction, performed by intracardiac embryo puncture until systole is verified. A 32-year-old G2 A1 conceived through IVF at 10 weeks. Ultrasound confirmed quadruplet pregnancy with all fetuses viable and minimal subchorionic hemorrhage. After counseling, the couple opted for reduction of quadruplets to twins. The pregnancy was uneventful in first and second trimesters. At 35 weeks, the woman presented with twin breech and premature preterm rupture of membranes (PPROM) and underwent emergency LSCS. First twin weighed 1.75 kg, second twin 1.75 kg. © 2023 Elsevier B.V., All rights reserved.