Diagnosis of ectopic pregnancy after in vitro fertilization and embryo transfer

Objective: The combination of transvaginal sonography and serum hCG measurement is reliable in the diagnosis of ectopic pregnancy (EP) in spontaneous pregnancies. In patients who became pregnant through IVF-ET, transfer of multiple embryos after IVF could be responsible for the different performance of these tests. We evaluated the discriminative capacity of transvaginal sonography in combination with hCG measurement in the diagnosis of EP after IVF-ET.

Design: Prospective cohort study.

Setting and Patient(s): Consecutive patients, pregnant through IVF-ET, who presented with clinically suspected EP.

Intervention(s): Transvaginal sonography, serum hCG measurement at 6, 9, and 15 days after ET and after a negative transvaginal sonography.

Main Outcome Measure(s): Ectopic pregnancy confirmed at laparoscopy.

Result(s): Between September 1993 and May 1996, 86 women were included in the study, of whom 24 had an EP. Transvaginal sonography identified 46 intrauterine pregnancies and 5 EPs, but serum hCG could not diagnose EPs in patients in whom transvaginal sonography did not show a gestational sac. Serum hCG measurement 9 days after ET could identify pregnancy failure with 100% specificity at a cut-off value of 18 IU/L, but it could not identify patients with EP with enough certainty to justify immediate treatment.

Conclusion(s): We recommend single serum hCG measurement 9 days after ET to discriminate between viable and nonviable pregnancies. Transvaginal sonography can be postponed until 5 weeks after ET, except for patients with abdominal pain and/or vaginal bleeding, or patients with a serum hCG level of <18 IU/L.     

Risk factors for ectopic pregnancy afterin vitro fertilization and embryo transfer

Purpose To find the incidence of ectopic pregnancy (EP) in patients who conceived in the IVF-ET program, and risk factors affecting the occurrence of EP.Methods We analyzed the effects of the indication for IVF, type of ovarian stimulation (hMG + hCG vs. GnRH + hMG + hCG), type of embryo transfer (transcervical intratubal, intrauterine in chest-knee position and intrauterine in lithotomy position) and number of embryos transferred on the occurrence of EP. EP was treated by laparotomy, prostaglandin E ₂ or laparoscopic surgery.Results In 7991 stimulated and 92 natural cycles treated in the Ljubljana IVF-ET program between May 1983 and June 1994 we achieved 1059 pregnancies, of which 44 were ectopic (incidence 4.1%), the main risk being tubal factor infertility. There were 38 (86.3%) tubal, 3 (6.8%) heterotopic, 1 (2.4%) ovarian, and 2 (4.5%) cornual EP. In two patients multiple tubal EP occurred (1 twin, 1 triplet). Forty-two patients (95.4%) had tubal factor infertility, 1 (2.3%) unexplained, and 1 (2.3%) patient had male factor. The incidence of EP in patients with tubal infertility was 5.4%, in patients with unexplained infertility 2.0% and in those with male factor 0.9%. There appeared to be no correlation between the two superovulatory methods. With transcervical intrauterine ET the incidence of EP was 0 of 5 clinical pregnancies (CP); with intrauterine in chest-knee position it was 26 (3.5%) of 738 CP; with intrauterine in lithotomy position it was 17 (5.4%) of 316 CP. The difference between the two types of intrauterine ET is not statistically significant. The incidence of EP did not correlate with the number of embryos transferred. The average initial values of beta hCG performed 17 days after ET were significantly lower in patients with EP than in those with normal singleton pregnancy (157±143 mIU/ml vs. 408±148 mIU/ml).Conclusions EP can complicate the IVF procedure. The main risk factor is tubal infertility with or without previous tubal surgery. The low initial value of beta hCG has a strong predictive value in the diagnosis of EP.Presented at the IXth World Congress on In Vitro Fertilization and Alternate Assisted Reproduction, April 3–7, 1995, Vienna, Austria.     

A case of twin pregnancy with complete hydatidiform mole and coexisting fetus following IVF-ET

Twin pregnancy consisting of complete hydatidiform mole (H-mole) and a coexisting fetus occurs with an estimated incidence of 1 per 22,000–100,000 pregnancies. The incidence of this unusual twin pregnancy with complete H-mole and a coexisting fetus after in vitro fertilization and embryo transfer (IVF–ET) is not thought to be greater than that of general population. We present an unusual twin pregnancy with complete H-mole and a coexisting fetus that occurred following IVF–ET, which was terminated at 21 weeks of gestation and developed into nonmetastatic gestational trophoblastic tumor.     

血绒毛膜促性腺激素β在异位妊娠病情监测中的应用

目的探讨监测绒毛膜促性腺激素-β（human chorionic gonadotropin,β-hCG）在异位妊娠（ectopic pregnancy,EP）病情监测中的应用。方法对123例具有相同保守治疗指征的EP患者,保守治疗前均常规监测β-hCG,间隔48h复测一次。按50mg/m2计算给药,采用甲氨蝶呤（methotrexate,MTX）单次肌肉注射,用药后第4d（96h）再次监测β-hCG下降情况,每周一次,至β-hCG降到正常（β-hCG〈100U/L）。EP保守治疗成功组93例根据β-hCG上升或下降分为A组37例、B组56例,EP保守治疗失败的30例为C组（保守后改手术治疗）。结果三组在年龄、孕龄、EP包块直径大小间比较,无统计学意义（P〉0.05）;第一次测定血的β-hCG值结果A与B组比较无统计学意义（P〉0.05）。间隔48h测定,A组β-hCG有所下降,B组升高,A与B组比较有统计学意义（P〈0.01）。应用MTX治疗后A组β-hCG下降幅度〉15%,B组β-hCG有不同程度的升高,与A组比较差异有统计学意义（P〈0.01）。C组因在观察中改行手术治疗,保守治疗失败未做比较。三组β-hCG降至正常的时间B组较A组长,C组最短,差异有统计学意义（P〈0.01）。结论EP保守治疗前后监测β-hCG值的高低有助于判断治疗效果和时间。     

Unilateral twin ectopic pregnancy managed with laparoscopic salpingectomy

We describe a rare case of unilateral twin tubal ectopic pregnancy in a multiparous lady in the right fallopian tube that was confirmed on laparoscopy and managed by laparoscopic salpingectomy.     

Tuboperitoneal fistula,ectopic pregnancy,and remnants of fallopian tube: a confocal microtomography analysis and 3D reconstruction of human fallopian tube pathologies

Objective: The aim of this study was to provide a three-dimensional (3D) microscopic reconstruction of morphological modifications of the fallopian tube (FT) following surgical sterilization (including tuboperitoneal fistula) and ectopic pregnancy (EP) using confocal microtomography (micro-CT).

Methods: Six specimens of FT from elective and emergency surgeries were selected: three remnants of the FT (RFT) from surgical sterilization, including one presenting tuboperitoneal fistula, and three FTs with EP. The specimens were fixed in formalin and stained with Lugol solution. Micro-CT studies were conducted on the specimens using protocols adapted from biological studies.

Results: Three RFTs from surgical sterilization and three FTs affected by EPs were successfully scanned using micro-CT. There was good contrast impregnation, allowing tissue segmentation and analysis of different sections of the FTs. Three FT specimens from EP exhibited considerable distortion of the tubal anatomy, mainly from the blood clot in the tubal abortion. Three RFT specimens exhibited some features observed in traditional microscopy, such as tubal distension and loss of normal anatomical characteristics of a normal FT, and indicated the presence of a tuboperitoneal fistula in one of the three specimens.

Conclusion: Micro-CT can identify morphological characteristics of FT pathologies previously described in a microscopic scale, with tissue contrast and the possibility of 3D reconstruction. Micro-CT is also useful in guiding traditional sectioning of specimens for histopathological studies.     

Ectopic pregnancy effects on the ipsilateral fallopian tube epithelium--an ultrastructural study

Ectopic pregnancy specimens of 6 human Fallopian tube fimbrial epithelia were studied utilizing ultrastructural, cytochemical and morphometric methods. The observations were compared with those made on 12 intrauterine pregnancy specimens. The morphometric measurements indicate earlier onset of atrophic changes in ectopic pregnancy. Deciliation in Ectopic pregnancy preceded that observed in intrauterine pregnancy. Cell height also decreased earlier in ectopic pregnancy than in intrauterine pregnancy. In addition, during the 1st trimester, ultrastructural localization of calcium revealed that, in ectopic pregnancy, the mitochondrial calcium, which was observed in intrauterine specimens, was shifted into the cytoplasmic compartment of the ciliary cell. Consequently, cytoplasmic calcium was found in the ectopic specimens and was less evident in the intrauterine specimens. Thus, a local atrophic effect is evident in ectopic pregnancy, which appears earlier than the atrophic process found in intrauterine pregnancy.     

Transverse myelitis following methotrexate treatment of ectopic pregnancy: a case report

Objective: Ectopic pregnancy is a common condition in the field of gynaecology, often treated with methotrexate. Adverse effects are common and usually mild. Severe adverse events are rare amongst patients treated with MTX for this condition.

Case: A 26-year-old healthy woman was admitted and treated medically with MTX for an ectopic pregnancy. The patient was treated in the standard drug labelled protocol with an intramuscular injection of 78?mg of MTX according to body surface area. Soon after, the patient presented to the emergency department with symptoms of bilateral paresthesia of the lower limbs which ascended to the pelvis. After a thorough work up and imaging via MRI a diagnosis of transverse myelitis was made. Treatment was successful with corticosteroids and symptoms subsided.

Conclusions: We propose that MTX should be used with caution and severe toxicity should be kept in mind with high index of awareness for any symptom development following treatment, especially neurological one.     

Risk factors for recurrent ectopic pregnancy following single-dose methotrexate treatment

Objective: Our study aimed to investigate the predisposing factors for recurrence of an ectopic pregnancy (EP) following single-dose methotrexate (MTX) treatment for a primary EP.

Methods: This was a retrospective cohort study performed in a tertiary care medical centre including all patients diagnosed with primary EP and treated with a single-dose regimen of intramuscular MTX. EPs with future recurrence were compared with first time only EPs, to identify risk factors for recurrent EP. Forward stepwise multivariate logistic regression analyses were subsequently carried out.

Results: The study included 272 women. Of those, 22 (8.1%) had a recurrent EP. Women in the recurrent EP group had a higher rate of abortions (45.5% vs 32.7%; p?=?0.02), previous pelvic surgery (45.5% vs 6.5%; p?<?0.001) and both pelvic and uterine surgery (4.5% vs 1.6%; p?<?0.001). Conception by assisted reproductive technology (ART) was more common among the non-recurrent EP group (23.0% vs 4.5%; p?=?0.04). Success of single-dose MTX treatment was lower in the recurrent EP group compared with the non-recurrent EP group (36.4% vs 65.7%; p?=?0.006). A history of pelvic surgery was independently associated with recurrent EP (adjusted odds ratio [OR] 17.6; 95% confidence interval [CI] 4.9, 63.2; p?=?0.001). Treatment success of single-dose MTX was independently protective for recurrent EP (adjusted OR 0.25; 95% CI 0.08, 0.76; p?=?0.02).

Conclusions: Among women with an EP, attention should be paid to those with previous pelvic surgery. Efforts should be made to achieve medical treatment success to prevent recurrent EP.     

Partial mole in ectopic pregnancy

Objective: To evaluate the incidence of molar pregnancy in the fallopian tube pregnancy. Setting: Outpatient clinic. Patient: 32-year-old Asian woman. Intervention: Left salpingectomy. Outcome: Molar ectopic pregnancy. Result: Ectopic partial mole pregnancy. Conclusion: Molar pregnancy can occur in ectopic pregnancy. Clinically, molar pregnancy mimics normal tubal ectopic pregnancy.     

HOXA10 gene expression in human fallopian tube and ectopic pregnancy

OBJECTIVE: The molecular mechanisms underlying ectopic implantation have not been well characterized. Here we investigate HOXA10 gene expression at the site of ectopic implantation as compared with the endometrium and with the normal fallopian tube. STUDY DESIGN: Northern blot analysis was used to evaluate HOXA10 gene messenger RNA level in various segments of normal pregnant and nonpregnant human fallopian tube, ectopic pregnancy, and endometrium. RESULTS: Normal human fallopian tube expressed minimal levels of HOXA10 gene messenger RNA in the nonpregnant state. A trend toward a greater expression of HOXA10 gene was observed in the normal fallopian tube during pregnancy, but the difference was not statistically significant (P =.075). HOXA10 gene messenger RNA expression was up-regulated significantly at the site of implantation in ectopic pregnancy (P <.001), and its expression approached that of the endometrium during normal pregnancy (P =.33). CONCLUSION: HOXA10 gene expression is up-regulated at the ectopic implantation site in the fallopian tube, approaching that of the endometrium in normal intrauterine gestation. Inherently increased HOXA10 gene expression in the fallopian tube or dysregulation of HOXA10 gene expression by an abnormally implanting blastocyst may play a role in ectopic implantation.     

A case of molar ectopic pregnancy

OBJECTIVE: To evaluate the occurrence of molar pregnancy in tubal ectopic pregnancy. DESIGN: Case report. SETTING: Outpatient clinic. PATIENT(S): A 27-year-old woman. INTERVENTION(S): Salpingectomy. MAIN OUTCOME MEASURE(S): Molar ectopic pregnancy. RESULT(S): Ectopic partial molar pregnancy. CONCLUSION(S): Molar pregnancy can occur in ectopic pregnancy. Molar pregnancy clinically mimics normal tubal ectopic pregnancy.     

Acute and chronic presentation of ectopic pregnancy may be two clinical entities

OBJECTIVE: The diagnosis of ectopic pregnancy (EP) is often confirmed at presentation (acute), but often requires serial beta-hCG levels to confirm the diagnosis (chronic). The purpose of this study is to analyze whether these clinical presentations represent a spectrum of disease. DESIGN: The retrospective cohort study of 452 patients diagnosed with EP at the University of Pennsylvania in the years 1990-1999. SETTING: University of Pennsylvania, Philadelphia, Pennsylvania. PATIENT(S): Four hundred fifty-two patients diagnosed with EP. Patients diagnosed with EP were divided into two groups according to the time of diagnosis. MAIN OUTCOME MEASURE(S): A total of 37 parameters were examined including historic and demographic factors, findings at presentation, and treatment and outcome variables. RESULT(S): The two groups were similar in terms of historic EP risk factors. Multivariable analysis demonstrates that women with a chronic presentation were less likely to have received fertility medications (odds ratio [OR] 0.23; 95% confidence interval [CI] 0.06-0.84), less likely to present with pain (OR 0.29; 95% CI 0.12-0.71), have a lower beta-hCG level at presentation (9,849 mIU/mL +/- 16,726 vs. 1,787 mIU/mL +/- 4,717), lower chance of rupture (OR 0.19; 95% CI 0.05-0.73), and less frequently have blood type 0. CONCLUSION(S): Women diagnosed with ectopic pregnancy can be categorized into two groups, those with an acute presentation and those with a chronic presentation. Differences in risk factors, presentation, and outcome may reflect differences in trophoblast viability or invasive potential.     

Spontaneous ectopic pregnancy occurring in the isthmic portion of the remnant tube after ipsilateral adnexectomy: report of two cases

Two cases of spontaneous ectopic pregnancy occurring in the isthmic portion of the remnant tube after previous ipsilateral adnexectomy are presented. Laparoscopic observation and postoperative histopathological examination suggested intrauterine transmigration of the fertilized egg as the etiology. Laparoscopic excision of the remnant tube was performed and the postoperative course was uneventful in both cases. Attention should be paid to this unusual type of ectopic pregnancy while examining patients with previous history of adnexal surgery.