Heterotopic pregnancy: successful management with aspiration of cornual/interstitial gestational sac and instillation of small dose of methotrexate

OBJECTIVES: Terminating a corneal pregnancy without jeopardizing a coexistent intrauterine pregnancy. METHODS: A 29-year-old woman with a 4-year history of primary infertility became pregnant after in-vitro fertilization and embryo transfer. A heterotopic pregnancy with a left cornual and intrauterine sacs was confirmed by early transvaginal scan examinations. The ectopic sac was aspirated under ultrasound guidance followed by local injection of 12.5 mg methotrexate. This was followed by serial ultrasound scans and serum betahCG assays. RESULTS: The fetal pole in the ectopic pregnancy disappeared following the procedure. She had no significant vaginal bleeding or any other unusual symptoms. The intrauterine pregnancy progressed satisfactorily until spontaneous onset of labour and vacuum extraction delivery at 39 weeks. The baby weighed 2.9 kg. CONCLUSIONS: Local injection of low-dose methotrexate following aspiration of a cornual pregnancy proved effective in halting the ectopic trophoblasts' growth without adversely affecting a coexistent intrauterine pregnancy. The injected ectopic trophoblasts resolved quickly despite the small dose of methotrexate used. This technique avoided a more costly surgical treatment with its associated risks in subsequent pregnancies.     

In situ methotrexate injection for treatment of recurrent endometriotic cysts

OBJECTIVE: Ovarian endometrioma recurrence is frequent. Conventional treatment of ovarian endometrioma is by surgical cystectomy. We proposed an alternative medical treatment for recurrent ovarian endometrioma: cyst aspiration followed by in situ methotrexate injection. STUDY DESIGN: From January 2002 to May 2003, 14 patients with recurrent homolateral ovarian endometrioma underwent transvaginal ultrasound guided cyst puncture and aspiration followed by methotrexate injection, whilst under general anasthesia. Recurrence rate during follow up was evaluated. RESULTS: No complication was reported. After a mean follow up of 20+/-5 month (min: 13, max: 29), four recurrences were diagnosed (28.6%). Two asymptomatic recurrences were not treated and two painful recurrences underwent a second cyst drainage with methotrexate injection. CONCLUSIONS: In situ methotrexate injection is a simple, effective and an interesting alternative to surgical treatment in women with recurrent homolateral ovarian endometrioma.     

Treatment of ectopic pregnancy by transvaginal intratubal methotrexate administration

Twelve women with tubal pregnancies were treated with intratubal transvaginal methotrexate injection (1 mg/kg body weight). Serum beta-hCG levels decreased in all patients, and the resolution time from injection to undetectable beta-hCG levels was 14-120 days. In spite of declining serum beta-hCG and unruptured tubal pregnancy, two patients subsequently requested definitive treatment for their ectopic pregnancies and underwent surgery. Four of six women found to have a living embryo in their gestational sacs required a repeat methotrexate injection; one of these also required a local potassium chloride injection. The tubal pregnancies resolved in nine patients treated with methotrexate alone. During resolution, we noted a gradually increasing resistance index of the blood flow in the region of the gestation, but the tube became distended to 4.4 +/- 0.4 cm before gradually decreasing in size. No complications or side effects were encountered. These findings suggest that intratubal transvaginal methotrexate administration can provide a safe alternative to surgical treatment for patients with early unruptured tubal ectopic pregnancy. However, the presence of a living embryo makes the ectopic pregnancy more resistant to methotrexate treatment.     

Testicular sperm aspiration and intracytoplasmic sperm injection for persistent infection of the ejaculate

OBJECTIVE: To report the successful use of testicular sperm aspiration and intracytoplasmic sperm injection in the presence of an Escherichia coli-infected ejaculate that previously caused repeated embryo degeneration. DESIGN: Case report. SETTING: University medical center. PATIENT(S): A 38-year-old woman who did not conceive for 6 years with repeated IVF attempts. Escherichia coli was isolated from both the oocyte culture dish and her male partner's ejaculate. INTERVENTION(S): Testicular sperm aspiration and intracytoplasmic sperm injection followed by ET. MAIN OUTCOME MEASURE(S): Clinical outcome. RESULT(S): Establishment of a pregnancy delivered at term. CONCLUSION(S): Patients undergoing IVF treatment who have repeated embryo degeneration caused by bacterial infection originating in the ejaculate may be treated successfully with testicular sperm aspiration and intracytoplasmic sperm injection.     

ICSI时不同单精子注入方式对胚胎体外发育的影响

目的:探讨卵母细胞胞浆内单精子注射(ICSI)时回吸与不回吸胞浆对胚胎体外发育的影响。方法:将在本中心接受ICSI治疗的90周期不孕患者的1077枚MII卵子随机分为A组(632枚)和B组(445枚)。A组ICSI时回吸胞浆至卵母细胞直径的1/4-1/2处;B组不回吸胞浆,比较2组的受精率、胚胎可用率和优质胚胎率等。结果:A组和B组的受精率分别为80.85%和82.02%,无统计学差异意义(P>0.05)。A组的胚胎可用率为53.88%,与B组(56.15%)比较无差异(P>0.05);B组的优质胚胎率为20.39%,显著高于A组的13.32%(P<0.05)。结论:ICSI时回吸胞浆和不回吸胞浆对体外受精均是有效的;不回吸胞浆可提高优质胚胎率,对胚胎发育更安全。     

In situ methotrexate injection after transvaginal ultrasound-guided aspiration of ovarian endometriomas: A randomized controlled trial

Objective

To evaluate prospectively the efficacy and safety of in situ methotrexate injection after transvaginal ultrasound-guided aspiration of ovarian endometriomas in well selected patients.

Design

Randomized controlled trial.

Setting

El-Menya infertility research and treatment center (MIRTC), Egypt.

Patients

Two hundred and ten patients complaining of symptomatic ovarian endometriomas during reproductive age.

Method

Transvaginal ultrasound aspiration (group I) versus aspiration and in situ methotrexate injection (group II).

Results

Of 210 patients, 188 patients were available for follow-up; malignant cells were not found in any of them. The overall success rate after complete follow up was 54.73% in group I versus 86.02% in group II, among those patients 25 patients (26.3%) needed single aspiration, 14 patients (14.7%) needed two aspiration, and 13 patients (13.6%) needed three aspiration in study group I versus 62 patients (66.6%) needed single injection, 11 patients (11.8%) needed two injections and 7 patients (7.5%) needed three injections in group II which represented statistically significant difference (P < 0.05). The cyst size and volume of fluid aspirated were statistically significant factors in the resolution of the cyst (P < 0.05), while patients age was not.

Conclusions

Transvaginal ultrasound-guided aspiration and in situ methotrexate injection is simple, safe, non-invasive and effective in the treatment of selected cases of ovarian endometriomas with much acceptability among patients.     

Cervical twin ectopic pregnancy after In Vitro fertilization-Embryo transfer (IVF-ET): case report

Introduction.?Cervical twin ectopic pregnancy after IVF-ET is rare and catastrophic complication. However, here is no consensus on the best treatment strategy.

Patient and method.?Case report of cervical twin ectopic pregnancy after IVF-ET treated by transvaginal ultrasound guided aspiration plus systemic single injection of methotrexate, which followed by full-term delivery in next IVF-ET cycle.

Conclusion.?Transvaginal ultrasound-guided aspiration and systemic methotrexate administration can be safely and easily used to treat cervical ectopic pregnancies and to preserve the fertility of the patient without any major complications.     

Nonsurgical management of unruptured tubal pregnancy with intra-amniotic methotrexate: preliminary report of two cases

Two cases of unruptured tubal pregnancy were managed conservatively by the aspiration and injection of 50 mg methotrexate into the amniotic sac with the use of a vaginal ultrasound transducer under local anesthesia. Both women experienced no pain or side effects and went home within 12 hours. Spontaneous menstruation began in both cases within 6 weeks of the procedure.     

Successful laparoscopic management of early splenic pregnancy: case report and review of literature

Splenic pregnancy is the least common form of ectopic pregnancy. A 32-year-old woman, gravida 5, para 2, had not menstruated for 46 days, and had spotty bleeding for 6 days and lower abdominal pain for 2 days. The initial β-human chorionic gonadotropin concentration was 38,913.3 IU/L. Transvaginal ultrasound examination demonstrated an empty uterine cavity, and a gestational sac 4.3 × 4.0 mm in diameter, with no fetal pole or yolk sac, located just adjacent to the splenic region. Laparoscopic surgery demonstrated intact pelvic organs and an ectopic mass on the spleen. The splenic pregnancy was successfully treated via laparoscopic embryo methotrexate injection, with preservation of the uterus and spleen. As evidenced in this case, laparoscopic embryo methotrexate injection is a minimally invasive and effective method of diagnosis and treatment of early splenic pregnancy.     

宫颈妊娠及宫内孕合并宫颈妊娠的保守治疗

目的:探讨宫颈妊娠的病因、诊断及保守性治疗方法。方法:回顾分析我院1996年1月1日至2010年12月31日收治的宫颈妊娠及体外授精胚胎移植术后宫内孕合并宫颈妊娠患者36例,探讨宫颈妊娠保守治疗方式的选择,并随访患者术后情况。结果:29例单纯宫颈妊娠:6例外院误诊为"难免流产",误诊率20.69%;10例经阴道B超引导下宫颈妊娠囊局部穿刺+MTX注射治疗,6例行子宫动脉栓塞术,6例MTX肌内注射治疗,7例腰麻下宫腔镜检查宫颈妊娠清除手术。7例宫内孕合并宫颈妊娠:1例阴道B超引导下局部妊娠囊穿刺注入KCl 1ml,3例期待疗法后清除宫颈妊娠物,3例腹部B超引导下宫颈妊娠物清除术。结论:阴道彩超用于宫颈妊娠的早期诊断有较大的价值,术前应充分评估,制定个体化的治疗方案。宫内孕合并宫颈妊娠的患者在腹部B超监测下清除宫颈妊娠物是有效的治疗方式之一,但要及时手术并且加强抗感染治疗。     

Nonsurgical Management of Primary Ovarian Pregnancy With Transvaginal Ultrasound-Guided Local Administration of Methotrexate

Primary ovarian pregnancy is a rare form of ectopic gestation and one that is often diagnosed only at the time of surgery. We report the first case to our knowledge of a live primary ovarian pregnancy diagnosed by transvaginal ultrasonography and successfully treated with transvaginal-guided aspiration and injection of methotrexate. Primary ovarian pregnancy can be diagnosed early in gestation with transvaginal sonography, affording the opportunity to successfully be managed with local administration of methotrexate.     

Successful treatment of two viable tubal pregnancies by two-step local injection.

Two viable tubal pregnancies were diagnosed by transvaginal ultrasound with a serum beta-hCG level of up to 3,004 mIU/mL in Case 1 and 16,676 mIU/mL in Case 2. Under transvaginal sonographic guidance, a local injection of potassium chloride (0.5 mL = 1.0 mEq) into the embryo was performed for the purpose of embryocide. In Case 1, a follow-up of serum beta-hCG levels showed an initial plateau and subsequent regression to negative, 49 days after the local injection. However, a persistent increase in serum beta-hCG levels was noted in Case 2 for two samples at intervals of two days during follow-up, 27,800 and 36,500 mIU/mL, in spite of the fact that no fetal cardiac activity was visible. Six days later, laparoscopy was done and methotrexate, 50 mg in 6 mL of normal saline, was injected into the ampullar mass of the right fallopian tube in two divided dosages. The serum beta-hCG levels then gradually decreased and returned to negative 60 days after the methotrexate injection. For a viable ectopic pregnancy, this new modality of two-step local injection, first with potassium chloride and then with supplemental methotrexate, separately by two procedures, may offer an additional choice of conservative treatment.     

Conservative treatment of cervical ectopic pregnancy with transvaginal ultrasound-guided aspiration and single-dose methotrexate

OBJECTIVE: To present a case of cervical ectopic pregnancy successfully treated with ultrasound-guided aspiration and single-dose methotrexate administered systemically. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 27-year-old nulliparous woman with a cervical ectopic pregnancy. INTERVENTION(S): Transvaginal ultrasound-guided aspiration of the cervical ectopic pregnancy followed by single-dose methotrexate administered systemically. MAIN OUTCOME MEASURE(S): Recovery of the patient, successful conservative treatment of the cervical ectopic pregnancy, with preservation of the uterus. RESULT(S): The cervical ectopic pregnancy was successfully aborted, and the reproductive capability of the patient was preserved. CONCLUSION(S): Transvaginal ultrasound-guided aspiration in combination with single-dose methotrexate administered systemically can be safely used to treat cervical ectopic pregnancies.     

Simultaneous bilateral tubal pregnancy after intracytoplasmic sperm injection treated by conservative medical treatment. Interest of sonographic follow-up

We describe a case of early bilateral tubal pregnancy diagnosed by transvaginal ultrasonography after intracytoplasmic sperm injection (ICSI) and embryo transfer (ET). A follow-up by transvaginal sonography was done with a systematic second scan (5 days) after the first diagnosis of left tubal ectopic pregnancy in case of assisted conception procedure. This follow-up sonographic strategy permitted us to perform a conservative treatment for this case of spontaneous bilateral tubal pregnancy by two consecutive (left then right) in-situ methotrexate injections under vaginal ultrasonographic guidance without any complications.     

Methotrexate/misoprostol vs. a more standard approach for termination of pregnancies of undetermined location: a randomized, controlled trial

OBJECTIVE: To conduct a randomized, controlled trial to compare a group of patients receiving methotrexate intramuscularly on day 1 and vaginal misoprostol on day 5 to terminate a pregnancy of undetermined location with a group in which the diagnosis was established prior to treatment. STUDY DESIGN: We randomized 43 women with a pregnancy of undetermined location to 2 study groups: (1) 1 group received methotrexate/misoprostol, and (2) the other group had a diagnosis established first and then were treated appropriately. The outcomes that were measured for the 2 groups were: (1) hospital admission rate, (2) laparoscopy rate, (3) uterine aspiration rate, (4) patient visits, and (5) interval to end point. RESULTS: The uterine aspiration rate was lower in the methotrexate/misoprostol group (0.0% vs. 77.3%, p<0.0001). The mean number of patient visits in the methotrexate/misoprostol group was higher (3.8 vs. 2.5 visits, p<0.0001), and the mean interval to the end point in the methotrexate/misoprostol group was higher (26.4 days vs. 4.5 days, p<0.0001). CONCLUSION: To terminate pregnancies of undetermined location, empirical methotrexate/misoprostol is associated with a lower uterine aspiration rate but more patient encounters and longer follow-up.     

经阴道超声引导下减胎术在输卵管间质部妊娠合并宫内孕中的应用——减胎成功2例报告

目的探讨孕早期采用经阴道超声引导下减胎术减灭宫外妊娠胚芽的临床治疗效果。方法通过阴道超声减胎抽吸宫外妊娠组织。结果对2例诊断为未破裂输卵管间质部的早期异位活胎妊娠,通过经阴道超声引导下减胎穿刺治疗,被保留的宫内胎儿持续妊娠至足月分娩。结论孕早期采用经阴道超声引导下减胎术选择性抽吸输卵管间质部胚芽,可获得理想的临床治疗效果。但是本方法仅去除胚芽组织,对残余的绒毛组织,需密切追踪随访。     

Conservative nonsurgical treatment of early detected tubal pregnancies with intra-amniotic methotrexate

Four cases of early detected tubal pregnancies were managed conservatively by aspiration and administration of 20 mg methotrexate into the amniotic sac during laparoscopy. All three women for whom hysterosalpingograms are available had patent tubes on the side of the former ectopic pregnancy six months after treatment. Spontaneous menstruation occurred within six weeks after methotrexate application in all cases.     

Cumulative experience of percutaneous epididymal sperm aspiration (PESA) with intracytoplasmic sperm injection

Objective: Our objective was to evaluate the recovery rate of spermatozoa from the epididymis using a percutaneous aspiration technique and to assess the fertilisation rate after intracytoplasmic sperm injection. Materials and Methods: Fifty-four patients with azoospermia had a total of 59 cycles at IVF with intracytoplasmic sperm injection (ICSI). The cause of the azoospermia was failed vasectomy reversal in 23 cases, congenital absence of the vas in 22 cases, partial testicular failure in 5 cases, and retrograde ejaculation in 2 cases, while the remaining 2 patients had erectile disorders. Results: A total of 741 oocytes was collected and 521 metaphase II oocytes were subsequently microinjected. Normal fertilisation occurred in 274 oocytes (52.6%), and of these, 234 cleaved (85.4%). In 54 cycles, embryo transfer of more than one embryo occurred (91.5%) and a total of 155 embryos was replaced. The pregnancy rate was 30.5% per cycle and 33.3% per embryo transfer. The implantation rate was 14.2%; failure of fertilisation occurred in two cycles, while in three other cycles the embryos did not cleave. Conclusions: Percutaneous epididymal sperm aspiration can be used successfully to retrieve sperm in men with azoospermia due to obstructive, or nonobstructive, disorders. The technique is simple, cost-effective, and associated with fewer complications than an open microsurgical operation.     

Successful transvaginal ultrasound-guided ablation of a cervical pregnancy in a patient with simultaneous intrauterine pregnancy after in vitro fertilization and embryo transfer

Heterotopic pregnancy, or simultaneous intrauterine and extrauterine gestation, is a relatively rare condition. However, induced ovulation and assisted reproductive technologies have markedly increased the incidence of this condition. In this article, a case of heterotopic pregnancy after in vitro fertilization and embryo transfer is presented in which the viable cervical pregnancy was treated by transvaginal ultrasound-guided puncture and injection of potassium chloride in conjunction with methotrexate at week 6 of gestation. At week 12 of gestation, the intrauterine gestation was viable and complete resorption of the cervical pregnancy had occurred. At week 30 of gestation, a healthy baby was delivered by Caesarian section after prelabour rupture of membranes.     

剖宫产后子宫瘢痕妊娠合并宫内妊娠的诊断及治疗

目的:通过回顾分析相关文献,总结剖宫产后子宫瘢痕妊娠合并宫内妊娠(HCSP)的临床表现、诊断、治疗及预后等,从而为临床诊疗提供参考。方法:检索PubMed、万方及中国期刊全文数据库中的HCSP相关文献。通过阅读文献全文,总结分析HCSP的临床表现及诊断方法,并重点探讨其治疗方法及治疗方法与预后的关系。结果:共收集HCSP患者15例,其中自然妊娠6例,体外受精-胚胎移植(IVF-ET)9例。诊断时间为孕5周至8+4周,其中6例患者有阴道流血,其余均无特殊不适;患者均通过阴道超声得以确诊。1例患者因无生育要求而选择甲氨蝶呤直接终止妊娠;14例患者中,期待治疗、宫腔镜及腹腔镜手术治疗各1例,超声监测下原位减胎术[抽吸和(或)药物注射)]11例,患者均成功减胎并继续妊娠。1例因孕12周超声提示胎儿畸形而终止妊娠;13例通过剖宫产而获得活婴,其中3例为足月择期剖宫产,10例因急诊手术指证而行剖宫产终止妊娠,4例出现术中大出血需抢救治疗。结论:剖宫产术后的再次妊娠,尤其是通过辅助生殖技术而受孕者需考虑到HCSP的可能。阴道超声是HCSP诊断及治疗的重要工具。目前超声监测下原位减胎术是治疗HCSP的主要方法,并可获得成功的宫内继续妊娠,但继续妊娠者孕期及围产期并发症多,需严格按高危妊娠积极处理。