Simultaneous ectopic pregnancy with intrauterine twin gestations after in vitro fertilization and embryo transfer

A simultaneous ectopic tubal pregnancy with viable intrauterine twin gestations after IVF-ET of five fertilized eggs is presented. Pelvic ultrasound and serial quantitative hCG levels were not helpful in the diagnosis of the tubal pregnancy. The risk of multiple pregnancies and of concomitant intrauterine and extrauterine gestations increases with transfer of a greater number of embryos. Karyotype of the tubal pregnancy was normal (46,XX).     

An analysis of factors associated with ectopic pregnancy following in vitro fertilization and embryo transfer

Five ectopic pregnancies occurred in 75 in vitro fertilization and embryo transfer (IVF-ET) pregnancies (6.7%) in Ogikubo Hospital IVF program between 1985 and 1989. The indication for IVF in 70 pregnancies was a tubal factor. Thirty cases were among 70 pregnancies with hydrosalpinx, and 40 cases were with other tubal conditions. All of the five cases had tubal disease. Four of them had hydrosalpingos. The percentage of ectopic pregnancies for the 30 pregnancies with hydrosalpinx was 13.3%, while for 40 pregnancies with other tubal conditions it was 2.5%. However, there was no significant difference between the two groups. No correlation was found in other parameters including superovulatory methods, oocyte recovery procedure, number of embryos transferred, embryo transfer procedure, and endocrine changes after embryo transfer. In this study, we were unable to identify a difference between ectopic pregnancy and intra-uterine gestation in IVF-ET. However, further study is required to clarify whether hydrosalpinx increases the risk of ectopic pregnancy in IVF-ET.     

Early pregnancy wastage after gamete manipulation

Summary. The outcome of 1034 pregnancies in women who conceived after referral for infertility management in seven treatment groups is detailed. The mean early pregnancy wastage (before 20 weeks gestation) was 27% and ranged from 18% after AID (artificial insemination by donor semen) to 33% after IVF-ET (in-vitro fertilization and embryo transfer). These differences were not due to maternal age which was similar in all groups (means between 29.7 and 32.7 years). Excluding the AID group, there was a high rate of ectopic pregnancy which was significantly higher after GIFT (gamete intrafallopian transfer) and was only partly related to underlying tubal disease. Blighted ova was the main category of early pregnancy loss and was highest after AIH (artificial insemination by husband's semen). There was a higher rate of biochemical pregnancies after GIFT, PROST (pronuclear stage tubal transfer) and IVF-ET. Our findings confirm a high pregnancy wastage rate in subfertile women and highlight deficiencies in the sperm separation, gamete handling and IVF/embryo culture techniques.     

Bilateral tubal pregnancies after the termination of intrauterine pregnancy following gamete intrafallopian transfer

It is well known that the prevalence of heterotopic pregnancies following assisted reproductive technology (ART) is much higher than among spontaneous pregnancies. Here, we illustrate a very rare case of bilateral simultaneous tubal pregnancies combined with intrauterine pregnancy (incomplete abortion) following gamete intrafallopian transfer (GIFT). In this case, unsuspected bilateral tubal pregnancies were diagnosed when laparotomy was performed 10 days after the termination of an intrauterine pregnancy. We conclude that a careful monitoring after the termination of an intrauterine pregnancy should be performed when the patient has prolonged genital bleeding, which might be a warning signal of heterotopic pregnancy existence even in patients without any risk factors of ectopic pregnancy. (Reprod Med Biol 2002; 1 : 65–67)     

Simultaneous ectopic pregnancy with intra-uterine gestation after in vitro fertilization and embryo transfer.

A case of combined intra-uterine and tubal ectopic pregnancy is described following in vitro fertilization and the transfer of two four-cell and one two-cell embryos. This phenomenon is known to be related to ovarian stimulation by gonadotropin therapy, and there is an increased risk with tubal disease. Techniques applied at the time of embryo transfer, the use of culture medium with 50% fetal cord serum to convey the embryos to the uterus, the catheterization method, and the position of the patient during transfer are presented. The risk of multiple pregnancies and combined intra-uterine and ectopic gestations increases with numbers of transfers and large volume of transfer medium. We would therefore recommend that after IVF-ET treatment in women with tubal disease, intensive care should be taken in the early follow-up period to rule out the possibility of ectopic pregnancy. In this case, a viable ongoing intra-uterine pregnancy was confirmed after surgery for right ampullary ectopic pregnancy. And a 2,925 g male in excellent condition was delivered by Cesarean section without complications.     

In vitro fertilization with concurrent pelvic reconstructive surgery

The recent advent of ultrasound-guided follicular aspiration by various approaches now allows access to ovaries previously deemed inaccessible by laparoscopy; however, a small group of candidates for in vitro fertilization and embryo transfer (IVF-ET) require laparotomy for associated gynecologic disorders. Twenty-five IVF-ET cycles at the time of laparotomy were compared with 309 IVF-ET cycles in which oocytes were retrieved laparoscopically. Five pregnancies occurred in the IVF-ET cycle with laparotomy and one pregnancy occurred spontaneously following microsurgical tubal reconstruction. The pregnancy rate per embryo transfer was 25% in the laparotomy IVF-ET patients compared with 15.4% for the laparoscopy IVF-ET group. Obvious advantages of combining IVF-ET and pelvic reconstructive surgery include a single anesthesia exposure and economic benefits. Patients with a long history of infertility undergoing tubal reconstructive surgery may be offered combined IVF-ET. Extended anesthesia exposure with pelvic surgery demonstrated no adverse effects on the pregnancy rate.     

Simultaneous tubal and intra-uterine pregnancy following in vitro fertilization and embryo transfer

A case of simultaneous ectopic and intra-uterine pregnancy following in vitro fertilization and embryo transfer (IVF-ET) is described. On day 56 after ET the tubal pregnancy ruptured, with massive hemoperitoneum. Following salpingectomy, the intra-uterine pregnancy continued to term when delivery was carried out by cesarean section owing to non-progress of labor and suspected fetal distress. The pitfalls in diagnosing a simultaneous pregnancy of this kind following IVF-ET are discussed.     

A case of retroperitoneal ectopic pregnancy following IVF-ET in a patient with previous bilateral salpingectomy

The numbers of ectopic pregnancies have increased because of the popularization of assisted reproductive techniques. However, the retroperitoneal space is an exceptional location for ectopic pregnancy because the entrance to the retroperitoneal space is unknown. A woman 31 years of age who had received bilateral salpingectomy because of a right tubal ectopic pregnancy and a left hydrosalpinx 4 years earlier was treated by in vitro fertilization and embryo transfer (IVF-ET). Ultrasonography and magnetic resonance imaging (MRI) revealed a gestational sac attached to the inferior vena cava in the midabdomen of the retroperitoneal space. Single-dose methotrexate administration was administered twice. However, because of sudden upper abdominal pain with a drastic decline of hemoglobin, an emergent laparotomy was performed. The hematoma and a gestational sac were removed from the aorta and inferior vena cava. Ectopic pregnancy following IVF-ET in a patient with bilateral salpingectomy is likely to be the cause of implantation at this unusual site. An unusual ectopic pregnancy has a high risk of life-threatening massive bleeding. Intensive transabdominal ultrasound scanning and whole abdominal MRI should be performed for the early diagnosis of unruptured ectopic pregnancy.     

Ectopic pregnancy following the treatment of tubal infertility.

To evaluate the prognosis for the patient who becomes pregnant after infertility treatment, we analyzed the occurrence of ectopic pregnancy following reconstructive surgery and in vitro fertilization/embryo transfer (IVF/ET) for tubal infertility. The results of 474 microsurgical operations and the results of 2,119 stimulated IVF/ET cycles for tubal infertility in the Reproduction Unit of Ljubljana University Department of Obstetrics and Gynecology are presented. The ratio of patients who subsequently had only ectopic pregnancies to the number of operations was 12%. Ectopic pregnancies represented 28% of all pregnancies after surgery. In IVF/ET cycles for tubal infertility, ectopic pregnancy represented 2.8% of all pregnancies and 3 permiles of all transfers. There was one (0.5%) heterotopic pregnancy. The likelihood of live births (30%, one or more times) after surgery compensates the high risk for ectopic pregnancy. While the risk for ectopic pregnancy after IVF/ET is much lower than the risk after tubal surgery, it is still rather high compared with the risk in the normal population. In the cases with severe tubal lesions IVF/ET is preferable to tubal surgery. The results show the importance of considering ectopics when deciding upon treatment and in patients who become pregnant after treatment for tubal infertility.     

Tubal ectopic pregnancy after in vitro fertilization and embryo transfer: a role for proximal occlusion or salpingectomy after failed distal tubal surgery?

OBJECTIVE: To assess predisposing factors to tubal pregnancy after in vitro fertilization-embryo transfer (IVF-ET). DESIGN: Retrospective analysis of 891 ET cycles. SETTING: University-based IVF program. PATIENTS, PARTICIPANTS: All ET cycles performed in the study period were included; the indication for IVF was tubal factor in 640 (72%) and other (nontubal) factors in 251 (28%) cycles. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Observing a higher than expected number of tubal pregnancies in our program; we examined subgroups to determine those at highest risk. RESULTS: Tubal pregnancies comprised 12% of clinical pregnancies in the tubal factor group but only 2.6% in the cycles nontubal factor group (P less than 0.05). Of 640 ET cycles in the tubal factor group, 359 were performed in patients who had prior tubal reconstructive surgery; tubal pregnancies comprised 15.6% of the clinical gestations in this subgroup. In the remainder of the tubal factor group (no prior tubal surgery), 281 ET cycles yielded a tubal pregnancy rate of only 5.5% (P less than 0.05). CONCLUSIONS: Women with prior reconstructive surgery for distal tubal disease are at highest risk of developing tubal pregnancy after IVF.     

The role of tubal pathology and other parameters in ectopic pregnancies occurring in in vitro fertilization and embryo transfer

Contradictory findings were reported concerning the role of tubal disease in the genesis of ectopic pregnancy in in vitro fertilization and embryo transfer (IVF-ET). We report on six ectopics that occurred in 141 IVF-ET pregnancies (4.3%). All of the six cases were among 84 patients with tubal disease, and none occurred in the remaining 57 patients with other etiological factors. No correlation was found in other parameters including: ovulation induction, number of embryos transferred, and luteal support. A comparison between the ectopics and six matched controls demonstrated similar estradiol levels, but beta-hCG levels on day 15 to 17 after ET were lower. Homolateral salpingectomy was performed in all six cases, but a contralateral resection was carried out in three of them. More comprehensive studies are needed to clarify whether tubal pathology really increases the risk for ectopic gestation in IVF-ET.     

Laparoscopic tubal anastomosis.

OBJECTIVES: To evaluate the pregnancy outcome after laparoscopic tubal anastomosis. METHODS: From December 1998 to December 2001, 26 patients with bilateral tubal ligation who underwent laparoscopic tubal anastomosis were prospectively evaluated. Patients' age varied from 28 to 37 years. RESULTS: Laparoscopic tubal reversal was performed in 23 patients. Bilateral reversal was possible in all but two patients. The operation time ranged from 95 to 155 min and all patients were discharged in the following morning after surgery. After 3 months, tubal patency was confirmed in 15 patients (15/23). Pregnancy rate was 56.5% (13/23), without ectopic pregnancies. The average time from tubal reversal and pregnancy was 6 months. CONCLUSIONS: In selected cases, laparoscopic tubal reversal can be offered to patients who had been submitted to tubal sterilization and desire new pregnancies. Patient selection as well as meticulous surgical technique are key factors in achieving satisfactory pregnancy rates.     

The relative chance of pregnancy following tubal or uterine transfer procedures

In a 7-month study period, a total of 113 pregnancies were generated in 380 women (30%) undergoing transfers in one of four assisted conception procedures: gamete intrafallopian transfer (GIFT), pronuclear stage tubal transfer (PROST), tubal embryo stage transfer (TEST), and in vitro fertilization and embryo transfer (IVF-ET). It was shown that both the pregnancy rate per transfer procedure and the number of pregnancy sacs arising per embryo transferred were significantly higher among the groups having tubal transfer (P less than 0.001). There were no significant differences in the pregnancy or implantation rates among the three groups having tubal transfer procedures when the GIFT results were adjusted for a 72% fertilization rate noted in the combined IVF-ET and PROST groups. Early pregnancy wastage showed a similar pattern among the four groups and, overall, 67% of pregnancies advanced beyond 20 weeks.     

Early pregnancy wastage after gamete manipulation

The outcome of 1034 pregnancies in women who conceived after referral for infertility management in seven treatment groups is detailed. The mean early pregnancy wastage (before 20 weeks gestation) was 27% and ranged from 18% after AID (artificial insemination by donor semen) to 33% after IVF-ET (in-vitro fertilization and embryo transfer). These differences were not due to maternal age which was similar in all groups (means between 29.7 and 32.7 years). Excluding the AID group, there was a high rate of ectopic pregnancy which was significantly higher after GIFT (gamete intrafallopian transfer) and was only partly related to underlying tubal disease. Blighted ova was the main category of early pregnancy loss and was highest after AIH (artificial insemination by husband's semen). There was a higher rate of biochemical pregnancies after GIFT, PROST (pronuclear stage tubal transfer) and IVF-ET. Our findings confirm a high pregnancy wastage rate in subfertile women and highlight deficiencies in the sperm separation, gamete handling and IVF/embryo culture techniques.     

Ectopic pregnancy: its relationship to tubal reconstructive surgery

Ectopic pregnancy is the shady companion of tubal surgery. Among patients with ectopic pregnancy, relatively few have a history of tubal surgery as their underlying etiologic factor when compared with other etiologies such as PID. Nevertheless, a history of tubal surgery should place the patient at a higher-risk group for ectopic pregnancy; 3% to 20% of these patients will encounter an ectopic pregnancy after the corrective surgery. The incidence of ectopic pregnancy after tubal surgery is extremely variable and is closely linked to the degree of restoration of normal functional and anatomic integrity after the surgical procedure. This depends, to a large extent, on the amount of previous damage to the tube and its potential reversibility. Major improvements in surgical technique can, therefore, have reduced, but not eliminated, the occurrence of tubal pregnancy. The incidence of ectopic pregnancy associated with any given tubal surgical procedure should be taken into consideration when surgery is contemplated. When the risk of ectopic pregnancy is unacceptably high, or when the patient is reluctant to be exposed to a high risk of ectopic pregnancy, IVF-ET could be offered as an alternative. Table 11 represents the incidence of ectopic pregnancy associated with the various surgical procedures. The figures demonstrate the wide variation in outcome for the same procedure.     

Bilateral tubal and twin pregnancies in Ile-Ife, Nigeria

Three cases of unilateral tubal twin pregnancies and four cases of simultaneous bilateral tubal pregnancy recorded in a Nigerian University Teaching Hospital were reviewed. The incidences were 1 in 68 and 1 in 51 ectopic pregnancies respectively. High twinning rates within the environment and tubal damage from pelvic infections were considered as possible etiologic factors.     

Rare presentation of ectopic pregnancy following IVF-ET: live twin gestation in the same fallopian tube

We report a case of a twin ectopic pregnancy (EP) after in vitro fertilization and embryo transfer (IVF-ET). A 24-year-old nulligravida presented with lower abdominal pain and vaginal bleeding 4 weeks after embryo transfer. Serum β-HCG levels were 40 IU/mL, 90 IU/mL, and 1970 IU/mL on ET days 12, 14, and 23, respectively. Ultrasound examination revealed two ectopic gestational sacs with fetal heart beats in the left adnexa, without evidence of intrauterine pregnancy. At laparoscopy, one isthmic and another ampullary sac were detected in the left tube and left salpingectomy was performed. The patient was discharged healthy on postoperative day 2. Albeit extremely rare, ectopic pregnancies with abnormal presentation can be encountered following IVF-ET. Single embryo transfer may be advised to protect from ectopic pregnancies after IVF-ET.     

Economic Evaluation of in vitro Fertilization-Embryo Transfer (IVF-ET) and Neosalpingostomy for Bilateral Tubal Obstruction

Objectives: to determine the reproductive outcome and estimate the cost for a Jive birth after a single IVF-ET cycle and neosalpingostomy via laparotomy or laparoscopy in patients with bilateral tubal obstruction.Design: retrospective review of medical records.Setting: tertiary reproductive medicine university institute.Patients: three cohorts of infertility patients, treated for bilateral tubal obstruction were compared. Thirty-seven patients with bilateral distal tubal obstruction were treated between July 1990 and July 1994 with laparoscopic bilateral neosalpingostomy using a Coherent ultra-pulse CO₂ laser. Seventy-two patients with bilateral distal tubal obstruction had undergone neosalpingostomy prior to July 1990 by laparotomy, using the CO₂ laser and microsurgical techniques. One hundred and twenty-seven patients with all forms of bilateral tubal obstruction were treated with a single cycle of IVF-ET in the same institute between July 1990 and December 1994. The three groups were comparable in female age and length of infertility.Results: the live birth rate was 19 percent (14 of 72), 22 percent (8 of 37) and 19 percent (24 of 127), and the ectopic pregnancy rate was seven percent (5 of 72), eight percent (3 of 37) and three percent (4 of 127) for the laparotomy, laparoscopy and IVF-ET cycle groups, respectively. The estimated cost for alive birth was $10,497 following laparoscopy, while it was $29,532 and $28,300 following laparotomy and IVF-ET, respectively.Conclusions: the reproductive performance following bilateral laparoscopic neosalpingostomy is at least equal to the pregnancy rate following neosalpingostomy via laparotomy and a single IVF-ET cycle. The least expensive live birth is associated with laparoscopic neosalpingostomy.     

体外受精-胚胎移植后宫内妊娠并发输卵管残端出血——2例临床分析

目的:探讨因输卵管积液等行腹腔镜下绝育术后助孕、宫内成功妊娠而并发输卵管残端出血的病因及预治。方法:回顾性分析2例宫内妊娠并发输卵管残端出血患者的临床资料。结果:2例患者经腹腔镜手术止血成功,并保住了宫内胎儿,获得满意的治疗效果。结论:宫内妊娠并发输卵管残端出血原因可能与前次腹腔镜绝育术中不恰当的电凝导致残端组织愈合不良、宫角受损未予成形缝合以及手术器械使用不当等有关,应采用恰当的手术方式加以防范。     

Treatment-independent, treatment-associated, and pregnancies after additional therapy in a program of in vitro fertilization and embryo transfer

Although the technique of in vitro fertilization and embryo transfer (IVF-ET) was developed for couples with untreatable tubal factor infertility, IVF-ET is now being applied to women with other causes of infertility and normal pelvic anatomy. In an effort to determine the treatment-independent pregnancy rate, we retrospectively reviewed the first 245 couples enrolled in the IVF-ET program at Duke University Medical Center. There were 19 treatment-independent pregnancies in 18 women and 3 treatment-associated pregnancies in cycles in which the oocyte retrieval was canceled (in 2 women washed intrauterine insemination was substituted for oocyte retrieval). Six pregnancies were established after an unsuccessful attempt at IVF-ET with additional non-IVF-ET therapy, including washed intrauterine insemination in three couples, and donor insemination in two couples. These observations suggest that a significant number of treatment-independent pregnancies will occur in couples clinically deemed appropriate for IVF-ET, pregnancies can be established in cycles of controlled hyperstimulation without oocyte retrieval, and additional non-IVF-ET therapy can result in pregnancy despite failure of IVF-ET in selected couples.