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。     

Management strategies of heterotopic pregnancy following in vitro fertilization-embryo transfer

ObjectiveThe purpose of this study was to evaluate the efficiency and safety of different treatment modalities for heterotopic pregnancy (HP) in vitro fertilization-embryo transfer (IVF-ET) cycles to avoid influence on intrauterine pregnancy (IUP).Materials and methodsCases of HP (n = 90) were from the IVF/ICSI registry database at the Reproductive Hospital Affiliated to Shandong University. An additional 360 women were randomly selected as controls. The primary outcome to examine the risk factors, diagnostic modalities and the impact of different treatment modalities for HP.ResultsOur results showed that surgical treatment had a certain effect on improving the live-birth rate, although the effect was not statistically significant (87.9% vs. 70.8%, P = 0.055). The risk factors for HP included previous tubal surgery and hydrosalpinx. Fourteen days after embryo transfer, the serum levels of β-human chorionic gonadotropin (β-hCG) and estradiol (E2) were lower in the HP group than in the IUP group (P < 0.05). Furthermore, age and endometrial thickness showed a significant difference between the early abortion and the live-birth groups of HP.ConclusionsIn our retrospective study, we supported early surgical laparoscopic intervention to minimize the incidence of abortion of IUP, which resulted in a better live-birth rate. A history of ectopic pregnancy and previous tubal surgery may increase the risk of HP. Low levels of serum β-hCG and E2 on the 14th day after embryo transfer could indicate the incidence of HP.     

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.     

宫内宫颈复合妊娠一例

复合妊娠发病率低,临床表现缺乏特异性,与普通异位妊娠一样,可伴有腹痛、阴道不规则出血等,有的患者甚至没有任何症状,而且由于宫内妊娠囊的存在,易忽略异位妊娠囊,因此早期诊断困难,常误诊为早期流产。回顾重庆市妇幼保健院（我院）近5年移植周期数据（共41 596个移植周期）,仅2020年收治1例宫内妊娠合并宫颈妊娠患者。该患者既往有多次宫腔操作史,并多次行宫腔粘连分离术,新鲜周期因子宫内膜薄而取消移植,后来院行冻融胚胎移植助孕,解冻并移植卵裂期胚胎2枚,患者因移植术后反复阴道不规则出血就诊,早期急诊以“先兆流产”收入院行保胎治疗,后B超证实系宫内宫颈复合妊娠,患者保留宫内妊娠意愿强烈,遂行减胎术保守治疗（2次减胎术）,最终分娩1女活婴。本病例提示复合妊娠易漏诊和误诊,应尽早明确诊断,如病情稳定、孕周小,减胎术是一种有效的治疗手段。     

Laparoscopic surgery for heterotopic pregnancies: a case report and a brief review

A heterotopic pregnancy is in effect a multiple pregnancy with one or more intrauterine pregnancies coexisting with an ectopic pregnancy and is rarely spontaneous. With the increasing popularity of ovulation induction performed during assisted reproductive techniques, it will not be surprising to observe that this phenomenon has increased significantly. However, diagnosis is often delayed because of its rarity and difficulty. We report a case of a woman with a viable intrauterine pregnancy who had a complication of ovarian hyper-stimulation syndrome secondary to ovulation induction following in vitro fertilization and embryo transfer, but who, during hospitalization, presented with clinically progressive abdominal pain. An unruptured ectopic pregnancy of the right fallopian tube was diagnosed accidentally by laparoscopy and laparoscopic salpingectomy was immediately performed. Post-operative follow-up revealed that the intrauterine pregnancy continued normally. She delivered a normal female baby at 38 weeks of gestation. The promising neonatal outcome might suggest that laparoscopy might be safely performed to aid differential diagnosis in an uncertain condition during pregnancy: therefore, laparoscopic surgery might be an appropriate method to manage some carefully selected patients with HP. A brief review of the published literature on the role of laparoscopy in the diagnosis and management of heterotopic pregnancy is given.     

An unexpected quadruplet heterotopic pregnancy after bilateral salpingectomy and replacement of three embryos

OBJECTIVE: To report a case of combined intrauterine and interstitial twin pregnancies after bilateral salpingectomy and IVF with replacement of three embryos. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 31-year-old woman known to have bilateral salpingectomy for ectopic pregnancies who underwent IVF. INTERVENTION(S): Laparotomy. MAIN OUTCOME MEASURE(S): Postoperation intrauterine monozygotic twins survival and birth. RESULT(S): After removing the interstitial monozygotic twin pregnancy, the patient had an uneventful postoperative course and delivered two healthy girls by cesarean section at 38 weeks' gestation. CONCLUSION(S): Heterotopic pregnancy can still occur in women treated by IVF after bilateral salpingectomy. The early sonography follow-up of IVF pregnancy would be of value because of the reported higher incidence of pathological pregnancies and especially monozygotic twinning.     

Uncomplicated pregnancy and normal singleton delivery after surgical excision of heterotopic (cornual) pregnancy following in vitro fertilization/embryo transfer

A 39 year-old woman with previous salpingectomy developed a symptomatic heterotopic right cornual pregnancy identified by transvaginal ultrasonography at six weeks’ gestation. The patient had previously undergone an ipsilateral partial salpingectomy, and the conception was established four months later after one cycle of controlled ovarian hyperstimulation, in vitro fertilization (IVF) and embryo transfer. We performed immediate surgical excision of the ectopic implantation with conservation of the intrauterine pregnancy. Progesterone was administered as 200 mg/d lozenge (troche) plus 200 mg/d rectal suppository, maintained from day of embryo transfer through the perioperative period and until 11th gestational week. Following an uneventful obstetrical course, a healthy male infant was delivered by cesarean at term. In this report, we review the incidence and significance of heterotopic gestation in the context of IVF/embryo transfer. Risk factors for complex intra- and extra-uterine pregnancies are also outlined. Additionally, the clinical management of heterotopic pregnancy, including a novel approach to progesterone supplementation, is discussed. Received: 14 August 2001 / Accepted: 25 September 2001     

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。     

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。     

体外受精 - 胚胎移植后异位妊娠的危险因素、诊断及治疗

目的　探讨体外受精 -胚胎移植 (IVF-ET)后异位妊娠 (EP)的危险因素、诊断及治疗方法。方法　对我院 1992年 10月～ 2 0 0 2年 6月接受体外受精-胚胎移植治疗 (包括单精子胞浆内注射 ,ICSI)后 82 1例临床妊娠中 38例异位妊娠进行回顾性分析。结果　IVF -ET后异位妊娠的发生率 4 6 % ,多胚胎不同部位妊娠(HP)的发生率 0 6 %。异位妊娠组取卵数明显多于对照组。单因素分析发现异位妊娠史、盆腔炎性疾病 (PID)史是IVF-ET后异位妊娠的危险因素。结论　盆腔炎性疾病史、异位妊娠史是IVF -ET后异位妊娠的高危因素。胚胎移植后妇女激素水平可能与异位妊娠的发生相关 ,但需进一步的研究证实。早期诊断和微创性治疗 ,减少异位妊娠的并发症和死亡率     

Very early pregnancy wastage in in vitro fertilization and embryo transfer (IVF-ET)

The occurrence and incidence of early pregnancy wastage in an in vitro fertilization and embryo transfer (IVF-ET) program have been studied in 750 patients. In 297 (39.6%) a pregnancy was diagnosed; of these, 14.8% were biochemical and 24.8%, clinical pregnancies. In the latter group 23.6% aborted, while 75.8% had clinical ongoing pregnancies. The mean embryo quality score of the biochemical pregnancy group was similar to that of the clinical ongoing pregnancy group but statistically different from that of the clinical abortion group (P<0.005). Furthermore, the clinical ongoing pregnancy rate in women with previous biochemical pregnancy was 24.7%, a significantly higher percentage compared to clinical ongoing pregnancies achieved in IVF-ET cycles (P<0.05). It is possible that biochemical pregnancy does not represent an index for infertility but rather an intact stage of reproduction leading toward implantation. The high clinical pregnancy rate in subsequent cycles may probably serve as an encouraging sign or a marker for future clinical pregnancy.     

The significance of plasma progesterone levels during early pregnancies achieved after in vitro fertilization (IVF) treatment

Objective Corpus luteum steroidogenesis is lower for in vivo ectopic pregnancy than for intrauterine pregnancy. There is a progesterone hallmark level distinguishing between viable intrauterine pregnancy and nonviable or ectopic pregnancy. This study attempts to answer whether this is also true for in vitro fertilization-treated patients. Study Design Using information retrieved from a computerized database, we compared the plasma 17Β-estradiol (E ₂) and progesterone during the luteal phase and for every 2 to 3 days for several weeks during early pregnancy between those patients with proven ectopic pregnancies and those with singleton and multiple intrauterine pregnancies. Vaginal ultrasonography to detect an intrauterine gestational sac was performed from day 19. A total of 73 pregnancies resulted from the replacement of fresh embryos in our in vitro fertilization-embryo transfer program. Results Only at day 10 post embryo transfer did those patients with ectopic pregnancy show statistically lower mean (SD) serum levels of E ₂ [2257 (SD, 2351) pmol/L] and plasma progesterone [PP; 221 (SD, 283) nmol/L] compared with patients with intrauterine pregnancy, whose mean E₂ was 8846 (SD, 5871) pmol/Land mean PP was 805 (SD, 582) nmol/L (P=0.008). For the rest of the follow-up until surgery was performed in ectopic pregnancy, there were no differences of statistical significance between extrauterine pregnancy and the intrauterine pregnancy groups. Furthermore, only on day 10 post embryo transfer, did we find a discriminatory zone (confidence interval, 95%) for E ₂ levels (903 to 3502 pmol/L for EP vs 6116 to 9493 pmol/L for a singleton and 4875 to 9493 pmol/L for multiple pregnancies). PP levels were 26 to 283 nmol/L for ectopic pregnancy versus 496 to 1096 nmol/L for both singleton and multiple pregnancies. An intrauterine gestational sac was visualized at a mean of 23.2 (SD, 4) days after embryo transfer. On this day, the mean P levels were 982.6 (SD, 286.2) nmol/L for intrauterine and 804.5 (SD, 502.4) nmol/L for ectopic pregnancies (P=NS. Conclusions Except for day 10 post embryo transfer, the steroidogenesis in ectopic pregnancy after in vitro fertilization treatment does not differ from successful intrauterine pregnancy. This observation negates an impaired steroidogenesis for ectopic pregnancy after in vitro fertilization and makes the PP level irrelevant in the diagnosis of pregnancy implantation.     

Heterotopic Quadruplet Pregnancy After ICSI Conception

Background

Heterotopic pregnancy (HP) is a condition characterized by the coexistence of multiple fetuses at two or more implantation sites. It occurs in 1% of pregnancies after assisted reproductive techniques (ART). Presence of triplet intrauterine pregnancy with ectopic gestational sac is one of the rarest forms of HP. Ectopic pregnancy is implanted in the ampullary segment of the fallopian tube in 80% of cases. Most of the patients present with acute abdominal symptoms due to rupture of the tube.

Case Presentation

This article reports a case of quadruplet heterotopic pregnancy after intracytoplasmic sperm injection (ICSI) with an ampullary ectopic pregnancy and intrauterine triplet pregnancies. The ruptured ampullary pregnancy was emergently managed by right salpingectomy. This was followed by embryo reduction at 12 + 6 weeks and successful outcome of intrauterine twin pregnancy.

     

Concomitant abdominal and intrauterine pregnancy after in vitro fertilization in a woman with bilateral salpingectomy. A case report

BACKGROUND: Abdominal pregnancy is a rare event, and the concomitant presence of an intrauterine pregnancy is very exceptional. CASE: A case of concomitant abdominal and intrauterine pregnancy following in vitro fertilization and embryo transfer (IVF-ET) occurred in a woman with bilateral salpingectomy. The abdominal pregnancy was successfully treated surgically, with preservation of the intrauterine pregnancy. CONCLUSION: A careful ultrasound examination should be performed on women who have undergone IVF-ET, and the possibility of abdominal pregnancy should be kept in mind in the differential diagnosis of acute abdomen.     

体外受精-胚胎移植术后复合妊娠研究进展

复合妊娠（heterotopic pregnancy,HP）是一种极其危险的异位妊娠,自然受孕者中HP的发生率并不高,但随着近年体外受精-胚胎移植（in vitro fertilization and embryo transfer,IVF-ET）术以及促排卵技术的普及,HP的发生率较前有所上升。HP患者早期一般仅有腹痛、阴道出血等非特异性症状,且由于宫内妊娠囊的存在使得宫外妊娠囊特别容易误诊和漏诊,从而易导致患者宫外妊娠囊继续发展,引起腹腔内大出血甚至休克等危及生命的严重后果。因此,充分了解HP的相关危险因素,在行ET术或促排卵技术前采取相应的预防HP发生的措施、发生HP后尽早进行确诊及确诊后采取有效的治疗对改善患者的预后显得尤为重要。综述近年IVF-ET后HP的诊断及管理措施进展。     

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.     

Heterotopic pregnancy after in vitro fertilization-embryo transfer.

OBJECTIVE: A ruptured cornual pregnancy is a rare and challenging problem. We present two cases of cornual pregnancies after in vitro fertilization and embryo transfer (IVF-ET) treated by cornual resection, with an excellent perinatal outcome for the intrauterine pregnancy in both cases. A literature review of cornual pregnancy after IVF-ET is also included. CASE REPORTS: Two women had undergone IVF-ET because of tubal problems. Emergent laparotomy was performed because of internal bleeding at 12 weeks of gestation in one case and 17 weeks in the other, and in both cases, ruptured cornual pregnancies were found. Cornual resection and primary repair were performed. The women were discharged on the 6th and 7th postoperative day, respectively, and they underwent an elective cesarean delivery at 37 weeks of pregnancy. They were delivered of healthy babies, one weighing 2700 g and the other 2310 g. CONCLUSION: These cases illustrate that good perinatal outcomes can be achieved by surgical intervention in heterotopic pregnancies, even in the event of a ruptured cornu.     

体外受精-胚胎移植术后宫内外同时妊娠32例临床分析

目的:探讨宫内外同时妊娠(HP)的发生率、危险因素、诊断、治疗方式及预后。方法:回顾分析2013年1月至2015年12月南京大学医学院附属鼓楼医院妇产科收治的32例HP患者的临床资料。结果:我院体外受精-胚胎移植(IVF-ET)术后HP的发生率为1.54%(32/2076);HP患者均行IVF-ET,且均移植胚胎两枚,合并输卵管疾病者占71.88%(23/32);经阴道超声诊断正确率为84.38%(27/32);29例要求保留宫内妊娠,患者的保胎成功率为82.76%(24/29),其中保守治疗、减胎治疗、腹腔镜手术、开腹手术保胎成功率分别为80.00%(4/5)、100%(3/3)、83.33%(5/6)、80.00%(12/15);各种治疗方法的保胎成功率无统计学差异(P>0.05)。结论:输卵管病变、IVF-ET是HP的主要危险因素;经阴道超声对诊断有意义;手术治疗是主流的治疗方法;HP患者预后较好。     

Cornual Suture at the Time of Laparoscopic Salpingectomy Reduces the Incidence of Interstitial Pregnancy after In Vitro Fertilization

Study Objective

To investigate the effect of cornual suture at the time of laparoscopic salpingectomy on the incidence of interstitial pregnancy (IP) after in vitro fertilization (IVF).

Simultaneous bilateral tubal pregnancies after in vitro fertilization and embryo transfer: report of a case.

Ectopic pregnancies continue to be a major complication of in vitro fertilization and embryo transfer (IVF-ET). A case of bilateral simultaneous tubal pregnancy after IVF-ET is described. The patient underwent ovum pick-up (OPU) through a laparotomy with concomitant pelvic surgery. Embryo transfer (ET) was performed two days after OPU; this resulted in bilateral tubal pregnancies, diagnosed and treated one month apart. There are several possible causal mechanisms for the increased rate of ectopic pregnancies following IVF-ET. It is important to recognize that care in the transfer technique, with respect to the catheter position and limiting the volume of transfer medium to 20 microL, and an awareness of previous occlusion of the tubal ostia, or of a salpingectomy before IVF-ET, can help to minimize this complication rate. Two important points are the possibility of a simultaneous bilateral tubal pregnancy after IVF-ET, and the necessity of carefully examining both adnexa at the time of surgery for an ectopic pregnancy. Early and accurate diagnosis of a simultaneous bilateral ectopic pregnancy can prevent the necessity of a second operation and reduce maternal morbidity and mortality.