Pregnancy: Heterotopic abdominal pregnancy following in-vitro fertilization/embryo transfer presenting as massive lower gastrointestinal bleeding

We present a case that, as far as we know, is the first reportof lower gastrointestinal haemorrhage as a complication of heterotopicpregnancy induced by artificial reproductive technology. Theheterotopic abdominal pregnancy caused erosion of the intestinalwall and massive rectal bleeding, 8 weeks after in-vitro fertilization/embryotransfer. The source of the bleeding could not be identifieddespite comprehensive investigation including gastroscopy, ultra-sonography,sigmoidoscopy, ⁹⁹Tc (technetium) scanning and angiography. Tagged-erythrocyteisotope scanning revealed an abnormal concentration in the leftlower quadrant, compatible with active bleeding in the areaof the terminal ileum. Laparotomy disclosed a heterotopic abdominalpregnancy, causing erosion of the intestinal wall at this site.As assisted reproductive technologies become more and more commonthis rare complication of intestinal erosion should be keptin mind in cases of lower gastrointestinal bleeding.     

Pregnancy: Heterotopic pregnancies after in-vitro fertilization and embryo transfer

A total of 20 cases of heterotopic pregnancy were encounteredamong 2650 clinical pregnancies (0.75%) resulting from in-vitrofertilization/embryo transfer at Bourn Hall Clinic (Cambridge,UK) during the period July 1984-July 1993. The aetiology ofheterotopic pregnancy in the series is multifactorial, withtubal damage as the main factor. Transvaginal ultrasonographyshowed a high sensitivity for making correct diagnoses of heterotopicpregnancies compared with transabdominal ultrasonography (93.3versus 50.0%). The mean plasma human chorionic gonadotrophin(HCG) concentration on day 13 after embryo transfer was similarto those of uncomplicated intrauterine pregnancies and hencewas of no diagnostic value. The serial plasma HCG concentrationsof patients who delivered were significantly higher than forthose who aborted their intrauterine pregnancies (P < 0.01),although the sample of data available was too small to makefirm inferences. It does appear that serial HCG concentrationsmay have a predictive value of fair accuracy regarding the outcomeof the intrauterine pregnancy in heterotopic pregnancies. Theclinical presentations of the 20 cases at first examinationwere quite variable, with 45% (9/20) of patients asymptomatic.Tubal pregnancy in one patient resolved spontaneously, two caseswere treated by an injection of potassium chloride into thegestational sac and the remaining 17 cases were treated by salpingectomy.In 10 patients the intrauterine pregnancy resulted in live birthand the remaining 10 patients aborted spontaneously.     

Spontaneous bilateral cornual uterine dehiscence early in the second trimester after bilateral laparoscopic salpingectomy and in-vitro fertilization: case report.

A bilateral cornual uterine dehiscence is reported, which occurred 14 weeks after in-vitro fertilization (IVF) in a patient having a medical history of previous bilateral salpingectomy via laparoscopy. Uterine rupture is a rare obstetric complication usually occurring during the third trimester of pregnancy within a uterus which has previously undergone an operation. Ectopic pregnancy is a well known complication of IVF. Post-salpingectomy cornual localization with rupture has also been published. Possible causes are discussed and the attention of the counselling physician is directed to the necessary awareness of such a complication in this high risk population. The reported case is an extreme rarity: a similar case has not been previously published in the literature.     

Delivery rates after in-vitro fertilization following bilateral salpingectomy due to hydrosalpinges: a case control study.

This retrospective case-control study assessed the impact of bilateral salpingectomy due to uni- or bilateral hydrosalpinges on the outcome of in-vitro fertilization (IVF) in a large consecutive series of patients. The effect of bilateral salpingectomy due to hydrosalpinges on pregnancy outcome was compared in 139 patients (263 cycles) and 139 age-matched controls with tubal infertility without hydrosalpinges (296 cycles). The delivery rates per initiated cycle as well as the implantation rates were equal in the two groups (21.7 versus 21.6% and 19 versus 21%). The number of embryos, the cleavage stage, and the embryo morphology score were equal in the two groups. Among 92 patients treated with 182 IVF cycles who underwent salpingectomy between 1.5 and 5 years prior to their first IVF cycle, the delivery and the implantation rates were 22.5 and 20.5% respectively. Of the patients with salpingectomy after an average of 1.7 failed IVF cycles and who re-entered the IVF programme 3 and 6 months subsequent to surgery, 47 were treated with 83 IVF cycles. The live birth and the implantation rates after surgery in this group were 20.5 and 20% respectively. It is concluded that bilateral salpingectomy due to hydrosalpinges restores a normal delivery as well as implantation rate after IVF treatment compared to controls. A favourable outcome is also found in patients operated on after repeated IVF failures. Furthermore, a normal live birth rate as well as a high implantation rate is maintained for at least three IVF cycles subsequent to surgical treatment.     

Pregnancy: The prediction of ectopic pregnancy after in-vitro fertilization and embryo transfer

Data from 135 patients who suffered ectopic pregnancies andfrom 135 patients who progressed to singleton deliveries afterin-vitro fertilization and embryo transfer have been analysedretrospectively. The ectopic pregnancies represent all suchcases observed at Bourn Hall Clinic between 1983 and 1993. Thedelivered group was randomly selected from the same time period.The ectopic pregnancies included 20 heterotopic, eight ovarianand six bilateral tubal pregnancies; the remainder were singletontubal pregnancies. The aim of this study was to identify thevariables which differed systematically for the two groups ofpatients and to explore whether such variables could be usedto predict ectopic pregnancy at an early stage. The mean plasmaconcentration of human chorionic gonadotrophin and progesteronefor the ectopic pregnancy group was significantly lower thanthat for the singleton delivery group (P < 0.001). However,there was such a degree of overlap that it was impossible todevise a cut-off concentration for either hormone which wouldoffer a clinically useful predictor of ectopic pregnancy. Nevertheless,using the discriminant function analysis of these data, togetherwith the history of pelvic inflammatory disease, we could predictup to 90% of cases of ectopic pregnancy by day 23 after embryotransfer, long before ultrasound imaging would be useful.     

Uterine rupture in first or second trimester of pregnancy after in-vitro fertilization and embryo transfer

We report five cases of early rupture of cornual pregnancy withhistory of previous salpingectomy and cornual resection followingin-vitro fertilization (IVF) and embryo transfer. We discussthe predisposing factors, diagnostic and therapeutic modalitiesin these patients. A high index of suspicion is required foran early diagnosis. It is imperative that the physicians whocare for the patients be fully aware of the possibility of sucha complication in a high risk population; therefore, appropriatecounselling and close follow-up might help to avoid such obstetricalcatastrophes, by termination of pregnancy, either surgicallyor medically.     

Advanced heterotopic pregnancy after in-vitro fertilization and embryo transfer, with survival of both the babies and the mother.

A combination of an extra-uterine and an intra-uterine pregnancy is defined as heterotopic pregnancy. An infertile patient, pregnant at her fourth in-vitro fertilization/embryo transfer attempt, was diagnosed at 21 weeks' gestation as having simultaneous abdominal and intra-uterine pregnancy. Expectant management under strict hospitalization was proposed and accepted by the couple, fetal assessment was by serial ultrasound evaluation of growth and amniotic fluid volume and by non-stress tests. Planned operative delivery was accomplished at 34 weeks' gestation. Both the mother and infants are alive and well.     

Multiple pregnancy after in-vitro fertilization and embryo transfer: report of a quadruplet pregnancy and delivery

The first baby from in-vitro fertilization (IVF) was born in England in 1978 as a result of retrieval of a single preovulatory oocyte in the course of a natural cycle (Steptoe and Edwards, 1978). At present most programmes of IVF throughout the world do not use natural cycles producing only one oocyte, but rather multiple oocyte cycles produced by clomiphene citrate (CC), human menopausal gonadotrophin (HMG), or pure follicle stimulating hormone (FSH), either separately or in combination, sequentially or concomitantly, for the induction of multiple follicular maturation.     

Pregnancy: Intramural pregnancy following difficult embryo transfer

We report an intramural pregnancy following a difficult embryotransfer in a 31 year-old woman, having in-vitro fertilizationand embryo transfer for tubal factor infertility. The creationof a ‘false passage’ at a previous instrumentationof the cervix may be implicated in the ectopic placement ofembryos     

Heterotopic pregnancy after IVF-ET: report of a case and a review of the literature

A case of heterotopic, intrauterine and tubal ectopic pregnancy is reported, following in-vitro fertilization and transfer of four 4-cell embryos. The literature on the subject is reviewed and the possible aetiological factors, as well as the clinical essentials for early pre-operative diagnosis are discussed.     

Simultaneous rupturing heterotopic pregnancy and acute appendicitis in an in-vitro fertilization twin pregnancy

The presentation of acute abdominal pain in young women is not an unusual occurrence in casualty and gynaecology departments. Both acute appendicitis and ectopic pregnancy have to be considered and investigated, as these two conditions are accepted as the most common surgical causes of an acute abdomen. Difficulties in correctly identifying the cause of the pain can be hazardous to the patient and care needs to be taken in obtaining a prompt and accurate diagnosis enabling the most appropriate management. The case report presented here describes the extremely unusual occurrence of both these acute conditions happening simultaneously with the added complication of an ongoing twin pregnancy and it highlights the need to look beyond the most obvious diagnosis and always to expect the unexpected.     

Heterotopic triplet pregnancy: report of a case with bilateral tubal pregnancy and an intrauterine pregnancy

The first report of an ectopic pregnancy following IVF was published in 1976, and since then heterotopic pregnancies (HPs) have been reported at an increasing rate. Although cases of the co-existence of a bilateral tubal and an intrauterine pregnancy following IVF-embryo transfer have been reported, a case of heterotopic triplet pregnancy caused by unilateral tubal embryo transfer has not yet been published in the literature. Here we report on a 38-year-old women (gravida 3, para 1) with a history of infertility who presented to our infertility clinic for evaluation. Hysterosalpingography revealed bilaterally patent Fallopian tubes and stricture of the cervical canal. She conceived after receiving HMG combined with pure FSH, followed by IVF-tubal embryo transfer. Four embryos were replaced into the right tube. Approximately 5 weeks after tubal embryo transfer, the patient presented with lower abdominal tenderness and shock due to internal bleeding. She underwent an emergency laparotomy under the impression of HP. Bilateral tubal pregnancy with right tubal rupture was noted during the operation. The post-operative course was uneventful. Early intervention and thorough inspection of the peritoneal cavity in patients with haemodynamic instability can prevent jeopardizing the life of the mother as well as the ongoing pregnancy.     

Heterotopic pregnancies after in-vitro fertilization and embryo transfer--a Danish survey

Thirteen cases of heterotopic pregnancy were diagnosed among1171 pregnancies established in Denmark after in-vitro fertilizationand embryo transfer (IVF-ET). Thus the frequency of heterotopicpregnancy was 13/1171 or 1.1%. In five cases the diagnosis ofheterotopic pregnancy was made by ultrasound at 6–9 weeksof gestation; three of these patients were asymptomatic, whiletwo patients presented with abdominal pain and vaginal bleeding.All these patients had an unruptured ectopic pregnancy. Eightcases were diagnosed at the time of surgery; all these patientspresented with abdominal pain. Only two of the 13 patients hadvaginal bleeding. In nine of the 13 cases the intra-uterinepregnancy resulted in term delivery, while one pregnancy isongoing. In pregnancies following IVF-ET, this diagnosis shouldparticularly be considered in cases with abdominal pain; vaginalbleeding may be absent. Ultrasound examination may lead to earlydiagnosis even in asymptomatic cases. In most cases, removalof the ectopic gestation will allow the intrauterine pregnancyto proceed to term.     

Consecutive triplet pregnancies following in-vitro fertilization and embryo transfer. Two case reports

The number of multiple pregnancies has been increasing as a result of the relatively widespread use of drugs for induction of ovulation and assisted conception techniques. This paper details the first reported cases of triplet pregnancies occurring in consecutive IVF cycles in two patients.     

Twin pregnancy with a complete hydatidiform mole and co-existing fetus following in-vitro fertilization: case report.

Hydatidiform mole with a co-existing live fetus is a rare event. We report the case of a 41 year old Caucasian woman who attended for in-vitro fertilization. Three embryos, containing two apparently normal pronuclei, were transferred into the uterus. A twin pregnancy with a live fetus and a complete mole ensued. The pregnancy was managed conservatively until 28 weeks gestation when, following an episode of major antepartum haemorrhage, a live female infant was delivered by Caesarean section. The mole, weighing over 1.7 kg, was successfully evacuated. Following delivery, serum human chorionic gonadotrophin concentrations returned to baseline and remain within the normal range at 24 months. Both mother and daughter are well on assessment 24 months later.     

Simultaneous intrauterine and ectopic pregnancies following in-vitro fertilization and gamete intra-fallopian transfer. A review of nine cases

This paper reports nine cases of simultaneous intrauterine and ectopic pregnancies which followed in-vitro fertilization (three cases) and gamete intra-Fallopian transfer (six cases). The ectopic pregnancies were treated by aspiration and injection of potassium chloride and methotrexate (five cases), salpingectomy (three cases) or laparoscopic evacuation (one case). In five of the nine patients the intrauterine pregnancies continued until after the 35th week and the patients delivered live infants. The role of vaginal ultrasound scanning in making the diagnosis was emphasized. The literature on heterotropic pregnancy is reviewed.     

Broad ligament twin pregnancy following in-vitro fertilization

We report the first case of an ectopic twin pregnancy in the broad ligament following in-vitro fertilization and embryo transfer in a patient with a previous ipsilateral (left) salpingo-oophorectomy. The previous surgery was for endometriosis. We discuss the possible contribution of the embryo transfer technique, limitations of preventive measures and importance of transvaginal ultrasound in establishing the diagnosis.     

Infertility: Assessments of embryo transfer after in-vitro fertilization: effects of glyceryl trinitrate

The role of embryo transfer and its associated difficultieson the outcome of human in-vitro fertilization (IVF) were examinedusing a standardized procedure and a scoring system (embryotransfer scores 1–5). This system was used to assess anyeffects of the smooth muscle relaxant glyceryl trinitrate (GTN)on embryo transfer. Patients (n = 120) were randomized in adouble-blind manner at their first embryo transfer to receivesublingual GTN or placebo before the transfer. Retrospectiveanalysis showed that higher pregnancy rates were associatedwith uncomplicated transfers (score 1; P < 0.01). The outcomemeasures included pregnancy rate, total time of cervical manipulation(embryo transfer time) and embryo transfer score. All pregnancieshad a transfer score of 1 or 2, but no recorded parameter differentiatedbetween pregnant or non-pregnant cycles, and GTN had no significanteffect on any parameter.     

Ovarian hyperstimulation syndrome and benign intracranial hypertension in pregnancy after in-vitro fertilization and embryo transfer: case report.

Ovarian hyperstimulation syndrome (OHSS) is a dangerous and sometimes life-threatening complication of ovulation induction with exogenous gonadotrophins. While many complications of severe OHSS are recognized we have only identified one review detailing neurological problems. This report concerns a 32-year-old patient with bilateral tubal blockage who achieved her first pregnancy following in-vitro fertilization (IVF) and embryo transfer. Shortly after embryo transfer she developed clinical signs of moderate OHSS with symptoms which were later diagnosed as benign intracranial hypertension (BIH). The BIH was treated effectively using repeated lumbar puncture and diuretics. Spontaneous labour and delivery occurred at 40 weeks' gestation. There was no neurological sequel and no recurrence of the BIH 2 years after the pregnancy. The possible link between OHSS and BIH is discussed as well as the risks of further pregnancy.     

Pregnancy: Endometrial ultrasonography as a predictor of pregnancy in an in-vitro fertilization programme

The endometrial pattern and thickness were analysed by ultrasonographyin 139 cycles stimulated for in-vitro fertilization (IVF) onthe day of administration of human chorionic gonadotrophin (HCG).A semi-programmed schedule based on the pill + clomiphene citrate+ human menopausal gonadotrophin (HMG) was used in all cycles.On the day of HCG administration, endometrial pattern and thicknesswere assessed with an Ultramark 4 (ATL) ultrasound equippedwith a 5 MHz vaginal probe. Endometrial pattern I (a ‘tripleline’multilayer) was observed in a total of 105 cycles (76%), andpattern II (fully homogeneous and hyperechogenic in relationto myometrial tissue) in 34 (24%). The incidence of clinicalpregnancy did not differ (P = 0.52) between the groups withendometrial patterns I (23.8%) and II (29.4%). Endometrial thicknesson the day of HCG administration in the group with pattern I(8.4 ± 1.9 mm) was similar (P = 0.96) to that observedin the group with pattern II (8.4 ± 2.0 mm). In addition,the endometrial thickness of the patients who became pregnant(8.0 ± 1.7 mm) did not differ (P = 0.15) from that ofwomen who did not achieve pregnancy (8.6 ± 2.0 mm). Theconclusion from the present data is that ultrasonographic analysisof endometrial thickness and refringency on the day of HCG administrationhad no predictive value for conception in IVF cycles.