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.     

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.     

Heterotopic trigeminal pregnancy in infertile women after ovulation stimulation and embolisation of a uterine myoma

Heterotopic pregnancy is a simultaneous occurrence of intra-uterine pregnancy and ectopic pregnancy. The incidence of ectopic pregnancy has increased as a consequence of assisted reproduction and ovulation stimulation agents. In this report, we describe the case of a 34-year-old nulliparous woman who became pregnant after ovulation induction with clomiphene. According to her gynaecologic history, she had embolisation of a uterine myoma. The report presents a case of ectopic and twin intra-uterine pregnancy. After total laparoscopic salpingectomy, she had normal intra-uterine pregnancy.     

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.     

The influence of uterine position on pregnancy rates with in vitro fertilization-embryo transfer

Summary We found no difference in clinical pregnancy rates following IVF-ET in women with anteverted versus retroverted uteri. Patients can be reassured that the probability of clinical pregnancy following IVF-ET is not compromised by uterine position.     

Heterotopic pregnancy following ovulation induction by clomiphene citrate and timed intercourse: a case report

We report a combined intra-uterine and unruptured tubal pregnancy following ovulation induction by clomiphene citrate (CC) and timed intercourse. The diagnosis of heterotopic pregnancy (HP) is the major problem until occurrence of tubal rupture. Because HP is a life-threatening condition, the diagnosis should be made as soon as possible. In a spontaneous conception, HP is a rare event. The risk of HP significantly increases after ovulation induction. Clomiphene itself could be associated with a high HP rate. We present a case with normally developing intra-uterine singleton pregnancy succesfully managed by salpingectomy of synchronous tubal pregnancy following ovulation induction by CC and a review of the literature.     

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 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).     

Bilateral Ovarian Pregnancy After in Vitro Fertilization and Embryo Transfer in a Patient with Tubal Factor Infertility

Primary ovarian pregnancy is very rare event after natural pregnancy or assisted reproductive technology (ART) procedures. Although there are a few reports about unilateral ovarian pregnancy after in vitro fertilization and embryo transfer (IVF-ET), there has been no report about bilateral ovarian pregnancy. Moreover, it is difficult to diagnose an ovarian pregnancy following in vitro fertilization and embryo transfer because of enlarged ovary, fluid collection in pelvic cavity, and its low incidence. We present a case of a patient who underwent IVF-ET due to tubal factor infertility, but the patient developed bilateral ovarian pregnancy and was performed both ovarian wedge resection through laparotomy.     

Results of prednisolone given to improve the outcome of in vitro fertilization-embryo transfer in women with antinuclear antibodies

OBJECTIVE: To evaluate the association of antinuclear antibodies (ANA) with outcome of in vitro fertilization-embryo transfer (IVF-ET) as well as the effect of short-term immunosuppression with prednisolone on implantation, clinical pregnancy and live birth rates following IVF-ET. STUDY DESIGN: The study group consisted of 120 women, 22-42 years old, in whom IVF-ET was performed and whose ANA could be measured. Prednisolone (15-60 mg/d for 5 days) was administered starting 1 day after oocyte retrieval to some women with or without ANA, without randomization. The 223 IVF-ET cycles were divided into prednisolone-nontreated ANA-negative cycles, prednisolone-treated ANA-negative cycles, prednisolone-nontreated ANA-positive cycles and prednisolone-treated ANA-positive cycles. Retrospective analysis of rates of implantation, clinical pregnancy, and live birth were evaluated in the four groups. RESULTS: Overall, ANA positivity was noted in 20.0% of subjects (24/120) and 25.1% of cycles (56/223). Implantation and clinical pregnancy rates in the prednisolone-nontreated ANA-positive group were 0% (0/41 transplanted embryos) and 0% (0/15 cycles), significantly lower than in the other groups. The live birth rate in this group was significantly lower than in the prednisolone-nontreated ANA-negative group and non-significantly tended to be lower than in the other 2 CONCLUSION: Implantation, clinical pregnancy and live birth rates following IVF-ET were low when ANA was detected. Implantation and clinical pregnancy rates were improved significantly by prednisolone, but the live birth rate was not.     

Risk factors in ectopic pregnancy. Results of a population-based case-control study.

In a population-based case-control study, possible risk factors for ectopic pregnancy were compared in 119 patients with ectopic pregnancy and in 119 age-matched controls with intra-uterine pregnancy from each of the following categories: deliveries, spontaneous abortions and induced abortions. The following factors were found significantly more often in cases of ectopic pregnancy: a history of earlier ectopic pregnancy, a history of salpingitis, a history of earlier operation on the Fallopian tubes, a history of infertility, and a pregnancy that had occurred in spite of an intra-uterine contraceptive device. A history of appendectomy was also found significantly more often among the cases. There was no significant correlation between ectopic pregnancy and a history of no earlier pregnancy, earlier deliveries, earlier spontaneous or induced abortions or a history of other gynecological operations and increased risk of ectopic pregnancy. One or more of the risk factors were found in 76.5% of cases and 23% of controls.     

Delayed appearance of plasmatic chorionic gonadotropin in pregnancies after in vitro fertilization and embryo transfer

The detection of pregnancy through the rise of human chorionic gonadotropin hormone secretion, on maternal plasma level, has been studied in normally developed pregnancies following in vitro fertilization and embryo transfer (IVF-ET), and compared with two other groups of pregnancies, the first group being pregnancies following artificial insemination with donor semen (AID) in spontaneous cycles ("AID group") and the second group being pregnancies following in vivo fertilization in a stimulated cycle ("stimulated group"). The day of human chorionic gonadotropin detection level significant for pregnancy (Dd) has been first defined and then determined for each pregnancy. Thereafter, mean levels for Dd (Dd) have been compared for each pregnancy group. It has been found that in pregnancies following IVF-ET, Dd is 12.05 +/- 0.8 days after ovulatory stimulus, which is delayed in comparison with spontaneous cycle pregnancies (Dd = 9.5 +/- 1.0) and with stimulated cycle pregnancies (Dd = 8.0 +/- 1.5). The hypothesis to explain this observation is then discussed.     

Serum progesterone and human chorionic gonadotropin in very early pregnancy: implications for clinical management

We studied beta-human chorionic gonadotropin (beta-HCG) and progesterone (P) in maternal serum in 71 patients with a positive urine pregnancy test with a threshold of 50 U HCG/liter urine and an ultrasound examination without demonstrable fetal heart beat. Patients were divided into three groups: ongoing intra-uterine pregnancy of more than 12 weeks duration (n = 23), ectopic pregnancy (n = 14), and abnormal intra-uterine pregnancy (blighted ovum, early spontaneous abortion) resulting in dilatation and curettage (n = 34). We found that both beta-HCG and progesterone levels were significantly lower in abnormal pregnancies but that there was less overlap between the progesterone values in normal, ectopic and abnormal pregnancy as compared to beta-HCG levels. There was a positive correlation between beta-HCG levels less than 5000 mU/ml and serum progesterone in ectopic pregnancies but not in normal or abnormal intra-uterine pregnancies. The size of the gestational sac correlated with serum beta-HCG levels but not with serum progesterone levels in normal intra-uterine pregnancies. We conclude that serum progesterone levels (cut-off point 15 ng/ml) in very early pregnancy can be helpful to differentiate between normal intra-uterine pregnancy and abnormal intra-uterine or ectopic pregnancy.     

Intra-uterine adhesions and fertility outcome: how to optimize success?

PURPOSE OF REVIEW: To review the etiology, diagnosis, and clinical manifestations of intra-uterine adhesions and to address treatment with a specific focus on fertility outcome. RECENT FINDINGS: Intra-uterine adhesions can cause recurrent pregnancy loss and infertility. The gravid or recently postpartum uterus is particularly susceptible to adhesion formation following instrumentation. While sonohysterography and hysterosalpingography are useful as screening tests of intra-uterine adhesions, hysteroscopy remains the mainstay of diagnosis and treatment. Hysteroscopic lysis of adhesions with scissors, electrosurgery, or laser can restore the size and shape of the endometrial cavity. Significantly obliterated cavities may require multiple procedures to achieve a satisfactory anatomical result. Postoperative mechanical distention of the endometrial cavity and hormonal treatment to facilitate endometrial regrowth appear to decrease the high rate of adhesion reformation. Newer antiadhesive barriers may also prevent the recurrence of intra-uterine adhesions. Endometrial development can remain stunted due to a scant amount of residual functioning endometrium and fibrosis. Potential pregnancy complications, especially placenta accreta, after the treatment of intra-uterine adhesions should be anticipated and discussed with the patient. SUMMARY: Diagnosis and treatment of intra-uterine adhesions are integral to the optimization of fertility outcomes. Favorable results in terms of pregnancy and live birth rates can be expected after hysteroscopic adhesiolysis.     

Successful glucocorticoid treatment for patients with abnormal autoimmunity on in vitro fertilization and embryo transfer

Purpose: To analyze the effects of glucocorticoid treatment for patients with abnormal autoimmunity on IVF-ET outcomes, low-dose predonisolone or dexamethasone was administered in 51 IVF-ET cycles of 41 patients with positive antinuclear antibody (ANA), anti-DNA antibody, and/or lupus anticoagulant (LAC). Rates of clinical pregnancy and implantation in these patients were compared with those in 48 cycles without corticosteroid therapy. Autoantibody-negative patients were also treated with IVF-ET combined with (29 cycles) or without (57 cycles) glucocorticoid administration, and the pregnancy and implantation rates were investigated. Results: Without glucocorticoid treatment, the pregnancy rate per cycle and implantation rate per embryo in antibody-positive patients were 10.4 and 3.8%, respectively. Significant increases in pregnancy (35.3%) and implantation (13.2%) rates were observed with corticosteroid treatment. In antibody-negative patients, the rates of pregnancy and implantation showed no significant differences with versus without the glucocorticoid administration. Conclusions: Our results indicate that because autoimmune abnormalities may be at least one cause of implantation failure following IVF-ET, the combined use of low-dose corticosteroid can be effective for autoantibody-positive women.     

Endometriosis and infertility Surgery and ART: An integrated approach for successful management

OBJECTIVES: Laparoscopy is considered the gold standard for treatment of endometriosis. In vitro fertilization and embryo transfer (IVF-ET) is often used to treat women with infertility associated with endometriosis. The objective of the study was to evaluate the pregnancy rate after surgical treatment and to assess whether a combined approach with laparoscopic surgery followed by IVF-ET can improve the "overall" pregnancy rate. STUDY DESIGN: A retrospective observational study was carried out on 107 infertile patients who underwent laparoscopic surgery for endometriosis and came at follow-up for a period of time between 1 and 11 years. Sixty-seven patients who did not become pregnant after surgery subsequently underwent IVF-ET. RESULTS: The pregnancy rate achieved after the integrated laparoscopy-IVF approach was 56.1%. The pregnancy rate after surgery, was significantly lower (37.4%). The fecundity rate for spontaneous conceptions within 6 months of laparoscopy (23.2%) was significantly higher (P<0.05) than for the following intervals. The cumulative fecundity in women older than 35 years was significantly lower than in younger women. CONCLUSIONS: In patients with endometriosis-associated infertility, surgery followed by IVF-ET is more effective than surgery alone. When patients fail to conceive spontaneously, after a maximum of 1 year from laparoscopic surgery, IVF should be suggested.     

Fertility following conservative surgery for tubal pregnancy

Eighty seven conservative surgical interventions for unruptured tubal pregnancy were performed on 83 patients. Salpingotomy was performed in 66 cases and expression of tubal pregnancy in 21 cases. In this patient group, 76.7% (56 out of 73) experienced intra-uterine pregnancy following surgery and 71.2% (52 out of 73) had a live birth. The recurrence rate of tubal pregnancy was 12.3%. Of the 42 patients with a normal contralateral tube, 36 (85.7%) had an intra-uterine pregnancy, 80.9% had a live birth and 7.1% had a recurrent tubal pregnancy. Sixty percent of the patients who underwent operation on their single tube, had a live birth and 66.6% had an intra-uterine pregnancy; the recurrence of tubal pregnancy in this group was 26.6%. No recurrence of tubal pregnancy was found in the group of patients who underwent expression of tubal gestation. It is suggested that the expression of tubal gestation (milking) is a safe procedure for conserving future fertility, and that the indications for conservative surgical management in patients with unruptured tubal gestation should be broadened to include all patients interested in future pregnancies, regardless of the current state of the contralateral tube.     

The prediction of pregnancy failure by measurement of pregnancy-associated plasma protein A (PAPP-A) following in vitro fertilization and embryo transfer

Circulating PAPP-A was measured serially in five patients following successful IVF-ET. PAPP-A concentrations were consistently normal in all three patients in whom pregnancies progressed normally to term. Depressed levels of PAPP-A were observed in one patient who miscarried spontaneously at 17 weeks' gestation despite ultrasound evidence of normal fetal development. Circulating PAPP-A was not detected in the fifth patient, whose tubal pregnancy ruptured at 8 weeks. These data are discussed in relation to surveillance of pregnancies following 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.     

Heterotopic pregnancy following in vitro fertilization.

We report 4 cases of heterotopic pregnancy following in vitro fertilization. All 4 patients were treated by surgical removal of the ectopic pregnancy products. In 3 patients, the intra-uterine fetus was alive prior to surgery. Two of the 3 gave birth to a healthy baby while the third pregnancy has progressed uneventfully for 12 weeks since the operation.