Severe ovarian hyperstimulation syndrome and combined intrauterine and tubal pregnancy after in-vitro fertilization and embryo transfer

Ovarian hyperstimulation syndrome (OHSS) and hetero-topic pregnancyare two well recognized entities occurring after in-vitro fertilization(TVF). This is the first reported case of a severe OHSS andcoexistent heterotopic pregnancy after FVF and embryo transfer.Diagnosis of tubal pregnancy was obscured both by stimulatedovaries which prevented accurate ultrasound definition and thecoexistence of an intrauterine pregnancy which accounted forhuman chorionic gonadotropbin (HCG) concentrations and alsofor aggravation of the OHSS. The roles of transvaginal ultrasound,diagnostic laparoscopy and early paracentesis in the managementof this rare complication of assisted reproductive technologiesare discussed.     

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.     

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     

Pregnancy: Combined intra-uterine and extra-uterine pregnancy in the contralateral tube after gamete intra-Fallopian transfer

A case of combined intra-uterine and contralateral tubal pregnancyafter gamete intra-Fallopian transfer (GIFT) is presented. Laparotomywith partial tubal resection was performed after tubal rupture.The intra-uterine pregnancy is still ongoing without complications.Heterotopic pregnancies are dangerous conditions for the patientand should be taken into account after transfer of multipleoocytes. To our knowledge this is the first report of a heterotopicpregnancy in the contralateral tube after GIFT.     

Rare association of ovarian implantation site for patients with heterotopic and with primary ectopic pregnancies after ICSI and blastocyst transfer

Two cases of patients with ruptured ovarian pregnancies (P1 = ovarian heterotopic and P2 = primary ovarian ectopic) after intracytoplasmic sperm injection and blastocyst transfer are presented. Laparoscopy was performed on day 40 and day 27 after transfer in cases P1 and P2 respectively. In both cases the ectopic pregnancies were located on the left ovary and were successfully removed by laparoscopy preserving the ovaries. In case P1 the intrauterine pregnancy was not affected. A healthy boy was born after 37 weeks of pregnancy. In this way, potential fertility of the patients and the intrauterine pregnancy were maintained. These cases occurred during a series of blastocyst transfers in which 129 pregnancies were obtained. There were no cases of ovarian ectopic/heterotopic pregnancies from January 1996 to September 1999 in 814 pregnancies obtained from day 2 or day 3 embryo transfers. Because the ovarian ectopic pregnancies occurred in patients with day 5 embryo transfer who otherwise did not have any predisposing factors for ectopic pregnancy, it is advisable to conduct a large scale analysis of future data about the possible association between blastocyst-stage embryo transfer and the somewhat higher risk of unexpected complications of clinical outcome.     

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.     

Rare ectopic pregnancies after in-vitro fertilization: one unilateral twin and four bilateral tubal pregnancies

Between 1985 and 1989, one unilateral twin and four bilateral tubal pregnancies were encountered among 124 extrauterine pregnancies and 1648 intrauterine pregnancies following in-vitro fertilization and embryo transfer. The two factors associated with this high incidence of single and multiple extrauterine pregnancies were tubal damage and multiple embryo transfer. Embryos at different stages of development appear to have the capacity to implant ectopically. Despite advances in diagnostic capabilities, ectopic pregnancy remains a major cause of maternal mortality. Early diagnosis prior to rupture must be made if mortality and morbidity are to be abolished. The use of transvaginal sonography has improved the diagnosis of ectopic pregnancy and should be routinely used in all pregnancies following assisted conception. The identification of an intrauterine pregnancy should not be sufficient to rule out the possibility of an extrauterine pregnancy or even bilateral tubal pregnancies.     

Successful non-surgical management of a heterotopic abdominal pregnancy following embryo transfer with cryopreserved-thawed embryos.

Heterotopic pregnancy is an increasingly common complication of assisted reproductive technology. Abdominal pregnancy is a rare and life-threatening form of ectopic pregnancy that can present as the extrauterine portion of a heterotopic pregnancy. We present the case of a cryopreserved-thawed embryo transfer that resulted in a simultaneous intrauterine and abdominal pregnancy first recognized at 10 weeks gestation. Ultrasound-guided transvaginal injection of potassium chloride into the abdominal pregnancy resulted in asystole and spontaneous resorption of the ectopic fetus, while the intrauterine pregnancy continued and resulted in a liveborn vaginal delivery at full term. Selective embryo reduction using a non-surgical approach in a haemodynamically stable patient can therefore be considered in the management of heterotopic abdominal pregnancy if diagnosed relatively early.     

Heterotopic Caesarean scar pregnancy combined with intrauterine pregnancy successfully treated with embryo aspiration for selective embryo reduction: case report

Ectopic pregnancy situated in a Caesarean section scar is a rare but potentially life-threatening event. Because of its rarity, there are no universal treatment guidelines to manage this condition. We report a case of IVF-induced triplet heterotopic pregnancy of early gestational age that included one Caesarean scar pregnancy diagnosed as early as 6 weeks gestation. Treatment with embryo aspiration under vaginal ultrasonography for selective embryo reduction was given and the concurrent intrauterine twin pregnancy was preserved successfully.     

An unexpected triplet heterotopic pregnancy after replacement of two embryos

We report a case of a triplet heterotopic pregnancy consisting of an intrauterine monozygous twin pregnancy and a tubal pregnancy after replacement of only two embryos in an in-vitro fertilization cycle with donor spermatozoa. This case demonstrates that sonographic demonstration of two intrauterine pregnancies after transfer of two embryos does not exclude the presence of an ectopic pregnancy. As both heterotopic pregnancy and spontaneous monozygotic twinning are more frequent after the use of assisted reproductive techniques, this combination, although extremely rare, must be kept in mind, especially in older patients with pre-existing tubal damage.      

Comparative analysis of pregnancy rates after the transfer of early dividing embryos versus slower dividing embryos

BACKGROUND: We compared retrospectively the pregnancy outcome in two subgroups of ICSI patients, using early division (26 h post injection) to the 2-cell stage as a criterion for embryo quality and viability (ability to produce a pregnancy). METHODS AND RESULTS: In the early dividing embryo (EDE) group, at least one of the transferred embryos was early dividing. In the late dividing embryo (LDE) group, no early dividing embryo was transferred. Additionally, tubal and uterine transfer in the two groups was also evaluated. Clinical pregnancy rates in the EDE group were significantly increased when compared with that in the LDE group (41.3 versus 20.0%). This was also true for ongoing pregnancy rates (33.3 versus 16.3%). The tubal transfer route showed increased (but not significant) ongoing pregnancy rates when compared with uterine transfer in both EDE (38.5 versus 25.0%) and LDE (22.7 versus 8.3%) groups respectively. In uterine transfer cycles, however, clinical pregnancy rates for EDE were significantly increased compared to LDE (37.5 and 11.1% respectively). The baby rate (number of live babies/embryos transferred) was also significantly increased in the EDE group and the tubal transfer group. Statistical analysis of pregnancy outcome, adjusted for the total number of embryos transferred (expressed as percentage risk difference - %RD), resulted significantly in favour of EDE compared to LDE (RD = 18%, P = 0.02). When adjusted for the combined factors: total number of embryos transferred, EDE and LDE, the pregnancy outcome result was significantly in favour of tubal transfer compared to uterine transfer (RD = 15%, P = 0.05). Pregnancy results of the LDE group only were significantly better in the tube compared to the uterus (RD = 19%, P = 0.04) but not significantly so for the EDE group (RD = 10%, P = 0.4). CONCLUSION: Early division is associated with embryo quality and a very easy and successful embryo transfer selection method. Our results also suggest that when EDE are available, both tubal and uterine embryo transfer can be considered. When only LDE are available, however, tubal transfer should be the preferred transfer route.     

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.     

Pregnancy: Heterotopic pregnancy obtained after in-vitro fertilization and embryo transfer following bilateral total salpingectomy: case report

Heterotopic (coexistent ectopic and intra-uterine) pregnancyis common following in-vitro fertilization and multiple embryotransfer. Total bilateral salpingectomy is generally consideredto eliminate the risk of ectopic, and hence heterotopic pregnancy.This is, however, not strictly correct as it does not eliminatethe risk of interstitial tubal pregnancy. This is the firstreported case of a heterotopic pregnancy following total bilateralsalpingectomy. The diagnostic pitfalls and a suggested methodof avoiding them are discussed.     

Heterotopic pregnancy associated with gamete intra-fallopian transfer.

Recent reports in the literature have focused on the increased risk of heterotopic pregnancy after the transfer of multiple concepti or oocytes. In an international collaborative patient registry between 1985 and 1989, 601 clinical pregnancies resulted from 2092 gamete intra-Fallopian transfer (GIFT) retrieval cycles. Five of the pregnancies were heterotopic (0.83%). After surgical intervention, all five cases of combined gestation resulted in live birth from intrauterine pregnancies. Routine vaginal ultrasonographic examination of the adnexa in patients who conceive after GIFT may help early diagnosis of heterotopic pregnancy. If the diagnosis is made early, conservative treatment may preserve the future fecundity of the patient and more intrauterine pregnancies may be salvaged.     

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.     

Ectopic pregnancy in the ampulla of the fallopian tube at 16 gestational weeks: lessons from a case report

BackgroundIt is uncommon to find ampullary tubal pregnancy in the second trimester.MethodsA 35-year-old G4P3 at 16 gestational weeks presented with a day history of sudden severe lower abdominal pain and no vaginal bleeding. The patient had a normal pulse of 82/minutes, haemoglobin concentration of 6.3 g/dl and ultrasonography showed an empty uterus with an alive fetus in the right adnexa. She was provisionally diagnosed to have an abdominal pregnancy.ResultsThe patient had an emergency laparotomy where 2.2 L of haemoperitoneum and a slow-leaking right ampullary tubal pregnancy were found. Right total salpingectomy was performed and she had an uncomplicated post-operative follow-up. Histology of the lesion confirmed tubal pregnancy.ConclusionThe growth of a pregnancy in the ampulla beyond the first trimester is possibly due to increased thickness and or distensibility of the fallopian tube. A tubal pregnancy may present with a normal pulse despite significant haemorrhage.     

Pregnancy: Analysis of the risk factors with regard to the occurrence of ectopic pregnancy after medically assisted procreation

In a retrospective study (1985–1989) based on data fromthe Centre for Reproductive Medicine in Brussels, a total of23 ectopic pregnancies (2.24%) occurred after 3800 embryo, zygoteor gamete transfers. This number was low compared with the datapublished elsewhere. Tubal damage was a major risk factor towardsdeveloping an ectopic pregnancy after in-vitro fertilizationand embryo transfer. The number of ectopic pregnancies afterthe association of clomiphene citrate and human menopausal gonadotrophin(HMG) was significantly higher in patients with tubal (7.8%)and non-tubal indications (2.1%) compared with those stimulatedwith gonadotrophin-releasing hormone (GnRH) and HMG (2.18% and0.84%, respectively). The number of replaced embryos was notassociated with the rate of ectopic pregnancy and neither didtransfer technique (intra-uterine or intra-Fallopian transfer)influence the ectopic pregnancy rate.     

CASE REPORT: Continuation of a donor oocyte pregnancy in a functionally agonadal patient without early oestrogen support

A 40 year old functionally agonadal patient was the recipientof fertilized donated oocytes. She accidentally discontinuedall oestrogen support on the day preceding embryo transfer untilit was reinstated 12 days later. However, a pregnancy was establishedand resulted in the birth of healthy normal twin infants. Thiscase report suggests that minimal amounts, if any, of oestradiolare sufficient to maintain an early pregnancy, provided adequateamounts of progesterone are given. This is consistent with arecent study conducted in subhuman primates.     

Spontaneous resolution of ectopic pregnancy in a surrogate after oocyte donation and frozen embryo transfer

A case of tubal pregnancy in a young and healthy woman participatingin a programme of in-vitro fertilization (IVF) gestational surrogacyis reported. The gestational surrogate was the 30 year old fertilesister of a 25 year old patient affected by stage 1 ovariancancer. After mandatory oncological consultation, the donorwas recommended to prospectively undergo controlled ovarianhyperstimulation cycles for embryo banking before being treatedby total hysterectomy. Available embryos were cryopreservedand after adequate endometrial preparation using artificialcycles of hormone replacement therapy, three thawed frozen embryoswere transferred to the surrogate. At 17 days following embryotransfer the surrogate was noted to have a negative -human chorionicgonadotrophin (HCG) serum concentration. All medication wassuspended and a few days later normal menstrual bleeding occurred.After 2 weeks, the (-HCG concentrations, performed as part ofroutine follow-up evaluation, were showing signs of trophoblastactivity (236 mIU/ml). Taking into account the stable conditionof the patient, a decision was made to undertake expectant managementAt 43 days after embryo transfer, a complete tubal abortionwas apparently seen in the posterior cul-de-sac by ultrasoundassociated with a subtle and short lasting pelvic pain. We stressthat this ectopic gestation was able to maintain prolonged viabilityin conditions of absent corpus luteum and exogenous steroidsupplementation.     

Simultaneous bilateral tubal pregnancy after intracytoplasmic sperm injection

Since the advent of assisted reproductive technology, the concernabout ectopic implantation of embryos has increased dramatically.Simultaneous bilateral tubal pregnancy is the least common typeof ectopic implantation of two embryos. In this report we presentthe first case of simultaneous bilateral tubal pregnancy afterintracytoplasmic sperm injection (ICSI) and embryo transfertreatment. The present case had no risk factor for ectopic pregnancy.Therefore, for early diagnosis and management of such cases,close clinical follow-up and routine ultrasonography followingICSI are necessary.