Heterotopic pregnancy from in vitro fertilization

A case of heterotopic or combined intrauterine and tubal ectopic pregnancy is described following in vitro fertilization and the transfer of five four-cell embryos. The phenomenon is known to be related to ovarian stimulation by gonadotropin therapy, and there is an increased risk with underlying tubal disease. This patient had both variables. Techniques applied at the time of embryo transfer are also implicated, namely, the use of culture medium with 50% maternal serum to convey the embryos to the uterus, the catheterization method, and the position of the patient during transfer.     

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.     

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.     

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.     

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).     

Heterotopic triplet pregnancy: report of a patient with remnant tubal ectopic and intrauterine twin pregnancy after frozen-thawed embryo transfer

A case of heterotopic triplet pregnancy after frozen-thawed embryo transfer is presented. The patient conceived after transfer of three frozen-thawed embryos at a fertility clinic where she had previously undergone laparoscopic left salpingectomy due to pyosalpinx. Approximately 4 weeks after the embryo transfer, she presented with a complaint of abnormal genital bleeding and was diagnosed by ultrasound as having a dichorionic twin pregnancy. One week later, she was referred to our hospital because of lower abdominal pain. Hematoperitoneum was suspected based on findings of low blood pressure and tachycardia. Diagnostic emergent laparoscopy demonstrated an ectopic pregnancy in the remnant isthmic portion of the left tube. Laparoscopic excision of the remnant fallopian tube was performed, but the procedure resulted in early-pregnancy loss of one of the twins. The risk of heterotopic pregnancy is not small under assisted reproductive technology. Attention should be paid to the risk of tubal pregnancy after transferring more than two embryos or controlled ovarian hyperstimulation, even after salpingectomy has been performed.     

Bilateral ectopic pregnancy after transfer of two embryos

OBJECTIVE: To report a case of bilateral tubal ectopic pregnancy (EP) after the transfer of two embryos. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 43-year-old multigravida with bilateral tubal pregnancy. INTERVENTION(S): Operative laparoscopy with right linear salpingostomy and left salpingectomy. MAIN OUTCOME MEASURE(S): Laparoscopy revealed an unruptured left isthmic tubal EP and an unruptured right ampullary tubal EP. RESULT(S): Pathology confirmed immature placental villi in the right tube and placental tissue in the left tube. The patient was discharged home without incident on the day after surgery. CONCLUSION(S): This is a rare case of bilateral tubal pregnancy after the transfer of only two embryos. It is critical to perform a close inspection of the abdomen, pelvis, and contralateral tube after surgery for EP.     

Normal Term Intra-uterine Pregnancy in a Nulliparous Patient After 3 Consecutive Ectopic (Tubal) Pregnancies

Summary: A case of normal term intra-uterine pregnancy in a nulliparous patient after 3 consecutive ectopic (tubal) pregnancies is presented.     

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.     

Ovarian heterotopic pregnancy after IVF and contralateral tubal ectopic pregnancy after GIFT.

One case of ovarian ectopic associated with twin intrauterine viable pregnancy after in vitro fertilization, and one case of contralateral tubal ectopic pregnancy after gamete intra fallopian transfer performed with normal fallopian tubes, are reported. The possible pathogenesis and the management are discussed. The risk of ectopic pregnancy after assisted conception can be present even when the fallopian tubes are apparently normal.     

Ectopic pregnancy with postcoital contraception – a case report

The incidence of ectopic pregnancies is increasing. Common risk factors are tubal pathology, previous tubal surgery, previous ectopic pregnancy, intrauterine device use and embryo transfer. Levonelle-2^®, a progesterone-only postcoital contraceptive works by a combination of mechanisms including ovulation inhibition, prevention of fertilization, and inhibition of implantation. It is 85% effective and there have been 12 reported cases of ectopic pregnancy in the UK with its use. It is believed that progesterone slows the intratubal migration of the fertilized ovum. In the case reported here, a woman presented with an ectopic pregnancy after use of Levonelle-2 as postcoital contraception; there were no clinical predisposing risk factors. In the absence of any histological evidence of tubal damage, we suspect that the levonorgestrel from Levonelle-2 could have been responsible for delayed embryo transfer which resulted in the ectopic pregnancy.     

Ectopic pregnancy with postcoital contraception--a case report.

The incidence of ectopic pregnancies is increasing. Common risk factors are tubal pathology, previous tubal surgery, previous ectopic pregnancy, intrauterine device use and embryo transfer. Levonelle-2, a progesterone-only postcoital contraceptive works by a combination of mechanisms including ovulation inhibition, prevention of fertilization, and inhibition of implantation. It is 85% effective and there have been 12 reported cases of ectopic pregnancy in the UK with its use. It is believed that progesterone slows the intratubal migration of the fertilized ovum. In the case reported here, a woman presented with an ectopic pregnancy after use of Levonelle-2 as postcoital contraception; there were no clinical predisposing risk factors. In the absence of any histological evidence of tubal damage, we suspect that the levonorgestrel from Levonelle-2 could have been responsible for delayed embryo transfer which resulted in the ectopic pregnancy.     

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)     

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.     

Haemoperitoneum Complicating a Case of Combined Intra- and Extra-uterine Pregnancy at 25 Weeks of Gestation

Summary: A case is described of massive haemoperitoneum complicating a normal 25-week intra-uterine pregnancy. The source of the bleeding was a coexisting tubal ectopic gestation.     

Heterotopic pregnancy (triplets) following in vitro fertilisation: case report

We report a patient who had in vitro fertilization for secondary infertility due to tubal disease. Following transfer of three embryos, a twin intrauterine and a tubal ectopic pregnancy resulted (heterotopic pregnancy). Received: December 1998 / Accepted: 22 December 1998     

Improved fertility following conservative surgical treatment of ectopic pregnancy

Objective To evaluate fertility after salpingectomy or tubotomy for ectopic pregnancy.
Design Retrospective cohort study.
Setting Clinical University Center, Hvidovre Hospital, Copenhagen.
Population Two hundred and seventy-six women undergoing salpingectomy or tubotomy for their first ectopic pregnancy between January 1992 and January 1999 and who actively attempted to conceive were followed for a minimum of 18 months.
Methods Retrospective cohort study combined with questionnaire to compare reproductive outcome following salpingectomy or tubotomy for ectopic pregnancy. Cummulative probabilities of pregnancy for each group were calculated by the Kaplan-Meier estimator and compared by Cox regression analysis to control for potential confounders.
Main outcome measures Intrauterine pregnancy rates and recurrence rates of ectopic pregnancy after surgery for ectopic pregnancy.
Results The cumulative intrauterine pregnancy rate was significantly higher after tubotomy (88%) than after salpingectomy (66%) (log rank   P < 0.05  ) after correction for confounding factors. No difference was found in the recurrence rate of ectopic pregnancy between the treatments (16% vs 17%). In patients with contralateral tubal pathology, the chance of pregnancy was poor (hazard ratio 0.463) and the risk of recurrence was high (hazard ratio 2.25), assessed with Cox regression. The rate of persistent ectopic pregnancy was 8%.
Conclusion Conservative surgery is superior to radical surgery at preserving fertility. Conservative surgery is not followed by an increased risk of repeat ectopic pregnancy, but by the risk of persistent ectopic pregnancy, which should be taken into account when deciding on the operative procedure. Management in case of contralateral tubal pathology is disputed and should ideally be addressed in a randomised clinical trial.     

Twin heterotopic pregnancy after assisted reproduction. A case report

BACKGROUND: Heterotopic pregnancy is a potentially catastrophic form of ectopic pregnancy and is increasing in incidence secondary to assisted reproductive technology. Early diagnosis and intervention are important in avoiding short- and long-term morbidity. CASE: A 36-year-old, nulliparous woman became pregnant by in vitro fertilization and embryo transfer. A total of three embryos were transferred. She presented to the emergency room approximately six weeks after transfer with the complaint of severe abdominal pain. Laboratory analysis revealed a decreasing hematocrit with stable vital signs despite continued abdominal pain. On transvaginal ultrasound, two fetal poles were present, with cardiac activity in two of the three gestational sacs. At surgery the patient was found to have a ruptured tubal pregnancy in addition to the intrauterine gestations. Pathologic analysis revealed a twin tubal pregnancy. CONCLUSION: Heterotopic pregnancy should be considered in the differential diagnosis of any patient who becomes pregnant by assisted reproduction techniques and presents with signs and symptoms of ectopic pregnancy.     

The fallopian tube and reproductive health.

The fallopian tube is the essential link between the ovary and the uterus. Its transport mechanisms are now reasonably well understood and include orderly ovum transfer by the fimbria, and ovum/preembryo retention, with transport to the uterus on the third postovulatory day. Sperm/tube interaction ensures a reservoir and storage/activation system at the tubal isthmus. Ovum/tube interaction is driven by the HCO3 ion in the tubal secretions, which also supply pyruvate and other essential substances to the preembryo. Tubal function may be impaired/destroyed by salpingitis, a peritubal disease resulting from ruptured appendix, endometriosis, and ectopic pregnancy (often the result of prior tubal damage with partial occlusion or luminal adhesions). Prophylactic measures include counseling the patient on how to avoid sexually transmitted disease or inhibition of upward ascent of bacteria, and, in the case of ectopic pregnancy, how to use the most efficient contraceptive measures. The least intrusive transfer methods are helpful in avoiding tubal pregnancy following embryo transfer after in vitro fertilization, and results are improved by pretreatment removal of hydrosalpinges. Among adolescents, efforts should be made to preserve tubal function and to increase awareness of the importance of avoiding tubal disease with an eye to preserving future reproductive capacity.     

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.