Simultaneous ectopic pregnancy with intrauterine twin gestations after in vitro fertilization and embryo transfer

Effect of method of anesthesia on the reproductive and obstetric outcomes of heterotopic pregnancies

BACKGROUND

Anesthesia is commonly used for surgical termination of the extrauterine component of heterotopic pregnancy. We sought to evaluate the effects of general and regional anesthesia during salpingectomy on reproductive and obstetric outcomes of heterotopic pregnancies.

METHODS

A two-center, retrospective cohort study was conducted, and 49 heterotopic pregnancies were included. Baseline characteristics, reproductive and obstetric outcomes were compared between the general anesthesia and regional anesthesia groups.

RESULTS

Baseline characteristics were comparable for age, weeks of gestation at diagnosis, and duration of anesthesia. No significant difference was found in pregnancy outcome, perinatal outcome or neonatal weight (P >0.05). The rate of miscarriage in the general anesthesia group was 23.5% versus the regional anesthesia group 15.6% (P >0.05).

CONCLUSION

With respect to reproductive and obstetric outcomes, this retrospective study found no difference between general anesthesia and regional anesthesia used for early heterotopic pregnancy.

Heterotopic pregnancy following IVF-ET: successful treatment with salpingostomy under spinal anesthesia and continuation of intrauterine twin pregnancy

The extended use of assisted reproductive technologies is increasing the heterotopic pregnancies, leading to a potentially dangerous condition for the intrauterine pregnancy and the mother. We report a case of unruptured heterotopic pregnancy following IVF-ET at 6 weeks of gestation and the patient was treated with salpingostomy under spinal anesthesia. The intrauterine twin pregnancy course was uneventful with the delivery of healthy babies at 34th week by Cesarean section.

Heterotopic triplets: tubal ectopic and twin intrauterine pregnancy. A review of obstetric outcomes with a case report

INTRODUCTION

Heterotopic triplets hardly take place, but nowadays the extended use of assisted reproductive technologies is increasing the ectopic pregnancies rate and subsequently the heterotopic pregnancies, leading to a potentially dangerous condition for the woman and the intrauterine pregnancy.

MATERIAL AND METHODS

Fourteen cases previously reported in the literature of patients presenting an intrauterine twin pregnancy which became complicated by a tubal ectopic pregnancy have been reviewed. The case of a patient following a homologous intrauterine insemination treatment, resulting in live birth of both twins, is also described.

CONCLUSION

Although the diagnosis of heterotopic triplets with tubal ectopic is challenging, a timely surgical treatment will preserve intrauterine gestation with a great chance of a successful obstetric outcome for both twins.

Clinical Outcomes of Tubal Heterotopic Pregnancy: Assisted vs. Spontaneous Conceptions

BACKGROUND

It has not been established whether the clinical outcomes of tubal heterotopic pregnancy resulting from assisted conception are different to those of spontaneous conception. The aim of this study was to compare the clinical course and the outcome of intrauterine gestation following surgical treatment for tubal heterotopic pregnancy according to the method of pregnancy.

METHODS

Medical records of 13 cases of tubal heterotopic pregnancy experienced in Seoul National University Hospital during 1990-2004 and 30 case reports of tubal heterotopic pregnancy published in the Korean Journal of Obstetrics and Gynecology during 1980-2004 were reviewed retrospectively. The clinical outcomes were compared between the assisted (n = 23) and spontaneous conception groups (n = 20).

RESULTS

The assisted conception group had a significantly higher preoperative systolic blood pressure and a previous history of pelvic pathology. The spontaneous group had a higher incidence of tubal rupture and hemoperitoneum. The assisted conception group had a higher live birth rate than the spontaneous group (47.8 vs. 20%, p = 0.056).

CONCLUSIONS

In tubal heterotopic pregnancy, the assisted conception group had a more favorable clinical course and intrauterine gestation outcome following surgical treatment when compared with the spontaneous conception group.

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 uterine straightening by passive bladder distension before embryo transfer in IVF cycles

PURPOSE

The present study investigated the effect of bladder distension on in vitro fertilization and embryo transfer (IVF-ET) results.

METHODS

The study comprised 796 patients after successful transvaginal oocyte pickup and IVF, who, on the basis of bladder filling for ET, were divided into two groups. In group E, 385 patients underwent ET with an empty bladder, and in group F, 411 patients underwent ET with a full bladder.

RESULTS

Sixty-four pregnancies were achieved in group E (16.6%), compared to 110 pregnancies in group F (26.8%, P = 0.006). A similar pregnancy loss rate was observed in both groups, 13 in group E (20.3%) and 29 in group F (26.4%; P = NS).

CONCLUSIONS

A significantly higher pregnancy rate was achieved with routine bladder distension before ET, probably attributable to the smooth and easy insertion of the ET catheter.

Heterotopic pregnancy and assisted reproduction--an update

PURPOSE

Heterotopic pregnancy, an extremely rare event in the past, has become a common complication of assisted reproduction techniques.

METHODS AND RESULTS

This serious sequella of IVF/ET or GIFT is probably the result of ovarian hyperstimulation and the transfer of several embryos into the uterus or tubes of a preselected population suffering from mechanical infertility. The techniques and medium used for embryo transfer may also be involved. Delayed diagnosis resulting in rupture, hemorrhage, and emergency intervention with its serious consequences is being reported in nearly half of the cases.

CONCLUSIONS

The prognosis for a viable intrauterine pregnancy, however, is good, and these combined pregnancies have produced a living child in about 70% of cases. A High index of suspicion, repeated ultrasounds, and early intervention are mandatory to salvage the viable intrauterine pregnancy and avoid maternal mortality.

Heterotopic pregnancy after ovulation induction and assisted reproductive technologies: a literature review from 1971 to 1993

OBJECTIVE

To review and analyze records on heterotopic pregnancy occurring after ovulation induction and assisted reproductive technologies.

DATA IDENTIFICATION

Case reports in the English literature related to the topic were identified through a computerized bibliography search up to December 1993.

CONCLUSIONS

The incidence of heterotopic pregnancies increased in recent years because of the escalating use of new reproductive technologies in infertile patients and has stabilized at approximately 1:100 pregnancies with these procedures. The main reasons for development of such a condition in these patients are past tubal or pelvic disease and multiple ovulations or multiple ET. Progress has been made in diagnosis of heterotopic pregnancy during the last two decades, mainly because of development of ultrasonographic techniques, especially transvaginal ultrasonography. Treatment of heterotopic pregnancy should be prompt to avoid maternal morbidity and mortality from extensive intraperitoneal bleeding. No increased intrauterine fetal mortality due to hemoperitoneum has been proven in the present review, except in advanced cornual pregnancies. More experience is needed for application of new treatment modalities such as salpingocentesis, which are used successfully for ectopic pregnancy, in treatment of heterotopic pregnancy. With early diagnosis and skillful treatment, the outcome of the intrauterine pregnancy is favorable and its survival rate should increase in the future.

In vitro fertilization versus tubal surgery: is pelvic reconstructive surgery obsolete?

OBJECTIVE

To compare the results of pelvic reconstructive surgery with cumulative success rates of IVF for couples with tubal factor infertility.

DATA RESOURCES

Outcomes of pelvic surgery were obtained from a review of articles from the literature identified by directed Medline searches. Cumulative pregnancy rates of 771 couples with tubal factor infertility treated at the Cornell IVF program between December 1989 and December 1992 were calculated by life-table analysis.

RESULTS

Overall delivery rate per transfer for patients with tubal factor was 28.9% (303 deliveries per 1,048 transfers) and did not appear to be affected significantly by the presence of a secondary diagnosis. A significant decline in pregnancy rates was observed with advancing age: age < 30 years, 48.4%; 30 to 34 years, 44%; 35 to 38 years, 28%; 39 to 40 years, 20%; 41 to 42 years, 9%; and > 42 years, 4.3%. Cumulative pregnancy rates for cycles 1 to 4 were 32%, 59%, 70%, and 77%, respectively, in patients with only tubal factor, and 28%, 55%, 62%, and 75% in patients with tubal combined with other associated infertility factors.

CONCLUSIONS

Our experience suggest that > 70% of women with tubal factor infertility will have a live birth within four cycles of treatment with IVF. These results compare favorably with the best outcomes after tubal reconstructive surgery. In older women, because of the rapid decline of fertility potential with advancing age, efforts should be directed toward the treatment method that provides the highest likelihood of success within the shortest time interval.

Heterotopic pregnancy following administration of human menopausal gonadotropin and following in vitro fertilization and embryo transfer: two case reports and review of the literature

We report two cases of heterotopic (combined intra- and extra-uterine) pregnancy in women treated for infertility. In the first case the patient conceived following administration of human menopausal gonadotropin. In the seventh week of gestation she had a spontaneous abortion and in the eighth week required urgent laparotomy for acute abdomen due to the rupture of pregnant right tube. In the second case the patient conceived from IVF-ET; in the eighth week a salpingectomy was made. The intrauterine pregnancy continued regularly until term and the patient was delivered of a healthy baby by caesarean section. We reviewed the literature and we found that heterotopic pregnancy is an insidious disease with a constant increase of incidence, especially in infertile women submitted to therapy for ovulation induction or assisted reproductive techniques. All the patients who have risk factors should be submitted to careful controls in early pregnancy, including an ultrasound transvaginal scan.

Ultrasound Evaluation of Heterotopic Pregnancy

Transabdominal ultrasound combined with transvaginal scanning is a valuable tool for the diagnosis of heterotopic pregnancies. A case of a concurrent intrauterine and extrauterine pregnancy is discussed. Also included is a discussion of the incidence, symptoms, and causes of heterotopic pregnancy, and the findings and treatments associated with ectopic pregnancies.

Ruptured ectopic pregnancy in a patient with a recent intrauterine abortion

The case of a 33-year-old woman who presented with abdominal pain referable to the lower abdomen is discussed. She had had an uncomplicated intrauterine abortive procedure two weeks earlier. It was determined that a ruptured ectopic pregnancy was the etiology of her abdominal pain. The rare phenomenon of combined intrauterine and extrauterine pregnancy is discussed.

Risk factors for ectopic pregnancy in 556 pregnancies after in vitro fertilization: implications for preventive management

OBJECTIVE

To analyze risk factors for ectopic pregnancy (EP) after in vitro fertilization (IVF).

DESIGN

A retrospective study of IVF pregnancies was performed between November 1983 and December 1989.

SETTING

This study was conducted in a tertiary care center, the Port-Royal University Hospital.

PATIENTS

Patients' records were reviewed for 48 EP and 508 intrauterine pregnancies obtained by IVF.

INTERVENTIONS

Forty-six salpingectomies were performed for EP after IVF.

MAIN OUTCOME MEASURE

We evaluated the impact on the ectopic rate of tubal status, the type of ovarian stimulation and luteal phase support, and the number of embryos transferred.

RESULTS

Forty-three of 48 EP occurred in patients with tubal infertility. The rate of EP was significantly higher when the indication was tubal (11.1%) than when it was endometriosis (2.1%) or unexplained infertility (3.4%). Pathological findings revealed tubal lesions in all 46 salpingectomies.

CONCLUSIONS

Ectopic pregnancy after IVF appears related to pre-existing tubal pathology. However, routine prophylactic salpingectomy to prevent the risk of EP does not appear justified.

Heterotopic pregnancies after in vitro fertilization and embryo transfer

Seventeen cases of heterotopic pregnancies are reported among 1648 clinical pregnancies after in vitro fertilization. The high prevalence of tubal damage among IVF patients and the use of superovulation and multiple embryo transfer might predispose patients to the condition. Nine patients reported abdominal pain and vaginal bleeding, five patients did not have symptoms, and three had acute abdominal emergencies. Transvaginal ultrasonography was superior to transabdominal ultrasonography in the diagnosis of extrauterine pregnancies. The presence of an intrauterine gestation sac in a patient without symptoms should not exclude the diagnosis of a concomitant extrauterine pregnancy until the pelvis is carefully visualized. Early diagnoses of viable ectopic pregnancies before rupture abolishes mortality and morbidity and offers the chance of patient selection for conservative treatment. In two patients the extrauterine gestation sac was treated by transvaginal aspiration and injection of potassium chloride under ultrasonographic guidance. The outcome of the intrauterine pregnancy was favorable regardless of the method of treatment of the ectopic pregnancy.

Combined intrauterine and tubal pregnancy after in vitro fertilization and embryo transfer

A case of combined intrauterine and tubal pregnancy after in vitro fertilization and embryo transfer is reported. As soon as the diagnosis was made at 9 weeks gestation, the fetal heart movement of the tubal pregnancy disappeared, and the patient was managed without surgery throughout the pregnancy course. After an infant was delivered, a right salpingectomy was performed and the diagnosis was histologically confirmed. Risk factors and treatments of combined pregnancy are discussed.

Bilateral tubal pregnancy with intra-uterine gestation after IVF-ET: therapy by bilateral laparoscopic salpingectomy; a case report

A patient with heterotopic (combined) pregnancies after IVF-ET was treated by bilateral laparoscopic salpingectomy. The patient was delivered of a healthy newborn in the 38th week of pregnancy.

Survival of the cornual pregnancy in a heterotopic gestation after in vitro fertilization and embryo transfer

We present a case of combined intrauterine and cornual (interstitial) pregnancy after IVF-ET, with survival of the infant after the cornual pregnancy. The diagnosis of this rare phenomenon is difficult; a high index of suspicion and frequently ultrasound monitoring may enable early diagnosis in other forms of heterotopic pregnancy. Although the benefits of IVF-ET far outweight the risks of ectopic pregnancy, it is imperative that physicians who care for these patients be fully aware of the possibility of such a complication in this high-risk population.

Heterotopic pregnancy associated with in vitro fertilization and embryo transfer: a possible role for routine vaginal ultrasound

A case of an asymptomatic heterotopic pregnancy resulting from IVF-ET and diagnosed by TVU is presented. Heterotopic pregnancy should be considered a risk of IVF-ET, and TVU may facilitate early diagnosis.

In vitro fertilization patient presenting in hemorrhagic shock caused by unsuspected heterotopic pregnancy

A 30-year-old woman who had undergone in vitro fertilization and embryo transfer (IVF-ET) presented to the emergency department in hemorrhagic shock 4 weeks after a spontaneous abortion. She was found to have a ruptured uterus caused by an unsuspected second pregnancy located in the cornual region of the uterus. Women undergoing IVF-ET are at a higher risk for multiple pregnancies, ectopic pregnancies, and heterotopic pregnancies.

Heterotopic pregnancy after in vitro fertilization and ovulatory drugs

We report two cases of heterotopic pregnancy in women who were previously infertile. One of these patients conceived with the aid of ovulation stimulatory drugs, and the other from in vitro fertilization. In each case an ultrasound of the pelvis revealed a viable intrauterine pregnancy (twins in one case). Both patients presented in hypovolemic shock and required exploratory laparotomy. At the time of surgery a ruptured ectopic pregnancy with accompanying hemoperitoneum was found in each. Simultaneous ectopic and intrauterine pregnancy, though rare, should be suspected in patients who conceive with the aid of ovulatory drugs or in vitro fertilization.

The rising incidence of heterotopic pregnancy: two case reports

Two cases of associated intrauterine and extrauterine pregnancy are presented. In the past combined pregnancy was thought to be a rare obstetric event, with an estimated theoretical incidence of one in 30,000 gestations. A review of the medical records of the Sint-Augustinus Hospital revealed 3 cases of combined pregnancy out of a total of 12,338 pregnancies during the 5-year period January 1981 to December 1985. These data confirm recent communications which state that literature concerning heterotopic gestations has greatly underestimated its rate of occurrence in Western countries. For patients who have been treated with ovulation-inducing medication, the theoretical risk is particularly substantial.

Heterotopic pregnancy after in vitro fertilization and embryo transfer

We have presented a second case of heterotopic pregnancy after IVF-ET. The most likely cause is direct extrusion of embryos through the tubal ostia by the hydrostatic pressure associated with ET. The diagnosis of ectopic pregnancy must be suspected clinically and not ruled out on the sonographic demonstration of an intrauterine pregnancy. Early diagnosis is essential for the prevention of significant maternal morbidity and mortality after IVF-ET.

An analysis of factors associated with ectopic pregnancy in a human in vitro fertilization program

Between 1980 and 1985, in Monash University in vitro fertilization (IVF) program, ectopic pregnancy occurred in 10 of 256 IVF pregnancies. The incidence of ectopic pregnancy between 1983 and 1984 was 4% of the total pregnancies, or 4.2% of pregnancies excluding biochemical pregnancies. The incidence of ectopic pregnancy was distributed equally across the infertility classifications (tubal, idiopathic, male factor, and mixed). There appeared to be no relationship between superovulatory methods, endocrine changes before egg recovery, laparoscopic procedures, embryo transfer procedures, and number of embryos transferred. Nine of the ten patients were classified as having either tubal factor infertility before IVF or chronic tubal inflammation, which probably existed at the time of embryo replacement. No ectopic pregnancies were recorded in the 33 pregnancies obtained with superovulation with the use of clomiphene citrate alone. We were unable to identify a major predisposing factor for ectopic pregnancy in IVF.