An association between clomiphene citrate and ectopic pregnancy: a preliminary report

Ectopic pregnancy in left ovary and contralateral uterine tube diagnosed one week apart in In Vitro Fertilization with donor eggs: Case report

Bilateral ectopic pregnancy is a rare clinical condition with an estimated prevalence of 1/200 000 in spontaneous pregnancies. Studies have found that In Vitro Fertilization (IVF) is related to ectopic pregnancy independently, but the incidence of tubal disease in the donor egg recipient population is thought to be significantly lower than in the standard IVF population. We report the case of a patient participating in the egg-sharing program, who was diagnosed with ovarian ectopic pregnancy, treated with surgery. After one week, she was diagnosed with tubal ectopic pregnancy in the contralateral tube. The clinician should be aware that the treatment of one ectopic pregnancy does not preclude the occurrence of a second ectopic pregnancy in the same patient and should pay attention to the intra-operatory inspection of both side fallopian tubes in any ectopic pregnancy case. Routine ultrasound after ectopic pregnancy treatment may be reasonable, especially in high risk patients.

Heterochronic bilateral ectopic pregnancy after ovulation induction

Ectopic pregnancy is identified with the widely-applied assisted reproductive technology (ART). Bilateral ectopic pregnancy is a rare form of ectopic pregnancy which is difficult to be diagnosed at the pre-operation stage. In this paper, we presented an unusual case of heterochronic bilateral ectopic pregnancy after stimulated intrauterine insemination (IUI), where there has been a delay of 22 d between the diagnoses of the two ectopic pregnancies. Literature was reviewed on the occurrence of bilateral ectopic pregnancy during the past four years in the MEDLINE database. We found 16 cases of bilateral ectopic pregnancy reported since 2008, and analyzed the characteristics of those cases of bilateral ectopic pregnancy. We emphasize that ovulation induction and other ARTs may increase the risk of bilateral ectopic pregnancy. Because of the difficulty in identification of bilateral ectopic pregnancy by ultrasonography, the clinician should be aware that the treatment of one ectopic pregnancy does not preclude the occurrence of a second ectopic pregnancy in the same patient and should pay attention to the intra-operation inspection of both side fallopian tubes in any ectopic pregnancy case.

Diagnosis and Management of Ectopic Pregnancy

Ectopic pregnancy remains to be an important cause of maternal morbidity and mortality worldwide, although the incidence has remained unchanged especially in developed countries over the last decade. Several factors are responsible for this, including misdiagnosis and failure to institute timely appropriate treatment aimed at preserving fertility and minimizing the associated morbidity. Recent advances in imaging and biomonitoring have reduced the number of women presenting with ruptured ectopic pregnancy. Any attempt to reduce the consequences of ectopic pregnancies must, therefore, focus on improving the diagnosis of the unruptured type and evidenced-based treatment, which is cost effective. In this review, the authors discuss the diagnosis and treatment of this complication in the light of the recent evidence highlighting how improvements can be made to reduce the consequences.

Current status of endoscopic surgical management of tubal pregnancy

A worldwide increase in the incidence of ectopic pregnancy has been reported in the last two decades. Recently developed diagnostic tools markedly improved the early diagnosis capability. These include: 1, rapid and sensitive beta hCG and progesterone assays; 2, improved ultrasonographic visualization of the pelvic organs; 3, the wide application of diagnostic laparoscopy. Today, most cases are diagnosed before a rupture occurs. Accordingly, treatment has shifted from an immediate, life-saving intervention to conservative methods of management, directed at preserving fertility and reducing morbidity. Endoscopic surgical techniques have also rapidly improved in the last decade, thus, this treatment option apparently became the treatment of choice in most centers. Laparoscopic conservative treatment of tubal pregnancy is as effective and safe as treatment with laparotomy and has the advantage of decrease in hospital stay, cost, and delay in return to normal activity. This review will focus on the endoscopic surgical procedures and their place in view of the other surgical and non-surgical options.

Clomiphene citrate and pregnancy outcome

Data from Australia and elsewhere have shown consistently that adverse perinatal outcomes such as preterm birth and perinatal mortality are more common in pregnancies resulting from assisted conception with IVF and GIFT than normally conceived pregnancies. Factors that may contribute to the excess of poor outcomes include maternal factors, the assisted conception procedures themselves and possibly the influence of drugs used to induce superovulation. This review examines the medical literature describing pregnancies following ovulation induction with one of the drugs used to induce superovulation, clomiphene citrate, and compares their outcomes with Australian IVF and GIFT pregnancy outcomes. The review shows that whilst some studies have suggested higher rates of ectopic pregnancy, spontaneous abortion and congenital malformations in clomiphene citrate induced pregnancies, the findings are inconsistent and the data are flawed. There are only very poor data available on the incidence of preterm birth. Multiple pregnancy is a well-recognized adverse outcome of clomiphene citrate induced pregnancies. Attempts to improve perinatal outcomes of pregnancies following assisted conception will be helped by a better understanding of the relative contributions of maternal and treatment factors and further studies of pregnancy outcome after ovulation induction are needed.

Ectopic pregnancy and infertility following treatment of infertile couples: a follow-up of 929 cases

A follow-up analysis was made of 929 infertile couples, with special attention paid to ectopic pregnancy. The conception rate was 46%, and 9% of the pregnancies were ectopic. Previous ectopic pregnancy, an industrial occupation and smoking reduced the fecundity and increased the risk of ectopic pregnancy. Tubal damage as a verified reason for infertility and its treatment also increased the risk of ectopic pregnancy. Stepwise logistic regression analysis showed the strongest association with ectopic pregnancy to exist in the case of women with a previous ectopic pregnancy (9.9-fold risk) rather than women with primary infertility. Treatment of tubal damage by salpingostomy entailed a 6.0-fold risk and treatment by other methods a 2.8-fold risk. Women working in industry had a 3.5-fold risk of ectopic pregnancy compared with those in other professions.

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.

Ectopic pregnancy in adolescents: a clinical review for pediatricians

Pediatricians caring for sexually active female adolescents and young adults need to be aware of the history, symptoms, and signs of an ectopic pregnancy. A thorough history and physical examination, including the pelvic examination, as well as specific diagnostic tests such as repeated quantitative hCG measurements, and ultrasonography when indicated, are crucial to proper and early diagnosis of a nonruptured ectopic pregnancy manageable by laparoscopy. The key to early diagnosis is to include ectopic pregnancy in the differential diagnosis in any sexually active female patient who has abnormal vaginal bleeding or abdominal pain. With early diagnosis, close observation, and appropriate management, the outcome is more likely to be favorable, with minimal morbidity and risk of death.

A rapid evolution mechanism may contribute to changes in sex ratio, multiple birth incidence, frequency of auto-immune disease and frequency of birth defects in Clomid conceptions

Under conditions favourable to the horizontal transmission of genetic material, a clomiphene isomer is hypothesized to encourage an alternate ovulatory route, with consequence for the sex ratio, multiple birth incidence, incidence of auto-immune disease, and frequency of malformations.

The occurrence of ectopic pregnancy with and without clomiphene citrate use in assisted and nonassisted reproductive technology

An eleven-year review of treatment records of patients who became pregnant as a result of infertility treatment (n = 3692) was conducted. All records were examined to determine whether clomiphene citrate (CC) was used in the cycle of conception and whether or not an ectopic pregnancy occurred. Data were additionally analyzed for the incidence of ectopic pregnancy with and without assisted reproductive technology (ART). The incidence of ectopic pregnancy was similar between CC (3.4%) and non-CC (3.4%) treatment groups receiving non-ART treatment. For non-ART treatments, tubal disease and severe endometriosis resulted in an increase in ectopic pregnancies independent of CC use. The incidence of ectopic pregnancy in patients receiving CC + human menopausal gonadotropin (hMG) for in vitro fertilization (5.4%) and gamete intrafallopian transfer (3.1%) was similar compared to ART treatments with hMG alone. The incidence of ectopic pregnancy was more closely associated with infertility diagnosis rather than CC use.