Multiple-sited (heterotopic) pregnancy after in vitro fertilization and gamete intrafallopian transfer

Acute abdomen or life-threatening heterotopic pregnancy with tubal rupture: where does imaging play a role?

Heterotopic pregnancy (HP) is a rare, potentially life-threatening complication of an intrauterine pregnancy with a simultaneous ectopic pregnancy. There is a higher incidence with assisted reproduction techniques (ART) and radiology can be pivotal in its diagnosis. A 28-year-old woman underwent ART and at 7 weeks' gestation presented with acute right iliac fossa pain. Transvaginal ultrasound (US) imaging confirmed a viable intrauterine pregnancy. The patients' pain persisted however, and transabdominal US demonstrated a complex, heterogeneous right adnexal mass. Subsequent magnetic resonance imaging (MRI) confirmed an HP with a ruptured ectopic and haemoperitoneum. Emergency laparoscopic surgery and right salpingo-oopherectomy were performed without complication. We highlight the importance of considering HP as a diagnosis in the acute gravid abdomen, especially when initial investigations have confirmed a viable intrauterine pregnancy. Furthermore, this case highlights MRI as a useful modality in complex cases due to its high soft tissue contrast resolution using non-ionising radiation.

Spontaneous Heterotopic Pregnancy Associated with Massive Intraperitoneal Haemorrhage and a Normal Heart Rate, Illustrating the Concept of Relative Bradycardia

A 28-year-old, 9 and a half weeks pregnant (spontaneous conception) multigravida presented with abdominal pain and vaginal bleeding. On examination, her abdomen was diffusely tender, particularly in the right iliac fossa, though guarding was absent. Transabdominal and transvaginal ultrasonography demonstrated a viable intrauterine pregnancy and large-volume intraperitoneal haemoperitoneum; the right ovary could not be identified. The patient became hypotensive with decreased responsiveness, yet her heart rate remained normal. She proceeded to surgery where a ruptured right tubal ectopic pregnancy was identified and right salpingectomy was performed. Estimated blood loss was 3900ml. Postoperative recovery was uneventful. Ultrasound 3 days after surgery demonstrated a viable intrauterine pregnancy of gestational age 9 weeks + 1 day. The patient remains well. Her anomaly scan at 20 weeks and 6 days showed normal growth, amniotic fluid, and Dopplers with no obvious structural defects. She is currently 27 weeks pregnant and will be rescanned at 36 weeks.

Treatment of heterotopic caesarean scar pregnancy complicated with post termination increase in size of residual mass and morbidly adherent placenta

We report a case of a secundipara with heterotopic cesarean scar pregnancy (HCSP) treated with potassium chloride injection into the ectopic embryo followed by sac aspiration. The remaining "mass" increased in size threefold and was surrounded by a rich vascular network. An arteriovenous malformation was suspected; however, appropriate treatment was precluded because of the viability of the ectopic gestation. Sonographic examination revealed a morbidly adherent placenta, and attempt to resect the mass laparoscopically was complicated by bleeding that required hysterectomy. This case illustrates a complication of the intervention performed to preserve the intrauterine gestation in case of HCSP. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 46:227-230, 2018.

Management of cesarean heterotopic pregnancy with transvaginal ultrasound-guided potassium chloride injection and gestational sac aspiration, and review of the literature

Cesarean scar pregnancy is one of the rarest forms of ectopic pregnancy, located in the scar from a previous cesarean section. There are few reports of such pregnancies, and there is no consensus about the best management. Herein is reported a case of cesarean heterotopic pregnancy, diagnosed at 6 weeks' gestation and successfully treated via transvaginal ultrasound-guided potassium chloride injection and gestational sac aspiration, with preservation of the intrauterine pregnancy.

What is the best treatment of heterotopic cervical pregnancies for a successful pregnancy outcome?

Heterotopic pregnancy is rare event and the risk is increased with assisted reproductive technology procedures. Heterotopic cervical pregnancy is even more unusual. We report a rare case of heterotopic cervical pregnancy that was managed successfully. A 36-year-old women who conceived by IVF-ICSI was diagnosed with heterotopic cervical pregnancy. She visited the emergency room with vaginal bleeding at 5 weeks of gestation and underwent careful intracervical gestational sac reduction with forceps under abdominal guidance the next day. The postoperative course was uneventful and with regular check-ups, the intrauterine pregnancy (IUP) progressed unremarkably through 41 weeks with delivery of a healthy newborn. We reviewed a total of 37 cases of heterotopic pregnancy that have been reported in the English language literature. There have been many attempts to eliminate the cervical embryo while preserving the IUP, and complete cervical evacuation is important in order to avoid infection, bleeding, and premature birth.

Treatment of cornual heterotopic pregnancy via selective reduction without feticide drug

STUDY OBJECTIVE

To treat heterotopic pregnancy with a minimally invasive procedure, absent a feticide drug.

DESIGN

Retrospective study (Canadian Classification III).

SETTING

University-affiliated hospital, center of reproductive medicine, department of obstetrics and gynecology, central south university, Changsha Hunan China.

PATIENTS

A total of nine patients' diagnosed cornual heterotopic pregnancy resulted from assisted reproduction technology. Among nine, five patients selected the cornual embryo reduction.

INTERVENTIONS

Cornual embryo reduction and preservation of intrauterine embryo were done under guidance of transvaginal ultrasonography at 4-6 weeks after embryo transfer. No drug was given.

MEASUREMENTS

Safety of operative procedure and pregnancy outcome.

MAIN RESULTS

All five patients who underwent selective embryo reduction has no intraoperative or postoperative complication, however 3 of them delivered healthy babies while two aborted.

CONCLUSION

An early intervention should be carried in vital stable patients by means of puncturing and aspirating cornual heterotopic pregnancy under transvaginal ultrasound guidance.

Heterotopic pregnancy

Heterotopic pregnancy is a life-threatening condition. A recent case at our institution prompted a systematic review of the literature from 2005 to 2010. In the majority (71%) of cases reviewed, risk factors for a heterotopic pregnancy were present. However, in several instances (33%), previous sonographic reports of a normal intrauterine pregnancy gave false reassurance. These results highlight the complexity of diagnosis. In addition, our findings were compared with two previous reviews covering cases from 1971 to 2004. This comparison highlighted two important trends: first, the increasing role of ultrasound in the definitive diagnosis of a heterotopic pregnancy, and second, the development of conservative approaches to management. Medical knowledge and technology may be improving, but ultimately, even in the presence of a known intrauterine pregnancy, the simple dictum 'think ectopic' must not be forgotten.

Sextuplet heterotopic pregnancy presenting as ovarian hyperstimulation syndrome and hemoperitoneum

OBJECTIVE

To describe a case of bilateral ruptured heterotopic pregnancies presenting as persistent ovarian hyperstimulation syndrome in a quadruplet pregnancy.

DESIGN

Case report.

SETTING

University hospital and clinic.

PATIENT(S)

An infertile patient who conceived using gonadotropin therapy.

INTERVENTION(S)

Culdocentesis with resultant aspiration of sanguinous fluid prompted laparoscopic exploration and bilateral salpingectomies.

MAIN OUTCOME MEASURE(S)

Not applicable.

RESULT(S)

Gross hemoperitoneum and ruptured bilateral heterotopic sextuplet pregnancy.

CONCLUSION(S)

Patients who conceive after gonadotropin therapy should be closely monitored during treatment and in early pregnancy to recognize and minimize morbidity and complications. After superovulation, the presence of an intrauterine pregnancy, either single or multiple, does not rule out the possibility of ectopic pregnancy, and this should always be considered as a possibility in the setting of acute anemia.

Unilateral triplet ectopic pregnancy after in vitro fertilization and embryo transfer

OBJECTIVE

To present a case report of a unilateral triplet ectopic pregnancy (EP) conceived by IVF-embryo transfer.

DESIGN

Case report.

SETTING

University Hospital, Budapest, Hungary.

PATIENT(S)

A 26-year-old infertile woman with a history of right salpingectomy, hyperprolactinemia, and male factor infertility underwent IVF-embryo transfer of three embryos. Early transvaginal sonography revealed a triplet pregnancy in the left fallopian tube (two at interstitial and one at ampullary location).

INTERVENTION(S)

Multiple dose methotrexate (MTX) therapy was applied.

MAIN OUTCOME MEASURE(S)

Follow-up pelvic ultrasounds and laboratory testing confirmed fetal cardiac activity cessation and decreasing beta-hCG levels.

RESULT(S)

In spite of the decreasing beta-hCG levels the tube's diameter increased, the patient's symptoms escalated, and finally, the level of hemoglobin and hematocrit decreased. Laparotomy was performed with the removal of the left tube and cornual part of the uterus.

CONCLUSION(S)

Our case represents a very rare condition, a unilateral triplet EP after IVF-embryo transfer-the first one ever reported in the literature. After IVF-embryo transfer early ultrasound examinations are important to identify EPs at an early stage when medical management can still be taken into consideration. Strict monitoring is necessary to identify the success of medical intervention or the need for surgery.

Successful management of heterotopic cesarean scar pregnancy combined with intrauterine pregnancy after in vitro fertilization–embryo transfer

OBJECTIVE

To present a case of cesarean scar pregnancy combined with intrauterine pregnancy after IVF-embryo transfer. Successful embryo reduction was performed and preserved the normal intrauterine gestation.

DESIGN

Case report.

SETTING

Tertiary referral case center.

PATIENT(S)

A woman with cesarean scar pregnancy combined with intrauterine pregnancy after IVF-embryo transfer.

INTERVENTION(S)

Early diagnosis of heterotopic cesarean scar pregnancy and selective embryo reduction was performed by ultrasound-guided potassium chloride (KCl) directed injection.

MAIN OUTCOME MEASURE(S)

Successful pregnancy outcome.

RESULT(S)

A 38-year-old woman achieve pregnancy by IVF-embryo transfer. Heterotopic cesarean scar pregnancy was diagnosed at 7 weeks gestational age. A transvaginal ultrasound-guided KCl injection was given to terminate the cesarean scar embryo and a healthy infant was delivered 6 months later.

CONCLUSION(S)

Heterotopic cesarean scar pregnancy after IVF is extremely rare. Transvaginal intracardiac injection of KCl is a safe and reliable method to terminate the cesarean scar pregnancy. Satisfactory pregnancy outcome should be achieved.

"Rule out ectopic": Asking the right questions, getting the right answers

Sonographic evaluation of the pregnant patient suspected of harboring an ectopic pregnancy (EP) helps determine patient management. Although clinicians typically ask sonologists to "rule out" EP in these patients, the sonologist actually must answer 3 questions: (1) Is there an intrauterine pregnancy (IUP)? (2) Is the possibility of normally developing IUP reliably excluded? (3) Are there sonographic findings that identify or increase the likelihood of an EP? Understanding the rationale behind these questions and the sonographic findings that help to answer these questions enables the sonologist to contribute meaningfully to the care of patients with possible EP. Beginning the sonographic examination with a limited transabdominal approach has value. An IUP can be confidently diagnosed by identification of an intradecidual sac exhibiting the double decidual sac sign, yolk sac, or embryo. When the serum beta human chorionic gonadothropin exceeds 2000 mIU/mL, a technically excellent sonographic examination should identify an intradecidual sac potentially representing an IUP. Even without directly visualizing a yolk sac or embryo in the adnexa, the presence of an extraovarian mass or hemoperitoneum strongly predicts the possibility of EP. An intraovarian mass with peripheral hypervascularity is more likely to represent the corpus luteum rather than an intraovarian EP. Cervical EP can be distinguished from the cervical phase of a spontaneous abortion in progress by either demonstrating fetal heart motion or persistence or enlargement of findings on short-interval follow-up. Absence of a myometrial mantle surrounding one edge of an IUP positioned at the fundus is suspicious for an interstitial EP.

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 successfully managed by salpingectomy of synchronous tubal pregnancy following ovulation induction by CC and a review of the literature.

Heterotopic pregnancy after in vitro fertilization-embryo transfer

OBJECTIVE

A ruptured cornual pregnancy is a rare and challenging problem. We present two cases of cornual pregnancies after in vitro fertilization and embryo transfer (IVF-ET) treated by cornual resection, with an excellent perinatal outcome for the intrauterine pregnancy in both cases. A literature review of cornual pregnancy after IVF-ET is also included.

CASE REPORTS

Two women had undergone IVF-ET because of tubal problems. Emergent laparotomy was performed because of internal bleeding at 12 weeks of gestation in one case and 17 weeks in the other, and in both cases, ruptured cornual pregnancies were found. Cornual resection and primary repair were performed. The women were discharged on the 6th and 7th postoperative day, respectively, and they underwent an elective cesarean delivery at 37 weeks of pregnancy. They were delivered of healthy babies, one weighing 2700 g and the other 2310 g.

CONCLUSION

These cases illustrate that good perinatal outcomes can be achieved by surgical intervention in heterotopic pregnancies, even in the event of a ruptured cornu.

Acute pelvic pain: Evaluation and management

Acute pelvic pain in women is often a diagnostic dilemma. Obstetrical, gynecological, urological or gastrointestinal causes must be considered. Stabilization, immediate therapy and early consultation are often indicated. If no etiology is found, conservative management with frequent re-evaluation is adequate.

Maternal complication of cervical heterotopic pregnancy after successful potassium chloride fetal reduction

OBJECTIVE

To present a case of maternal morbidity encountered in a cervical heterotopic pregnancy after successful potassium chloride (KCl) injection for transvaginal multifetal pregnancy reduction.

DESIGN

Case report.

SETTING

Tertiary referral care center.

PATIENT(S)

A woman with heterotopic twin gestation after IVF.

INTERVENTION(S)

Diagnosis of a viable cervical heterotopic pregnancy was made at 6 weeks by ultrasound. A transvaginal reduction by KCl injection of the cervical pregnancy was performed under sonographic guidance.

MAIN OUTCOME MEASURE(S)

Maternal morbidity and mortality.

RESULT(S)

Although contents of the gestational sac within the cervix resolved, the trophoblastic tissue increased in both size and vascularity. The patient continued to have self-limited vaginal bleeding throughout the pregnancy. However, at 31 weeks, she had an acute hemorrhage, resulting in an emergency cesarean hysterectomy secondary to profuse bleeding from retained cervical trophoblastic tissue.

CONCLUSION(S)

Although KCl transvaginal multifetal pregnancy reduction might successfully terminate a cervical heterotopic pregnancy, the ongoing pregnancy might be complicated by persistence and even enlargement of remaining trophoblastic tissue, leading to obstetric hemorrhage.

Heterotopic gestation: another possibility for the emergency bedside ultrasonographer to consider

Emergency bedside ultrasonography has become an important tool in differentiating an intrauterine from an ectopic pregnancy. As the odds of a heterotopic pregnancy were thought to be minute, some ultrasonographers and Emergency Physicians certified in bedside ultrasonography have taught that an intrauterine gestation with fetal heart tones clinches the diagnosis of intrauterine pregnancy. However, with the current rise in heterotopic gestations, this standard of care should be re-evaluated. If emergency bedside ultrasonography reveals an intrauterine gestation in the presence of either a moderate amount of free fluid in the pelvis or a co-existent ovarian cyst, one must consider and search for a heterotopic pregnancy.

Ectopic pregnancy

Ectopic pregnancy is a high-risk diagnosis that is increasing in frequency and is still commonly missed in the emergency department. The emergency physician needs a high index of suspicion and must understand that the history, physical examination, and a single quantitative beta-hCG level cannot reliably rule out an ectopic pregnancy. Most pregnant patients who present to the emergency department during the first trimester with abdominal or pelvic pain, regardless of the presence of vaginal bleeding, should undergo further evaluation with ultrasonography. Ultrasound findings in conjunction with quantitative beta-hCG levels guide the management of the patient.

Successful management of a heterotopic Caesarean scar pregnancy: potassium chloride injection with preservation of the intrauterine gestation: case report

Caesarean scar pregnancy (CSP), in which the pregnancy is located in the scar of a previous Caesarean section, is a rare situation that carries a high risk of uterine rupture. Improved ultrasound imaging allows early diagnosis of this condition, but there is no standard management. We report the first case of CSP associated with a normal intrauterine pregnancy. Potassium chloride administered under transvaginal ultrasonographic guidance terminated cardiac activity in the CSP. The CSP resolved, and a healthy infant was delivered at 36 weeks. When the diagnosis is early and the patient asymptomatic, surgery can be avoided, the CSP can be terminated selectively and the intrauterine pregnancy thereby preserved.

Transvaginal sonographic diagnosis of live monochorionic twin ectopic pregnancy

Ectopic pregnancy is a leading cause of pregnancy-related deaths; its incidence has progressively increased in recent years. Spontaneous twin ectopic pregnancy, however, is extremely rare. Among more than 100 reported cases of twin tubal pregnancies, only 5 cases in which fetal cardiac motion has been visualized in both embryos have been reported. We describe an additional case of a live monochorionic twin ectopic pregnancy in a patient with no predisposing factor. With transabdominal sonography, we initially diagnosed a single ectopic pregnancy, visualized as an ill-defined mass in the left adnexa. However, with transvaginal sonography, we determined the left adnexal mass to contain a single monochorionic gestational sac with 2 embryos, each with cardiac motion. These findings were confirmed with color Doppler sonography and at laparotomy. The introduction of high-resolution transvaginal sonography has resulted in the earlier diagnosis of ectopic pregnancy and has contributed to a recent decrease in the maternal mortality and morbidity associated with this condition.

Ruptured ectopic pregnancy after elective termination of intrauterine pregnancy discovered by use of ultrasonography in the emergency department

The authors report a case of a 27-year-old female who was diagnosed as having a ruptured ectopic pregnancy approximately 12 hours after an elective termination of an intrauterine pregnancy (IUP) was performed. Multiple previous evaluations by an obstetrician for a chief complaint of abdominal pain revealed an IUP but did not disclose the underlying pathology. The ectopic pregnancy was identified by the emergency physician's use of ultrasound in the emergency department.

Cornual heterotopic pregnancy: contemporary management options

This review covers the clinical presentations, treatments, and outcomes of cornual heterotopic pregnancies reported in the literature. Infertile women with a history of ectopic pregnancy, tubal surgery, or disease are at increased risk for cornual heterotopic pregnancy when they undergo in vitro fertilization. Women who have undergone bilateral salpingectomy also seem to be predisposed to this condition when they undergo in vitro fertilization. We recommend that these patients be followed up closely after a successful in vitro fertilization cycle with monitoring of serum beta-human chorionic gonadotropin levels and serial transvaginal ultrasonography because of the high associated morbidity. Laparotomy remains the treatment of choice for rupture of a cornual heterotopic pregnancy. In the absence of cornual rupture, however, medical management is an option that eliminates the risk of surgery and anesthesia and results in outcomes similar to those associated with surgical treatment. Currently there is insufficient evidence to recommend any single treatment modality, and the decision should be based on such factors as clinical presentation, surgeon's expertise, side effects, overall cost, and the patient's preference.

Heterotopic pregnancy complicating in vitro fertilization

A review was undertaken of the cases of heterotopic pregnancy resulting from in vitro fertilization/embryo transfer (IVF/ET) and frozen embryo replacement (FER) in a 6-year cohort of women at National Women's Hospital in Auckland. The incidence of heterotopic pregnancy was 2.9% (5 cases) in 173 clinical pregnancies resulting from 901 embryo replacements. Of the 5 women with heterotopic pregnancy, 1 had unilateral tubal patency and 4 had bilateral tubal blockage; 3 had 'high responder' peak serum oestradiol levels (greater than 9,000 pmol/L) prior to oocyte pick-up (OPU); 3 had a serum human chorionic gonadotrophin beta subunit (beta-HCG) level greater than 600 IU/L on Day 14 following embryo transfer (ET) in the absence of a multiple intrauterine gestation on subsequent ultrasound scan. In the 4 women in whom unequivocal diagnosis of heterotopic pregnancy was not made on the initial ultrasound scan, there was delay in appropriate management, in 1 for more than 5 months. In conclusion, early IVF pregnancies require a transvaginal ultrasound scan performed by a sonographer experienced in the diagnosis of ectopic pregnancy and management of early pregnancy complications by clinicians in close consultation with the IVF centre itself. No single risk factor, laboratory test or combination of these is sensitive or specific enough to predict the occurrence of heterotopic pregnancy. The first-line surgical treatment of heterotopic pregnancy should be laparoscopic salpingectomy with excision of all except the intramural portion of the affected Fallopian tube.

Primary term ovarian pregnancy superimposed by intrauterine pregnancy: a case report

A case of primary ovarian pregnancy proceeding upto term superimposed by another intrauterine pregnancy is presented. Compound extrauterine and intrauterine pregnancy is a rare obstetric phenomenon and still rarer is a primary ovarian pregnancy proceeding upto the term. The condition was diagnosed at laparotomy during the second trimester of current pregnancy. Diagnostic laparotomy was done because the ovarian pregnancy was mimicking an ovarian tumur. The ovarian pregnancy was successfully managed by surgery. Normal vaginal delivery of a term intrauterine pregnancy occurred in due time. The difficulty of diagnosing the heterotopic pregnancy is discussed and the clinico-pathological features of primary term ovarian pregnancy is emphasized, as it is a very rare condition.

Ovarian pregnancy; relationship to an intrauterine device

Ovarian pregnancy is a rare form of ectopic pregnancy in which the gestational sac is implanted within the ovary. The incidence is 0.5 to 3% of all ectopic gestations. In contrast to patients with tubal pregnancies, traditional risk factors, such as pelvic inflammatory disease and prior surgical procedure upon the pelvis, may not play a role in the aetiology. In the 2 cases reported here, it seems that using an intrauterine contraceptive device was an important factor.

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.

Risk factors for ectopic pregnancy after in vitro fertilization and embryo transfer

PURPOSE

To find the incidence of ectopic pregnancy (EP) in patients who conceived in the IVF-ET program, and risk factors affecting the occurrence of EP.

METHODS

We analyzed the effects of the indication for IVF, type of ovarian stimulation (hMG + hCG vs. GnRH + hMG + hCG), type of embryo transfer (transcervical intratubal, intrauterine in chest-knee position and intrauterine in lithotomy position) and number of embryos transferred on the occurrence of EP. EP was treated by laparotomy, prostaglandin E2 or laparoscopic surgery.

RESULTS

In 7991 stimulated and 92 natural cycles treated in the Ljubljana IVF-ET program between May 1983 and June 1994 we achieved 1059 pregnancies, of which 44 were ectopic (incidence 4.1%), the main risk being tubal factor infertility. There were 38 (86.3%) tubal, 3 (6.8%) heterotopic, 1 (2.4%) ovarian, and 2 (4.5%) cornual EP. In two patients multiple tubal EP occurred (1 twin, 1 triplet). Forty-two patients (95.4%) had tubal factor infertility, 1 (2.3%) unexplained, and 1 (2.3%) patient had male factor. The incidence of EP in patients with tubal infertility was 5.4%, in patients with unexplained infertility 2.0% and in those with male factor 0.9%. There appeared to be no correlation between the two superovulatory methods. With transcervical intrauterine ET the incidence of EP was 0 of 5 clinical pregnancies (CP); with intrauterine in chest-knee position it was 26 (3.5%) of 738 CP; with intrauterine in lithotomy position it was 17 (5.4%) of 316 CP. The difference between the two types of intrauterine ET is not statistically significant. The incidence of EP did not correlate with the number of embryos transferred. The average initial values of beta hCG performed 17 days after ET were significantly lower in patients with EP than in those with normal singleton pregnancy (157 +/- 143 mIU/ml vs. 408 +/- 148 mIU/ml).

CONCLUSIONS

EP can complicate the IVF procedure. The main risk factor is tubal infertility with or without previous tubal surgery. The low initial value of beta hCG has a strong predictive value in the diagnosis of EP.

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.

Laparoscopic treatment of heterotopic pregnancy

The increasing frequency of pelvic inflammatory disease and use of ovulation-induction agents has resulted in a corresponding increase in the frequency of heterotopic pregnancy. In most reported cases the diagnosis was made retrospectively at the time of laparotomy. With improvements in ultrasonography and operative laparoscopy, the diagnosis can be made preoperatively and the disease treated surgically with low morbidity. In a woman who had received clomiphene citrate for ovulation induction, the diagnosis of heterotopic pregnancy was suspected preoperatively based on transvaginal ultrasonography. The patient was treated laparoscopically by partial salpingectomy, and subsequently delivered a normal infant.

Transferring more embryos increases risk of heterotopic pregnancy

OBJECTIVES

To analyze symptoms and signs that may distinguish heterotopic pregnancy from solely ectopic pregnancy (EP) after IVF. To determine if the number of embryos transferred is a risk factor for heterotopic compared with solely EP.

DESIGN

Retrospective cohort of 587 IVF pregnancies, 328 with distorted tubal anatomy.

SETTING

University Hospital, London, a referral center for Ontario provincial government-supported assisted reproductive technologies.

PARTICIPANTS

Couples undergoing IVF.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Heterotopic pregnancy, solely EP, intrauterine pregnancy, and distorted pelvic anatomy.

RESULTS

Of 587 pregnancies, 7 were heterotopic pregnancies and 24 were solely EP, all in the subset of 328 women with distorted tubal anatomy. Symptoms, signs and time of diagnosis were not different between heterotopic and solely ectopic gestations. Compared with solely EP, heterotopic pregnancies were associated with transfer of more embryos. With four or more embryos transferred, the odds ratio for development of heterotopic versus solely ectopic gestation was 10.0.

CONCLUSION

Heterotopic pregnancy occurred in 2% of gestations after IVF, all in women with distorted tubal anatomy. Transfer of four or more embryos was a risk factor for heterotopic pregnancy.

Complications of assisted reproductive techniques

OBJECTIVE

To review and appreciate the relevant data on assisted reproduction techniques and their potential complications.

DATA RESOURCES

Major publications on assisted reproduction that include the information concerning complications associated with this practice.

RESULTS

Assisted reproduction is a common practice in modern reproductive medicine. Complications are associated with ovulation induction and the extracorporeal methods that are used for IVF-ET, GIFT, and zygote intrafallopian transfer (ZIFT). These complications are associated with laparoscopy, anesthesia, oocyte retrieval, and laboratory facilities. Pregnancies resulting from assisted reproduction are more complicated than spontaneous pregnancies. There are higher rates of ectopic, heterotopic, and multifetal pregnancies; abortions; and premature deliveries. Increased rates of perinatal mortality and morbidity result from prematurity, and higher rates of maternal diseases in pregnancy (preeclampsia, diabetes mellitus, bleeding, anemia) contribute to fetal intra-uterine growth restriction and maternal morbidity.

CONCLUSIONS

Assisted reproduction practice should be well controlled in view of the potential for complications before and during pregnancies.

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.

Combined intrafallopian/intrauterine reduction of a quintuplet gestation

We describe the first successful outcome of a case of combined tubal and intrauterine quadruplet pregnancy in the literature. The patient's risk factors for combined pregnancy included a history of PID as well as the use of hMG therapy. A laparoscopic salpingectomy was performed, followed by a multifetal pregnancy reduction procedure. Two healthy infants were delivered at 37 weeks of gestation.