Very early medical abortion: treatment with mifepristone and misoprostol before ultrasonographic visualisation of an intrauterine pregnancy

INTRODUCTION

Abortion providers may be reluctant to commence abortion before ultrasound evidence of intrauterine pregnancy (IUP) due to concerns of missed ectopic pregnancy. In 2017, very early medical abortion (VEMA) was introduced at an abortion service in Edinburgh, UK. Following ultrasound, patients without confirmed IUP, and without symptoms or risk factors for ectopic pregnancy, could commence treatment immediately after baseline serum-human chorionic gonadotrophin (hCG) measurement, and return for follow-up serum-hCG a week later to determine treatment success (≥80% decline from baseline). This study aimed to compare clinical outcomes between two pathways: (1) VEMA; and (2) standard-of-care delayed treatment where treatment is only commenced on IUP confirmation by serial serum-hCG monitoring and/or repeat ultrasound.

METHODS

A retrospective database review was conducted of VEMA eligible patients from July 2017 to December 2021. Study groups were determined by patient preference. Records were searched for abortion outcomes, duration of care, number of appointments (clinic visits, ultrasounds, serum-hCG) and clinical data entries.

RESULTS

Of 181 patients included, 77 (43%) chose VEMA and 104 (57%) chose delayed treatment. 11/181 (6.1%) were lost to follow-up. Cohort ectopic prevalence was 4.4% and was not statistically different between groups (2.6% vs 5.8%, VEMA vs delayed group, respectively, p=0.305), as with complete abortion rates (93.3% vs 97.6%, p=0.256). All VEMA group ectopics were detected on the seventh day (from initial visit) while time-to-diagnosis for delayed group ectopics ranged from 7 days to 3 weeks. VEMA patients had significantly reduced duration of care (12 vs 21 days, p<0.001), number of visits (2 vs 3, p<0.001), ultrasounds (1 vs 2, p<0.001) and data entries (6 vs 9, p<0.001).

CONCLUSIONS

VEMA is safe, effective and reduces the duration of care, number of appointments and clinical administrative time. It should be offered to medically eligible patients.

Ectopic Pregnancy Risk in Users of Levonorgestrel-Releasing Intrauterine Systems With 52, 19.5, and 13.5 mg of Hormone

This study assesses the association between use of levonorgestrel intrauterine systems containing 52, 19.5, and 13.5 mg of hormone and ectopic pregnancy in a nationwide cohort study.

Combination of gefitinib and methotrexate to treat tubal ectopic pregnancy (GEM3): a multicentre, randomised, double-blind, placebo-controlled trial

BACKGROUND

Tubal ectopic pregnancies can cause substantial morbidity or even death. Current treatment is with methotrexate or surgery. Methotrexate treatment fails in approximately 30% of women who subsequently require rescue surgery. Gefitinib, an epidermal growth factor receptor inhibitor, might improve the effects of methotrexate. We assessed the efficacy of oral gefitinib with methotrexate, versus methotrexate alone, to treat tubal ectopic pregnancy.

METHODS

We performed a multicentre, randomised, double-blind, placebo-controlled trial across 50 UK hospitals. Participants diagnosed with tubal ectopic pregnancy were administered a single dose of intramuscular methotrexate (50 mg/m2) and randomised (1:1 ratio) to 7 days of additional oral gefitinib (250 mg daily) or placebo. The primary outcome, analysed by intention to treat, was surgical intervention to resolve the ectopic pregnancy. Secondary outcomes included time to resolution of ectopic pregnancy and serious adverse events. This trial is registered at the ISRCTN registry, ISCRTN 67795930.

FINDINGS

Between Nov 2, 2016, and Oct 6, 2021, 328 participants were allocated to methotrexate and gefitinib (n=165) or methotrexate and placebo (n=163). Three participants in the placebo group withdrew. Surgical intervention occurred in 50 (30%) of 165 participants in the gefitinib group and in 47 (29%) of 160 participants in the placebo group (adjusted risk ratio 1·15, 95% CI 0·85 to 1·58; adjusted risk difference -0·01, 95% CI -0·10 to 0·09; p=0·37). Without surgical intervention, median time to resolution was 28·0 days in the gefitinib group and 28·0 days in the placebo group (subdistribution hazard ratio 1·03, 95% CI 0·75 to 1·40). Serious adverse events occurred in five (3%) of 165 participants in the gefitinib group and in six (4%) of 162 participants in the placebo group. Diarrhoea and rash were more common in the gefitinib group.

INTERPRETATION

In women with a tubal ectopic pregnancy, adding oral gefitinib to parenteral methotrexate does not offer clinical benefit over methotrexate and increases minor adverse reactions.

FUNDING

National Institute of Health Research.

Future Perspectives of Ectopic Pregnancy Treatment-Review of Possible Pharmacological Methods

Ectopic pregnancy, that is, a blastocyst occurring outside the endometrial cavity of the uterus, affects nearly 2% of pregnancies. The treatment of ectopic pregnancy is surgical or pharmacological. Since surgical management is associated with numerous serious side effects, conservative treatment is sought. The treatment of choice in the majority of cases is based on pharmacotherapy with methotrexate (MTX) in a single- or multi-dose regimen. Although the efficacy of methotrexate reaches between 70 and 90%, its use requires specific conditions regarding both the general condition of the patient and the characteristic features of the ectopic pregnancy. Moreover, MTX can cause severe adverse effects, including stomatitis, hepatotoxicity and myelosuppression. Therefore, clinicians and researchers are still looking for a less toxic, more effective treatment, which could prevent surgeries as a second-choice treatment. Some studies indicate that other substances might constitute a good alternative to methotrexate in the management of ectopic pregnancies. These substances include aromatase inhibitors, especially letrozole. Another promising substance in EP treatment is gefitinib, an inhibitor of EGFR tyrosine domain which, combined with MTX, seems to constitute a more effective alternative in the management of tubal ectopic pregnancies. Other substances for local administration include KCl and absolute ethanol. KCl injections used in combination with MTX may be used when foetal heart function is detected in cervical ectopic pregnancies, as well as in heterotopic pregnancy treatment. Absolute ethanol injections proved successful and safe in caesarean scar pregnancies management. Thus far, little is known about the use of those substances in the treatment of ectopic pregnancies, but already conducted studies seem to be promising.

Are health care providers who work with cancer drugs at an increased risk for toxic events? A systematic review and meta-analysis of the literature

Objective. A systematic review and meta-analysis was conducted to test the hypothesis that oncology health care workers are at an increased risk of cancer, reproductive complications and acute toxic events.

Design. A structured literature search of Index Medicus/MEDLINE, CINAHL, EMBASE, the Cochrane Database of Systematic Reviews and Healthstar was performed from 1966 to December 2004 for human epidemiological studies evaluating the risk of toxic events in health care workers exposed to cytotoxic drugs. Raw data and adjusted odds ratios (OR) reported in eligible studies were combined using a random effects model to calculate point estimates and 95% confidence intervals (CI) for each potential risk outcome.

Main outcome measures. Adjusted OR for congenital malformations, stillbirths and spontaneous abortions among health care workers exposure to cytotoxic agents compared to a non-exposed control group.

Results. The systematic review identified 14 studies evaluating the outcomes of interest, seven of which were suitable for statistical pooling. Due to lack of evidence, we were unable to estimate a pooled OR for the risk of cancer and acute toxic events. However, no significant association was detected between exposure to cytotoxic drugs and; congenital malformations (OR=1.64; 95% CI: 0.91-2.94) and stillbirths (OR=1.16; 95% CI: 0.73-1.82). In contrast, an association was identified between exposure to chemotherapy and spontaneous abortions (OR=1.46; 95% CI: 1.11-1.92).

Conclusions. The results of this systematic review identified a small incremental risk for spontaneous abortions in female staff working with cytotoxic agents. Health policy decision makers should effectively communicate the magnitude of this risk to their staff and implement cost effective interventions for its reduction or elimination.

The association between smoking and ectopic pregnancy: why nicotine is BAD for your fallopian tube

Epidemiological studies have shown that cigarette smoking is a major risk factor for tubal ectopic pregnancy but the reason for this remains unclear. Here, we set out to determine the effect of smoking on Fallopian tube gene expression. An oviductal epithelial cell line (OE-E6/E7) and explants of human Fallopian tubes from non-pregnant women (n = 6) were exposed to physiologically relevant concentrations of cotinine, the principle metabolite of nicotine, and changes in gene expression analyzed using the Illumina Human HT-12 array. Cotinine sensitive genes identified through this process were then localized and quantified in Fallopian tube biopsies from non-pregnant smokers (n = 10) and non-smokers (n = 11) using immunohistochemistry and TaqMan RT-PCR. The principle cotinine induced change in gene expression detected by the array analysis in both explants and the cell line was significant down regulation (P<0.05) of the pro-apoptotic gene BAD. We therefore assessed the effect of smoking on cell turnover in retrospectively collected human samples. Consistent with the array data, smoking was associated with decreased levels of BAD transcript (P<0.01) and increased levels of BCL2 transcript (P<0.05) in Fallopian tube biopsies. BAD and BCL2 specific immunolabelling was localized to Fallopian tube epithelium. Although no other significant differences in levels of apoptosis or cell cycle associated proteins were observed, smoking was associated with significant changes in the morphology of the Fallopian tube epithelium (P<0.05). These results suggest that smoking may alter tubal epithelial cell turnover and is associated with structural, as well as functional, changes that may contribute to the development of 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.

Six Cases of Women with Diethylstilbestrol in Utero Demonstrating Long-Term Manifestations and Current Evaluation Guidelines

Diethylstilbestrol (DES), a nonsteroidal estrogen, was widely used in the United States from 1940 through 1971 to prevent pregnancy loss. In the late 1960s, an association was made with an increased incidence of clear cell adenocarcinoma in young women exposed in utero to DES. Additional study of these women over the next 35 years has shown an increased risk of other health problems including intraepithelial neoplasia, ectopic pregnancy, first trimester spontaneous abortion and second trimester pregnancy loss. The National Institutes of Health continues to fund studies to follow cohorts of DES-exposed mothers, daughters, sons and third generation children. The Centers for Disease Control have conducted a large DES Education Project and have established guidelines for management. The following six cases studies illustrate common problems seen in DES exposed daughters and management of problems encountered.

A randomized, double-blind, multicentre clinical trial comparing starting doses of 150 and 200 IU of recombinant FSH in women treated with the GnRH antagonist ganirelix for assisted reproduction

BACKGROUND

Studies with the GnRH antagonist ganirelix in assisted reproduction have indicated that compared with traditional GnRH agonist downregulation protocols, slightly fewer oocytes are retrieved. In this study it was investigated whether an increase in the starting dose of recombinant FSH (rFSH) could compensate for this loss.

METHODS

A randomized, double-blind, multicentre clinical trial comparing a starting dose of 150 and 200 IU of rFSH (follitropin beta), in women undergoing treatment with the GnRH antagonist ganirelix.

RESULTS

In total, 257 women were treated with rFSH, of whom 131 received 150 IU and 126 women 200 IU. Overall, 10.3 oocytes were retrieved in the 150 IU group and 11.9 in the 200 IU group (P=0.051). This difference became significant when women with cycle cancellation before HCG administration were excluded. Nearly 500 IU of additional rFSH was given in the high-dose group (2014 versus 1541 IU). In the low-dose group, 4.6 high-quality embryos were obtained compared with 4.5 in the high-dose group. Vital pregnancy rates were similar (31 and 25% in the 150 and 200 IU-treated women, respectively). Serum concentrations of FSH, estradiol and progesterone were significantly higher in the high-dose group at day 6 of rFSH treatment and on the day of HCG administration. In the high-dose group, serum LH concentrations were higher at day 6 of rFSH treatment but lower at the day of HCG administration.

CONCLUSION

By increasing the starting dose from 150 to 200 IU of rFSH, slightly more oocytes can be retrieved in GnRH antagonist protocols for assisted reproduction. However, because this did not translate into a higher number of high quality embryos, the clinical relevance of such a dose increase may be questioned.

Simultaneous intrauterine and ovarian pregnancy following treatment with clomiphene citrate

Heterotopic pregnancy is increasingly being diagnosed since the advent of assisted reproductive technology involving the use of superovulatory drugs and/or in-vitro fertilization and the availability of high-resolution ultrasound scans. There are reports of Heterotopic tubal pregnancies following clomiphene use. Heterotopic ovarian pregnancies are however rare. Clomiphene citrate, which is widely used in the primary care setting to treat anovulatory infertility, is felt safe. We present a case of heterotopic ovarian pregnancy following treatment with clomiphene citrate. The diagnosis and management of heterotopic ovarian pregnancy are also discussed.

The difference a day makes

A patient attended a clinic requesting Depo Provera after emergency contraception. She gave a history of normal menstruation, but a pregnancy test proved positive. Subsequently an ectopic pregnancy was diagnosed.

Long-term follow-up after quinacrine sterilization in Vietnam. Part II: interim safety analysis

OBJECTIVE

To determine the long-term safety of nonsurgical sterilization with quinacrine.

DESIGN

Observational cohort study.

SETTING

Rural provinces in northern Vietnam.

PATIENT(S)

Two thousand eight hundred forty women who had had quinacrine insertions and an age-matched comparison group of 1,658 women who had an intrauterine device (IUD) insertion between 1989 and 1993.

METHOD(S)

Interviews in 1994, 1995, and 1996 and review of available medical records. This is a planned interim analysis.

MAIN OUTCOME MEASURE(S)

Ectopic pregnancies and the occurrence of other adverse health events.

RESULT(S)

Over 90% of women were interviewed at least once. Despite matching on age, the groups differed on baseline parity. The ectopic pregnancy rates were similar after either one or two insertions and were similar to the rate of ectopic pregnancies after surgical sterilization in the United States. The quinacrine group reported more gynecologic health problems than the IUD group. However, after correcting for information bias, there was no dose-response effect between the one- and two-insertion quinacrine groups, suggesting the possibility of recall bias or differing baseline health status.

CONCLUSION(S)

Ectopic pregnancies do not appear to be increased compared with U.S. surgical sterilization rates. The data on other adverse events are more difficult to interpret.

[Successful outcome of an intrauterine twin pregnancy combined with ectopic pregnancy]

Authors present a case of twin intrauterine pregnancy combined with ectopic pregnancy. The simultaneous pregnancies occurred after the use of clomiphene citrate. In this case viable intrauterine twin gestation was observed by vaginal ultrasound examination, the simultaneous ectopic pregnancy was observed by laparotomy. Right salpingectomy was performed. The intrauterine twin pregnancy continued normally to the 35th week of pregnancy, finished with normal vaginal delivery. The healthy twin boys weighed 2650 g and 2070 g left the hospital in a good general condition on the 5th past delivery day. Authors discuss the etiology, the mode of diagnosis and the therapy of this rare condition.

Continued follow-up of pregnancy outcomes in diethylstilbestrol-exposed offspring

OBJECTIVE

To evaluate long-term pregnancy experiences of women exposed to diethylstilbestrol (DES) in utero compared with unexposed women.

METHODS

This study was based on diethylstilbestrol-exposed daughters, the National Collaborative Diethylstylbistrol Adenosis cohort and the Chicago cohort, and their respective nonexposed comparison groups. Subjects who could be traced were sent a detailed questionnaire in 1994 that contained questions on health history, including information on pregnancies and their outcomes. We reviewed 3373 questionnaires from exposed daughters and 1036 questionnaires from unexposed women.

RESULTS

The response rate was 88% among exposed and unexposed women. Diethylstilbestrol-exposed women were less likely than unexposed women to have had full-term live births and more likely to have had premature births, spontaneous pregnancy losses, or ectopic pregnancies. Full-term infants were delivered in the first pregnancies of 84.5% of unexposed women compared with 64. 1% of exposed women identified by record review (relative risk [RR] 0.76, confidence interval [CI] 0.72, 0.80). Preterm delivery of first births occurred in 4.1% of unexposed compared with 11.5% of exposed women, and ectopic pregnancies in 0.77% of unexposed compared with 4.2% of exposed women. Spontaneous abortion was reported in 19.2% of DES-exposed women compared with 10.3% in control women (RR 2.00, CI 1.54, 2.60). According to complete pregnancy histories (many women had more than one pregnancy), preterm births were more common in DES-exposed women (19.4% exposed versus 7.5% unexposed (RR 2.93 CI 2.23, 3.86). Second-trimester spontaneous pregnancy losses were more common in DES-exposed women (6.3% versus 1.6%; RR 4.25, CI 2.36, 7.66). More first-trimester spontaneous abortions occurred in DES-exposed women than in controls (RR 1.31, CI 1.13, 1.53), and DES-exposed women had at least one ectopic pregnancy more often than unexposed women (RR 3.84, CI 2.26, 6.54).

CONCLUSION

Pregnancy outcomes in DES-exposed women were worse than those in unexposed women.

Heterotopic pregnancy following ovulation stimulation with clomiphene: a report of three cases

Heterotopic pregnancy was a medical rarity, prior to the use of ovulation inducing drugs and advent of assisted reproduction technology. Three cases were encountered in the course of clinical practice in a teaching hospital, over a period of six and a half years. Two of them occurred in association with ovulation induction with CLOMIPHENE and the third case with no identifiable underlying cause. We postulate dizygotic twinning, highest among the Yoruba race of Nigeria as a possible aetiological factor. One of the two cases following CLOMIPHENE has been highlighted in more details, together with a review of literature. Diagnosis in all cases was made in retrospect following surgical intervention for the ruptured ectopic components. All the patients presented with persistent pregnancy symptoms, with sonographic confirmation of viable intrauterine fetuses which were carried to term.

Quinacrine sterilization: an assessment of risks for ectopic pregnancy, birth defects and cancer

Quinacrine sterilization (QS) involves transcervical insertion of quinacrine pellets using a modified Copper TIUD inserter. Pellets are placed at the fundus in the proliferative phase of the menstrual cycle. Efficacy is presently estimated at 1 pregnancy failure per 100 women at 2 years. Early complications are lower for QS than surgical sterilization and this is also true for risk of ectopic pregnancy with newer insertion protocols. The risk of birth defects is very low, when estimated from a model with reasonable assumptions for probability of insertion in a pregnant uterus or within 30 days of conception, probability of such exposed pregnancy being carried to term, and probability of quinacrine exposure to the fetus causing a birth defect. Although quinacrine is a mutagen it is unlikely to be a carcinogen. Concentrations of quinacrine in the uterus after transcervical insertion are higher than for oral administration for only a matter of a few hours, although this brief exposure is adequate to cause injury to the tubal epithelium, leading to inflammation and an occluding scar. Oral administration of quinacrine is accepted as non-carcinogenic. Each site of use of QS must make its own risk/benefit assessment. The benefits of any contraceptive that can raise contraceptive prevalence is greatest for developing countries.

Adverse effects associated with contraceptive implants: incidence, prevention and management

Contraceptive implants are increasingly being used for fertility regulation all over the world. Reversible long-term use is their most appealing feature for many users. They have the practical advantage of overcoming the risks of user failure and low continuation rates associated with other methods that require continuous attention or motivation. Disruption of menstruation, complications of insertion and removal, and infection at implant site, constitute the majority of adverse effects associated with contraceptive implants. This article reviews these various common adverse effects associated with contraceptive implants and their possible management and prevention. In addition, we also discuss very rare events, like psychiatric disorders, pseudotumor cerebri, thrombotic, thrombocytopenic purpura and thrombocytopenia, that have been reported by some researchers. Further surveillance and research is necessary to determine if these rare adverse events are causally related to contraceptive implants. Until such a time, providers of contraceptive implants should be more selective in prescribing the contraceptive implants, especially in women with a history of and/or risk factors for stroke, cerebral and coronary heart disease, thrombocytopenia and pseudotumor cerebri.

Ectopic pregnancy and occupational exposure to antineoplastic drugs

The incidence of ectopic pregnancy has risen substantially during the past two decades, but the aetiology of a third of cases remains unknown. We have used data from a survey of nurses in Paris, France, to examine the relation between ectopic pregnancy and various occupational exposures. We studied two groups of women--operating-theatre staff and nurses from other departments. The women were asked about outcomes of all pregnancies and occupational exposure to anaesthetic gases, formol, ionising radiation, and antineoplastic drugs during the first trimester of pregnancy. Of 734 pregnancies reported, 15 (2%) had been ectopic. In chi-square analysis, there were significant associations (p < 0.02) between ectopic pregnancy and exposure to antineoplastic drugs, the woman's age, and the number of previous pregnancies. Other occupational exposures and working in an operating theatre did not show significant associations. In logistic regression analysis with adjustment for gravidity, the odds ratio (by the exact method) for ectopic pregnancy associated with occupational exposure to antineoplastic drugs was 10.0 (95% CI 2.1-56.2). Because we had only small numbers of ectopic pregnancies, the odds ratios we estimated have wide confidence intervals. Our findings should be confirmed by a larger study specifically designed to investigate the relation between antineoplastic exposure and ectopic pregnancy.

The safety and efficacy issues of progestin-only oral contraceptives--an epidemiologic perspective

Progestogen-only oral contraceptives (POCs) are generally considered a good contraceptive choice for brestfeeding women and for women who want to use an oral form of contraception, but are not suited for, or cannot tolerate the side effects of, estrogen-containing preparations. However, a number of POCs' safety, efficacy and other related issues remain to be addressed. This paper reviews recent literature and evaluates these issues from an epidemiologic perspective. The small number of users imposes severe limitations in designing epidemiologic studies to address POCs' long-term safety issues, but available information suggests POCs are at least as safe as, if not safer than, COCs. Compared to COCs, POCs are more likely to cause menstrual disturbances which, in turn, could affect their acceptability and lead to poor compliance and hence higher pregnancy rates. POCs' efficacy has been estimated to be between 1.4 and 4.3 pregnancies per 100 woman-years of use. Lower pregnancy rates approaching those of COCs have been reported in centers with good counseling. POCs' benefits outweigh their risks. However, more studies are needed to further address POCs' safety and efficacy issues.

Subdermal progestin implant contraception

Sustained-release progestin contraceptives are a new approach to meeting a worldwide need for more effective and acceptable birth control. These contraceptive systems provide low, stable levels of synthetic progestins for periods of months to several years. Unlike earlier injectable and oral contraceptives, they do not cause peaks in progestin levels beyond those required for effective contraception, nor do they employ estrogens. For these reasons, sustained-release progestin systems are without some of the health risks attributed to birth control pills, and they are more effective, as well as easy to use, and completely reversible. They share common side effects, the most frequent of which is irregular menstrual bleeding caused by the erratic shedding of hypotrophic endometrium. Despite this and other minor side effects, most users find the sustained-release systems acceptable alternatives to other methods of contraception. Permanent or biodegradable subdermal implants, injections, intrauterine and intracervical devices, and vaginal rings are all employed as delivery systems for contraceptive progestins. The Norplant (Wyeth Ayerst, Radnor, PA) system, consisting of six silastic tubes filled with levonorgestrel and implanted under the skin, was recently approved by the US Food and Drug Administration and is already used by more than a half million women worldwide. The other sustained-release systems are in various stages of development, at least several years away from general use. When these new methods complete clinical trials, women will be able to choose from among implants, injections, or pellets with various durations of action, all providing convenient, highly effective contraception with low risk to health.

Contraception and ectopic pregnancy risk

Studies of the association of ectopic pregnancy with contraception have generated a conflicting array of results because of methodologic differences between studies. We estimated the absolute incidence rates of ectopic pregnancy for various contraceptives by multiplying the pregnancy rate by the proportion of pregnancies with ectopic implantation for each method. Our results indicated a more than 500-fold difference in ectopic pregnancy incidence, from a low of 0.005 ectopic pregnancies per 1000 women years of oral contraception or vasectomy to a high of 2.6 per 1000 women years of no contraception. These estimated incidence rates should be useful for clinicians and patients seeking to better understand the risks and benefits of contraceptives.

Ectopic pregnancy after luteal phase initiation of gonadotropin-releasing hormone analog before in vitro fertilization

Three patients had an undetected pregnancy when they commenced a GnRH-a on the 21st day of their cycle before ovulation stimulation for IVF. Two of the three pregnancies were later diagnosed as ectopic gestations. Based on this and previous case reports in the literature, it is suggested that luteal phase administration of GnRH-a may predispose to EPs, particularly in patients with damaged tubes, by reducing tubal motility secondary to a transient increase in circulating P concentrations.

The role of gonadotropins in the etiology of ectopic pregnancy

Our study indicates that the high rate of EP in MAP(+) patients, treated with hMG/hCG, is due to the fact that it is a selected group of infertile patients with probable additional underlying tubal disease. Absence of EP in MAP(-) patients indirectly support the theory that a mechanical factor is at work. It is, therefore, our opinion, that the cause of ectopic pregnancy lies in the patient and not in the drug (hMG/hCG).

Factors affecting fetal loss in induction of ovulation with gonadotropins: increased abortion rates related to hormonal profiles in conceptual cycles

Thirty-six first-trimester abortions (9.7%), 16 second-trimester abortions (4.3%), 11 ectopic pregnancies (2.9%), and 10 stillbirths (2.7%) occurred in 373 conceptual cycles after gonadotropin induction of ovulation. Fetal wastage was higher in spontaneous pregnancies that occurred before therapy (54.3%, p less than 0.0001) and lower with subsequent spontaneous pregnancies (10.1%, p less than 0.05). Significant risk factors for overall fetal loss during induced ovulation were a continuous rise of estrogen excretion until ovulation (p less than 0.01) and previous abortion (p less than 0.05). For first-trimester abortion, the risk factor was continuous estrogen rise (p less than 0.01); for second-trimester abortion, the risk factors were a low luteal pregnanediol-to-estrogen excretion ratio (p less than 0.002), increased age at conception (p less than 0.02), and high baseline estrogen excretion (p less than 0.05). Multiple pregnancy was not significant. The continuous rising estrogen pattern may serve as a marker of abnormal oocyte maturation. We propose that future studies on infertility treatment should report on pregnancy outcome.

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

Preliminary results of a case-control study suggest that CC or factors closely associated with CC therapy (or both) may increase the risk of ectopic pregnancy. It is hoped that these results will stimulate further research for more explicit evaluation of the role of CC and LPD in the etiology of ectopic pregnancy.

Fertility after discontinuation of oral contraceptives

Concern has been expressed regarding fertility following oral contraceptive (Pill) use. A review of the literature indicates that there is a slight delay in the return of fertility in Pill users but no permanent impairment results. A small proportion of women experience a prolonged period of amenorrhoea following cessation of combined oral contraception, but whether the Pill plays an aetiological role is doubtful since there appear to be no differences in endocrine profiles amongst women with amenorrhoea following Pill use and those with secondary amenorrhoea who have never used oral contraceptives. Factors which may predispose to amenorrhoea following Pill use are: late onset of menarche, previous oligomenorrhoea and low body weight. Following adequate investigation and treatment, fertility rates in women with the so-called post-Pill amenorrhoea syndrome return to normal. There is no evidence of any delay in the return of fertility in women who use the progestogen-only Pill.

In utero exposure to diethylstilbestrol: adverse effects on the reproductive tract and reproductive performance and male and female offspring

Exposure to diethylstilbestrol (DES) in utero is associated with adverse effects on the reproductive tract in male and female progeny. These effects include epididymal cysts, microphallus, cryptorchidism, and testicular hypoplasia in male subjects and adenosis, clear cell adenocarcinoma, and structural defects of the cervix, vagina, uterus, and fallopian tubes in female subjects. As these offspring have reached reproductive age, reports of adverse reproductive performance have been published, including still controversial reports of menstrual dysfunction and infertility. More well established are increased rates of spontaneous abortion, ectopic pregnancy, premature deliveries, and perinatal deaths, all contributing to an increase in overall adverse pregnancy outcome. Often there is correlation between the DES-associated anatomic abnormalities in the reproductive tract and the adverse reproductive performance. Altered male reproductive capacity is also suggested by diminished semen analyses and sperm penetration assays. A detailed review of these effects of in utero DES exposure is presented.

Pregnancy outcome in 98 women exposed to diethylstilbestrol in utero, their mothers, and unexposed siblings

The reproductive capability and labor complications of 98 women exposed to diethylstilbestrol (DES) in utero were compared with those of 3 separate control groups. The controls consisted of 167 age-matched, normal women, 20 siblings not exposed to DES who had achieved pregnancy, and their mothers. Spontaneous abortion, ectopic pregnancy, incompetent cervix, and premature labor occurred significantly more often in the DES-exposed population than in the normal controls. The controls also achieved a higher percentage of desired pregnancies overall; this was statistically significant (89.6 versus 75.0%, P less than .001). When compared with their mothers, however, the DES-exposed population achieved a greater percentage of desired, viable pregnancies (75.6 versus 67.0%, P less than .001). The unexposed siblings of the DES women achieved a higher percentage of desired, viable pregnancies than did their exposed sisters (86.9 versus 73.6%, P = .274), but less than the normal population (86.9 versus 89.6%).

Pregnancy outcome in women exposed to diethylstilbestrol in utero

The presence of anomalies in vagina, cervix, and uterine body of women exposed to diethylstilbestrol in utero has provoked interest and concern regarding the reproductive potential of these women. To expand and to evaluate better better the current knowledge in this matter, the outcomes of the pregnancies of exposed women registered in the Stilbestrol Clinic at the Stanford University Medical Center were examined. The results were combined with the published results of similar examinations of other institutions and a summation of all available data is presented. Although it is evident that the majority (79%) of exposed women who have become pregnant and not regularly sought abortion have obtained at least one living infant, the incidence of spontaneous abortion and preterm delivery has consistently been found to be greater in exposed women than in unexposed control women. One of every 30 pregnancies reported in exposed patients has been ectopically located. Additionally, there is suggestive evidence that exposed women with teratologic changes have a higher incidence of pregnancy loss than those without such changes. However, few of these observations can boast statistical validity and statistical validation of the same observation by separate investigators has not been obtained. Moreover, none of th teratologic changes in exposed patients has been seen to preclude normal pregnancy and term delivery.

Upper genital tract changes and pregnancy outcome in offspring exposed in utero to diethylstilbestrol

Hysterosalpingography (HSG) was performed on 267 diethylstilbestrol (DES)-exposed women. One hundred eighty-five (69%) of these women demonstrated an abnormality and 82 women had normal findings. A relationship between abnormal x-ray findings and structural abnormalities of the cervix and vaginal epithelial changes was noted. Ninety-three women on whom roentgenography was performed had a total of 144 pregnancies. The pregnancy outcome in this group of women was significantly worse than that found in a control population of 87 women who had 147 pregnancies. In addition, women with abnormal x-ray films were found to have a poorer pregnancy outcome than the group of women with normal findings. The women with abnormal x-ray films had more ectopic pregnancies, spontaneous abortions, and premature deliveries than women with normal x-ray films although these differences were not statistically significant. Significantly fewer women with abnormal findings than women with normal x-rays were delivered of term infants.

A comparison of pregnancy experience in DES-exposed and DES-unexposed daughters

Reproductive histories were compared for 226 DES-exposed and 203 -unexposed daughters whose mothers participated in a double-blind evaluation 27 years before. Irregular menstruation was slightly more common among the exposed (10%) than among the unexposed (4%). Nineteen of the exposed and only four of the unexposed had primary infertility. Among those at risk, 86% of the unexposed and 67% of the exposed had become pregnant. The reasons for these differences are not known. Comparison of evaluable first pregnancy outcome revealed full-term live birth to be more common among the unexposed (85%) than the exposed (47%). Premature live birth was experienced by 22% of the exposed but only 7% of the unexposed. Nonviable outcomes of stillbirth, neonatal death, miscarriage and ectopic pregnancy occurred in 31% of the exposed and 8% of the unexposed. The difference in pregnancy outcomes between the groups is highly significant. The DES-exposed with transverse cervicovaginal ridges were more likely to experience a nonviable outcome. Overall 82% of the exposed and 93% of the unexposed had at least one live offspring.

An unexpectedly high rate of ectopic pregnancy following the induction of ovulation with human pituitary and chorionic gonadotrophin

Six tubal ectopic pregnancies occurred in a series of 193 pregnancies following ovulation induced with human pituitary gonadotropin (hPG) and human chorionic gonadotrophin (hCG). The ectopic pregnancy rate of 3.1 per cent is higher than quoted incidences in the general population and occurred in the absence of predisposing factors. There was an association between ectopic pregnancy and elevated urinary oestrogen excretion in the peri-ovulatory phases of the induced ovulatory cycles. A urinary oestrogen excretion of greater than 200 microgram/24 hours on day 0 (the day after hCG was given) was associated with a 10 per cent chance of ectopic pregnancy (P less than 0.05).

Clomiphene citrate-induced concurrent ovarian and intrauterine pregnancy

A rare complication of ovulation induction with clomiphene citrate is presented. The value of ultrasound in the diagnosis of ectopic pregnancy with coexisting intrauterine pregnancy is illustrated.