Ectopic pregnancy following in vitro fertilization after bilateral salpingectomy: A review of the literature

Laparoscopic management of short-interval interstitial pregnancy after recent tubal ectopic pregnancy: A case report

A 24-year-old woman, G6P2032, initially presented with a right-sided ruptured tubal ectopic pregnancy. Salpingectomy was performed with care to completely remove the fallopian tube. The patient then presented with ipsilateral interstitial pregnancy 11 weeks later and initially underwent systemic methotrexate injection, which failed to resolve the pregnancy. She then underwent laparoscopic cornuostomy and dilation and curettage. Cornuostomy was performed with injection of dilute vasopressin around the gestational sac to help minimize blood loss, followed by hydrodissection and sharp dissection to remove the pregnancy. Judicial electrocautery was used and the myometrium and serosa were closed in layers. Attention was given to preserve uterine myometrial tissue integrity at the cornua. The patient recovered and was discharged. Her beta-hCG level trended from 11,902 mIU/mL pre-surgery to 7726 on postoperative day 0, and 289 on postoperative day 7. Pathology from the interstitial region showed fragments of chorionic villi, and the dilation and curettage pathology demonstrated decidualized secretory endometrium. Short-interval interstitial ectopic pregnancies after prior salpingectomy for tubal ectopic pregnancy are extremely rare. This case demonstrated successful management with a minimally invasive laparoscopic cornuostomy. This case also displays that ipsilateral interstitial pregnancy can occur after salpingectomy even after care is taken to remove all visible portions of the fallopian tube. Thus, patients should be counseled carefully about the risks of short-interval pregnancy after a recent tubal ectopic pregnancy.

Multiple Spontaneous Ectopic Pregnancies Following Bilateral Salpingectomy

Introduction

Ectopic pregnancy (EP) is a significant cause of gynaecological morbidity and mortality. Salpingectomy is the preferred management modality in recurrent ectopic pregnancies; although they do not eliminate the risk of reoccurrence. The aetiology of recurrent ectopic pregnancies remains unknown but there are identifiable risk factors associated with increased likelihood of occurrence.

Case Presentation

We present the case of a 30-year-old woman who attended the emergency unit with her second spontaneous ectopic pregnancy following a previous bilateral salpingectomy. She had prior multiple spontaneous ectopic pregnancies: laparoscopic salpingectomy for a left cornual EP in 2017 followed by laparotomic salpingectomy for a ruptured right EP after failed medical management in 2018. Lastly, she had laparoscopic removal of an EP sac in the scar of a previous left cornual EP in 2019. She presented with a history of missed periods, pelvic pain, and vaginal spotting. Her examination revealed left lower abdominal pain, soft, non-tender abdomen, and no cervical excitation. Pelvic ultrasound revealed a thin endometrium and no intrauterine pregnancy visualised. A suspicious complex mass near the left ovary with a ring-like structure was noted. Her β-HCG was (251 IU/L) which plateaued after 48 hrs (220 IU/L). She responded well to methotrexate with no need for surgical intervention this time.

Conclusion

This case is unique as it highlights the importance of keeping an open mind when managing recurrent ectopic pregnancies, especially when preventative surgical measures have been performed previously.

Rare Occurrence of Left Ampullary Ectopic Pregnancy After Ligation of the Left Fallopian Tube: A Case Report

Purpose

Ectopic pregnancy (EP) is rare among patients having received tubal ligation; in these cases, a fertilized ovum is implanted in the proximal tube stump. Distal tubal EP cases in patients having undergone ipsilateral tubal ligation and who have relatively intact contralateral adnexa are extremely rare. Here, we report a case of pregnancy in the distal stump of the ipsilateral fallopian tube following fallopian tubal isthmus ligation.

Case Presentation

A 28-year-old woman was admitted after having experienced lower abdominal pain for 10 days and amenorrhea for 1 week and receiving a transvaginal color ultrasonography finding of a heterogeneous echo (2.1 × 1.2 × 1.4 cm) near the left ovary. The patient had a medical history of transvaginal left tubal ligation under single-port laparoscopy for a left hydrosalpinx. Postoperatively, the patient had undergone in vitro fertilization for assisted reproduction. After ovum retrieval, whole-embryo cryopreservation had been performed due to the ovarian hyperstimulation syndrome trend. This pregnancy was natural after embryo cryopreservation. After the patient was admitted, laparoscopic exploration revealed an elevated ampulla in the distal stump of the left fallopian tube. Left salpingectomy with removal of the ectopic pregnancy in the distal remnant tube was performed under the guidance of transvaginal single-port laparoscopy. Serum β-human chorionic gonadotropin levels gradually decreased. Thereafter, the patient underwent two cycles of frozen embryo transfer, both of which resulted in chemical pregnancies.

Conclusion

This case suggests that gynecologists should pay attention to the possibility of fallopian tube ectopic pregnancy in the distal tubal segment post-tubal ligation.

A Case Report of Retroperitoneal Ectopic Pregnancy After in vitro Fertilization-Embryo Transfer and Literature Review

Background

Retroperitoneal ectopic pregnancy (REP) is an extremely rare type of ectopic pregnancy that can be life threatening. The pathogenesis of REP remains inconclusive and the diagnosis and treatment modalities are unclear.

Case Presentation and Review of the Literature

A 27-year-old woman (gravida: 3; parturition: 0) underwent transvaginal ultrasound (TVS) 40 days after in vitro fertilization-embryo transfer (IVF-ET); no intrauterine gestational sac was detected. The patient was asymptomatic and had no abnormalities on physical examination. β-HCG and progesterone were 18.210 mIU/mL and 10.891 ng/mL, respectively. Transabdominal ultrasound (TAS) showed that the gestational sac had implanted adjacent to the abdominal aorta and near a branch of the iliac artery. Laparoscopic exploration was performed under general anesthesia; intraoperative findings showed that the gestational sac was approximately 2.5 cm in diameter and in the same location as suggested by preoperative ultrasound. Histopathological examination confirmed the diagnosis of EP. On day three post-surgery, the levels of β-HCG had fallen to 911 mIU/mL. We further systematically reviewed the REP cases reported in the English literature and performed a review on the diagnosis and treatment of REP.

Conclusion

Clinicians should be alert to the occurrence of REP. Combined radiological examinations including ultrasonography (TAS and TVS), CT, and MRI are essential for the early diagnosis of REP. Once a definitive diagnosis is made, appropriate treatment should be administered immediately. Although there are cases of successful drug treatment described in the literature, surgery remains as the primary treatment option for REP.

Ovarian pregnancy after bilateral salpingectomy in a patient with in vitro fertilization: a case report

Ovarian pregnancy is rare but may occur with in vitro fertilization-embryo transfer in women who have undergone bilateral salpingectomy. We report a case of an approximately 30-year-old woman who had in vitro fertilization and a history of bilateral salpingectomy, and was diagnosed with an ovarian pregnancy. Laparoscopic enucleation of the gestational product in the ovary and ovarian remnant reconstruction were performed. The patient recovered well after surgery and was discharged home 5 days postoperatively. ß-human chorionic gonadotropin was undetectable 3 weeks after the surgery. Awareness of the possibility of ovarian pregnancy after in vitro fertilization-embryo transfer is the most important step in an early diagnosis and treatment. Salpingectomy should be carefully performed to eliminate the risk of heterotopic pregnancy, especially in cases where a subsequent gestation is desired.

Pregnancy outcomes following in vitro fertilization treatment in women with previous recurrent ectopic pregnancy

Objectives

The aim of this study was to investigate the impact of a history of recurrent ectopic pregnancy (EP) on pregnancy outcomes of subsequent in vitro fertilization (IVF) treatment.

Methods

A retrospective cohort study involving 457 women with a history of recurrent EP (REP group), 912 women with a history of single EP (SEP group), and 1169 women with a history of intrauterine pregnancy (IUP group) as the control group, was conducted. IVF outcomes were compared for each cohort.

Results

The incidence of EP in the REP group after IVF treatment was significantly lower than those in the SEP group (2.4% vs. 6.8%, P = 0.011), and similar to those in the IUP group (2.4% vs. 2.1%, P = 0.830). No significant differences were observed in the clinical pregnancy rate, miscarriage rate, and live birth rate among the three groups. There was no statistically significant difference in the recurrent EP rate between the salpingectomy and salpingostomy treatments. Adjusting for maternal and treatment factors did not influence live birth rates for women with previous REP compared with women with previous SEP and those with IUP. The odds of EP were 82.2% lower (OR 0.178, 95% CI 0.042–0.762; P = 0.020) in women who had blastocyst transfer compared with cleavage embryo transfer in the SEP group. The odds of EP were over six times (OR 6.260, 95% CI 1.255–31.220; P = 0.025) in women who underwent double embryo transfer as opposed to single embryo transfer in the IUP group.

Conclusion

Our results indicate that women with previous recurrent EP have a lower risk of EP after IVF in comparison with women with previous single EP. Previous EP has no significant adverse effect on the main IVF outcomes. The salpingostomy and salpingectomy treatments of EP do not significantly affect the incidence of recurrent EP after IVF.

Abdominal heterotopic pregnancy after in vitro fertilization and embryo transfer following bilateral salpingectomy: A case report and literature review

Background

Risk of heterotopic pregnancy following bilateral salpingectomy has increased considerably due to the widespread use of assisted reproductive technology. Poor understanding of this condition often causes delayed or missed diagnosis.

Objective

In this report, we describe the case of a 30-year-old pregnant woman with lower abdominal pain lasting for half a day and a history of bilateral salpingectomy. Two embryos had been transferred 21 days preceding her presentation.

Methods

Case report.

Results

Laparoscopic surgery revealed intraperitoneal hemorrhage and proper ovarian ligament pregnancy confirmed by histopathology. Viable intrauterine pregnancy was verified 3 days later by ultrasound examination.

Conclusion

Heterotopic pregnancy is a serious condition that may be life-threatening. Clinicians should be aware of the potential for heterotopic pregnancy in patients receiving in vitro fertilization and embryo transfer after bilateral salpingectomy.

Heterotopic Pregnancy Secondary to in vitro Fertilization-Embryo Transfer: Risk Factors and Pregnancy Outcomes

Background

With the widespread application of assisted reproduction technology (ART) and increased pelvic inflammatory disease, the incidence of heterotopic pregnancy (HP) has risen. However, the risk factors and treatment of HP remain indefinite.

Objectives

To explore risk factors affecting the incidence of HP secondary to in vitro fertilization-embryo transfer (IVF-ET) and pregnancy outcomes after surgical treatment of HP.

Methods

29 patients with HP and 116 with an intrauterine-only pregnancy (IUP) after IVF-ET during the same period were included retrospectively from January 2015 to September 2020.

Results

Patients with HP had a higher proportion of previous ectopic pregnancies, multiple abortion history (≧2 times) and tubal indication for IVF than IUP. Besides, they had a greater possibility to end in spontaneous abortion (31.03 vs.13.79%, P = 0.028) and preterm delivery (25.00 vs. 7.00%, P = 0.035), less possibility to result in a live birth (58.62 vs. 78.45%, P = 0.028). History of multiple abortions (≥2 times) [odds ratio (OR) 3.031, 95% confidence intervals (CI) 1.087–8.453; P = 0.034], tubal infertility (OR 3.844, 95% CI 1.268–11.656; P = 0.017), previous ectopic pregnancies (OR 2.303, 95% CI 0.625–8.490; P = 0.021) and number of embryo transfer (OR 0.300, 95% CI 0.092–0.983; P = 0.037) resulted in an elevated proportion of HP in IVF treatment. Shorter operative duration, smaller size of the ectopic mass and location in the ampulla of the fallopian tube were associated with higher chance of survival in the coexistent intrauterine pregnancy after surgical treatment.

Conclusions

Previous history of ectopic pregnancy, multiple abortions, tubal infertility and multiple-embryo transfer may be considered as meaningful risk factors of subsequent HP following IVF-ET. In patients with HP treated by surgery, shorter operative duration, smaller size of the ectopic mass and location in the ampulla of the fallopian tube means better reproductive prognosis.

Heterotopic pregnancy after bilateral salpingectomy, IVF and multiple embryos transfer. A case report and systematic review of the literature

Heterotopic pregnancy after bilateral salpingectomy is an extremely rare complication of in vitro fertilisation/embryo transfer cycles. We report a case of a ruptured abdominal pregnancy on the omentum which was the stimulus to conduct the first systematic review on this complication according to 'PRISMA' guidelines (PROSPERO R.No CRD42020134104). PubMed, EMBASE and OpenAIRE databases were systematically reviewed for studies reporting (a) cases or case series of, (b) heterotopic pregnancies after, (c) prior bilateral salpingectomy, and (d) embryo transfer cycles. Twenty-two articles met the selection criteria including, with our case, 28 cases. Based on the results, clinical manifestations and laboratory findings can be unspecific or misleading. Transvaginal ultrasound is the main diagnostic tool as the ectopic foetus is more frequently located in the intramural part of the fallopian tubes, the tubal stump or the ovaries. Laparotomy or laparoscopy are the main treatment options with adequate perinatal outcome.

Paradigm shift from tubal ligation to opportunistic salpingectomy at cesarean delivery in the United States

BACKGROUND

Opportunistic salpingectomy is now recommended at the time of routine gynecologic surgery to reduce the risk of future ovarian cancer, and performance of opportunistic salpingectomy has increased markedly at the time of benign hysterectomy. Salpingectomy has also been suggested to be feasible at the time of cesarean delivery in women desiring sterilization; however, uptake has not been previously studied on a national level.

OBJECTIVE

This study aimed to examine recent population trends in the utilization and characteristics of salpingectomy at the time of cesarean delivery in the United States.

STUDY DESIGN

This is a population-based retrospective observational study querying the National Inpatient Sample between October 2015 and December 2018. The primary outcome measure was the temporal trend of bilateral salpingectomy at cesarean delivery, assessed with linear segmented regression with log transformation utilizing 3-month time increments. The secondary outcome measures included patient characteristics associated with bilateral salpingectomy, assessed with a multinomial regression model, and surgical outcome (hemorrhage, blood transfusion, hysterectomy, and oophorectomy) at the time of bilateral salpingectomy vs bilateral tubal ligation, assessed with generalized estimating equation in a propensity score-matched model.

RESULTS

There were 3,813,823 women at the age of 15 to 49 years who had cesarean deliveries included, of whom 397,260 (10.4%) had bilateral salpingectomy and 203,400 (5.3%) had bilateral tubal ligation overall. During the time period studied, performance of bilateral salpingectomy among women undergoing cesarean delivery significantly increased from 4.6% to 13.2% (odds ratio for the fourth quarter of 2018 vs the fourth quarter of 2015, 2.69; 95% confidence interval, 2.63-2.75; Figure panel). In contrast, performance of bilateral tubal ligation among women undergoing cesarean delivery significantly decreased from 11.3% to 2.4% (odds ratio, 0.20; 95% confidence interval, 0.19-0.21). By the third quarter of 2016, the number of women who had bilateral salpingectomy exceeded those who had bilateral tubal ligation at cesarean delivery (8.6% vs 7.3%). Increasing the utilization of bilateral salpingectomy did not vary across age groups; the salpingectomy rate increased from 7.5% to 21.1% among women at the age of ≥35 years and from 3.8% to 10.7% among women at the age of <35 years (both, P<.001). In a propensity score matched model, women in the bilateral salpingectomy group were more likely to have hemorrhage (3.8% vs 3.1%; odds ratio, 1.24; 95% confidence interval, 1.15-1.33), blood product transfusion (2.1% vs 1.8%; odds ratio, 1.16; 95% confidence interval, 1.04-1.30), hysterectomy (0.8% vs 0.4%; odds ratio, 2.28; 95% confidence interval, 1.84-2.82), and oophorectomy (0.3% vs 0.2%; odds ratio, 2.02; 95% confidence interval, 1.47-2.79) than those in the bilateral tubal ligation group. When restricted to the nonhysterectomy cases, the bilateral salpingectomy group had a higher rate of hemorrhage (3.4% vs 3.0%; odds ratio, 1.16; 95% confidence interval, 1.06-1.26) and oophorectomy (0.3% vs 0.1%; odds ratio, 1.75; 95% confidence interval, 1.22-2.50) than the bilateral tubal ligation group.

CONCLUSION

In the United States, the utilization of bilateral salpingectomy at the time of cesarean delivery increased rapidly between 2015 and 2018, replacing tubal ligation as the most common type of sterilization performed with cesarean delivery. The higher surgical morbidity in the bilateral salpingectomy group than the bilateral tubal ligation group observed in this study warrants further investigation.

Spontaneous Pregnancy after Total Bilateral Salpingectomy: A Systematic Review of Literature

OBJECTIVE

To assess the occurrence of spontaneous pregnancy after a history of total bilateral salpingectomy (BS).

DATA SOURCES

A systematic search was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, searching MEDLINE, Embase, Google Scholar, PubMed, SCOPUS, and Web of Science from database inception to February 20, 2020.

METHODS OF STUDY SELECTION

We included women with a history of total BS for any indication with subsequent spontaneous pregnancy. Excluded were women who had a history of incomplete/partial salpingectomy or tubal occlusion, who had pregnancy after assisted reproductive technology, and whose pregnancy was not appropriately confirmed via beta-subunit of human chorionic gonadotropin or ultrasound.

TABULATION, INTEGRATION, AND RESULTS

The systematic search retrieved 1942 articles; 39 studies were potentially eligible, and their full texts were reviewed. A total of 4 case reports were included. Total BS had been performed for other indications than permanent contraception in all cases. Pain was the most common presenting symptom. All 4 pregnancies were intrauterine in location. Treatment was based on desire to continue pregnancy and hemodynamic stability.

CONCLUSION

Spontaneous pregnancy after total BS is exceedingly rare. The present data suggest that it is reassuring to offer total BS as a form of permanent contraception. Prospective data are warranted to ascertain short- and long-term effects of total BS for permanent contraception including its efficacy.

Retroperitoneal ectopic pregnancy: A literature review of reported cases

To provide reference for the diagnosis and treatment of retroperitoneal ectopic pregnancy (REP), we conducted a review on all of the reported cases in English by summarizing their clinical manifestation, diagnosis, management and prognosis. A total of 25 literatures including 26 REP cases were collected from PubMed database. 40 % (10/25) of the patients had a history of tubal pregnancy, 65.4 % (17/26) was spontaneous pregnancy, and the average period of amenorrhea was 56.7 days. Abdominal pain is the most common (53.8 %, 14/26) symptom of REP. Ultrasound is the main method of diagnosing REP. Only 30.8 % (8/26) were diagnosed as REP at the initial visit, and 55.6 % (10/18) of those who were misdiagnosed received unnecessary invasive treatment. The pregnancy sites of REP are complex, and it can be simply divided into pelvic REP and abdominal REP. Due to preoperative misdiagnosis, 46.2 % (9/26) of REP experienced two or more treatments. Except for 2 patients who received local methotrexate (MTX) injection in the gestational sac, the other 24 patients underwent surgical treatment, and all patients had a good prognosis. Due to insufficient knowledge, the rate of misdiagnosis and mistreatment of REP is high. The key to diagnosing REP is to consider the possibility of REP and the scanning field during examination can cover the site of pregnancy. Local MTX injection and surgical resection are both effective methods for the treatment of REP.