Heterotopic Pregnancy After In Vitro Fertilization and Embryo Transfer After Bilateral Total Salpingectomy/Tubal Ligation: Case Report and Literature Review

Treatment effects of laparoscopy versus laparotomy on heterotopic pregnancy after in vitro fertilization and embryo transfer

OBJECTIVE

To compare the treatment effects of laparoscopy versus laparotomy on heterotopic pregnancy (HP) after in vitro fertilization-embryo transfer (IVF-ET).

METHODS

The retrospective case-control study enrolled 109 patients diagnosed with HP after IVF-ET treatment in our hospital from January 2009 to March 2020. All patients received surgical treatment by either laparoscopy or laparotomy. Data for general characteristics, diagnostic features, surgical parameters, as well as perinatal and neonatal outcomes were collected.

RESULTS

Sixty-two patients received laparoscopy and 47 received laparotomy. Significantly lower percentage of large hemoperitoneum (P = 0.001), shorter surgery duration (P < 0.001), less intraoperative blood loss (P = 0.001), higher rates of general anesthesia (P < 0.001), and lower cesarean section rates for singletons (P = 0.003) were found in the laparoscopy group. The perinatal and neonatal outcomes were comparable between the two groups. When interstitial pregnancy was considered alone, the surgical blood loss was significantly reduced in the laparoscopy group (P = 0.021), but there was no significant difference in hemoperitoneum, surgery duration, or perinatal and neonatal outcomes in singletons.

CONCLUSION

Both laparoscopy and laparotomy are effective surgical treatments for HP after IVF-ET. Laparoscopy is minimally invasive but laparotomy can be an alternative in emergency situations.

Successful Ultrasound-Guided Methotrexate Intervention in the Treatment of Heterotopic Interstitial Pregnancy: A Case Report and Literature Review

PURPOSE

This study aims to share the experience of minimally invasive ultrasound-guided methotrexate intervention in the treatment of heterotopic interstitial pregnancy (HIP) with good pregnancy outcomes, and to review the treatment, pregnancy outcomes, and impact on the future fertility of HIP patients.

METHODS

The paper describes the medical history, clinical manifestations, treatment history, and clinical prognosis of a 31-year-old woman with HIP, and reviews cases of HIP from 1992 to 2021 published in the PubMed database.

RESULTS

The patient was diagnosed with HIP by transvaginal ultrasound (TVUS) at 8 weeks after assisted reproductive technology. The interstitial gestational sac was inactivated by ultrasound-guided methotrexate injection. The intrauterine pregnancy was successfully delivered at 38 weeks of gestation. Twenty-five HIP cases in 24 studies published on PubMed from 1992 to 2021 were reviewed. Combined with our case, there were 26 cases in total. According to these studies, 84.6% (22/26) of these cases were conceived by in vitro fertilization embryo transfer, 57.7% (15/26) had tubal disorders, and 23.1% (6/26) had a history of ectopic pregnancy; 53.8% (14/26) of the patients presented with abdominal pain and 19.2% (5/26) had vaginal bleeding. All cases were confirmed by TVUS. In total, 76.9% (20/26) of intrauterine pregnancies had a good prognosis (surgery vs. ultrasound interventional therapy 1:1). All fetuses were born without abnormalities.

CONCLUSIONS

The diagnosis and treatment of HIP remain challenging. Diagnosis mainly relies on TVUS. Interventional ultrasound therapy and surgery are equally safe and effective. Early treatment of concomitant heterotopic pregnancy is associated with high survival of the intrauterine pregnancy.

Ovarian Pregnancy: 2 Case Reports and a Systematic Review

Ovarian pregnancy is a rare but well-known pathology. However, pathophysiology, diagnosis and treatment are not established. Therefore, all case reports on ovarian pregnancy published in PubMed from November 2011 till November 2022 were reviewed and two case reports were added. In these 84 case reports, 8% of ovarian pregnancies occurred in women without or with blocked oviducts and 23% were localised on the other side than the corpus luteum. Since symptoms are not specific, ovarian pregnancy has to be suspected in all women with abdominal bleeding. Surgical excision is the preferred treatment. However, since an associated intra-uterine pregnancy cannot be excluded, care should be taken not to interrupt this intra-uterine pregnancy with the uterine cannula or by damaging the corpus luteum. In conclusion, in women with abdominal bleeding, an ovarian pregnancy cannot be excluded, even in women with a negative pregnancy test or an empty uterus on transvaginal ultrasonography. Therefore, a laparoscopy is indicated but the surgeon should realise that an associated intra-uterine pregnancy also cannot be excluded and that therefore care should be taken not to interrupt this intra-uterine pregnancy by the uterine cannula or by damaging the corpus luteum.

Management of a uterine serosal heterotopic pregnancy after in vitro fertilization in a woman with bilateral salpingectomy: A case report and literature review

RATIONALE

Heterotopic pregnancy (HP) is defined as the simultaneous presence of intrauterine pregnancy and ectopic pregnancy (EP). HP after bilateral salpingectomy is extremely rare and may lead to serious complications if it is misdiagnosed and untreated timely. Here, we presented the first reported case of uterine serosal HP in a woman after assisted reproductive technology with bilateral salpingectomy because of bilateral tubal ectopic pregnancy.

PATIENT CONCERNS

A 27-years-old pregnant woman after in vitro fertilization with bilateral salpingectomy complained of a sudden onset of unprovoked abdominal pain, which was persistent and dull. She denied vaginal bleeding.

DIAGNOSES

Serum beta-human chorionic gonadotropin levels are difficult to predict HP. Transvaginal ultrasonography demonstrated 1 gestational sac in the uterine cavity and 1 thick-walled cystic mass over the upper of the uterus, with a large amount of fluid in the Pouch of Douglas. Emergency laparotomy revealed a uterine serosal pregnancy combined with intrauterine pregnancy.

INTERVENTIONS

This patient was successfully managed via emergency laparotomy to remove residual tissue and repair the rupture of the uterine serosal pregnancy.

OUTCOMES

At postoperative 4 days, repeat transvaginal ultrosonography presented 1 intrauterine gestational sac with a visible fetal bud and cardiac tube pulsation. Now the patient recover well and is in an ongoing pregnancy.

LESSONS

It is noteworthy that HP/ectopic pregnancy is still not prevented after bilateral salpingectomy. In cases of multiple embryo transfer, even if intrauterine pregnancy has been established, it is important to rule out HP/ectopic pregnancy in time. Early diagnosis and early management can significantly improve clinical outcomes.

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 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.

The rising incidence of heterotopic pregnancy: Current perspectives and associations with in-vitro fertilization

Heterotopic pregnancy is the simultaneous occurrence of an intrauterine and ectopic pregnancy. This study aims to review the current literature regarding heterotopic pregnancy with a focus on its diagnosis and associations with in-vitro fertilization (IVF). Studies have shown that ovarian hyperstimulation syndrome and multiple embryo transfer during IVF are associated with an increased risk of heterotopic pregnancy. Tubal abnormalities such as pelvic inflammatory disease and previous tubal or abdomino-pelvic surgery have also been identified as risk factors. Diagnosis is challenging as the falsely reassuring presence of an intrauterine fetus frequently delays early intervention. Treatment should be individualised, but is often prompt surgical intervention, and focuses on terminating the ectopic pregnancy while minimizing harm to the mother and intrauterine fetus.

A Case of Heterotopic Ovarian Pregnancy after in vitro Fertilization: Early Diagnosis and Single-port Access Conservative Laparoscopic Treatment

Here, we reported the case of a 32-year-old pregnant woman who presented with sudden abdominal pain at 5 weeks of gestation and diagnosed as ruptured heterotopic ovarian pregnancy. She was conceived after in vitro fertilization. Right ovarian pregnancy was noticed, and we performed right ovarian wedge resection via single-port access laparoscopic surgery. Intrauterine pregnancy had remained intact, and she delivered a term baby. Rapid diagnosis in early gestation and minimally invasive laparoscopy resulted in a satisfactory pregnancy outcome without other complications. Single-port laparoscopic surgery can be feasible and appears to be a good first treatment option in a ruptured heterotopic ovarian pregnancy.

Rare heterotopic pregnancy after frozen embryo transfer: a case report and literature review

Background

Heterotopic pregnancy occurred after frozen embryo transfer with two D3 embryos, and the case had a history of bilateral salpingectomy due to salpingocyesis. An ectopic heterotopic pregnancy was implanted in the left psoas major muscle, which has not been previously reported.

Case presentation

A 33-year-old woman presented with left back pain after curettage due to foetal arrest in the uterus without vaginal bleeding and spotting, and painkillers relieved the pain initially. When the painkillers ceased to work, the patient returned to the hospital. The β-human chorionic gonadotropin (β-hCG) level remained increased compared with the time of curettage, and a diagnosis of retroperitoneal abdominal pregnancy was suggested by ultrasonography and computerized tomography (CT) with the gestational sac implanted in the left psoas major muscle at the left hilum level. Laparotomy was performed to remove the ectopic pregnancy. During the operation, we carefully separated the adipose tissue between the space of the left kidney door and left psoas major muscle, peeled away the gestational sac that was approximately 50 mm × 40 mm with a 25-mm-long foetal bud, and gave a local injection of 10 mg of methotrexate in the psoas major muscle. Fifty days later, β-hCG decreased to normal levels.

Conclusion

It is necessary to pay more attention to the main complaints to exclude rare types of ectopic pregnancies of the pelvis and abdomen after embryo transfer.

Transvaginal Reduction of a Heterotopic Cornual Pregnancy with Conservation of Intrauterine Pregnancy

Here we report a case of heterotopic cornual pregnancy after in vitro fertilization who was diagnosed at 6 weeks after frozen embryos transfer. The heterotopic pregnancy was successfully terminated by transvaginal ultrasound-guided selective fetal reduction. At 38+1 weeks, she underwent a cesarean section and delivered a healthy 3300 g male infant with Apgar score of 10-10' evaluated at 1 min and 5 min.

Two cases of intrauterine pregnancy with tubal stump pregnancy after in vitro fertilization and embryo transfer following ipsilateral salpingectomy: A case report

RATIONALE

The recently increased rate of heterotopic pregnancies (HPs) has been largely attributed to the increased use of assisted reproduction technologies (ARTs). HP is a rare and potentially life-threatening condition. It is unusual in natural conception cycles, occurring in 1:10,000 to 1:50,000 pregnancies. However, with the increased use of ART such as in vitro fertilization and embryo transfer (IVF-ET), the incidence has risen to 0.5-1%.

PATIENT CONCERNS

Case 1 was a 28-year-old woman who presented to our center complaining of a sudden onset of right-side lower abdominal pain with a small amount of vaginal bleeding. She had undergone IVF-ET and received a thawed embryo transfer with two embryos 23 days previously. She had a history of right salpingectomy for an ectopic pregnancy during the downregulation of her ovulatory cycle 1 year ago. Case 2 was a 25-year-old woman who presented to our center complaining of a sudden onset of right-side lower abdominal pain. She had also undergone thawed embryo transfer following IVF-ET with two embryos 35 days previously. She had a history of right salpingectomy for an ectopic pregnancy 1.5 years previously.

DIAGNOSES

Both patients were diagnosed as having a heterotopic pregnancy.

INTERVENTIONS

Patient 1 underwent emergency laparoscopy; patient 2 underwent emergency laparotomy and both were treated medically to prevent abortion of the intrauterine pregnancies.

OUTCOMES

Patient 1 had an incomplete abortion and underwent uterine curettage on the day 10 after the operation. Patient 2 experienced no further complications during pregnancy and a healthy baby girl was born at the 38th gestational week.

LESSONS

Reproductive physicians need to pay more attention to patients who have received more than one embryo at transfer, especially those with a history of salpingectomy.

Live birth after treatment of a spontaneous ovarian heterotopic pregnancy: A case report

Spontaneous heterotopic pregnancies occur in about 1/30000 pregnancies, with the ovarian subtype comprising 2.3% of the total. We report the case of a healthy 32-year-old woman, gravida 4, para 3, who presented to the emergency room with severe abdominal pain. Two weeks earlier, pelvic ultrasound had revealed a 6-week intrauterine pregnancy. She was hemodynamically stable, but had rebound tenderness on the right iliac fossa. Transvaginal ultrasound revealed an evolutive intrauterine pregnancy with a gestational age (GA) of 8 weeks, with a synchronous evolutive adnexal pregnancy of the same GA and some free fluid in the pouch of Douglas. She underwent an urgent laparoscopy which showed an intact gestational sac containing an embryo on the right ovary associated with mild hemoperitoneum. An ovarian wedge resection was performed to preserve ovarian tissue. The intrauterine pregnancy had no complications and the patient delivered vaginally at term. Heterotopic pregnancy is potentially life-threatening. Despite being extremely rare after natural conception, and even more so in the absence of major risk factors, it should be considered in any pregnant woman with abdominal pain. A high index of suspicion is important for a prompt diagnosis, selection of the appropriate surgical treatment and successful obstetric outcomes.

Spontaneous rupture of the uterus following salpingectomy: a case report and literature review

Laparoscopic salpingectomy (LPSC) is the main treatment for ectopic pregnancy, which leads to spontaneous uterine rupture (UR) during pregnancy. We report the characteristics of a woman who had spontaneous UR during pregnancy with a history of salpingectomy. We experienced a 31-year-old woman with a UR in pregnancy with a history of LPSC twice. The patient had a successful pregnancy. We also performed a literature review including cases with spontaneous UR after LPSC. Twenty-seven case reports of 48 women were included in our review. Thirty-five (83.33%, 35/42) women previously received LPSC and 15 (31.25%) developed interstitial pregnancies. The interval between pregnancy and the last surgery did not affect the frequency of interstitial pregnancy and gestational age. Fetal outcomes in patients with UR at the third trimester were better than those at the first and second trimesters. We suggest that close observation and timely treatment by experienced clinicians lead to good outcomes of pregnant women with suspected UR.

A case of heterotopic pregnancy after clomiphene-induced ovulation

Heterotopic pregnancy is a rare condition in which both intrauterine and extrauterine pregnancies occur simultaneously. It was reported to be very rare in normal conceived pregnancy. However, with the considerable progress of the assisted reproductive techniques, the incidence of heterotopic pregnancy increased. Furthermore, the incidence also increases in previous abortions. In this case report, we will present and discuss a patient who had heterotopic pregnancy after clomiphene-induced ovulation as well as a history of previous abortion where the extrauterine fallopian tube ruptured and was managed surgically while the intrauterine pregnancy was preserved.

Spontaneous ovarian heterotopic pregnancy

Heterotopic pregnancy is a simultaneous intrauterine and ectopic pregnancy. We report a case of a spontaneous ovarian heterotopic pregnancy. A 36-year-old woman, gravida 7 para 4-1-1-5 at 4 weeks gestation (spontaneous conception), presented to the emergency department with vaginal spotting, lower abdominal cramps with human chorionic gonadotropin(hCG) 10 772 mIU/mL (hCG at T0). Abdominal and pelvic examinations were benign. Transvaginal sonogram (TVS) showed an intrauterine gestational sac and yolk sac, no fetal pole visualised. She was discharged home with a diagnosis of threatened abortion. The patient returned to the emergency department 3 weeks later (T1) at 7 weeks gestation with recurrent vaginal bleeding and lower abdominal pain. Her TVS showed an empty uterus with small amount of free fluid in the cul-de-sac. A small 2 cm round mass noted in the adnexa with hCG of 4663 mIU/mL (hCG at T1). Laparoscopy revealed normal fallopian tubes bilaterally and a ruptured right ovarian ectopic pregnancy. Pathology was consistent with ectopic pregnancy. Abnormal hCG patterns should raise suspicion for heterotopic pregnancy.

Management and outcome of heterotopic interstitial pregnancy: Case report and review of literature

Objective

To report a case of heterotopic interstitial pregnancy after in vitro fertilization-embryo transfer (IVF-ET), presenting with a second trimester uterine rupture. To review the clinical presentations, risk factors, treatment options, and outcome of heterotopic interstitial pregnancies.

Methods

We describe the clinical presentation, management, and outcome of a patient with a heterotopic interstitial pregnancy, diagnosed following second trimester rupture of the interstitial pregnancy. We reviewed all published cases of heterotopic interstitial pregnancies.

Results

A 35-year-old pregnant woman with a past history of right adnexectomy and 16 weeks pregnant with dichorionic diamniotic twins following IVF-ET, was admitted to our department with unexplained recurrent abdominal pain and anemia. Further investigation showed a hemoperitoneum and because of hypovolemic shock an emergency laparotomy was performed, with diagnosis of a ruptured heterotopic interstitial pregnancy. The uterine defect was sutured using simple interrupted sutures. The intrauterine pregnancy progressed uneventful afterwards.We found 86 cases in the published literature, reporting on heterotopic interstitial pregnancies. 80.2% (69/86) occurred after IVF-ET. History of uni- or bilateral salpingectomy is a major risk factor, present in 39.5% (34/86). 37.2% (32/86) presented with cornual rupture. Surgery was performed in 53.5% (46/86) of cases. Medical management was possible in case of unruptured, early diagnosed heterotopic interstitial pregnancy (32.6% (28/86)). Watchful waiting was only possible when the interstitial pregnancy miscarried (5.8% (5/86)). The live birth rate of the intrauterine pregnancy, when viable at presentation, was 70.0% (56/80). The live birth rate of the interstitial pregnancy was only 4.7% (4/86).

Conclusions

The majority of cases are diagnosed by detailed ultrasound in the setting of early follow-up after IVF-ET and are asymptomatic at diagnosis. Yet, a substantial number of patients present with cornual rupture. Risk factors are IVF-ET and a history of salpingectomy. Depending on clinical presentation, treatment options include watchful waiting, medical treatment, or surgery. Unfortunately, the interstitial pregnancy is generally lost, and only has a chance of survival in case of presentation at a viable gestational age. The outcome of the coexisting intrauterine pregnancy is generally good.

Unilateral Salpingectomy and Methotrexate Are Associated With a Similar Recurrence Rate of Ectopic Pregnancy in Patients Undergoing In Vitro Fertilization

STUDY OBJECTIVE

To determine whether different treatment approaches of ectopic pregnancy (EP), particularly unilateral salpingectomy and methotrexate, affect its recurrence rate in patients undergoing in vitro fertilization (IVF).

DESIGN

A retrospective cohort study (Canadian Task Force classification II-2).

SETTING

An academic medical center.

PATIENTS

Patients with a history of a previous EP who achieved pregnancy after IVF cycles between January 2004 and August 2015 were included. The recurrence rate of EP was compared between patients who underwent different treatment approaches for a previous EP.

INTERVENTIONS

IVF.

MEASUREMENTS AND MAIN RESULTS

A total of 594 patients were included. Seventeen patients had a recurrence of EP (2.9%). Patients with a history of ≥2 EPs were associated with a significantly higher recurrence rate of EP than those with 1 previous EP (8.5% vs. 1.8%; p = .01; odds ratio [OR] = 2.2; 95% confidence interval [CI], 1.2-4.4). Patients who underwent unilateral salpingectomy (n = 245) had a comparable recurrence rate of EP after IVF with those who received methotrexate (n = 283) (3.6% vs. 2.8%; p = .5; OR = 1.3; 95% CI, 0.4-3.4). This OR remained unchanged after adjusting for patient's age, number of previous EPs, number of transferred embryos, and peak estradiol level during stimulation (adjusted OR = 1.4; 95% CI, 0.5-3.8). None of the patients who underwent bilateral salpingectomy (n = 45) or salpingostomy (n = 21) had a recurrence of EP after IVF.

CONCLUSION

The recurrence rate of EP significantly correlates with the number of previous EPs. Treatment of EP with methotrexate has a comparable recurrence rate of EP after IVF with unilateral salpingectomy. Therefore, the risk of recurrence should not be a reason to favor salpingectomy over methotrexate in this population.