The role of tubal pathology and other parameters in ectopic pregnancies occurring in in vitro fertilization and embryo transfer

Simultaneous bilateral tubal ectopic pregnancy after intracytoplasmic sperm injection and embryo transfer, in a patient with Stage 3 endometriosis

Introduction

The incidence of extrauterine pregnancy increases to 2-12% following in vitro fertilization -embryo transfer. Several pathogenic theories have been suggested, including abnormal hormonal secretion or exogenous hormones administered in assisted reproductive technology (ART).

Case report

A 32-year-oId nulliparous woman with primary infertility and Stage 3 endometriosis was treated by ART with intracytoplasmic sperm injection and embryo transfer. The patient showed simultaneous bilateral extrauterine pregnancy, managed by laparoscopic salpingectomy.

Discussion

The various possible pathophysiological mechanisms are described, with a review of the literature on simultaneous bilateral extrauterine pregnancy following ART. In pregnancies following ART, ectopic pregnancy should always be screened for by serum β-human chorionic gonadotropin monitoring and transvaginal ultrasound until the implantation site can be confirmed as the incidence is higher than in spontaneous pregnancy. Even if serum β-human chorionic gonadotropin concentration increases normally, possible bilateral ectopic pregnancy should always be investigated if no intrauterine gestational sac can be seen.

The risk of ectopic pregnancy following tubal reconstructive microsurgery and assisted reproductive technology procedures

PURPOSE

The incidence of ectopic pregnancy (EP) in the general population is 2%, whereas the EP rate following assisted reproductive technologies (ART) is between 2.1 and 11%. EP is also an adverse effect of tubal surgery with incidences up to 40% depending on the type, location, and severity of tubal disease and the surgical procedure.

METHODS

This paper looks at the incidence of EP following tubal reconstructive microsurgery, analyzes risk factors for EP following own 1,295 ART cycles and looks on the incidence of EP in 128,314 pregnancies following ART according to the presence or absence of tubal infertility using data from the German IVF Registry (DIR).

RESULTS

In our clinic, the EP rate following resterilization was 6.7%. In the presence of acquired tubal disease, the EP rate following adhesiolysis, salpingostomy, salpingoneostomy, fimbrioplasty, and anastomosis was 7.9%. The EP rate following ART in our clinic was 5.6%. Previous abdominal surgeries, microsurgical procedures, hydro-/sactosalpinges, salpingitis, salpingitis isthmica nodosa, and periadnexal adhesions showed a significant positive correlation with EP as outcome. Data of DIR demonstrate a significantly increased incidence of EP in the presence of tubal pathology. The highest EP rate related to all clinical pregnancies was 4.5% (95% CI 3.0-6.0) in smoking women <30 years with tubal pathology following IVF.

CONCLUSIONS

In the presence of tubal infertility, the incidence of EP following ART and tubal microsurgery are approximately comparable with each other and higher than in women without tubal infertility. The success of infertility surgery depends on a careful selection of appropriate patients.

The role of tubal reconstructive surgery in the era of assisted reproductive technologies

Tubal reconstructive surgery has fewer indications in the era of assisted reproductive technologies than in the past, but is still appropriate and effective treatment for properly selected individuals.

Ectopic pregnancy rates with frozen compared with fresh blastocyst transfer

OBJECTIVE

To compare the rate of ectopic pregnancy (EP) with fresh versus frozen blastocyst transfer in our program during the same time period.

DESIGN

Retrospective analysis.

SETTING

University IVF program.

PATIENT(S)

Women who achieved a clinical pregnancy after IVF between 1998 and 2005.

INTERVENTION(S)

In our program, cryopreservation is performed at the blastocyst stage. Embryo transfer was performed 1 to 1.5 cm short of the fundus by abdominal ultrasound guidance.

MAIN OUTCOME MEASURE(S)

The incidence of EP was examined in relation to fresh versus frozen blastocyst transfer.

RESULT(S)

In the frozen blastocyst group, there were 5 EPs out of 180 clinical pregnancies (2.8%), and there were 10 EPs out of 564 clinical pregnancies (1.8%) in the fresh blastocyst group.

CONCLUSION(S)

The rate of EP is not significantly increased after the transfer of frozen thawed blastocysts compared with fresh blastocyst transfer.

The role of tubal reconstructive surgery in the era of assisted reproductive technologies

Tubal reconstructive surgery has fewer indications in the era of assisted reproductive technologies than in the past, but is still appropriate and effective treatment for properly selected individuals.

Recurrent heterotopic pregnancy after bilateral salpingectomy in an IVF patient: case report

PURPOSE

To report a rare clinical case of recurrent heterotopic pregnancy in the same patient following bilateral salpingectomy and in-vitro fertilization (IVF) treatments.

METHODS

A 35 year-old woman, suffering from mechanical infertility, was treated by IVF, resulting in two episodes of heterotopic pregnancies within 2 years. The first episode ended in bilateral salpingectomy due to unilateral tubal pregnancy and contralateral severely damaged tube. The intrauterine pregnancy ended in early missed abortion. The second heterotopic pregnancy presented as bleeding cornual pregnancy, managed by laparoscopic resection of the tubal stump, and ended in a term singleton delivery.

CONCLUSION

The possibility of cornual heterotopic pregnancy following bilateral salpingectomy, though very rare, should be considered by every gynecologist treating IVF patient.

Ectopic pregnancy: a review

Ectopic pregnancy is a major clinical problem, occurring in 75,000 cases per year in the United States. With in vitro fertilization, embryo transfer, microsurgical techniques, and better early diagnosis, the rates of ectopic pregnancies have increased. Transvaginal sonography along with beta-human chorionic gonadotrophin monitoring are the standards for evaluation of suspected ectopic pregnancy. When ectopic pregnancy is present, transvaginal sonography most often demonstrates an adnexal finding directly related to the extra-uterine gestation itself, a hematoma caused by it, or both. Although tubal location is most common, it is important to recognize unusual locations of ectopic pregnancy such as isthmic, cervical, ovarian, and abdominal. Ultrasound is the mainstay of diagnosis, but magnetic resonance imaging can be helpful in unusual or complicated cases. Current therapeutic options for an ectopic pregnancy are expectant management, systemic methotrexate injections, sonographically guided minimal invasive treatment, and surgery. This review encompasses diagnosis, treatment, and management of ectopic pregnancy.

Ectopic pregnancy rates with day 3 versus day 5 embryo transfer: a retrospective analysis

Background

Blastocyst transfer may theoretically decrease the incidence of ectopic pregnancy following IVF-ET in view of the decreased uterine contractility reported on day 5. The purpose of our study is to specifically compare the tubal pregnancy rates between day 3 and day 5 transfers.

Methods

A retrospective analysis of all clinical pregnancies conceived in our IVF program since 1998 was performed. The ectopic pregnancy rates were compared for day 3 and day 5 transfers.

Results

There were 623 clinical pregnancies resulting from day 3 transfers of which 22 were ectopic (3.5%). In day 5 transfers, there were 13 ectopic pregnancies out of 333 clinical pregnancies (3.9%). The difference between these rates is not statistically significant (P = 0.8).

Conclusions

Our data suggests that the ectopic pregnancy rate is not reduced following blastocyst transfer compared to day 3 transfer. While there may be several benefits to extended culture in IVF, the decision to offer blastocyst transfer should be made independently from the issue of ectopic pregnancy risk.

Effect of hydrosalpinx fluid on secretion of trophoblastic matrix metalloproteinases

OBJECTIVE

To determine if hydrosalpinx fluid affects trophoblastic metalloproteinases (MMPs) secretion.

DESIGN

Measurement of the effect of hydrosalpinx and peritoneal fluids (as controls) added to the medium on the MMPs secreted by cytotrophoblastic cells.

SETTING

Academic research center.

PATIENT(S)

Five samples of hydrosalpinx fluid were obtained at the time of ovocyte retrieval. Three samples of peritoneal fluids were collected at laparoscopic sterilization.

MAIN OUTCOME MEASURE(S)

The concentration and activity of MMP-2 and MMP-9, the concentration of the tissue inhibitor of metalloproteinases (TIMP-1), and the total gelatinolytic activity of the cytotrophoblastic cells were measured in the culture medium.

RESULT(S)

Hydrosalpinx significantly stimulated MMP-2, MMP-9, and TIMP-1. The net result was a significant stimulation of the total gelatinolytic activity. Peritoneal fluids increased MMP-2, MMP-9, and TIMP-1 concentrations, but the total gelatinolytic activity was not modified.

CONCLUSION(S)

In contrast to peritoneal fluids, hydrosalpinx stimulates the total gelatinolytic activity of cytotrophoblastic cells. This might indicate that the effect of hydrosalpinx on implantation rates may not be due to an inhibition of the capacity of an embryo to invade the endometrium. However, the stimulatory effect of hydrosalpinx on the net gelatinolytic activity could partly explain the increased incidence of ectopic pregnancies that have been described in the presence of hydrosalpinx.

Salpingectomy for repeated embryo nonimplantation after in vitro fertilization in patients with severe tubal factor infertility

PURPOSE

To evaluate the impact of salpingectomy on the rates of embryo implantation and pregnancy in patients with severe, irreversible tubal factor sterility.

METHODS

A retrospective study of patients with repeated failure of in vitro fertilization due to nonimplantation of the embryo. Seventy-two patients with severe and irreversible tubal factor sterility were selected following repeated failure of in vitro fertilization (IVF) due to assumed nonimplantation of the embryo: 35 underwent a salpingectomy before continuing IVF cycles and 37 continued IVF cycles without salpingectomy.

RESULTS

After the first IVF cycle consecutive to diagnosis of embryo nonimplantation, the implantation rate was 10.2% in the salpingectomy group and 6.1% in the group without the procedure (P = 0.5). After all IVF cycles, the rate was, respectively, 6.9% and 4.5% (P = 0.2). Salpingectomy improved the pregnancy rate (PR) per transfer (23.5% vs. 9.9%; P = 0.01). The curves of the cumulative probability of becoming pregnant show that salpingectomy resulted in pregnancy more rapidly.

CONCLUSIONS

Salpingectomy improves the PR per transfer in patients with severe and irreversible tubal factor sterility who have experienced repeated failure of IVF due to embryo nonimplantation. This procedure also reduces the number of IVF attempts needed to obtain pregnancy.

Ovarian function before and after salpingectomy in artificial reproductive technology patients

To determine the effect of the removal of the tube on ovarian function we studied 52 artificial reproduction technology cycles in 26 women before and after undergoing laparoscopic salpingectomy for ectopic pregnancy. Ovarian response was measured by the duration and quantity of human menopausal gonadotrophins used in the cycle, the pre-ovulatory concentrations of oestradiol, the number of oocytes retrieved, and the quality of the embryos. All parameters were compared between cycles carried out before and after salpingectomy as well as between affected and unaffected sides. Our findings show no significant difference in any of the parameters studied. We conclude that laparoscopic salpingectomy does not abate ovarian response in artificial reproduction technology cycles that follow the procedure.

The effect of hydrosalpinges on IVF-ET outcome

PURPOSE

Our purpose was to determine if the presence of a hydrosalpinx effects the outcome of in vitro fertilization (IVF)-embryo transfer.

METHODS

We performed a retrospective analysis of IVF cycle stimulation sheets.

RESULTS

A total of 1000 patients with tubal factor infertility was analyzed. There were 60 hydrosalpinx patients who underwent 116 initiated cycles with 106 embryo transfers, compared to 940 control patients undergoing 1428 initiated cycles with 1150 embryo transfers. Both groups had a similar response to ovarian stimulation, number of oocytes retrieved, and number of embryos transferred. The hydrosalpinx group had a significantly higher preclinical loss rate (22/59 = 37% vs 80/566 = 14%; P = 0.001), a significantly lower implantation rate (55/352 = 16% vs 795/3795 = 21%; P = 0.013), a trend toward a reduced delivery rate per transfer (28/106 = 26% vs 387/1150 = 34%; P = 0.066), a significantly higher ectopic pregnancy rate (5/59 = 8% vs 16/566 = 3%; P = 0.04), and a similar spontaneous abortion rate (9/37 = 24% vs 99/486 = 20%; P = 0.28) compared to the control tubal factor group.

CONCLUSIONS

This study demonstrates a decrease in implantation rates and an increase in preclinical miscarriages and ectopic pregnancies in patients with hydrosalpinges compared to tubal-factor patients without sonographic evidence of dilated fallopian tubes.

Risk factors for ectopic pregnancy in assisted reproduction

OBJECTIVE

To identify risk factors for ectopic pregnancy (EP) after IVF-ET.

DESIGN

Retrospective cohort study.

SETTING

In vitro fertilization clinic at a university hospital.

PATIENT(S)

A total of 725 women who conceived after IVF were studied with regard to background factors, indications for IVF, and factors related to the IVF procedure through review of their medical charts. The rate of EP was 4%, corresponding with 29 EPs, of which 2 were heterotopic.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Pregnancy outcome, defined as intrauterine pregnancy or EP. Background factors, indications for IVF, and factors related to the IVF procedure were analyzed for possible correlation with the outcome of EP. Risk factors for EP were identified by logistic regression analysis.

RESULT(S)

Tubal factor infertility, various previous abdominal surgeries, previous EP or pelvic infection, presence of a hydrosalpinx or fibroid, and type of transfer catheter used showed a positive correlation with EP as outcome. Logistic regression analysis identified two factors with predictive power: tubal factor infertility and previous myomectomy.

CONCLUSION(S)

Tubal factor infertility was the most prominent risk factor for EP after IVF. Previous myomectomy appeared to be another important risk factor, but this is a new finding that needs to be confirmed by further study.

Does previous salpingectomy improve implantation and pregnancy rates in patients with severe tubal factor infertility who are undergoing in vitro fertilization? A pilot prospective randomized study

OBJECTIVE

To evaluate the implantation rate and pregnancy rate (PR) in patients with severe tubal factor infertility who were undergoing IVF. Patients who had undergone salpingectomy were compared with those who had not.

DESIGN

A prospective randomized study.

SETTING

A department of obstetrics and gynecology at a university hospital.

PATIENT(S)

Thirty patients who previously had undergone salpingectomy and 30 patients who had not undergone salpingectomy before IVF treatment.

INTERVENTION(S)

Laparoscopy with or without salpingectomy followed by IVF with the use of combined GnRH agonist and hMG therapy in a long stimulation protocol.

MAIN OUTCOME MEASURE(S)

Embryo implantation rate and ongoing PR per transfer. The cumulative PRs were compared for the two groups of patients.

RESULT(S)

After the first IVF attempt, the implantation rate was 10.4% in the group with salpingectomy and 4.6% in the group without salpingectomy. For all IVF attempts, the respective embryo implantation rates in the two groups were 13.4% and 8.6%. The ongoing PR per transfer was 34.2% in the group with salpingectomy compared with 18.7% in the group without salpingectomy. After four IVF attempts, the probability of becoming pregnant was greater in the group of patients with salpingectomy (75%) than in the group without salpingectomy (63%).

CONCLUSION(S)

Previous salpingectomy in patients with severe tubal factor infertility who are undergoing IVF seems to increase the embryo implantation rate and the PR per cycle of IVF. This monocentric study must be followed by other similar studies to allow for a metaanalysis and confirm this clear trend with definitive evidence.

The significance of hydrosalpinx in in vitro fertilization

OBJECTIVE

To review the effects of hydrosalpinx on IVF/ET and the role of salpingectomy.

DESIGN

The literature on hydrosalpinx, IVF/ET, embryotoxicity, and salpingectomy for hydrosalpinx was identified through MEDLINE searches and reviewed.

RESULT(S)

Hydrosalpinx has been associated with poor fertility prognosis. IVF/ET is a better alternative to tubal surgery for those patients with severe distal tubal disease, and it is also more cost effective. However, the presence of hydrosalpinx has a negative effect on IVF/ET by decreasing the pregnancy rates and implantation rates compared with patients undergoing IVF/ET for tubal disease but without hydrosalpinx. The hydrosalpingeal fluid has been demonstrated to be embryotoxic to developing embryos, thus leading to increased early pregnancy losses. Poor endometrial receptivity has also been demonstrated in the presence of hydrosalpinges. Removal of the hydrosalpinges leads to improved IVF/ET rates comparable to those patients without hydrosalpinx. Therefore, salpingectomy has been recommended for patients with hydrosalpinx who will be undergoing IVF/ET.

CONCLUSION(S)

The presence of hydrosalpinx has a negative effect on IVF/ET because of the suspected embryotoxicity of the hydrosalpingeal fluid. Surgical removal of the hydrosalpinx has been shown to improve IVF/ET rates.

The predictive value of an initial serum beta human chorionic gonadotropin level for pregnancy outcome following in vitro fertilization

PURPOSE

Our purpose was to assess the predictive value for pregnancy outcome of an initial serum quantitative beta-hCG measurement obtained 11 or 12 days after embryo transfer in an in vitro fertilization program.

METHODS

A prospective, descriptive study of 153 pregnancies achieved via in vitro fertilization-embryo transfer was performed. Initial beta-hCG levels and subsequent pregnancy outcomes were compared.

RESULTS

The overall mean initial beta-hCG level was 91 +/- 85.8 mIU/ml for normal (singleton, multiple-gestation) pregnancies and 29 +/- 24.9 mIU/ml for abnormal (miscarriage, ectopic) pregnancies (P < 0.01; power, > 80%). While 93.9% of patients with initial beta-hCG levels > or = 42 mIU/ml had normal pregnancies, 56.4% of those with initial levels < 42 mIU/ml experienced abnormal outcomes. With 42 mIU/ml as the cutoff level for predicting a normal pregnancy, this screening test yielded a sensitivity of 79.3% and a specificity of 83.8%.

CONCLUSIONS

Initial serum beta-hCG levels obtained 11 or 12 days after embryo transfer may be predictive of pregnancy outcome in an in vitro fertilization program.

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.

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.

Ectopic pregnancies after in vitro fertilization and embryo transfer

OBJECTIVE

Our objective was to analyze the risk factors, stimulation characteristics, and future fecundity of patients with ectopic pregnancies after in vitro fertilization (IVF).

METHODS

We retrospectively evaluated all cases of ectopic pregnancy occurring between January 1989 and March 1993 (Cornell series 1 to 17). A case-control group of intrauterine pregnancies was used for comparison of the stimulation and transfer characteristics.

RESULTS

Twenty-seven of 1123 pregnancies (2.4%) were ectopic, following 2812 fresh IVF embryo transfers, while 8 of 105 pregnancies (7.6%) were ectopic, following 405 frozen-thawed embryo transfers. Tubal factor was the cause of infertility in the majority (85.7%) of ectopic pregnancies. No difference was found between the ectopics and the matched controls in stimulation and transfer characteristics. Thirty ectopic pregnancies were ampullary, two were interstitial, two were cervical, and one was heterotopic. Twenty of the patients subsequently underwent 29 IVF attempts, with a pregnancy rate of 41.4% per transfer.

CONCLUSIONS

Ectopic pregnancy after IVF appears to be related to preexisting tubal pathology; embryo transfer of cryopreserved thawed embryos in a natural cycle may result in a higher ectopic rate in these patients; in subsequent IVF cycles the intrauterine pregnancy rate of these patients is not decreased.

Intramural pregnancy after in vitro fertilization and embryo transfer

A case of intramural but not interstitial pregnancy, established after IVF/ET, is described. The etiologic, diagnostic, and therapeutic aspects of this clinical dilemma are discussed.