Recurrent Heterotopic Pregnancy Following Frozen-Thawed Embryo Transfer: A Case Study and Comprehensive Literature Review.

BACKGROUND Recurrent heterotopic pregnancy is a serious and rare pregnancy complication that occurs after in vitro fertilization and embryo transfer, posing a great threat to the safety of the mother and intrauterine fetus. We report a case of recurrent heterotopic pregnancy after in vitro fertilization and embryo transfer. We also reviewed the literature to explore the causes, diagnosis, treatment, and prevention of recurrent heterotopic pregnancy. CASE REPORT A 32-year-old woman with tubal factor infertility underwent in vitro fertilization and embryo transfer. Oocyte extraction was performed twice, while embryo transfer was performed 4 times, with 2 embryos transferred each time. No pregnancies occurred during the 2 fresh embryo transfer cycles; however, heterotopic pregnancies occurred during both frozen-thawed embryo transfer cycles. Ultrasonography detected only the first heterotopic pregnancy, at 6 weeks after embryo transfer. As the intrauterine embryo had stopped developing, laparoscopically monitored dilatation and curettage and removal of the affected fallopian tubes were performed. The second heterotopic pregnancy was detected 3 weeks after embryo transfer, guided by the ultrasound examination conducted earlier. After timely surgical treatment, a live birth occurred. CONCLUSIONS This case and review of the literature elucidates the importance of considering the possibility of a heterotopic pregnancy during ultrasound examinations, especially in patients who utilized assisted reproductive technology to transfer multiple embryos.

[Clinical characteristics analysis of heterotopic cervical pregnancy].

Objective: To investigate the clinical characteristics of heterotopic cervical pregnancy (HCP). Methods: A retrospective analysis was conducted based on the general clinical data, assisted reproductive technology (ART) data, diagnosis and treatment data, and pregnancy outcomes of 17 patients diagnosed with HCP who received ART at the Reproductive Medicine Center of Peking University Third Hospital from January 2011 to April 2022. Results: The age of 17 HCP patients was (34.2±1.5) years, all of whom occurred after the application of ART; Among them, 11 cases had a history of uterine cavity operation. All 17 patients had vaginal bleeding, with only 1 case accompanied by abdominal pain. The gestational age at the diagnosis of HCP was [6+2 (5+2-6+4)] weeks. Two patients underwent conservative observation and were closely followed up. Both of them had intrauterine pregnancy until full-term and underwent cesarean section; One patient underwent ultrasound-guided cervical pregnancy reduction surgery, resulting in miscarriage due to premature rupture of membranes at 18+1 weeks of intrauterine pregnancy; One patient underwent ultrasound-guided cervical pregnancy reduction surgery, followed by uterine artery embolization, hysteroscopy, removal of cervical pregnancy lesions, and curettage due to excessive bleeding; One patient underwent uterine artery embolization, hysteroscopy, cervical pregnancy lesion clearance, and curettage due to excessive vaginal bleeding; One patient underwent hysteroscopy examination, cervical pregnancy lesion removal surgery, and uterine curettage due to embryo arrest during intrauterine pregnancy; 11 cases underwent ultrasound-guided cervical pregnancy lesion clearance surgery, all of which resulted in live births. Among the 13 delivery patients, 4 cases were premature and 9 cases were full-term; 5 cases of vaginal delivery and 8 cases of cesarean section. Conclusions: The most common clinical manifestation of HCP is vaginal bleeding. Ultrasound guided cervical pregnancy lesion clearance surgery is safe and feasible, and with good pregnancy outcomes.

Interstitial heterotopic pregnancy after bilateral total salpingectomy in IVF patients: a case report and literature review.

OBJECTIVES: Heterotopic pregnancy of an intrauterine pregnancy and an interstitial or stump pregnancy after bilateral salpingectomy is a rare complication of in vitro fertilization (IVF) that can lead to severe hemorrhage; prompt identification and management are important. The aim of this paper was to present a case report and an updated literature review of women who had had combined interstitial/stump and intrauterine pregnancies during an in an IVF cycle after total bilateral salpingectomy. MATERIAL AND METHODS: We conducted a search in PubMed for reported heterotopic pregnancy, of a combined intrauterine pregnancy with an interstitial or stump pregnancy, in women who underwent IVF after bilateral salpingectomy. RESULTS: Our search yielded 13 heterotopic pregnancies in women who underwent IVF after bilateral salpingectomy. Forty-six percent of the women had more than two embryos transferred, and all the women had a history of ectopic pregnancies or tubal infertility. Most of the women presented at 6-7 weeks of pregnancy with vaginal bleeding and/or abdominal pain. A ruptured ectopic pregnancy was presented in 42%. Ultrasound was the main diagnostic tool in most cases. Only two women had been medically treated with local KCL or methotrexate, while 83% underwent surgical treatment. Five women had uncomplicated cesarean sections near or at term. CONCLUSIONS: Women with bilateral total salpingectomy remain at risk of heterotopic pregnancy, which poses a diagnostic and treatment challenge. This risk may be reduced by the reduction in the number of transferred embryos in IVF. For those who wish to preserve intrauterine pregnancy, cornual resection can be performed with good prognosis.

Heterotopic twin pregnancy in unicornuate uterus and non-communicating rudimentary horn with survival of both fetuses: Magnetic resonance imaging and 3D reconstructions findings.

We reported a case of heterotopic twin pregnancy in a unicornuate uterus with a non-communicating rudimentary horn with survival of both fetuses. The diagnosis was made late at 28 weeks of gestation, with suspicion raised by ultrasound and confirmed by magnetic resonance imaging (MRI). During hospitalization, obstetric ultrasound with color Doppler was performed every 2 days to assess fetal well-being and myometrial thickness, which was determined by measurements of the uterine wall at the accessory horn. Elective cesarean section was performed at 33 + 5 weeks of gestation. Delivery started with the fetus in the rudimentary horn, with subsequent extraction of the fetus in the unicornate uterus. Three-dimensional virtual reconstruction allowed a spatial view of the both uterus and fetuses with better understanding of the obstetrical condition by the parents and interactive discussion by the multidisciplinary medical team.

Heterotopic pregnancy: a case report of intrauterine hydatidiform mole with tubal pregnancy.

We herein report a rare case of simultaneous intrauterine molar pregnancy and tubal pregnancy. A woman of childbearing age who had never been pregnant underwent an ultrasound examination 70 days after the onset of menopause. She had a history of ovulation induction. The ultrasound findings suggested a partial hydatidiform mole. She was then pathologically confirmed to have a complete hydatidiform mole after uterine suction dilation and curettage. On postoperative day 4, an ultrasound examination before discharge showed an inhomogeneous mass in the left adnexal region with mild lower abdominal pain. On postoperative day 17, the blood human chorionic gonadotropin level did not drop as expected, and a follow-up examination still indicated a mass in the left adnexal region. We were unable to rule out an ectopic hydatidiform mole. Hysteroscopy with laparoscopic exploration of the left adnexal mass and salpingotomy suggested a diagnosis of intrauterine hydatidiform mole combined with left tubal pregnancy.

Pseudogestational Sac Delaying Diagnosis of Ectopic Pregnancy: A Case Report.

BACKGROUND: Diagnosis of ectopic pregnancy can be complicated by nonspecific laboratory and radiographic findings. The multiple alternative diagnoses must be weighed against each other based on the entire clinical presentation. CASE REPORT: We present a case of a 20-year-old woman who arrived to the Emergency Department (ED) with abdominal pain and ended up being transferred for an Obstetrics evaluation of a possible heterotopic pregnancy. Her radiology-performed ultrasound had revealed an "intrauterine gestational sac" along with an adnexal mass near the right ovary. The patient was not undergoing assisted-reproductive fertilization, nor did she have meaningful risk factors for heterotopic pregnancy. The patient was managed expectantly over the ensuing week to see whether the intrauterine fluid was a true gestational sac. After multiple repeat ED visits, the diagnosis of ectopic pregnancy was made. Ultimately, the patient elected for surgical management of her ectopic pregnancy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case offers a reminder of the subtleties of radiographic identification of intrauterine pregnancies and the ever-present need to "clinically correlate."

Laparoscopic removal of heterotopic cesarean scar pregnancy.

OBJECTIVE: To present the laparoscopic management of heterotopic cesarean scar pregnancy and discuss other treatment options. DESIGN: Surgical video article. The Institutional Ethics Committee approved the video reproduction. SETTING: Tertiary referral to a university hospital. PATIENT: A 29-year-old woman with spontaneous heterotopic cesarean scar pregnancy presented for vaginal spotting. Ultrasound revealed two gestational sacs at 7 weeks and 6 days of gestation with fetal cardiac activity. One sac was in a normal intrauterine (IU) location, and the other was in a previous cesarean section scar. INTERVENTIONS: Scar pregnancy was excised laparoscopically, preserving IU pregnancy. No additional measures were taken to reduce bleeding. The bladder was filled with 150 cc isotonic to determine its boundaries. The peritoneum was dissected away from the cervix. After removing the ectopic pregnancy material, the myometrial defect was excised. The uterine wall was closed in three layers using 2-0 V-Loc sutures. MAIN OUTCOME MEASURES: Ongoing IU pregnancy after laparoscopic removal of cesarean scar pregnancy and term delivery. RESULTS: The procedure was completed in 67 minutes. Total blood loss was <100 cc. The ongoing pregnancy follow-up was uneventful. Delivery was planned for the 37th-38th weeks. Although instructed to visit immediately after experiencing pain, the patient arrived after the 38th week and reported having pain for 2 days. During the cesarean section, a rupture was observed at the previous incision site, which was fortunately incomplete. A healthy male infant (weight, 3,210 g; Apgar score, 9/10) was delivered. CONCLUSIONS: The most common approach for heterotopic scar pregnancy is embryo reduction with potassium chloride injection. However, the mass persists in the scar area, resulting in complications associated with excessive bleeding during a cesarean section in approximately half of cases. Moreover, almost all published cases of embryo reduction resulted in premature births before week 36. Considering the present case, laparoscopic surgery may be appropriate for managing heterotopic cesarean scar pregnancy by preserving IU pregnancy.

Combined hysteroscopic Bigatti shaver (IBS) and resectoscope removal of a heterotopic cesarean scar pregnancy in the first trimester.

OBJECTIVE: To report a case of heterotopic cesarean scar pregnancy reduction using a combined hysteroscopic integrated Bigatti shaver (IBS) and resectoscope with the preservation of a normal gestational sac in the uterine cavity under simultaneous transabdominal ultrasound guidance. DESIGN: Video article. SETTING: University-affiliated hospital. PATIENT: A 30-year-old woman, G5P2A2L2, with two previous cesarean deliveries and a history of fertility problems, was admitted with a heterotopic cesarean scar pregnancy at 7+2 gestational weeks. Ultrasound examination showed a dichorionic diamniotic pregnancy. The first gestational sac (1.7 × 1.7 × 0.6 cm) was located in the previous hysterotomy scars, with a thin layer of myometrium measuring 0.2 cm in thickness and a rich blood supply. The second chorionic sac (2.8 × 2.4 × 1.8 cm) was observed at the uterine fundus. Normal cardiac activity and yolk sacs were observed in both gestational sacs. The couple strongly desired to preserve the intrauterine pregnancy. INTERVENTION(S): After Institutional Review Board approval was obtained, a hysteroscopic IBS combined with a bipolar resectoscope was used to remove the heterotopic cesarean scar pregnancy while preserving the intrauterine gestational sac under simultaneous transabdominal ultrasound guidance. MAIN OUTCOME MEASURE(S): The heterotopic cesarean scar pregnancy was completely resected using hysteroscopy, and the gestational sac in the uterine cavity was successfully preserved. RESULT(S): Trophoblastic tissue was confirmed using histopathological examination. The patient had an unremarkable postoperative recovery. Subsequent serial ultrasonography confirmed a single ongoing pregnancy with normal growth parameters and a normal placental site. CONCLUSION(S): The inability of an IBS to perform coagulation can be offset by its combination with the bipolar resectoscope. Hysteroscopic IBS combined with resectoscope to remove a heterotopic cesarean scar pregnancy offers a short operation time and minimum blood loss. It could be an optimized approach for the management of heterotopic cesarean scar pregnancy in the first trimester when an intrauterine pregnancy needs to be preserved.

Laparoscopic resection of a salpingectomy stump remnant during early pregnancy: the diagnostic challenge posed in diagnosing a heterotopic stump pregnancy.

In this report, we present a case of a woman admitted in her first trimester of pregnancy with significant intraperitoneal haemorrhage from a left tubal stump remnant occurring concurrent to a viable intrauterine pregnancy. The patient was resuscitated and treated successfully with laparoscopic removal of her stump remnant to achieve haemostasis. However, despite extensive investigation, the pathology of her haemorrhagic stump remained inconclusive. Stump ectopic pregnancy is an established phenomenon, although it presents a diagnostic challenge when occurring as a heterotopic pregnancy. Further, persisting trophoblastic tissue is a rare but established feature of incomplete removal of ectopic pregnancy post salpingectomy. Here, we discuss challenges of diagnosis in such cases and present a case report of a presumed stump remnant heterotopic pregnancy from spontaneous conception.

Ultrasound manifestations and clinical analysis of 50 cases of heterotopic pregnancy.

OBJECTIVE: To investigate the value of ultrasonography in the diagnosis of heterotopic pregnancy and the follow-up. METHODS: A retrospective analysis of 50 cases of clinically diagnosed heterotopic pregnancy in our hospital was performed, the clinical characteristics and ultrasonographic manifestations of the patients were summarized, the reasons for initial ultrasound missed diagnosis and misdiagnosis were analyzed, and the pregnancy outcomes were followed up. RESULTS: Among the 50 cases, the initial ultrasound diagnoses of intrauterine pregnancy were all gestational sac type, 32 cases of ectopic pregnancy were located in the fallopian tube, and 10 cases were located in the uterine horn, 1 case at cervix, and 1 case at caesarean section scar. Forty-one cases were consistent with surgery and/or pathology, representing initial ultrasound diagnosis coincidence rate of about 82%. Six cases were missed in the initial ultrasound examination (12%), and three cases were misdiagnosed (6%). The maximum diameter of the intrauterine gestational sac was 9-48 mm, the average was about 24.90 ± 9.56 mm, the maximum diameter of the ectopic pregnancy gestational sac or mass was 11-63 mm, and the average was about 31.45 ± 13.82 mm (p < 0.05). Intrauterine pregnancy outcomes were followed up, 45 patients with complete data and 5 patients were lost to follow-up. The follow-up rate was about 90%. CONCLUSION: Combining the patient's medical history and clinical characteristics can reduce missed diagnosis and misdiagnosis of heterotopic pregnancy. Ultrasonography has important value in the assessment of intrauterine pregnancy growth and development, and the integrity of maternal uterus.

Spontaneous Heterotopic Pregnancy with Ovarian Localization: Case Report.

Heterotopic pregnancies are a rare phenomenon defined by the simultaneous occurrence of intrauterine and extrauterine pregnancy. The incidence of heterotopic pregnancy occurring through natural fertilization is low but is increased by risk factors such as assisted reproductive techniques or pelvic inflammatory disease increase. We report the case of a 36-year-old female patient in the 6th week of pregnancy who presented to the emergency unit with severe acute lower abdominal pain. Laboratory chemistry and sonography revealed a suspected heterotopic pregnancy. The patient was admitted for observation. The sonographic reevaluation on the next day confirmed the suspicion of extrauterine gravidity with intact intrauterine gravidity with additional decreasing hemoglobin and hematoperitoneum, so that laparoscopy was indicated. Intraoperatively, the mass on the left ovary was removed without complications. The patient could be discharged quickly postoperatively after a complication-free course and gave birth to a healthy child by spontaneous partus in the 38th week of gestation. Due to their rarity, there is limited research related to heterotopic pregnancies, and most scientific articles are case studies. Diagnostically, the most important thing in clinical practice is to think about the possibility of EUG even if there is evidence of an intact IUG. Transvaginal sonography is of particular importance in diagnostics. The performance of prospective cohort studies is desirable for the evidence-based diagnosis and therapy of affected patients in the future.

Challenges in the diagnosis and management of a ruptured heterotopic gestation following ultrasound-guided embryo transfer in low resource settings: a case report.

BACKGROUND: Heterotopic pregnancies are increasing in incidence with the advent of rising prevalence of in vitro fertilization and embryo transfer (IVF-ET) globally. Although rare, this condition is a serious potentially life-threatening gynaecological complication. CASE PRESENTATION: We present the case of a 36-year-old Ghanaian woman who conceived following IVF and presented two weeks after confirmation of intrauterine gestation with sudden onset lower abdominal pain. A diagnosis of ruptured heterotopic pregnancy was made, laparotomy and salpingectomy was done followed with further management of the intrauterine gestation. CONCLUSION: To the best of our knowledge, this is the first reported case of heterotopic pregnancy in Ghana. A high index of suspicion for heterotopic pregnancy is required even in the presence of a confirmed intrauterine gestation following IVF-ET.

Case Report of an exceptional spontaneous abdominal heterotopic pregnancy with superfetation: Diagnosis and treatment: Heterotopic pregnancy with superfetation (8+1 WG & 5+4 WG).

Heterotopic pregnancy is an extremely rare condition in which an intrauterine and an extrauterine pregnancy co-exist. In spontaneous conceptions, heterotopic pregnancy occurs in only 1/30 000 pregnancies. The treatment of heterotopic pregnancy must be as minimally invasive as possible to preserve the development of the intrauterine pregnancy. Superfetation, defined as the coexistence of 2 or more foetuses of different gestational ages, remains particularly exceptional and poorly explained (second ovulation? embryonic diapause?). Here, we present an extremely rare case of a spontaneous heterotopic evolutive pregnancy with superfetation, consisting of an embryo in the pouch of Douglas estimated at 8 + 1 weeks of gestation (WG) and a progressive intrauterine pregnancy estimated at 5 + 4 WG. We treated the extrauterine pregnancy with an intra-cardiac injection of potassium chloride echo-guided via the vaginal route, and the patient then underwent exploratory laparoscopy 9 days later and lavage and aspiration of the abdominal heterotopic pregnancy due to pain and biological inflammatory syndrome probably caused by pelvic mass syndrome and peritoneal irritation from the foetal necrosis. She has not yet given birth and is currently at 36 WG.

The risk factors for miscarriage of viable intrauterine pregnancies in patients with heterotopic pregnancy after surgical intervention.

To summarize the clinical characteristics and explore the risk factors for miscarriage of a viable intrauterine pregnancy following surgical intervention in patients with heterotopic pregnancy (HP). A total of 106 women diagnosed with HP that underwent surgical intervention in the Women's Hospital School of Medicine Zhejiang University between January 2014 and December 2021 were included in this retrospective study. They were divided into a miscarriage group (n = 13) and an ongoing pregnancy group (n = 93) according to the outcomes of the HP within 2 weeks after surgery. Data regarding clinical characteristics, surgical conditions, postoperative recovery, and complications were collected and compared between the groups. Logistic multivariate analysis was performed to explore the risk factors for miscarriage in patients with HP within 2 weeks of surgical intervention. Among the 106 women with HP, 80 had tubal HP, 8 had cornual HP, and 18 had interstitial HP. Eighty-seven (82.1%) patients developed clinical symptoms that manifested primarily as abnormal vaginal bleeding and/or abdominal pain, whereas 19 (17.9%) patients had no clinical symptoms. The mean gestational age on the day of surgery was 7.2 weeks (inter-quartile range, 6.4-8.3). The miscarriage rate within 2 weeks of surgical intervention was 12.3% in patients with HP. Compared to the ongoing pregnancy group, the miscarriage group had a higher body mass index, earlier gestational age at treatment, and higher volume of hemoperitoneum (P < .05 for all). Logistic multivariate analysis indicated that the women with a hemoperitoneum volume > 200 mL had significantly higher risk of miscarriage after adjusting covariates [OR (odds ratio) = 5.285, 95% CI (confidence interval) (1.152-24.238), P < .05]. Hemoperitoneum volume was independently associated with miscarriage of viable intrauterine pregnancies in patients with HP within 2 weeks of surgical intervention.

Conservative Management of Heterotopic Pregnancy: A Case Report and Review of Literature.

BACKGROUND Tubal heterotopic pregnancy is an extremely rare complication of pregnancy, in which there is a simultaneous presence of a pregnancy in the uterine cavity and in an ectopic location, most commonly in the fallopian tube. The management of such cases is not clearly established. In the case of a desire to maintain an intrauterine pregnancy, the surgical procedure consisting of a salpingectomy or salpingostomy is the most common. Such a procedure is effective, but it involves potential complications typical of surgeries, so, in some cases, it seems reasonable to apply the expectant management. CASE REPORT A 31-year-old woman was admitted to the clinic due to pain in the right lower abdomen. An ultrasound examination revealed a gestational sac in the uterine cavity corresponding to 5 weeks of pregnancy with a yolk sac. A twin sac was found in the right fallopian tube. Due to the patient's mild symptoms, absence of bleeding into the peritoneal cavity, concerns about the safety of the embryo and the pregnant woman in case of surgery, conservative management was decided. On the 20th day, the patient was discharged from the clinic with a viable intrauterine pregnancy and a partially absorbed ectopic pregnancy. CONCLUSIONS In the case of an ectopic tubal pregnancy, if there are no symptoms of bleeding into the peritoneal cavity, it is possible to adopt a safe conservative approach with strict patient observation.