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.

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.

Management of 14 patients with cornual heterotopic pregnancy following embryo transfer: experience from the past decade.

OBJECTIVE: There are two major management approach for cornual heterotopic pregnancy, transvaginal cornual embryo reduction with ultrasound guidance, or laparoscopic cornual resection. This no consensus on the optimal management for cornual heterotopic pregnancy. Here, we are trying to determine the optimal management approach for patients with viable cornual heterotopic pregnancy following embryo transfer. METHODS: This is a retrospective cohort study conducted at the locally largest reproductive center of a tertiary hospital. A total of 14 women diagnosed as viable cornual heterotopic pregnancy following embryo transfer. Six patients were treated with cornual pregnancy reduction under transvaginal ultrasound guidance without the use of feticide drug (treatment 1), and eight patients were treated with laparoscopic cornual pregnancy resection (treatment 2). RESULTS: All 14 patients of cornual heterotopic pregnancy following embryo transfer due to fallopian tubal factor, among which, 12 patients had cornual pregnancy occurred in the ipsilateral uterine horn of tubal pathological conditions. Nine (64.29%) showed a history of ectopic pregnancy. Thirteen (92.86%) patients were transferred with two embryos and only one patient had single embryo transferred. Six patients received treatment 1, and 2 (33.33%) had uterine horn rupture and massive bleeding which required emergency laparoscopic surgery for homostasis. No cornual rupture occurred among patients received treatment 2. Each treatment group had one case of spontaneous miscarriage. The remaining 5 cases in treatment 1 group and the remaining 7 cases in treatment 2 group delivered healthy live offspring. CONCLUSION: Patients with tubal factors attempting for embryo transfer, especially those aiming for multiple embryos transfer, should be informed with risk of cornual heterotopic pregnancy and the subsequent cornual rupture. Compared with cornual pregnancy reduction under transvaginal ultrasound guidance, laparoscopic cornual resection might be a favorable approach for patients with viable cornual heterotopic pregnancy.

Spontaneously conceived heterotopic pregnancy with abdominal pregnancy implanted on the vesicouterine pouch: A case report and literature review.

We report the case of a 36-year-old woman with spontaneously conceived heterotopic pregnancy with abdominal pregnancy. She visited the hospital at 5 weeks and 4 days of gestation and transvaginal ultrasonography revealed a normal intrauterine pregnancy. Two days later, she was urgently transported to the hospital due to extreme abdominal pain. Emergent laparotomy was performed to investigate the cause of massive intraperitoneal bleeding, which was confirmed to have been due to an abdominal pregnancy that implanted on the vesicouterine pouch. The hematic mass, including chorionic villi, was successfully removed from the peritoneum. The subsequent course of the intrauterine pregnancy was uneventful and a healthy baby was born at term. To the best of our knowledge, this is an extremely rare case report of a spontaneously conceived heterotopic abdominal pregnancy, in which the intrauterine pregnancy showed a successful outcome despite the collapse of the abdominal pregnancy at a very early stage.

Successful Transvaginal Microwave Ablation of a Heterotopic Cervical Pregnancy. A Case Report.

Heterotopic cervical pregnancy is a rare and potentially dangerous condition where the challenge is the removal of the ectopic pregnancy while preserving the intrauterine one. We present the case of an otherwise healthy 36-year-old woman with heterotopic cervical pregnancy after an IVF cycle for tubal infertility. At 6.5 weeks after a consultation with gynecologists and interventional radiologists, the patient agreed to undergo microwave ablation of the cervical pregnancy. Monthly ultrasound examination showed the persistence of non homogeneous and vascularized tissue in the cervix. Intrauterine pregnancy continued without complications until 37 weeks when a cesarean section was performed for sudden and profuse bleeding, in the presence of uterine contractions. A healthy baby girl was delivered, and the postoperative course was otherwise uncomplicated. Heterotopic cervical pregnancies are rare, and no consolidated and risk-free treatments are available at the moment. Here, we present a case of heterotopic cervical pregnancy treated successfully and without complications with microwave ablation.

Tubal infertility and pelvic adhesion increase risk of heterotopic pregnancy after in vitro fertilization: A retrospective study.

To analyze risk factors associated with heterotopic pregnancy and the uterine pregnant outcome of those patients after surgery.We retrospectively analyzed 22 patients diagnosed as HP after in vitro fertilization (IVF) between January 2015 and December 2018.HP was diagnosed at gestation age of 55.4 ±â€Š11.8 days. HP were presented as irregular vaginal bleeding, abdominal pain, and sometimes no symptoms. 81.8% of ectopic lesion in HP occurred at fallopian tubes, especially ampullary; cornual pregnancy takes up 13.6%. Compared with clinical intrauterine pregnancy (IUP), IVF with tubal infertility factors had higher risks of HP (OR 4.185, 95% CI 1.080- 16.217); IVF with pelvic adhesion also had higher risks of HP (OR 5.552 95% CI 1.677-18.382); IVF with more than 2 embryos transferred increased risks of HP (OR 23.253, 95% CI 1.804-299.767). The abortion rates of surgery-treated HP and IUP after IVF were 27.8% versus 10.3% (P = .042).These results demonstrate IVF with tubal infertility, pelvic adhesion or multiembryos transfer are risk factors of HP. Furthermore, surgery could induce abortion.

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

Ectopic pregnancy after bilateral salpingectomy is rare and is therefore easily misdiagnosed. To provide information regarding the clinical manifestations, diagnosis, management, mechanism and prognosis of this condition, we reviewed all cases reported in the English literature. All English language reports on ectopic pregnancy after bilateral salpingectomy were retrieved from the PubMed database. A total of 19 English language articles were collected and 20 cases of ectopic pregnancy were reported. Eleven of the 19 patients had a history of tubal pregnancy on one or both sides. All of these pregnancies were by IVF-ET. The site of ectopic pregnancy was the tubal stump in 8 cases, the abdominal cavity in 4 cases, the ovary in 3 cases, the retroperitoneum in 3 cases, and the uterine cornua in 2 cases. All patients underwent successful resection of the ectopic pregnancy, of which 10 were laparoscopic surgery and 10 were laparotomy. Six of 8 cases of heterotopic pregnancy were successful gestation to the last trimester and were delivered after treatment. Ectopic pregnancy is still possible following IVF-ET after bilateral salpingectomy. The location of these ectopic pregnancies is complex and it is necessary to beware of the possibility of a heterotopic pregnancy.

Early intervention for heterotopic caesarean scar pregnancy to preserve intrauterine pregnancy may improve outcomes: a retrospective cohort study.

RESEARCH QUESTION: What is the best intervention time and method for patients who are diagnosed with heterotopic caesarean scar pregnancy (HCSP) wishing to preserve intrauterine pregnancy. DESIGN: Four patients diagnosed with HCSP from January 2014 to May 2019 were enrolled. Because HCSP is rare, data on 27 published cases were extracted to augment the analysis. Clinical characteristics and medical documents related to fetal reduction and subsequent maternal-neonate outcomes were analysed. RESULTS: The intervention time was significantly earlier in the full-term birth group (6.76 ± 1.05 weeks) compared with pre-term birth group (8.02 ± 1.55 weeks; P = 0.042). The cumulative full-term delivery rate was 91.48% when the intervention was at 6 weeks' gestation and decreased to 42.02% at 8 weeks. The maternal-neonate outcome was similar among the selective fetal reduction and surgical removal groups as was delivery time (34.68 ± 3.12 versus 34.80 ± 6.64 weeks; P = 0.955). In the four cases undergoing selective fetal reduction, the residual mass grew by 1.16-7.07 times compared with the area before reduction. The maximum size of the residual mass was observed at 12-13 weeks and 22-25 weeks. CONCLUSIONS: Most patients with HCSP who choose to keep intrauterine pregnancy will be able to carry the fetus to term. Selective fetal reduction would be the first intervention of choice and should take place immediately after diagnosis. The residual mass after reduction could continue to grow throughout the whole pregnancy, although this should not be considered as an indication for termination. With good supervision and careful management, the pregnancy could be maintained and carried to term.

[A heterotopic pregnancy]. / Een heterotope zwangerschap.

BACKGROUND: Heterotopic pregnancy is a rare but life-threatening situation. This is a situation where a woman has one or more intrauterine pregnancies and at least one ectopic pregnancy. CASE DESCRIPTION: Heterotopic pregnancy was discovered in a 37-year-old woman during a routine ultrasound check. This pregnancy occurred after intrauterine insemination with ovulation induction. CONCLUSION: Heterotopic pregnancies require early diagnosis and treatment. Physicians should be extra vigilant when a woman has become pregnant after using assisted reproductive techniques, because these techniques increase the probability of heterotopic pregnancy. The symptoms of such pregnancies are similar to the symptoms of extrauterine gravidity. However, confirmed intrauterine gravidity does not exclude the existence of extrauterine gravidity. The diagnosis is based entirely on the transvaginal ultrasound. The intact intrauterine gravidity limits treatment options. Tubectomy is the treatment of first choice, but embryo aspiration could also be a safe method in certain circumstances.

Heterotopic pregnancy: Simultaneous viable and nonviable pregnancies.

Heterotopic pregnancy occurs when a patient has simultaneous intrauterine and ectopic pregnancies. Rates of heterotopic pregnancy have been rising with increased availability and access to in vitro fertilization and other advanced fertility technologies. Symptoms of heterotopic pregnancy are nonspecific, such as vague abdominal pain, so transvaginal ultrasound is a crucial part of the diagnostic process. Laparoscopy is the most commonly performed treatment of the ectopic pregnancy; other options include localized injections of methotrexate and/or potassium chloride. Following definitive termination of the ectopic pregnancy, many patients will successfully deliver the intrauterine pregnancy at term. Early identification of heterotopic pregnancy can reduce maternal morbidity and mortality.

Management strategies of heterotopic pregnancy following in vitro fertilization-embryo transfer.

OBJECTIVE: The purpose of this study was to evaluate the efficiency and safety of different treatment modalities for heterotopic pregnancy (HP) in vitro fertilization-embryo transfer (IVF-ET) cycles to avoid influence on intrauterine pregnancy (IUP). MATERIALS AND METHODS: Cases of HP (n = 90) were from the IVF/ICSI registry database at the Reproductive Hospital Affiliated to Shandong University. An additional 360 women were randomly selected as controls. The primary outcome to examine the risk factors, diagnostic modalities and the impact of different treatment modalities for HP. RESULTS: Our results showed that surgical treatment had a certain effect on improving the live-birth rate, although the effect was not statistically significant (87.9% vs. 70.8%, P = 0.055). The risk factors for HP included previous tubal surgery and hydrosalpinx. Fourteen days after embryo transfer, the serum levels of ß-human chorionic gonadotropin (ß-hCG) and estradiol (E2) were lower in the HP group than in the IUP group (P < 0.05). Furthermore, age and endometrial thickness showed a significant difference between the early abortion and the live-birth groups of HP. CONCLUSIONS: In our retrospective study, we supported early surgical laparoscopic intervention to minimize the incidence of abortion of IUP, which resulted in a better live-birth rate. A history of ectopic pregnancy and previous tubal surgery may increase the risk of HP. Low levels of serum ß-hCG and E2 on the 14th day after embryo transfer could indicate the incidence of HP.

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.

A rare case of heterotopic quintuplets pregnancy.

OBJECTIVE: We report a rare case of heterotopic pregnancy and high-order pregnancy occurring simultaneously following the use of the assisted reproductive technique (ART). CASE REPORT: A 29-year-old woman, Gravida 2 Para 1, became pregnant after receiving intrauterine insemination (IUI). She came to our emergency room due to diffuse low abdominal pain at seven weeks of gestational age. Transabdominal sonography (TAS) revealed a quadruplet intrauterine pregnancy with an enlarged left adnexa and intrapelvic fluid accumulation. Simultaneous occurrence of high-order pregnancy and left tubal pregnancy with internal hemorrhage was suspected. The patient received an emergent laparoscopic resection of the affected Fallopian tube and recovered well for the remaining hospitalization course. Afterwards, she received fetal reduction procedure and eventually gave birth to twin babies. CONCLUSION: Gynecologist should increase the awareness of heterotopic pregnancy in patients receiving ART. On the other hand, reproductive endocrinologist should reduce the risk of high-order pregnancy without compromising pregnancy rate.

Heterotopic cervical pregnancy after in-vitro fertilization - case report and literature review.

Heterotopic cervical pregnancy is an uncommon condition, with a rising incidence due to the increasing number of pregnancies resulting from in-vitro fertilization (IVF). Although it is associated with maternal-fetal complications, there is no consensus in the literature about the best approach for this condition. This study aims to report a case of cervical heterotopic gestation after IVF in which the intrauterine pregnancy was preserved, with spontaneous elimination of the cervical gestational sac after patient sedation and introduction of the vaginal speculum. In addition, we reviewed the literature on the subject, which demonstrated that most cases have a favorable outcome, especially after treatment with surgical excision of the cervical pregnancy. The growing body of evidence is still scarce to define the best treatment for this condition.

The effect of local aspiration and methotrexate injection on live interstitial pregnancy coexisting with live intrauterine pregnancy after assisted reproductive technology.

AIM: To share the experience of local aspiration and instillation of methotrexate (MTX) to selective reduction of live interstitial pregnancy and to evaluate its clinical effect and the outcome of intrauterine pregnancy. METHODS: Twelve patients with heterotopic interstitial pregnancy were enrolled at Women's Hospital, Zhejiang University School of Medicine, from 2006 to 2017. All the pregnancies were derived from assisted reproductive technology (ART). The transvaginal aspiration to interstitial pregnancy sac and local instillation of MTX (range from 12.5 to 30 mg) were performed for the patients under ultrasound-guide. The prognosis and pregnancy outcomes were followed up. RESULTS: No severe side effects of medical treatment were observed in all patients. Three cases underwent subsequent laparotomy cornual resection, and no perioperative complications were found in these three patients. Twelve patients gave birth to 13 healthy infants without congenital anomalies. The average birth weight and gestational age was 2837 g (SD ± 605 g) and 36.8 weeks (SD ± 2.4 weeks). No growth anomalies and mental retardation were observed in live birth offspring. CONCLUSION: The transvaginal ultrasound-guided aspiration and injection of MTX might be a feasible alternative treatment for heterotopic interstitial pregnancy when vital signs of patients are stable.

Study on the incidence and influences on heterotopic pregnancy from embryo transfer of fresh cycles and frozen-thawed cycles.

PURPOSE: The purpose of this study was to determine the heterotopic pregnancy rate using fresh versus frozen-thawed embryo transfers and factors associated with heterotopic pregnancy (HP). Management and clinical outcomes after heterotopic pregnancy were also evaluated. METHODS: In this retrospective cohort study, we included 12,484 women who had clinical pregnancies after in vitro fertilization treatment at our fertility center between 2012 and 2017. Patients received fresh day 3 embryos (F-D3 group), fresh day 5 blastocysts (F-D5 group), frozen-thawed day 3 embryos (T-D3 group), or frozen-thawed day 5 or 6 blastocysts (T-D5/6 groups) transfers. The primary outcome measure was the occurrence of heterotopic pregnancy. Factors associated with heterotopic pregnancy were analyzed using logistic regression. RESULTS: The heterotopic pregnancy rates were 0.58% in the F-D3, 0.39% in F-D5, 0.56% in T-D3, and 0.33% in T-D5/6 groups, but no differences were found between groups. The risk factors of HP included a history of previous ectopic pregnancy (odds ratio [OR] 5.805, 95% CI 4.578-9.553, P = 0.016) and pelvic inflammation diseases (OR 1.129, 95% CI 1.021-3.178, P = 0.047). Salpingectomy was performed in 62.9% patients either through laparoscopy or through laparotomy. The early abortion rate and late abortion rate were 29.03% and 1.61%, respectively. In total, 66.13% of the patients had a live birth, either a singleton (90.24%) or twins (9.76%). CONCLUSION: No significant difference in the incidence of heterotopic pregnancy in fresh IVF cycles vs. frozen-thawed cycles could be demonstrated in a large cohort of patients. The risk factors of HP included history of ectopic pregnancy and PID. The clinical outcome after heterotopic pregnancy appears to be favorable.

Should sexual intercourse be avoided during the embryo transfer cycle? Life-threatening ruptured heterotopic pregnancy after single thawed embryo transfer: case report and review of the literature.

BACKGROUND: To report the life-threatening complication of a raptured heterotopic pregnancy occurring from thawed single embryo transfer. CASE REPORT: A 33-year-old woman underwent in vitro fertilization (IVF) under a step-up regimen. After oocyte collection, blastocysts were frozen, and a single frozen-thawed blastocyst was then transferred according to the natural cycle. On day 17 after embryo transfer, an intrauterine pregnancy was confirmed. On day 28, she complained of sudden abdominal pain and ultrasonography revealed marked fluid retention in the peritoneal cavity. Emergency laparoscopy was performed, revealing hemoperitoneum and a ruptured interstitial heterotopic pregnancy (HP), which was then resected laparoscopically. Because sexual intercourse had occurred shortly before the transfer, a HP comprising a spontaneous pregnancy and a pregnancy achieved by assisted reproductive technology was assumed. The fetus in the uterus survived and was delivered. CONCLUSION: In this case, however, despite the single embryo transfer during the natural-cycle frozen-thawed embryo transfer process, the risk of life-threatening complication as a HP as a consequence of spontaneous pregnancy after sexual intercourse remained.

[Five cases of interstitial heterotopic pregnancy after IVF-ET treated by laparoscopic surgery].

To evaluate the efficency and safety of laparoscopic surgery in the treatment of interstitial heterotopic pregnancy (IHP) after IVF-ET, five patients with interstitial heterotopic pregnancy after IVF-ET treated by laparoscopy in our hospital from Jan. 2012 to Jan. 2015 were retrospectively analyzed. All operations were finished laparoscopically without any major complications and they successfully delivered. The results suggest that laparosccpic surgery is feasible and safe for IHP to maintain the trauterine pregnancy, and it can diagnose and treat IHP at early stage, which cause mininmal injuries and less disturbance to trauterine pregnancy and ensure rapid recovery.

Surgical Management of a Heterotopic Cesarean Scar Pregnancy With Preservation of an Intrauterine Pregnancy.

BACKGROUND: Spontaneously conceived heterotopic pregnancies are rare. A heterotopic cesarean scar pregnancy involves an intrauterine pregnancy and a second pregnancy in the cesarean scar. Treatment approaches include both medical and surgical management. We present a surgical approach to the treatment of a heterotopic cesarean scar pregnancy with preservation of an intrauterine gestation. CASE: A 29-year-old woman, gravida 4 para 1021, presented at 5 weeks of gestation with spotting. Ultrasonography revealed a heterotopic cesarean scar pregnancy. The patient underwent resection of the ectopic pregnancy through minilaparotomy in an attempt to conserve the intrauterine pregnancy. She subsequently delivered an early-term neonate. CONCLUSION: Laparotomy with resection of the ectopic pregnancy is an option for treatment of an early heterotopic cesarean scar pregnancy when the patient desires conservation of the intrauterine pregnancy. Excision was not associated with pregnancy complications.