Its frequency is 0.3–3.0 of all ectopic gestations.[1] Although the incidence of ectopic pregnancy is on the rise, ovarian pregnancy after in-vitro fertilization and embryo transfer IVF
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a gonadotropin with antagonist protocol Recombinant Follicle Stimulating Hormone was given (total units 1275 IU) Fixed antagonist protocol starting from fifth day of stimulation was given Trigger was given with recombinant human chorionic gonadotropin (HCG) 250 mcg on Day 9 Oocyte retrieval was done under general anesthesia on Day 11 of cycle Five oocytes were retrieved
Out of the five oocytes, three fertilized Day 3 embryo transfer (ET) was done (Day 14 of cycle) One embryo was 6 cellar Grade 1, second one was 4 cellar Grade 1, and third one was 6 cellar Grade 2 Embryos were placed 1.1 cm away from fundus under ultrasound guidance with K-soft 1000(Cook) (William A Cook Australia Pty Ltd, Brisbane, Australia) embryo transfer catheter
Urine pregnancy test on Day 19 after ET showed a positive result Serum beta HCG
on Day 24 after ET was 1270.93 mIU/mL So, transvaginal sonography (TVS) was advised, which did not reveal any intrauterine or extra uterine gestational sac (GS)
Repeat serum beta HCG after 48 h (Day 26 after ET) was raised to 3495.99 mIU/mL TVS revealed an empty uterus with endometrial thickness of 11.5 mm A well-defined GS was seen in right ovary with good decidual reaction and a yolk sac The GS size was 7.1
mm × 6.2 mm × 6.8 mm There was no free
INTRODUCTION
The first case of ovarian pregnancy was reported by St Maurice in 1689 Since then, many cases have been reported in the literature Hertig estimated that ovarian pregnancy occurs in one in 25,000–40,000 pregnancies Its frequency is 0.3–3.0 of all ectopic gestations.[1]
Although the incidence of ectopic pregnancy
is on the rise, ovarian pregnancy after in-vitro
fertilization and embryo transfer (IVF-ET) is
a rare entity Incidence of ovarian pregnancy after IVF has been reported to be 0.3%.[2]
Here we report a case of unruptured ovarian
pregnancy following in-vitro fertilization/
intracytoplasmic sperm injection (IVF/ICSI)
CASE REPORT
The patient was a 27 year old female who was married for 5 years She was a case
of secondary infertility with previous one spontaneous abortion at 8 weeks It was
a natural conception The patient had undergone intrauterine insemination (IUI) seven times previously
The patient was investigated for secondary infertility Husband’s semen analysis revealed severe oligospermia She was advised IVF/
ICSI in view of male factor and previous failed IUI attempts The patient underwent
A rare case of unruptured viable secondary ovarian pregnancy after IVF/ICSI treated by conservative
laparoscopic surgery
ABSTRACT
Although the incidence of ectopic pregnancy is on the rise, ovarian pregnancy after in vitro
fertilization and embryo transfer is a rare entity Here, we report a case of unruptured
ovarian pregnancy following in-vitro fertilization/intracytoplasmic sperm injection, which
was treated by conservative laparoscopic surgery
KEY WORDS: Conservative laparoscopic surgery, ectopic pregnancy, secondary ovarian pregnancy, wedge resection of ovary
Bharti Dhorepatil,
Aarti Rapol
Pune Fertility Center, Shivaji
Nagar, Pune, India
Address for correspondence:
Dr Bharti Dhorepatil,
Director and Chief IVF
Consultant, Pune Fertility
Center, Shivaji Nagar,
Pune – 411 005, India
E-mail: bdhorepatil@gmail.
com
Received: 18.11.11
Review completed: 18.11.11
Accepted: 07.01.12
Access this article online
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Website:
www.jhrsonline.org
DOI:
10.4103/0974-1208.97808
Case Report
Trang 262 Journal of Human Reproductive Sciences/Volume 5/Issue 1/Jan - Apr 2012
fluid in the pelvis The patient was diagnosed as a case of
unruptured ovarian pregnancy [Figures 1 and 2]
Thorough counseling of the couple regarding different
treatment options was done The couple opted for
conservative medical management She weighed 57 kg and
was hemodynamically stable The pulse was 82/min and
blood pressure was 110/70 mmHg The patient was given
inj methotrexate 50 mg, i.e., 50 mg/m2,under supervision
Pulse and blood pressure was monitored There were no
signs of methotrexate toxicity
Repeat serum beta HCG on Day 3 after methotrexate (Day
1 being the day of methotrexate administration) was found
to be raised to 5147.97 mIU/mL
Repeat TVS revealed intact GS with fetal pole and good
cardiac activity There was minimal free fluid in the pelvis
The couple was counseled and the decision for laparoscopic
surgery was taken
There was collection of blood, approximately 200 mL, in
the peritoneal cavity Left ovary and left fallopian tube were
normal Right ovarian fossa was filled with blood clots
Right ovary was stuck to the right ovarian fossa Clots were
separated and ovary was separated from the ovarian fossa
Right ovary revealed an intact ectopic pregnancy, which
started bleeding after separation from ovarian fossa The
ovary was held with grasping forceps and a wedge resection
of right ovary along with the ectopic pregnancy was done
using harmonic current Remaining ovarian tissue was
observed for hemostasis GS with part of ovary (specimen)
was sent for histopathological examination [Figure 3]
Postoperatively, the patient was stable She was discharged
on Day 2 of surgery
Histopathology revealed ectopic products of conception
Ovarian tissue was seen with the products of conception
Rest of ovarian tissue showed luteal changes
DISCUSSION
The Spiegelberg’s[3] criteriafor an ovarian pregnancy
include: (1) Fallopian tubes, including fimbria, must be
intact and separate from the ovary, (2) the pregnancy must
occupy the normal position of the ovary, (3) the ovary
must be attached to the uterus through the uteroovarian
ligament, and (4) there must be ovarian tissue attached to
the pregnancy in the specimen.[3] In our case, the pregnancy
was clearly seen in the ovary
Ovarian pregnancy following IVF is a rare entity With
rigorous review of literature, very few case reports were
found.[2,4,5]
When an ectopic pregnancy occurs after Assisted Reproductive Technology (ART), it is most likely the result of a uterine contraction causing carefully placed embryos to be ejected into the fallopian tube Various strategies to reduce the risk of this occurring are typically employed The use of ultrasound guidance to place embryos and the use of minimal fluid to
Figure 1: Right ovary with the single gestational sac with yolk sac
Figure 2: A well-defined gestational sac with yolk sac and good
decidual reaction
Figure 3: Part of ovary seen clearly along with the intact ectopic
pregnancy
Trang 363 Journal of Human Reproductive Sciences/Volume 5/Issue 1/Jan - Apr 2012
transfer them helps There is some evidence that transferring
blastocysts that are ready to implant instead of earlier embryos
may also reduce the incidence Sometimes, however, despite
the best-laid plans, ectopic pregnancies do occur.[6]
Although methotrexate is an effective therapeutic option for
the management of unruptured ectopic pregnancy, it may
fail despite the presence of factors predicting successful
outcome.[7] In this case, factors predicting successful
outcome were fulfilled, such as beta HCG levels less than
5000 mIU/mL, patient hemodynamically stable with no
signs or symptoms of active bleeding or hemoperitoneum,
size of the gestation not more than 3.5 cm at its greatest
dimension on US measurement, and no contraindications
to the use of methotrexate
Fertility after conservative surgical procedure does not
appear to be affected, and ovarian wedge resection is the
treatment of choice.[7] Patients with ovarian pregnancy
have a good prognosis for future fertility and, therefore,
conservative surgical management is advocated.Since our
patient was a case of infertility, preservation of her ovary
was of utmost importance for us Fertility in patients treated
for ovarian pregnancy remains unaffected and subsequent
pregnancies are most invariably intrauterine.[2,8]
The diagnosis of an ovarian ectopic pregnancy is seldom made
before surgery Because initial diagnosis in ovarian pregnancy
is difficult, many of these cases will be diagnosed as possible
tubal pregnancies only.[7] This case was different because it
was clearly diagnosed before we started the management
Early detection of an ovarian pregnancy prior to rupture of
the GS and onset of active bleeding permits laparoscopic
surgery and removal of the ectopic pregnancy without
excessive removal of healthy ovarian tissue This case was
detected early due to which it was possible to save major part of the ovary
This is especially important in young patients who may desire to maintain their reproductive capability.[2]
ACKNOWLEDGMENT
Dr Shehbaaz Daruwala, MD (Path), Embryologist and Dr Harshal Pandve, MD (PSM), Research Consultant for technical support.
REFERENCES
1 Hertig AT Discussion of Gerin-Lojoie L Ovarian pregnancy Am J Obstet and Gynecol 1951;62:920.
2 Marcus SF, Brinsden PR Analysis of the incidence and risk factors
associated with ectopic pregnancy following in-vitro fertilization and
embryo transfer Hum Reprod 1995;10:199.
3 Spiegelberg O Zur kasuistik der ovarialschwangerschaft Arch Gynaecol 1878;13:73-9
4 Carter JE, Jacobson A Reimplantation of a human embryo with subsequent ovarian pregnancy Am J Obstet Gynecol 1986;155: 282-3.
5 Narvekar SA, VijayKumar PK, Shetty N, Gupta N, Ashwini GB, Rao KA
Unruptured ovarian pregnancy following in-vitro fertilization: Missed
diagnosis followed by successful laparoscopic management J Hum Reprod Sci 2008;1:39-41.
6 Geoffrey Sher Ectopic pregnancy: Causes, Diagnosis and Treatment Available from: http://www.ivfauthority.com/2009/11/ectopic-pregnancy-causes-diagnosis-and.html
7 Bagga R, Suri V, Verma P, Chopra S, Kalra J Failed medical management
in ovarian pregnancy despite favorable prognostic factors – A case report Med Gen 2006;8:35.
8 Raziel A, Golan A, Pansky M Ovarian pregnancy: A report of twenty cases in one institution Am J Obstet Gynecol 1990;163:1182-5.
How to cite this article: Dhorepatil B, Rapol A A rare case of unruptured
viable secondary ovarian pregnancy after IVF/ICSI treated by conservative laparoscopic surgery J Hum Reprod Sci 2012;5:61-3.
Source of Support: Nil, Conflict of Interest: None declared.
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