Rare disease
CASE REPORT
Bilateral ectopic pregnancy following ICSI Mehtap Polat,1 Fazilet Kübra Boynukalın,1 İrem Yaralı,1 Hakan Yaralı1,2 1
IVF Unit, Anatolia IVF and Women Health Center, Ankara, Turkey 2 Department of Obstetrics and Gynecology, Hacettepe University Faculty of Medicine, Ankara, Turkey Correspondence to Professor Hakan Yaralı, [email protected] Accepted 30 May 2014
SUMMARY Bilateral tubal ectopic pregnancy is a rare clinical condition with an estimated prevalence of 1/200 000 spontaneous pregnancies. There is paucity of data on the prevalence of this rare condition following intracytoplasmic sperm injection and embryo transfer (ICSI-ET) cycles. We report two patients with bilateral tubal ectopic pregnancy following ICSI-ET. Both patients had normal, reassuring β-human chorionic gonadotropin dynamics during follow-up; the diagnosis was performed when no gestational sac was noted at the first planned antenatal visit. Of the two patients, one was treated medically and the other surgically with laparoscopic salpingotomy and salpingectomy for the right and left sides, respectively. Both patients thereafter conceived and delivered healthy infants following subsequent ICSI-ET attempts.
BACKGROUND Bilateral tubal ectopic pregnancy is a rare clinical condition with an estimated prevelance of 1/200 000 deliveries. Only a small number of patients who underwent medical treatment for bilateral ectopic pregnancy and thereafter conceived an intrauterine pregnancy and had healthy delivery have been reported.
CASE PRESENTATION Introduction Bilateral tubal ectopic pregnancy is a very rare clinical condition with an estimated prevalence of 1/200 000 deliveries of spontaneous conceptions.1 The prevalence of ectopic pregnancy following in vitro fertilisation (IVF) ranges between 2.1% and 9.4% of all clinical pregnancies.1 2 There is paucity of data, however, on the prevalence of this rare condition following intracytoplasmic sperm injection and embryo transfer (ICSI-ET) cycles. We report two cases of bilateral ectopic pregnancy following ICSI-ET.
Case 1
To cite: Polat M, Boynukalın FK, Yaralı İ, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014204814
A 37-year-old patient underwent an ICSI-ET cycle because of a 7-year infertility due to severe oligospermia. She had no history of abdomino/pelvic surgery or dilation and curettage. Owing to the presence of severe male factor infertility and a no risk factor for tuboperitoneal factor infertility, pre-ICSI hysterosalpingography (HSG) and laparoscopy were not performed. Luteal-long gonadotropin-releasing hormone (GnRH) agonist protocol with recombinant follicle stimulating hormone (rFSH) stimulation was performed; two embryos were transferred on day 3 under ultrasonographic guidance. As a routine, embryo(s) were loaded and transferred in 25 μL volume of culture medium at our centre. The
Polat M, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-204814
couple had three surplus embryos that were frozen. The patient conceived and normal follow-up serum β-human chorionic gonadotropin (βhCG) dynamics was noted; the βhCG levels were 46, 120 and 276 mIU/mL on the 11th, 14th and 16th days after ET. However, no intrauterine gestational sac was observed at the first screening in early pregnancy at the sixth week of gestational age. Transvaginal ultrasonography scan revealed bilateral empty extrauterine sacs with hyperechoic rings, 22.6×20.3 mm on the right side and 26.9×26.2 mm on the left side, without fluid in the pouch of Douglas (figure 1). The βhCG level at the time of diagnosis was 1721 mIU/mL. Since she did not have acute abdomen and high initial βhCG level, medical treatment was opted for. Single-dose methotrexate (MTX) injection (50 mg/m2) was administered; she had uneventful decrease with final normalisation of βhCG levels in 3 weeks. Thereafter, she underwent a thaw cycle; unfortunately, she did not conceive. At the third attempt, she had an intrauterine pregnancy and delivered a healthy, term, singleton baby.
Case 2 A 35-year-old patient had one unsuccessful ICSI-ET attempt at another centre. She had primary infertility of 5-year duration due to oligospermia. Her HSG was normal. Luteal-long GnRH agonist protocol with rFSH stimulation was performed; two embryos were transferred on day 3. Normal serum βhCG dynamics was noted; the βhCG levels were 53, 148 and 310 mIU/mL on the 11th, 13th and 15th days after ET. No intrauterine gestational sac with bilateral empty extrauterine sacs with hyperechoic rings, 34.2×29.6 mm on the right side and 44.6×38.2 mm on the left side, was observed at the first antenatal visit at the sixth week of gestational age. At the time of diagnosis, the βhCG level was 6013 mIU/mL. Having discussed the pros and cons of medical and surgical treatment options, the couple preferred the surgical treatment. At laparoscopy, bilateral ampullary unruptured tubal ectopic pregnancy with normal uterus and bilateral ovaries were noted (figure 2). Laparoscopic linear salpingotomy was performed for the right side; however, partial salpingectomy needed to be performed due to consistent oozing following linear salpingotomy on the left side. Histological examination confirmed the diagnosis for both tubes. Following another ICSI-ET attempt, she conceived and delivered a healthy, term, singleton baby.
INVESTIGATIONS We chose one ultrasonographic image (figure 1) and one laparoscopic operation picture (figure 2) to explain diagnosis of bilateral ectopic pregnancy. 1
Rare disease Figure 1 Ultrasonographic view of bilateral ectopic pregnancy.
DIFFERENTIAL DIAGNOSIS
Case 2
The clinical signs of presenting patients can have very different spectrum. Patients can present with acute abdominal signs and symptoms; sometimes, diagnosis can be defined incidentally. As in our two cases, the diagnosis can also be carried out when no gestational sac in the intrauterine cavity is noted at the first planned antenatal visit despite reassuring initial βhCG dynamics during early gestation. Ultrasonographic findings that support the diagnosis of ectopic pregnancy include an inhomogeneous adnexal mass, an empty extra uterine sac with a hyper echoic ring or adnexal sac with/without yolk sac, fetal pole or cardiac activity.
Laparoscopic linear salpingotomy was performed on the right side; however, partial salpingectomy needed to be performed due to oozing on the left side.
TREATMENT Case 1 Since the patient did not have acute abdomen, medical treatment was opted for. Single-dose MTX injection (50 mg/m2) was administered; she had an uneventful decrease in βhCG levels in 3 weeks. 2
OUTCOME AND FOLLOW-UP Case 1 Thereafter, she underwent a thaw cycle; unfortunately, she did not conceive. At the third attempt, she had an intrauterine pregnancy and delivered a healthy, term, singleton baby.
Case 2 She thereafter conceived an intrauterine pregnancy and had a healthy, term singleton delivery following another ICSI-ET attempt.
DISCUSSION Ectopic pregnancy is still one of the most common and important emergencies of gynaecology, associated with significant maternal mortality.3 The maternal mortality of ectopic Polat M, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-204814
Rare disease At the time of laparoscopy, either linear salpingotomy or total/partial salpingectomy may be performed based on the status of the fallopian tube and whether the ectopic is recurrent or not. For the second case, at the time of laparoscopy, since the tubes were normal, bilateral linear salpingotomy was performed; however, left partial salpingectomy needed to be performed due to persistent oozing from the site of salpingotomy. We conclude that, although very rare, bilateral ectopic pregnancy may be encountered following ICSI-ET. Patients may either present with acute abdomen or a lack of intrauterine gestational sac and typical appearance of ectopic mass, at the time of the first scheduled antenatal visit despite the reassuring initial βhCG doubling. Medical or surgical treatment options may be opted for based on the clinical status and detailed consultation with the couple.
Learning points
Figure 2 Laparoscopic view of bilateral ectopic pregnancy.
pregnancy in the UK is 4/10 000; it will not be wrong to predict much higher figures in developing countries. The prevalence of ectopic pregnancy is 2.1–9.4% of all clinical pregnancies following IVF.1 2 The contributing risk factors for the occurrence of ectopic pregnancy following IVF include advanced maternal age, pre-existing tubal disease, multiple ET, high embryo transfer and loading embryo(s) in a high volume of culture medium.4–7 In our two patients, no predisposing risk factor could be identified apart from transferring two embryos. Bilateral tubal ectopic pregnancy, however, is a very rare clinical condition. The prevalence is 1/200 000 of the deliveries of spontaneous conceptions. There are only a few case reports of bilateral ectopic pregnancy following ICSI-ET.8 9 The diagnosis is usually carried out when the patient presents with acute abdomen following a rupture or leakage from the ectopic pregnancy. As in our two cases, the diagnosis can also be carried out when no gestational sac in the intrauterine cavity is noted at the first planned antenatal visit despite reassuring initial βhCG dynamics during early gestation. Ultrasonographic findings that support the diagnosis of ectopic pregnancy include an inhomogeneous adnexal mass, an empty extra uterine sac with a hyper echoic ring or adnexal sac with/without yolk sac, fetal pole or cardiac activity.10–12 Medical or surgical treatment options may be opted for based on the clinical status, physician’s surgical experience and patient preference following detailed consultation. Haemodynamic stability with no evidence of acute intraperitoneal bleeding, serum βhCG level less than 5000 mIU/mL, absence of fetal cardiac activity and ectopic mass measuring less than 4 cm in diameter are the preferred conditions for medical treatment.13 14 However, the couple should be informed of the possibility of acute abdomen and the necessity for surgical treatment despite the initial employment of medical treatment. In our first case, medical treatment was preferred since the patient was haemodynamically stable and had a βhCG level of 1712 mIU/mL at the time of diagnosis. However, the second case with a βhCG level of 6013 mIU/mL at the time of diagnosis preferred surgical treatment.
Polat M, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-204814
▸ The prevalence of bilateral ectopic pregnancy following spontaneous conceptions is 1/200 000. There is paucity of data on the prevalence of this rare condition following intracytoplasmic sperm injection and embryo transfer (ICSI-ET) cycles. ▸ It is extremely difficult to diagnose bilateral ectopic pregnancy preoperatively. Serum β-human chorionic gonadotropin can be higher than in a single ectopic pregnancy; however, it is not very decisive. ▸ As treatment options for patients, radical or conservative surgery and medical therapy should be considered. When assessing treatment options, the patient’s clinical and physical examination findings, the physician’s experience alongside and the patient’s fertility expectation should certainly be taken into account. ▸ When medical treatment is preferred in order to protect fertility, an eventual development of acute abdominal pain during the follow-up and operational necessity should be kept in mind. ▸ Bilateral adnex should carefully be examined in patients diagnosed with ectopic pregnancy in order to reduce maternal mortality and morbidity. In this regard, adnex, ovaries and peritoneal surfaces must be examined in patients on whom surgery is performed.
Contributors MP and HY participated in the acquisition of data, revision of the manuscript for intellectual content and approval of the final version. FKB and IY participated in the revision of the manuscript for intellectual content. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 2
3 4
Edelstein MC, Morgan MA. Bilateral simultaneous tubal pregnancy: case report and review of literature. Obstet Gynecol Surv 1989;44:250–2. Azem F, Yaron Y, Botchan A, et al. Ectopic pregnancy after in vitro fertilization-embryo transfer (IVF-ET): the possible role of the ET technique. J Assist Reprod Genet 1993;10:302–4. Berg CJ, Chang J, Callaghan WM, et al. Pregnancy-related mortality in the United States, 1991–1997. Obstet Gynecol 2003;101:289–96. Jurkovic D. Ectopic pregnancy. In: Edmonds DK, ed. Dewhurst’s textbook of obstetrics and gynaecology. 7th edn. Massachusetts: Blackwell Publishing, 2007:106–16.
3
Rare disease 5 6
7 8
9
Nama V, Manyonda I. Tubal ectopic pregnancy: diagnosis and management. Arch Gynecol Obstet 2009;279:443–53. Kissler S, Wiegratz I, Kohl J, et al. Repeated ectopic pregnancy after ICSI therapy and embro transfer—a case report and literaturereview. J Reproduktions Med Endokrinol 2006;3:387–9. Klipstein S, Oskowitz SP. Bilateral ectopic pregnancy after transfer of two embryos. Fertil Steril 2000;74:887–8. Mock P, Olivennes F, Doumerc S, et al. Simultaneous bilateral tubal pregnancy after intracytoplasmic sperm injection treated by conservative medical treatment. Interest of sonographic follow-up. Eur J Obstet Gynecol Reprod Biol 2001;94:155–7. Kahraman S, Alatas C, Tasdemir M, et al. Simultaneous bilateral tubal pregnancy after intracytoplasmic sperm injection. Hum Reprod 1995;10:3320–1.
10 11
12 13
14
Kirk E, Bourne T. Diagnosis of ectopic pregnancy with ultrasound. Best Pract Res Clin Obstet Gynaecol 2009;23:501–8. Condous G, Okaro E, Khalid A, et al. The accuracy of transvaginal ultrasonography for the diagnosis of ectopic pregnancy prior to surgery. Hum Reprod 2005;20:1404–9. Sentilhes L, Bouet PE, Jalle T, et al. Ultrasound diagnosis of spontaneous bilateral tubal pregnancy. Aust N ZJ Obstet Gynaecol 2009;49:695–6. Lipscomb GH, Bran D, McCord ML, et al. Analysis of three hundred fifteen ectopic pregnancies treated with single-dose methotrexate. Am J Obstet Gynecol 1998;178:1354–8. ASRM Practice Bulletin. Treatment of ectopic pregnancy. Fertil Steril 2008;90:206–13.
Copyright 2014 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
4
Polat M, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-204814
CASE REPORT
Bilateral ectopic pregnancy following ICSI Mehtap Polat,1 Fazilet Kübra Boynukalın,1 İrem Yaralı,1 Hakan Yaralı1,2 1
IVF Unit, Anatolia IVF and Women Health Center, Ankara, Turkey 2 Department of Obstetrics and Gynecology, Hacettepe University Faculty of Medicine, Ankara, Turkey Correspondence to Professor Hakan Yaralı, [email protected] Accepted 30 May 2014
SUMMARY Bilateral tubal ectopic pregnancy is a rare clinical condition with an estimated prevalence of 1/200 000 spontaneous pregnancies. There is paucity of data on the prevalence of this rare condition following intracytoplasmic sperm injection and embryo transfer (ICSI-ET) cycles. We report two patients with bilateral tubal ectopic pregnancy following ICSI-ET. Both patients had normal, reassuring β-human chorionic gonadotropin dynamics during follow-up; the diagnosis was performed when no gestational sac was noted at the first planned antenatal visit. Of the two patients, one was treated medically and the other surgically with laparoscopic salpingotomy and salpingectomy for the right and left sides, respectively. Both patients thereafter conceived and delivered healthy infants following subsequent ICSI-ET attempts.
BACKGROUND Bilateral tubal ectopic pregnancy is a rare clinical condition with an estimated prevelance of 1/200 000 deliveries. Only a small number of patients who underwent medical treatment for bilateral ectopic pregnancy and thereafter conceived an intrauterine pregnancy and had healthy delivery have been reported.
CASE PRESENTATION Introduction Bilateral tubal ectopic pregnancy is a very rare clinical condition with an estimated prevalence of 1/200 000 deliveries of spontaneous conceptions.1 The prevalence of ectopic pregnancy following in vitro fertilisation (IVF) ranges between 2.1% and 9.4% of all clinical pregnancies.1 2 There is paucity of data, however, on the prevalence of this rare condition following intracytoplasmic sperm injection and embryo transfer (ICSI-ET) cycles. We report two cases of bilateral ectopic pregnancy following ICSI-ET.
Case 1
To cite: Polat M, Boynukalın FK, Yaralı İ, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014204814
A 37-year-old patient underwent an ICSI-ET cycle because of a 7-year infertility due to severe oligospermia. She had no history of abdomino/pelvic surgery or dilation and curettage. Owing to the presence of severe male factor infertility and a no risk factor for tuboperitoneal factor infertility, pre-ICSI hysterosalpingography (HSG) and laparoscopy were not performed. Luteal-long gonadotropin-releasing hormone (GnRH) agonist protocol with recombinant follicle stimulating hormone (rFSH) stimulation was performed; two embryos were transferred on day 3 under ultrasonographic guidance. As a routine, embryo(s) were loaded and transferred in 25 μL volume of culture medium at our centre. The
Polat M, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-204814
couple had three surplus embryos that were frozen. The patient conceived and normal follow-up serum β-human chorionic gonadotropin (βhCG) dynamics was noted; the βhCG levels were 46, 120 and 276 mIU/mL on the 11th, 14th and 16th days after ET. However, no intrauterine gestational sac was observed at the first screening in early pregnancy at the sixth week of gestational age. Transvaginal ultrasonography scan revealed bilateral empty extrauterine sacs with hyperechoic rings, 22.6×20.3 mm on the right side and 26.9×26.2 mm on the left side, without fluid in the pouch of Douglas (figure 1). The βhCG level at the time of diagnosis was 1721 mIU/mL. Since she did not have acute abdomen and high initial βhCG level, medical treatment was opted for. Single-dose methotrexate (MTX) injection (50 mg/m2) was administered; she had uneventful decrease with final normalisation of βhCG levels in 3 weeks. Thereafter, she underwent a thaw cycle; unfortunately, she did not conceive. At the third attempt, she had an intrauterine pregnancy and delivered a healthy, term, singleton baby.
Case 2 A 35-year-old patient had one unsuccessful ICSI-ET attempt at another centre. She had primary infertility of 5-year duration due to oligospermia. Her HSG was normal. Luteal-long GnRH agonist protocol with rFSH stimulation was performed; two embryos were transferred on day 3. Normal serum βhCG dynamics was noted; the βhCG levels were 53, 148 and 310 mIU/mL on the 11th, 13th and 15th days after ET. No intrauterine gestational sac with bilateral empty extrauterine sacs with hyperechoic rings, 34.2×29.6 mm on the right side and 44.6×38.2 mm on the left side, was observed at the first antenatal visit at the sixth week of gestational age. At the time of diagnosis, the βhCG level was 6013 mIU/mL. Having discussed the pros and cons of medical and surgical treatment options, the couple preferred the surgical treatment. At laparoscopy, bilateral ampullary unruptured tubal ectopic pregnancy with normal uterus and bilateral ovaries were noted (figure 2). Laparoscopic linear salpingotomy was performed for the right side; however, partial salpingectomy needed to be performed due to consistent oozing following linear salpingotomy on the left side. Histological examination confirmed the diagnosis for both tubes. Following another ICSI-ET attempt, she conceived and delivered a healthy, term, singleton baby.
INVESTIGATIONS We chose one ultrasonographic image (figure 1) and one laparoscopic operation picture (figure 2) to explain diagnosis of bilateral ectopic pregnancy. 1
Rare disease Figure 1 Ultrasonographic view of bilateral ectopic pregnancy.
DIFFERENTIAL DIAGNOSIS
Case 2
The clinical signs of presenting patients can have very different spectrum. Patients can present with acute abdominal signs and symptoms; sometimes, diagnosis can be defined incidentally. As in our two cases, the diagnosis can also be carried out when no gestational sac in the intrauterine cavity is noted at the first planned antenatal visit despite reassuring initial βhCG dynamics during early gestation. Ultrasonographic findings that support the diagnosis of ectopic pregnancy include an inhomogeneous adnexal mass, an empty extra uterine sac with a hyper echoic ring or adnexal sac with/without yolk sac, fetal pole or cardiac activity.
Laparoscopic linear salpingotomy was performed on the right side; however, partial salpingectomy needed to be performed due to oozing on the left side.
TREATMENT Case 1 Since the patient did not have acute abdomen, medical treatment was opted for. Single-dose MTX injection (50 mg/m2) was administered; she had an uneventful decrease in βhCG levels in 3 weeks. 2
OUTCOME AND FOLLOW-UP Case 1 Thereafter, she underwent a thaw cycle; unfortunately, she did not conceive. At the third attempt, she had an intrauterine pregnancy and delivered a healthy, term, singleton baby.
Case 2 She thereafter conceived an intrauterine pregnancy and had a healthy, term singleton delivery following another ICSI-ET attempt.
DISCUSSION Ectopic pregnancy is still one of the most common and important emergencies of gynaecology, associated with significant maternal mortality.3 The maternal mortality of ectopic Polat M, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-204814
Rare disease At the time of laparoscopy, either linear salpingotomy or total/partial salpingectomy may be performed based on the status of the fallopian tube and whether the ectopic is recurrent or not. For the second case, at the time of laparoscopy, since the tubes were normal, bilateral linear salpingotomy was performed; however, left partial salpingectomy needed to be performed due to persistent oozing from the site of salpingotomy. We conclude that, although very rare, bilateral ectopic pregnancy may be encountered following ICSI-ET. Patients may either present with acute abdomen or a lack of intrauterine gestational sac and typical appearance of ectopic mass, at the time of the first scheduled antenatal visit despite the reassuring initial βhCG doubling. Medical or surgical treatment options may be opted for based on the clinical status and detailed consultation with the couple.
Learning points
Figure 2 Laparoscopic view of bilateral ectopic pregnancy.
pregnancy in the UK is 4/10 000; it will not be wrong to predict much higher figures in developing countries. The prevalence of ectopic pregnancy is 2.1–9.4% of all clinical pregnancies following IVF.1 2 The contributing risk factors for the occurrence of ectopic pregnancy following IVF include advanced maternal age, pre-existing tubal disease, multiple ET, high embryo transfer and loading embryo(s) in a high volume of culture medium.4–7 In our two patients, no predisposing risk factor could be identified apart from transferring two embryos. Bilateral tubal ectopic pregnancy, however, is a very rare clinical condition. The prevalence is 1/200 000 of the deliveries of spontaneous conceptions. There are only a few case reports of bilateral ectopic pregnancy following ICSI-ET.8 9 The diagnosis is usually carried out when the patient presents with acute abdomen following a rupture or leakage from the ectopic pregnancy. As in our two cases, the diagnosis can also be carried out when no gestational sac in the intrauterine cavity is noted at the first planned antenatal visit despite reassuring initial βhCG dynamics during early gestation. Ultrasonographic findings that support the diagnosis of ectopic pregnancy include an inhomogeneous adnexal mass, an empty extra uterine sac with a hyper echoic ring or adnexal sac with/without yolk sac, fetal pole or cardiac activity.10–12 Medical or surgical treatment options may be opted for based on the clinical status, physician’s surgical experience and patient preference following detailed consultation. Haemodynamic stability with no evidence of acute intraperitoneal bleeding, serum βhCG level less than 5000 mIU/mL, absence of fetal cardiac activity and ectopic mass measuring less than 4 cm in diameter are the preferred conditions for medical treatment.13 14 However, the couple should be informed of the possibility of acute abdomen and the necessity for surgical treatment despite the initial employment of medical treatment. In our first case, medical treatment was preferred since the patient was haemodynamically stable and had a βhCG level of 1712 mIU/mL at the time of diagnosis. However, the second case with a βhCG level of 6013 mIU/mL at the time of diagnosis preferred surgical treatment.
Polat M, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-204814
▸ The prevalence of bilateral ectopic pregnancy following spontaneous conceptions is 1/200 000. There is paucity of data on the prevalence of this rare condition following intracytoplasmic sperm injection and embryo transfer (ICSI-ET) cycles. ▸ It is extremely difficult to diagnose bilateral ectopic pregnancy preoperatively. Serum β-human chorionic gonadotropin can be higher than in a single ectopic pregnancy; however, it is not very decisive. ▸ As treatment options for patients, radical or conservative surgery and medical therapy should be considered. When assessing treatment options, the patient’s clinical and physical examination findings, the physician’s experience alongside and the patient’s fertility expectation should certainly be taken into account. ▸ When medical treatment is preferred in order to protect fertility, an eventual development of acute abdominal pain during the follow-up and operational necessity should be kept in mind. ▸ Bilateral adnex should carefully be examined in patients diagnosed with ectopic pregnancy in order to reduce maternal mortality and morbidity. In this regard, adnex, ovaries and peritoneal surfaces must be examined in patients on whom surgery is performed.
Contributors MP and HY participated in the acquisition of data, revision of the manuscript for intellectual content and approval of the final version. FKB and IY participated in the revision of the manuscript for intellectual content. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 2
3 4
Edelstein MC, Morgan MA. Bilateral simultaneous tubal pregnancy: case report and review of literature. Obstet Gynecol Surv 1989;44:250–2. Azem F, Yaron Y, Botchan A, et al. Ectopic pregnancy after in vitro fertilization-embryo transfer (IVF-ET): the possible role of the ET technique. J Assist Reprod Genet 1993;10:302–4. Berg CJ, Chang J, Callaghan WM, et al. Pregnancy-related mortality in the United States, 1991–1997. Obstet Gynecol 2003;101:289–96. Jurkovic D. Ectopic pregnancy. In: Edmonds DK, ed. Dewhurst’s textbook of obstetrics and gynaecology. 7th edn. Massachusetts: Blackwell Publishing, 2007:106–16.
3
Rare disease 5 6
7 8
9
Nama V, Manyonda I. Tubal ectopic pregnancy: diagnosis and management. Arch Gynecol Obstet 2009;279:443–53. Kissler S, Wiegratz I, Kohl J, et al. Repeated ectopic pregnancy after ICSI therapy and embro transfer—a case report and literaturereview. J Reproduktions Med Endokrinol 2006;3:387–9. Klipstein S, Oskowitz SP. Bilateral ectopic pregnancy after transfer of two embryos. Fertil Steril 2000;74:887–8. Mock P, Olivennes F, Doumerc S, et al. Simultaneous bilateral tubal pregnancy after intracytoplasmic sperm injection treated by conservative medical treatment. Interest of sonographic follow-up. Eur J Obstet Gynecol Reprod Biol 2001;94:155–7. Kahraman S, Alatas C, Tasdemir M, et al. Simultaneous bilateral tubal pregnancy after intracytoplasmic sperm injection. Hum Reprod 1995;10:3320–1.
10 11
12 13
14
Kirk E, Bourne T. Diagnosis of ectopic pregnancy with ultrasound. Best Pract Res Clin Obstet Gynaecol 2009;23:501–8. Condous G, Okaro E, Khalid A, et al. The accuracy of transvaginal ultrasonography for the diagnosis of ectopic pregnancy prior to surgery. Hum Reprod 2005;20:1404–9. Sentilhes L, Bouet PE, Jalle T, et al. Ultrasound diagnosis of spontaneous bilateral tubal pregnancy. Aust N ZJ Obstet Gynaecol 2009;49:695–6. Lipscomb GH, Bran D, McCord ML, et al. Analysis of three hundred fifteen ectopic pregnancies treated with single-dose methotrexate. Am J Obstet Gynecol 1998;178:1354–8. ASRM Practice Bulletin. Treatment of ectopic pregnancy. Fertil Steril 2008;90:206–13.
Copyright 2014 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
4
Polat M, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-204814
