A rare case of unruptured viable secondary ovarian pregnancy after IVF/ICSI treated by conservative laparoscopic surgery.

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.

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 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 fluid in the pelvis. The patient was diagnosed as a case of unruptured ovarian pregnancy [Figures 1 and 2].

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

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].

Figure 3

Part of ovary seen clearly along with the intact ectopic pregnancy

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] criteria for 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.[245]

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 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.[28]

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]