Authored by Qing Zhen Xie*
Abstract
Embryo implantation occurs at the fallopian tubes, namely tubal pregnancy, is the major pattern of ectopic pregnancy. Laparoscopic salpingectomy and salpingotomy are the common ways to treat tubal pregnancies based on the damage degree of the tubes. Repeated ectopic pregnancies after unilateral or bilateral salpingectomy are rare reported but not uncommon in assisted reproductive technology (ART). This case report presents three women have had unilateral/bilateral laparoscopic salpingectomy due to at least two previous tubal pregnancies, but they experience repeated tubal pregnancies during their ART treatment. We suggest that the gynecologists should take carefully consideration on patient’s future fertility when performing the surgical treatment on tubal pregnancies. Salpingectomy without proximal tube ligation potentially increase the risk of residual tubal pregnancy in ART treatment. Frozen blastocyst transfer might be an optimal option for those women with the history of repeated ectopic pregnancy.
Keywords: Repeated ectopic pregnancy; Tubal pregnancy; Assisted reproductive technology
Introduction
The incidence of ectopic pregnancy has increased to a level of 2% in developed countries and may seriously affect women’s health and future fertility [1]. Most of ectopic pregnancies occur in the fallopian tubes, namely tubal pregnancy. Tubal pregnancy may be life-threatening if the patients have fallopian tube rupture, heavy bleeding, or hemorrhagic shock. Tubal pregnancies can be treated by either medication or surgery. Methotrexate injection combines with mifepristone is often used to treat ectopic pregnancies that diagnosed at early stage [2]. Surgery is required when patients have viable fetus located at the fallopian tube, or at risk of tube rupture and heavy bleeding. There are two ways to remove the tubal pregnancy by laparoscopy. Salpingectomy will be performed if the damage or bleeding is severe, the affected tube will be removed with the ectopic gestational sac. However, if the damage is minimal, the ectopic gestational sac can be removed from the tube by salpingotomy and leaving the tubes in situ. However, the surgical damages may potentially cause tubal factor infertility [3].
Assisted reproductive technology (ART) has been widely applied in the treatment of infertility, especially for the women with tubal factor infertility. Patients with tubal factor infertility due to previous tubal pregnancy can be treated by in vitro fertilization and embryo transfer (IVF-ET) [4]. However, on the other hand, ART has been associated with increased ectopic pregnancy rate as high as 8.6% [5]. Repeated tubal pregnancy after unilateral/ bilateral salpingectomy is rarely reported but is not uncommon in ART. The patients suffer more painfulness and cost more expenses if they have repeated tubal pregnancy during their ART treatment. Currently, the pathogenesis of ectopic pregnancy is still unknown, and there is no effective method to prevent ectopic pregnancy.
This study presents three cases of repeated tubal pregnancy during their ART treatment. The three patients all received laparoscopic unilateral/bilateral salpingectomy or medication treatment for previous tubal pregnancies. They were diagnosed as tubal infertility, however, they experienced repeated tubal pregnancy during their IVF-ET treatment. One of the three cases had tubal pregnancy located at the right tube with previous pregnancy treated by methotrexate injection, the other two cases had tubal pregnancy located at the residual part of the tube which was removed by salpingectomy previously.
Case Reports
Case 1
A 31-year-old female gravid 3 para 0 with previous history of two tubal pregnancies, a left-side tubal pregnancy with her previous partner was removed via laparoscopy in 2014, a rightside tubal pregnancy with her present husband was treated by methotrexate injection combined with oral mifepristone tablets in 2016. The patient received IVF treatment and transferred two embryos in 2017 and her serum beta-hCG was 125 IU/L 12 days later. The patient was referred to our clinic with vaginal bleeding for 2 days and it has been 32 days since her embryo transfer. No intrauterine gestational sac was observed by transvaginal ultrasound, but there was a mixed mass image of 3.9*2.7 cm in the area of right fallopian tube, and a dark area at depth of 2.9 cm in the pelvic cavity. Her serum beta-HCG was 1520 IU/L and increased to 2280 IU/L after 48 hours. Although we explained that there is no way to prevent tubal pregnancy, the patient strongly claimed for bilateral salpingectomy or ligation to avoid repeated tubal pregnancy. During the laparoscopy, we found a right-side tubal pregnancy with active bleeding, as well as approximately 400 ml of hemoperitoneum (Figure 1). The tubal pregnancy was removed by monopolar/bipolar electrosurgical devices plus with proximal tubal ligation on right-side tube. The pathologic diagnosis confirmed tubal pregnancy (right fallopian tube) with salpingitis. Her serum beta-HCG was decreased to 14 IU/L five days later. Two months later, this patient started a new IVF treatment cycle in our center. We performed frozen-thawed blastocyst transfer for the patient. An intrauterine pregnancy was confirmed after 30 days of transfer, the patient received C-section delivery at 39 weeks of gestation without any prenatal and perinatal complications.
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