Ectopic pregnancy secondary to in vitro fertilisation-embryo transfer: pathogenic mechanisms and management strategies

Abstract

BackgroundEctopic pregnancy (EP) is the leading cause of maternal morbidity and mortality during the first trimester and the incidence increases dramatically with in vitro fertilisation and embryo transfer (IVF-ET). The co-existence of an EP with a viable intrauterine pregnancy (IUP) is known as heterotopic pregnancy (HP) affecting about 1% of patients during assisted conception. EP/HP can cause significant morbidity and occasional mortality and represent diagnostic and therapeutic challenges, particularly during fertility treatment. Many risk factors related to IVF-ET techniques and the cause of infertility have been documented. The combination of transvaginal ultrasound (TVS) and serum human chorionic gonadotrophin (hCG) is the most reliable diagnostic tool, with early diagnosis of EP/HP permitting conservative management. This review describes the risk factors, diagnostic modalities and treatment approaches of EP/HP during IVF-ET and also their impact on subsequent fertility treatment.MethodsThe scientific literature was searched for studies investigating EP/HP during IVF-ET. Publications in English and within the past 6 years were mostly selected.ResultsA history of tubal infertility, pelvic inflammatory disease and specific aspects of embryo transfer technique are the most significant risk factors for later EP. Early measurement of serum hCG and performance of TVS by an expert operator as early as gestational week 5 can identify cases of possible EP. These women should be closely monitored with repeated ultrasound and hCG measurement until a diagnosis is reached. Treatment must be customised to the clinical condition and future fertility requirements of the patient. In cases of HP, the viable IUP can be preserved in the majority of cases but requires early detection of HP. No apparent negative impact of the different treatment approaches for EP/HP on subsequent IVF-ET, except for risk of recurrence.ConclusionsEP/HP are tragic events in a couple’s reproductive life, and the earlier the diagnosis the better the prognosis. Due to the increase incidence following IVF-ET, there is a compelling need to develop a diagnostic biomarker/algorithm that can predict pregnancy outcome with high sensitivity and specificity before IVF-ET to prevent and/or properly manage those who are at higher risk of EP/HP.

Cervical Ectopic Pregnancy of 45,XO Embryo After In Vitro Fertilization/Embryo Transfer

“…A history of tubal factor infertility and pelvic inflammatory disease are significant risk factors for ectopic pregnancies after IVF. 7 Although the most common site for ectopic pregnancies are uterine tubes, unusual locations such as cornual, isthmic or cervical sites can be observed. Serial serum hCG and TVUSG monitoring after IVF, leads to early diagnosis of the abnormal location and development of the pregnancy.…”

Laparoscopic management of ruptured heterotopic pregnancy after intrauterine insemination

“…3 The embryo may be located within the fallopian tube (90% of cases), an ovary, the cervix, the abdomen or a previous cesarean section scar. 1 Diagnosis often occurs at less than eight weeks gestational age through the routine ultrasonography screening and close clinical follow-up that usually occur with assisted reproductive technologies. 3,4 Tubal cases tend to be diagnosed earlier, because the confined space results in earlier pain or rupture.…”

Aberrant expression of interleukin-6 and its receptor in Fallopian tubes bearing an ectopic pregnancy with and without tubal cytomegalovirus infection

“…Although PID and/or a history of sexually transmitted infection are major risk factors for EP [37,40], none of the earlier studies correlated their findings with possible tubal infection [5,49]. The present study measured the prevalence of tubal infection with CMV and a significant increase in the frequency of positive cases by PCR was observed in specimens obtained from EP (22.9 %) compared with control (8.2 %) and it was associated with 3 times greater risk of developing EP.…”

“…A pregnancy implanted outside the intrauterine cavity is known as ectopic pregnancy (EP) and, in the majority of cases (98 %), is located in the ampullary region of the Fallopian tube [40]. EP represents 1-2 % of all pregnancies and causes almost 10 % of all maternal deaths during the first trimester worldwide [18,22,24].…”

“…However, tubal EP has long been attributed to failure of the tubal rhythmic smooth muscle contraction and/or ciliary beat activity thereby leading to an EP. Tubal pregnancy could also develop following failure of the normal biological interactions between intrauterine endometrium, Fallopian tube and embryo due to pathological alterations in the tubal microenvironment resulting in an increase in tubal epithelial receptivity and/or impaired endometrial receptivity [38,40].…”