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Successful Laparoscopic Management of a Rare Complication After Embryo Transfer: Ovarian Pregnancy

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Successful Laparoscopic Management of a Rare Complication After Embryo Transfer: Ovarian Pregnancy Case report and literature review Videosurgery Successful laparoscopic management of a rare complication after embryo transfer: ovarian pregnancy. A case report and up-to-date literature review Turgut Aydin1, Burak Yucel1, Huseyin Aksoy2, Suheyla Ekemen3 1Assisted Reproduction Unit, Acibadem Hospital, Kayseri, Turkey 2Department of Obstetrics and Gynecology, Military Hospital, Kayseri, Turkey 3Department of Pathology, Acibadem Aile Hospital, Istanbul, Turkey Videosurgery Miniinv 2015; 10 (4): 574–579 DOI: 10.5114/wiitm.2015.55893 Abstract Ovarian pregnancy (OP) after embryo transfer is very rare. Due to the rarity and the asymptomatic nature, there are still difficulties in diagnosis and treatment. The traditional operative treatment for OP has been oophorectomy. How- ever, the desire to maintain reproductive capability and improvements in laparoscopy have more recently led to con- servative laparoscopic techniques. This rare complication could be diagnosed early and managed by a conservative laparoscopic approach. Here we present a survey of the literature and a case of successful laparoscopic management of ovarian pregnancy after intracytoplasmic sperm injection and embryo transfer. The current case is the first case in the literature in which ovarian pregnancy occurred after a single embryo transfer. We also summarize the literature about management of ovarian pregnancy after embryo transfer. Key words: ovarian pregnancy, laparoscopic surgery, fertilization in vitro, infertility. Introduction patients who have received assisted reproduction treatments [2]. Approximately one percent of all pregnancies Here, we present a case of OP after ICSI-ET, and are ectopic. An increased incidence of ectopic preg- an up-to-date literature review. This case differs nancies (5%) after intracytoplasmic sperm injection from previously presented cases. In the literature, all – embryo transfer (ICSI-ET) is a well-known phenom- OP cases after ICSI-ET occurred with the transfer of enon. Ovarian ectopic pregnancy (ovarian pregnancy multiple (2 or more) embryos. The OP occurred after – OP) is a rare phenomenon following natural con- a single ET in our case. ception (3% of all ectopic pregnancies) or ICSI-ET (0.27% per clinical pregnancy) [1]. Case report The traditional operative treatment for OP has been oophorectomy. However, the desire to main- She was 31 years and primary infertile for five tain reproductive capability and improvements in years. In her history, she noted that she had an op- laparoscopy have more recently led to conservative eration of vaginal septum resection 4 years before laparoscopic techniques. Conservative management (Table I). Because of male factor infertility (non-ob- methods are gaining more importance in infertile structive azoospermia), the couple was taken into Address for correspondence Burak Yucel MD, Gynecology and Obstetrics Department, Kayseri Acibadem Hospital, Acibadem Hastanesi, Seyit Gazi M., MKP Bulvari, No: 1, 38100 Kayseri, Turkey, phone: +90 5326009554, e-mail: [email protected] 574 Videosurgery and Other Miniinvasive Techniques 4, December/2015 Successful laparoscopic management of a rare complication after embryo transfer: ovarian pregnancy. A case report and up-to-date literature review Table I. Properties of the case Age Indication Attempt Transfer Number of Implantation Surgery Prognosis day transferred site embryos 31 Male factor 2. 5th 1 Right Laparoscopic re- After one more (non-obstructive moval of the mass attempt with frozen azoospermia) embryo transfer, pregnant the assisted reproduction program. They previously The left and right fallopian tubes were normal with- had one ICSI cycle without conception in a differ- out dilatation or bleeding from the fimbrial end. The ent in vitro fertilization (IVF) center. Histopatholog- left ovary showed a fresh corpus luteum cyst without ical diagnosis was hypospermatogenesis. 200 IU bleeding. The approximately 2 cm well-defined gesta- of recombinant follicle-stimulating hormone (FSH) tional sac, implanted on the right ovary, was actively (Gonal-F; Merck Serono S.p.A, Modugna, Ba, Italy) bleeding (Photo 1). The product of conception was combined with a gonadotrophin-releasing hormone bluntly prepared and enucleated from the orthotropic (GnRH) antagonist protocol (Cetrorelix; Merck Sero- ovarian tissue and removed from the ovary using mi- no, Halle, Germany) were administered daily for con- croscissors and spoon forceps. After complete separa- trolled ovarian stimulation. Oocyte triggering was tion of the trophoblast from the right ovary, it could achieved by the administration of human chorionic be easily removed from the abdominal cavity through gonadotropin (hCG) (Pregnyl; Organon S.p.A, Roma, a 10 cm trocar in the midline. Adequate hemostasis Italy). Eight oocytes were retrieved. Seven of them on the ovarian tissue was maintained using bipolar were mature (metaphase II: M2) and injected. Four coagulation. Uterine curettage was also performed embryos cleaved to day three and then three 8-cell and showed proliferative endometrium free of chori- embryos cleaved to the blastocyst stage. A single ex- onic villi. Histopathologic examination of the tissues panded blastocyst was transferred at day five using removed from the ovary showed signs of diffuse a soft catheter (Wallace Sure View Embryo Replace- bleeding alongside chorion villi, decidual cells and de- ment Catheter; Smith Medical, Hythe, Kent, UK) and cidual changed stroma with normal ovarian cortical the remaining two embryos were frozen. Vaginal tissue in the outer margins (Photo 2). progesterone gel (Crinone; Merck Serono, Bedford- She was discharged a day after the operation. shire, United Kingdom) was given for luteal support. Post-operative recovery was excellent. Follow-up Serum β-hCG on the 10th day of embryo transfer quantitative serum β-hCG levels declined appropri- was 39 mIU/ml. After 2 days, serum β-hCG increased ately and reached an undetectable level in 2 weeks. to 83 mIU/ml. All findings were normal. She was ad- Three months later, she had thawed single embryo mitted to our hospital with lower abdominal pain transfer; she conceived and has an ongoing 22 weeks 2 weeks later. She was pale, but the vital signs were pregnancy. stable. Pelvic examination revealed a tender right adnexal mass. Serum β-hCG was 1.634 mIU/ml. Discussion Transvaginal sonography showed that the uterine Ovarian pregnancy is one of the rarest forms of cavity was empty; significant free fluid in the pouch ectopic pregnancies with a reported incidence of of Douglas and right ovary had a hypo-echoic area of from 1/7,000 to 1/60,000 pregnancies and accounts 2 × 2 cm. In addition, Doppler sonography revealed for about 1–3% of all extra-uterine pregnancies [3]. increased peripheral vascularity giving a ring-of-fire On the other hand, OP after ICSI-ET is even rarer, and appearance around the hypo-echoic area. just a few cases have been reported in the literature. Emergency laparoscopy was performed with the For this review, we performed a PubMed search, us- pre-diagnosis of ectopic pregnancy. In the overview, ing the keywords “Primary ovarian ectopic pregnan- hemorrhage from the ruptured ectopic pregnancy cy”, “ovarian pregnancy”, “intracytoplasmic sperm was identified; there was approximately 500 ml of injection embryo transfer” and “ICSI-ET” for the last bloody, clotted fluid in the abdomen. In the back- 20 years. It revealed 13 papers and 15 cases in the ground, a soft, slightly enlarged uterus was found. literature from 1994 to the present (Table II). Videosurgery and Other Miniinvasive Techniques 4, December/2015 575 Turgut Aydin, Burak Yucel, Huseyin Aksoy, Suheyla Ekemen Normal left tuba Uterus Right ovary Primary ovarian pregnancy Normal right tuba Photo 1. Intraoperative view of pelvis Ovarian stroma Chorionic villi Photo 2. Histopathologic view of ovarian pregnancy 576 Videosurgery and Other Miniinvasive Techniques 4, December/2015 Successful laparoscopic management of a rare complication after embryo transfer: ovarian pregnancy. A case report and up-to-date literature review Table II. Review of cases of OP after ICSI-ET Author Age Indication Attempt Transfer Number of Implantation Surgery Prognosis day transferred site embryo Ramachandran 33 Male factor NA NA NA Right ovary Laparotomy After 2 more attempts, pregnant et al. (2012) [12] (partial ovariectomy) Dunnne 34 NA NA 5th 2 Right ovary Laparoscopic wedge NA et al. (2012) [13] resection Kamath 35 Male factor 1st 3rd 3 Left ovary and Laparoscopic wedge Single ongoing intrauterine et al. (2010) [11] intrauterine resection pregnancy Priya 27 Unexplained infertility 3rd 3rd 3 Right ovary Laparoscopic partial Weekly β-HCG that showed et al. (2009) [14] oophorectomy decreasing levels 27 Male factor 4th NA 2 Left ovary Laparoscopic NA (Azoospermia) salpingo-oophorectomy Dursun 31 Unexplained infertility 6th 5th 2 Left ovary Laparoscopic cyst resection Became pregnant spontaneously et al. (2008) [15] and adhesiolysis and delivered a term healthy infant Trolice 37 Diminished ovarian NA 3rd 4 Left ovary Laparoscopic ovarian Single intrauterine pregnancy in et al. (2008) [16] reserve wedge resection following IVF, delivered a term healthy infant Gavrilova-Jordan 39 Male factor 1st 2nd 5 Left ovary Laparoscopic cyst An uneventful post-operative recovery et al. (2006) [8] (Azoospermia) resection Hsu 29 Bilateral tubal 3rd 5th 3 Left ovary First methotrexate admission, NA et al. (2005) [7] obstruction with then laparoscopic resection hydrosalpinx of mass Atabekoglu
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