Concurrent ovarian and ipsilateral tubal ectopic pregnancies after a double embryo transfer: a case report.

Abstract

Ectopic pregnancies are one of the few conditions which constitute a gynecologic emergency, as it may result in a life threatening complication. The incidence in the general population is approximately 2 % [1]; however a significant increase has been reported after the use of In-Vitro Fertilization (IVF), ranging from 2.1 to 8.6 % [2, 3]. An ectopic pregnancy may implant in different places throughout the female pelvis; however, tubal pregnancies are by far the most common implantation site. Ovarian localization of an ectopic gestation accounts for no more than 3 % of all ectopic pregnancies [4]. The clinical signs and symptoms of an ovarian ectopic are the same as those seen with a tubal pregnancy, and the diagnosis is usually made by pathology, due to the fact that an ovarian ectopic pregnancy is often misdiagnosed during surgery as a hemorrhagic corpus luteum. Though of little clinical use today, there are specific diagnostic criteria for an ovarian ectopic described by Spiegelberg in 1878: (1) an intact ipsilateral tube, clearly separate from the ovary; (2) a gestational sac occupying the position of the ovary; (3) a gestational sac connected to the uterus by the ovarian ligament; and (4) ovarian tissue in the wall of the gestational sac [5]. The risk of ovarian pregnancy after assisted reproductive techniques is approximately 0.3 % and is likely to increase with widespread use of these procedures [6–8]. However, given the extremely low incidence of an ovarian ectopic pregnancy, even after ovulation induction and assisted reproduction, it still remains a very rare diagnosis. Ectopic pregnancies may also be seen in the presence of another coexisting simultaneous pregnancy. The diagnosis of co-existing pregnancies may be delayed, as the patient may present without symptoms and normally rising HCG levels, and usually with an intrauterine pregnancy. There are different proposed theories to explain the increased incidence of these pregnancies after assisted reproductive technologies (ART). Those include the high proportion of patients with tubal disease, high levels of estradiol (E2) and progesterone (P), and high numbers of transferred embryos or ovulated oocytes in this population [9–11]. This case report describes the rare occurrence of a tubal pregnancy with a concurrent ipsilateral ovarian ectopic pregnancy.