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

Bassem Refaat,William L Ledger,Elizabeth Dalton

doi:10.1186/s12958-015-0025-0

Bassem Refaat, William L Ledger + Show 1 more

Open Access

https://doi.org/10.1186/s12958-015-0025-0

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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.

Highlights

Ectopic 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)
IVF-ET is a major risk for the development of EP and the incidence is greater by 2–3 folds than that seen in the general population
Several factors related to the cause of female infertility and applied technical procedures during IVF-ET have been described as major risk factors for EP/heterotopic pregnancy (HP)

Summary

Results

Prevalence EP is estimated to be 1-2% of all natural conceptions and the incidence increases following ART [4]. A more recent RCT showed that AH neither improved pregnancy rate nor increased risk of EP in 121 women < 38 years [78] and a later retrospective analysis of 1126 AH cycles reported that there was no effect on the prevalence of EP in an antibiotic and steroid treatment group compared with an untreated group [79]. Diagnosis of HP HP is a rare but potentially life-threatening event and early diagnosis and treatment are essential in order to best preserve the viable IUP and avoid maternal morbidity and mortality [122,123] This challenging condition should be suspected in all patients who conceive following ART regardless of the presence or absence of currently recognised risk factors, after transfer of multiple embryos. It is reassuring to show that the effects of MTX, after it is used as a medical treatment for an EP, does not affect or further compromise a woman’s future reproductive potential [206,222,223]

Conclusions

Background