Abstract
We present a case of spontaneous bilateral tubal pregnancy in a woman following hysterosalpingography (HSG), which to our knowledge has not been reported previously. A 29-year-old woman, gravid 0, was referred to our clinic for treatment of left tubal pregnancy after 8 weeks of amenorrhea. Seven weeks prior to that, the patient underwent HSG for evaluation of tubal patency and left tubal obstruction was diagnosed. Initially, except for minimal tenderness over the left adnexa, physical examination was unremarkable. The initial result of a quantitative test for b-human chorionic gonadotropin (bhCG) was 1,584 mIU/ml, but 48 h later this value was 1,886 mIU/ml. The patient’s condition remained stable. Transvaginal ultrasound revealed no evidence of an intrauterine pregnancy, no fluid in the cul-de-sac and an approximately 3 cm-sized ovarian echo at both adnexa. The left tube had a complex structure measuring 2.8 9 1.5 9 1.8 cm. The patient was counseled, and she opted for methotrexate (MTX) therapy, 50 mg/m intramuscularly. Serum b-hCG levels were found to be 1,857 mIU/ml on day 2 after treatment, 1,500 mIU/ml on day 5, and 1,638 mIU/ml on day 7. The patient’s hCG level did not drop, and a second cycle of MTX was injected; however, b-hCG was still 1,405 mIU/ml on day 4 after the second cycle of treatment. We decided that surgical intervention was necessary. Laparoscopy revealed an approximately 3 cm-sized unruptured left ampullary pregnancy, and a left salpingostomy was performed to remove it. Inspection of the right tube revealed an approximately 1 cm-sized bulging area in the ampullary region (Fig. 1). Linear salpingostomy was performed. Pathology confirmed that conceptuses had been removed from both the right and left tubes. Followup b-hCG was 247 mIU/ml on postoperative day 1. Bilateral tubal pregnancy is a rare clinical entity. The reported instance is 1 in 2,00,000 pregnancies [1]. Bilateral tubal pregnancies are more common after assisted reproductive technology, such as ovulation induction [2], in vitro fertilization and embryo transfer (IVF-ET) [3–5], or intracytoplasmic sperm injection (ICSI) [6], than they are after spontaneous conception [1]. The risk factors related to spontaneous ectopic pregnancy are well known, such as pelvic inflammatory disease, endometriosis, previous surgery and its sequelae, and infertility. Spontaneous bilateral tubal pregnancy is also related to the factors previously mentioned, along with double spontaneous ovulation. HSG is a commonly performed diagnostic investigation to assess tubal patency in infertility patients. It has potential therapeutic effects on subfertility [7]. There is evidence for the effectiveness of tubal flushing with oil-soluble contrast media in increasing the odds of pregnancy and live birth versus no intervention; however, there is no significant association between this procedure and miscarriage or ectopic pregnancy [7]. The diagnosis of bilateral ectopic pregnancy can be achieved by finding chorionic villi in surgical specimens obtained from both tubes [1]. There can be great difficulty in diagnosing this condition before surgery, however, in which the level of b-hCG is not particularly useful. Indeed, most often, contralateral ectopic pregnancy is asymptomatic or difficult to differentiate from pelvic pain secondary to medical treatment or to controlled ovarian hyperstimulation [6]. H.-J. Seol S.-Y. Tong (&) Department of Obstetrics and Gynecology, School of Medicine, Kyung Hee University, Seoul, South Korea e-mail: sytong@hanmail.net
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