BackgroundNon-tubal ectopic (NTE) pregnancies account for 7-10% of ectopic pregnancies, but disproportionately high mortalities.1,2 Infertility and assisted reproductive technology (ART) are risk factors, but limited data exists on NTE from fertility centers.1ObjectiveThe purpose of this case series was to review all confirmed NTEs at a high-volume fertility center to gain insights into diagnosis and outcomes.Materials and MethodsNTE from all pregnancy cycles (spontaneous (SPON), ovulation induction (OI), frozen embryo transfer (FET), Fresh ET, donor egg (DE)) were included over a 10 year period (2009-2019). Ultrasounds were performed in our center, and confirmed by outside radiologist. Cases were reviewed for medical, surgical and fertility history, NTE diagnosis and management, and subsequent pregnancy outcomes. Rates are reported as % or median (range).Results15 NTEs were identified; 9 cornual (7 ART, 2 SPON), 5 cesarean scar (C-scar, all ART) and 1 cervical (SPON). No abdominal or ovarian NTE were identified. No NTE resulted from OI. Age at diagnosis was 40 years (31-51). Infertility diagnoses and type of ART cycles were mixed (53% FET, 13% fresh ET, 20% DE, 60% euploid embryo). The majority of NTEs presented without symptoms (47%) or with vaginal bleeding (40%). Median cycle day (CD) of diagnosis was CD 42 (37-52) by outside ultrasound for cornual and c-scar NTEs. The cervical NTE was initially diagnosed as pregnancy failure on CD 45, with final diagnosis on CD 77. 83% of NTE from ART had a human chorionic gonadotropin (hCG) CD 28 level <70mIU/mL and 67% had a hCG CD 35 level <1000mIU/mL. All C-scar NTEs and 44% of cornual NTEs had fetal cardiac activity. 1st line treatment included medical and surgical approaches: expectant management (3), single dose methotrexate (MTX) (4), combination MTX (1), misoprostol (1), D&C (3), laparoscopy (2). 47% failed, including 100% of single dose MTX. 2nd line treatment included single dose MTX (2), multidose MTX (2), double uterine balloon (1) or D&C (3). 1 C-scar NTE hemorrhaged requiring transfusion and uterine artery embolization. Median CD of resolution was 96 (67-159). 60% of patients tried for pregnancy at our center after resolution of NTE; 27% had a successful live birth or ongoing pregnancy. Interestingly, 2 patients with cornual NTE had histories of bilateral salpingectomy, presenting with high hCGs (21,361 and 31,819), failed initial management (MTX requiring 2nd dose, then wedge resection, and laparoscopic resection and subsequent MTX), and took the longest time to resolution (CD 157 and CD 159). Of these 2 cornual NTEs: 1 became pregnant on a subsequent ART cycle; the other has not attempted further treatment.ConclusionsNTEs are rare, even in high volume fertility clinics. Early sonographic diagnosis and close monitoring can prevent morbidities, but first line treatments often fail. Day 28 and 35 hcg levels can be useful in risk assessment, diagnosis and patient counseling. Patients with history of bilateral salpingectomies may require closer evaluation and longer time to resolution of cornual NTEs.SupportNo financial support to disclose