Unruptured ovarian pregnancy following in-vitro fertilization - Review Article
Ovarian Pregnancy
For Correspondence - Dr.Rashmi Srivastava, 59, Rampuram colony, Rajendra Nagar East, Gorakhnath, Gorakhpur( UP ) -273015
Email – dr.rashmi.srivastava@gmail.com
ABSTRACT – From the beginning of an era of in- vitro fertilization, chances were always there for the fertilized ovum to stuck the site other than where it should be. Although the most common site of implantation other then the uterus is a fallopian tube, it can be in the ovary, on the peritoneum, in the broad ligament, some times even in the liver or spleen.
I here report the result of a few articles published in different journals regarding unruptured ovarian pregnancy after in-Vitro fertilization and embryo transfer and its further laparoscopic management.
In the ovary, when it get implants many a time due to the texture of ovary, it becomes very difficult to diagnose it. Although in each of these case reports, the diagnosis was before any catastrophe, so the patient remained hemodynamically stable, and the recovery period was small, and the outcome was better.
Authors have reported that initially, the diagnosis was a little bit confusing, although beta HCG level increasing in the same ratio as it does in ectopic pregnancies. Diagnosis got confirmed only after diagnostic laparoscopy and totally after HPE, which confirmed chorionic villi within the ovarian tissue.
The authors also mentioned that ovarian ectopic always hid behind the ruptured corpus luteum, which was the first thing that comes in mind after seeing ovary. The authors also mentioned possible modes of transport of this fertilized ovum or zygote through reverse migration through fallopian tubes to the ovary.
KEYWORDS – In-vitro fertilization, Unruptured ovarian pregnancy
Materials and Methods – Retrospective analysis of different case reports from journals and Internet sites. These studies have been done on a large number of patients treated in reputed institutes, studies done in these institutes and published in reputed journals.
RESULTS – The author presented a case of ovarian pregnancy following a fresh embryo blastocyst transfer that was managed surgically by removal of the gestational sac from the ovary while preserving the ovary. Ovarian pregnancy is a challenging diagnosis; however, clinicians should be aware of the possible risk of ovarian pregnancy in ART treatment. It should be actively pursued in high-risk patients in order to prevent complications.
Early diagnosis and management of these patients are mandatory. The differential diagnosis of OEP should be strongly suspected and managed aggressively. Ultrasound should be urgently sought, and if the diagnosis of OEP is suspected, operative laparoscopy where expertise exists should be preferred. The author demonstrates his two cases that ovarian ectopic pregnancies can be just as easily treated with the laparoscope as other types of ectopic pregnancies.
This case report describes the ovarian ectopic pregnancy after a double embryo transfer, diagnosed by genetic analysis. The author believes that laparoscopy remains the gold standard for diagnosis as well as treatment of ovarian pregnancy. There are few reports of successful use of systemic methotrexate in ovarian pregnancy. Successful treatment of ovarian pregnancy with 50-mg methotrexate injected into the ectopic sac at laparoscopy has also been reported.
The rarity of this type of ectopic pregnancy universally results in the lake of therapeutic protocols on optimal management. The selection of treatment modalities based on the severity of symptoms, medical condition of the patient's desire to preserve fertility, gestational age, and surgical experience. Laparoscopic conservative surgery (ovarian cystectomy or wedge resection) with the repair of the ovarian tissue is the standard management and the aim should be to conserve the ovary on which the ectopic pregnancy is attached. For hemodynamically unstable patients, urgent laparotomy should be considered. Methotrexate is a good alternative to laparoscopic management in case of unruptured ovarian ectopic pregnancy. However, its toxicity has to be taken into account. Ovarian ectopic pregnancy has a varied surgical presentation, and in spite of advances in clinical sciences, correct pre-surgical diagnosis of ovarian ectopic still remains uncertain as it commonly mixes with tubal ectopic, ruptured Corpus luteum and torsion of the ovary.
Discussion – Although ovarian pregnancy is a rare event, awareness of this condition is important as timely recognition, and early referral is of prime importance. This case demonstrates that ovarian pregnancy may be diagnosed and treated conservatively with ovarian cystectomy by the use of operative laparoscopy.
In these cases, during embryo transfer after IVF, some factors like very Deep deposition near to fundus or an excessive amount of culture media and uterine contraction thought to be the culprit for movement of the embryo through the fallopian tube and its implantation in the ovary.
Every time Spielberg Criteria for an ectopic ovarian pregnancy fulfilled, which was- (1) Fallopian tubes, including fimbria, must be intact and separate from the ovary. (2) The pregnancy must occupy the normal position of the ovary.(3) The ovary must be attached to the uterus through the uteroovarian ligament. (4)There must be ovarian tissue attached to the pregnancy in the specimen.
Conclusions - In every case diagnosis, although difficult, but patient managed well laparoscopically. They took the Spiegelberg criteria and Beta HCG level for correct diagnosis. Recovery was good, and the hospital stay was short (2-3 days )
Acknowledgements - Dr.Rashmi Srivastava , Dr.R.K.Mishra (WLH ), Dr.J.S.Chawhan (WLH)
References –
1.Dr.Bharti Dhorepatil, Dr.Aarti Rapol . A rare case of unruptured viable secondary ovarian pregnancy after IVF/ICSI treated by conservative laproscopic surgery , Journal of Human Reproductive Science2012 Jan –Apr;5(1):61-63
2.Narvekar SA, VijayKumar PK, Shetty N, Gupta N, Ashwin GB and Rao KA . Unruptured ovarian pregnancy following in-vitro fertilization : Missed diagnosis followed by successful laproscopic management ,Journal of Human Reproductive Sciences 2008 Jan-Jun ; 1(1):39-41
3.Nitin . Ovarian cystectomy of an ovarian ectopic pregnancy conceived by in vitro fertilization , Fertil Sci Res 2015;2:37-9
4.Bagga R, Suri V,Verma P, Chopra S, Kalra J. Failed medical management in ovarian pregnancy despite favorable prognostic factors – A case report . Med Gen 2006; 8: 35.
5.Pope CS, Cook EK, Arny M, Novak, Grow DR. Influence of embryo transfer depth on in-vitro fertilization and embryo transfer outcomes. Fertil Steril.2004; 81: 51-8
6.Comstock C, Huston K, Lee W. The ultrasonographic appearance of ovarian ectopic pregnancies . Obstet Gynecol.2005: 105: 42-5
7.Einenkel J, Baier D, Horn LC, Alexender H. Laparoscopic therapy of an intact primary ovarian pregnancy with ovarian hyperstimulation syndrome: Case report . Hum Reprod. 2000;15:2037-40
8. Jha S, Bosworth K, Quadri A, Ibrahim A. Ovarian ectopic pregnancy .BMJ Case Rep 2011
9. Tinelli A, Hudelist G, Malvasi A, Tinelli R . Laparoscopic management of ovarian pregnancy . JSLS 2008; 12: 169-72
10. Raziel A, Schachter M, Mordechai E, Friedler S, Panski M, Ron – El R . Ovarian pregnancy a 12 – year experience of 19 cases in one institution . Eur J Obstet Gynecol Biol 2004;114 :92-6
11. Choi HJ, Im KS, Jung HJ, Lim KT, Mok JE, Kwon YS. Clinical analysis of ovarian pregnancy: a report of 49 cases. Eur J Obstet Gynecol Reprod Biol. 2011;158(1):87–9
12. Kashima, K. , Yahata, T. , Yamaguchi, M. , Fujita, K. , Tanaka, K. Ovarian pregnancy resulting from cryopreserved blastocyst transfer. J Obstet Gynaecol Res. 2013; 39(1): 375–377.
