The incidence of ectopic pregnancy, which affects 1.5-2.1% of patients receiving IVF, is the primary cause of maternal morbidity and mortality during the first trimester when assisted reproductive technology (ART) is used. (1)
What is an ectopic pregnancy?
The ectopic pregnancy will eventually grow inside the tube and explode if it is not discovered, causing significant intra-abdominal bleeding and death.
Historically, laparotomy (open abdominal surgery) and fallopian tube removal have been used to treat ectopic pregnancies. The most popular kind of surgery nowadays is laparoscopic excision of the ectopic tumor and preservation of the fallopian tube.
In clinically stable patients, the use of the medication methotrexate (MTX) for the treatment of ectopic pregnancy has largely superseded surgical intervention. (2)
What causes ectopic pregnancy?
Fertilization of the egg occurs in the fallopian tube. The fertilized egg (embryo) goes to the uterus via peristaltic movements of the healthy fallopian tube and implants in the endometrial cavity 6-7 days after ovulation. The embryo may hatch from the egg and implant into the fallopian tube wall if the transfer of the embryo from the fallopian tube to the uterus is delayed.
Pelvic inflammatory disease (PID), which is frequently a predisposing factor and is brought on by chlamydia or gonorrhea, damages the inner lining of the tube. If the tubes are surgically opened (neosalpingostomy) or repaired (tuboplasty) as a result of a prior tubal injury, the chance of an ectopic pregnancy increases. With each subsequent ectopic pregnancy, the risk of ectopic pregnancy rises as well.
About 15% of second ectopics result in danger, and 25% to 30% of third ectopics do as well. The possibility of an ectopic pregnancy may also be increased by smoking and a contentious past abortion. Depending on each case, the exposure to sexually transmitted diseases (STDs), and other factors, the risk may rise even further. (2)
What are the symptoms and signs of an ectopic pregnancy?
The first test to be performed is a pregnancy test if the patient does not menstruate. Ectopic pregnancy should be ruled out if the test is positive and there is abdominal pain or vaginal spotting/bleeding. Ectopic pregnancy pain can take the form of cramps or lower abdominal/pelvic pain and is relatively frequent.
Bleeding can be very light or very heavy, such as during menstruation or an early miscarriage (such as the last few days of a regular period). As the pregnancy is in the fallopian tube rather than the uterus, hormonal stimulation of uterine (endometrial) cells that continue to grow is what causes bleeding.
Because of blood coming from the end of the tube extending to the upper abdomen, shoulder pain may occasionally be the primary complaint (the tube does not need to be ruptured). Blood in this location has the potential to irritate the phrenic nerve, resulting in shoulder or back pain. Other signs of significant intra-abdominal hemorrhage include fainting and dizziness. In these situations, urgent surgery is necessary to preserve the patient’s life. (2)
What do studies show about ectopic pregnancy with IVF?
IVF in Turkey has a known risk of ectopic pregnancy, especially abdominal ectopic. The described case emphasizes the need to keep this uncommon kind of ectopic pregnancy in the differential when atypical ectopic presentations occur as well as the diagnostic challenges associated with it.
Following IVF, cases of abdominal ectopic pregnancy have been reported more frequently when there has been tubal factor infertility, a history of tubal ectopic pregnancy and tubal surgery, a higher number of transferred embryos, and fresh embryo transfers, according to a systematic review of the literature. These correspond to well-established risk factors for ectopic pregnancy following IVF treatment in Turkey. (3)
Marcus, S. F., & Brinsden, P. R. (1995). Analysis of the incidence and risk factors associated with ectopic pregnancy following in-vitro fertilization and embryo transfer. Human Reproduction, 10(1), 199-203.