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[Triple extra-uterine pregnancy following in vitro fertilization and embryo transfer]
Abstract
Es wird berichtet über eine EUG, bei der es nach IVF/ET zu einer eklopen Nidation von drei der vier transferierten Embryonen in den beiden, irreparabel geschädigten Tuben gekommen war. Die ektope Nidation in beiden Tuben ist in erster Linie als Hinweis auf die Bedeutung uterotubarer Transportmechanismen in der periovulatorischen Phase zu verstehen, weshalb es unwahrscheinlich ist, daß eine EUG nach intrakavitärem Embryotransfer auch bei technisch einwandfreier Durchführung - völlig zu vermeiden ist.
In Anbetracht mehrerer frustraner IVF-Behandlungsversuche ist die gleichzeitige Nidation von drei der vier transferierten Embryonen als hoch anzusehen und muß als Unterstützung der These interpretiert werden, daß dem Tubenmilieu ein begünstigender Einfluß auf die Entwicklung humaner Präimplantationsembryonen zukommt.
... Jansen et al (1988a), reported the first successful pregnancy following transfer of fertilised oocytes at the pronuclear stage and cryostored donor semen (Jansen et al, 1988b) transcervically and under ultrasound guidance into the Fallopian tube using a specially designed tubal cannulation system. Pregnancies were also reported following the transfer of gametes, using either the Jansen technique (Bustillo et al, 1988) or hysteroscopic guidance (Wurfel, 1988;Possati et al, 1991). ...
The role of the Fallopian tube in assisted reproduction remains unclear. The work described in this thesis was undertaken; (1) to study cyclical oestrogen and progesterone receptor changes in the endometrium and Fallopian tube, (2) to determine ultrastructural similarities and differences between endometrial and endosalpingeal epithelia at the different stages of the cycle, (3) to collect tubal fluid and attempt to isolate tubal specific proteins, and (4) to determine the clinical impact of tubal environment in assisted reproduction by conducting a randomised trial comparing tubal and uterine embryo replacements after in vitro fertilization of oocytes. Oestrogen (ER) and progesterone receptors were studied with specific monoclonal antibodies and employing an immunohistochemical technique. The results showed that, in the tube, both the isthmic and ampullary epithelial and stromal ER increased in the follicular phase to a peak at mid cycle, then declined in the late luteal phase whilst the fimbrial end depicted an opposite pattern of staining. Progesterone receptors persisted in all tubal wall layers and endometrial stroma throughout the cycle, but disappeared completely from endometrial gland epithelium in the late luteal phase. The ultrastructural study showed; (1) an increase in ciliated cells along the tube being highest at the fimbria, (2) late follicular phase increase in cytoplasmic fragments and cellular material within the isthmic lumen, but not in the outer tubal segments and (3) similar secretory pattern and surface epithelial changes in the endometrial gland, isthmic and ampullary tubal epithelia. Gel electrophoresis of tubal flushing demonstrated two non-serum bands appearing in the late follicular and luteal phases of the cycle. One hundred and two women were included in the randomised controlled study. Analysis of all treatment cycles (n=227) showed that; (1) the first attempt resulted in a pregnancy rate per embryo transfer (PR/ET) of 29% for tubal and 20% for uterine replacements, and an implantation rate (IR) of 15% and 12% respectively, and (2) women with unexplained infertility benefit most following tubal transfer (PR/ET; tubal 32%, uterine 15% - IR; 14% and 7% respectively). Factors associated with increased PR in the first attempt include previous pregnancies, absent female or male factors, unexplained infertility, and human chorionic gonadotrophin luteal support. Despite an apparently higher PR and IR following tubal transfer, no significant differences were observed in the multiple pregnancy and live birth rates, nor in the implantation rate in cycles resulting in pregnancy. These findings suggest that the embryos' quality is not enhanced following tubal transfer.
... Literature search revealed only one such case report. [2] This report describes a rare case of triple ectopic gestation following IVF-ET. ...
... Although the increased rates in pregnancy after IVF represent a welcomed trend in the advanced reproductive technologies, the gains have not eliminated the risk of an ectopic pregnancy (9). In fact an iatrogenic transfer of multiple embryos to the uterus after an IVF represents a major risk factor for a heterotopic pregnancy (10). ...
A 35 year-old woman at 7-week gestational age was referred to our hospital. The patient
was diagnosed with the heterotopic interstitial pregnancy by transvaginal ultrasonogra-
phy after receiving in vitro fertilization (IVF) and embryo transfer.
Laparoscopic excision and curettage was successfully performed at 8.4-gestational age
under general anesthesia and the patient was discharged 2 days after operation without
any post-operative complications. The woman had normal antenatal follow-up and deliv-
ered a healthy baby at term by cesarean section.
... Furthermore, corticosteroids could also help with implantation and embryonic development and have therefore been proposed for the treatment of recurrent pregnancy loss [18]. Corticosteroids are shown to stimulate estradiol and progesterone productions, which are immunoregulating biomolecules, during pregnancy, as it's well known that progesterone is needed to maintain pregnancy [19]. There are numerous anecdotal reports of successful treatment of POF/POI and infertility with low-dose corticosteroid immunosuppression [20]. ...
To establish importance of anti-ovarian antibodies (AOA) testing in infertile women.
A clinical reproductive outcome comparative study between two groups of women undergoing IVF-ET. Group 1 consists of women tested positive for AOA, put on corticosteroid therapy, reverted to AOA negative and then taken up for IVF-ET. Group 2 were seronegative for AOA.
Major urban infertility reference centre and National research institute.
Five hundred seventy infertile women enrolled for IVF-ET.
AOA testing, corticosteroid therapy and IVF-ET/ICSI.
Comparable clinical outcome and significance of AOA testing established.
AOA positive serum samples were sent periodically to re-investigate presence of AOA after corticosteroid therapy and women turned AOA negative were taken up for IVF-ET. Of the 70/138 women in group 1 who were treated with corticosteroids and turned seronegative for AOA, 22/70 were poor responders and needed donor oocyte-recipient cycles. Results demonstrated that fertilization and clinical pregnancy rates between both groups are comparable. Nevertheless, it is also observed that there is poor response to stimulation protocol, smaller number of oocytes retrieved and more spontaneous abortions in group 1 women. Hence not all outcomes following the treatment are comparable between the two groups. Usefulness of the test was established in two case studies.
AOA testing could be included in the battery of tests investigating and treating infertility.
We report on our experience with surgical pelviscopy in the treatment of ectopic pregnancies after in-vitro fertilisation and, in comparison, during spontaneous cycles and during cycles with ovarian hyperstimulations and IUI. From 1.1. 1988 to 31.12.1990, 54 patients underwent this operation, 25 of these having undergone the IVF programme. All IVF patients had an extensive history of tubal sterility. Therefore, we found difficult anatomic conditions during the operation in most cases. Furthermore, the special conditions of the IVF treatment itself (e.g., multiple transfer of embryos into the uterus) caused a higher incidence of complicated situations (one triple ectopic, three ovarian ectopic pregnancies and one simultaneous pregnancy). Firstly, our experience leads to the conclusion, that surgical pelviscopy can be used for management of more complicate problems and can be regarded, so far, as an alternative to laparotomy. Secondly, laparotomy should not be replaced by pelviscopy in difficult situations (e.g., ovarian ectopics pregnancies). Surgical pelviscopy reduces the trauma of treatment, a consideration, which is very important especially for IVF patients. Because of the extraordinary problems related to ectopic pregnancies after IVF, we are at present sceptical about the use of other methods (e.g., instillation of prostaglandins or methotrexate) for these patients. Subsequently, 19 patients in the IVF group conceived with an intrauterine pregnancy after repeated IVF treatment. In the second group, 8 spontaneous intrauterine conceptions have occurred since.
A 39 year-old woman with previous salpingectomy developed a symptomatic heterotopic right cornual pregnancy identified by transvaginal ultrasonography at six weeks' gestation. The patient had previously undergone an ipsilateral partial salpingectomy, and the conception was established four months later after one cycle of controlled ovarian hyperstimulation, in vitro fertilization (IVF) and embryo transfer. We performed immediate surgical excision of the ectopic implantation with conservation of the intrauterine pregnancy. Progesterone was administered as 200 mg/d lozenge (troche) plus 200 mg/d rectal suppository, maintained from day of embryo transfer through the perioperative period and until 11th gestational week. Following an uneventful obstetrical course, a healthy male infant was delivered by cesarean at term. In this report, we review the incidence and significance of heterotopic gestation in the context of IVF/embryo transfer. Risk factors for complex intra- and extra-uterine pregnancies are also outlined. Additionally, the clinical management of heterotopic pregnancy, including a novel approach to progesterone supplementation, is discussed.
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