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A woman in her 30s and respective partner, both with no relevant medical record, presented with a 4-year history of primary infertility. The tests performed on the couple did not reveal abnormalities, other than mild asthenozoospermia in the spermogram. Hysterosalpingography confirmed bilateral tubal patency. During the investigation, a spontaneous right tubal pregnancy was diagnosed, which required urgent treatment with salpingectomy.
The couple proceeded to in vitro fertilisation (IVF), with a yield of eight transferable embryos (freeze-all strategy was decided to prevent the risk of ovarian hyperstimulation syndrome). In the first frozen embryo transfer (FET), one embryo was transferred, but no pregnancy was achieved. In the second FET, the couple opted for transfer of two embryos after being informed of associated risks. According to the surveillance protocol, a positive human chorionic gonadotropin test was obtained 10 days later, and the first transvaginal ultrasound was performed 20 days after transfer, which corresponds to 5 weeks and 6 days’ pregnancy of a 5-day embryo transfer. The ultrasound (figure 1) revealed simultaneously an intrauterine gestational sac and an extrauterine gestational sac in the left adnexal area. In each gestational sac, the presence of an embryo of 2.5 and 2.6 mm, respectively, was observed, both with visualised cardiac movements.
Transvaginal grey-scale ultrasound image accomplishing criteria to diagnose a heterotopic pregnancy. (A) An intrauterine gestational sac (yellow star) and an extrauterine gestational sac (yellow arrow), both with an embryo with 2.5 and 2.6 mm, respectively. (B) An intrauterine gestational sac in a transversal section of the uterus. (C) The extrauterine gestational sac with left tubal implantation in a more amplified version.
The presumptive diagnosis of heterotopic pregnancy (HP), which is defined as a simultaneous presence of an intrauterine and an ectopic pregnancy, was assumed. A laparoscopic approach with transumbilical open (Hasson) technique for establishing pneumoperitoneum was decided. Considering the diagnosis of a viable pregnancy, the patient underwent general anaesthesia only after the correct positioning in the operating table. A laparoscopy procedure with non-instrumentation of the uterus, intra-abdominal pressure between 8 mm Hg and 12 mm Hg, was conducted by an experienced surgeon to minimise operative time.
Intraoperatively, close to the left uterine wall, an enlargement in the isthmic portion of the left uterine tube (figure 2) was seen, with adhesions of the pavilion and fimbriae to the sigmoid colon.
(A) Clinical photograph showing an enlargement in the isthmic portion of the left uterine tube (black arrow), compatible with tubal ectopic pregnancy. (B) Better visualisation of the same image (yellow arrow) by exposing the left uterine tube in all its extension.
Given the importance of preserving the intrauterine pregnancy, a conservative approach with salpingostomy was decided to reduce the potential risk of bleeding (figure 3). The trophoblastic content was aspirated and the histopathological result was compatible with chorionic villi from the first gestational trimester, confirming a tubal ectopic pregnancy. The intrauterine pregnancy is currently at the 17th week of gestation and is uneventful.
Status post left salpingostomy (*).
Spontaneous HP is rare, with an estimated incidence of 1/30 000 pregnancies.1 In the setting of IVF with embryo transfer procedures, some authors suggested that this incidence could be higher, with tubal abnormalities and the number of embryos transferred being the most important risk factors.1–3
Considering the widespread use of assisted reproduction technologies is mandatory to maintain a high level of suspicion and awareness about the specific sonographic criteria of HP, which represents the diagnostic modality of choice.2 Figure 1 represents an HP with tubal ectopic pregnancy and clearly demonstrates an intrauterine gestational sac and an extrauterine gestational sac.
According to the literature, clinical presentation is non-specific and approximately 60% of HP diagnoses are established intraoperatively.2–5 The sonographic diagnostic rate was higher in the setting of follow-up after IVF with embryo transfer, reaching 92.4%.2 This fact reinforces that clinical awareness and expert systematic ultrasound examinations contribute to diagnosis of HP.3
Besides preventing complications and a potentially life-threatening situation, an early diagnosis is the key for adopting a conservative approach while preserving a viable intrauterine pregnancy.5
Learning points
Close surveillance of women undergoing medically assisted reproduction by experienced clinicians is essential, with high level of suspicion and awareness about heterotopic pregnancy (HP).
Once the diagnosis of HP is made, confirming the presence of intrauterine and extrauterine pregnancy with visualisation of heartbeat embryos in both gestational sacs, an early surgical approach is mandatory. This is the best option to preserve the intrauterine pregnancy while preventing the serious complications of a potential ruptured ectopic pregnancy.
This case reinforces the importance of giving priority to single embryo transfer. Despite being a successful case, it could have resulted in serious maternal complications, without obtaining a viable pregnancy.
Ethics statements
Patient consent for publication
Footnotes
Contributors JF and AT conceived of the presented idea. JF developed the theory and performed the computations. AS and IB was responsible for the revision of the case. All authors discussed the results and contributed to the final manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.