A case report of bilateral tubal ectopic pregnancy following day 5 embryo transfer

The incidence of ectopic pregnancy after in vitro fertilization (IVF) ranges from 2.1 to 9.4 of all clinical pregnancies [1]. Bilateral tubal pregnancy is a rare clinical condition which occurs in only 1 per 200,000 pregnancies [2]. We present a case of bilateral tubal pregnancy in a woman who underwent IVF treatment, in whom three morulae were transferred. A 35-year-old woman who had a 17-year history of primary male factor infertility was admitted with complaints of abdominal pain and vaginal bleeding. She had been treated with two cycles of controlled ovarian hyper-stimulation plus intrauterine insemination. Additionally, the patient underwent two cycles of intracytoplasmic sperm injection (ICSI) with the standard long protocol the previous year. In the first ICSI cycle, two 4-cell grade A (excellent grade) embryos were transferred 48 h after oocyte injection. In the second ICSI cycle, three embryos were transferred 48 h following oocyte injection. Those transferred in the second cycle consisted of two 4-cell grade A embryos and one 4-cell grade B embryo. The patient had regular menstrual cycles with no history of pelvic inflammatory disease. Bilateral tubal patency was revealed on hysterosalpingography and hysteroscopy was normal. Because of repeated implantation failures, the patient elected to undergo an ICSI blastocyst transfer. She was treated with the standard long protocol as previously mentioned [3]. Ten oocytes were retrieved, of which six were fertilized and cleaved. Three morula stage embryos were transferred 120 h after injection. A soft embryo transfer (ET) catheter (Labotect GmbH; Göttingen, Germany) was used to transfer the embryos, which was done without complications. The luteal phase was supported with vaginal progesterone (Abureihan Pharmaceutical Co, Tehran, Iran), 400 mg twice daily until the day of the β-hCG assay. Two weeks after ET, the patient’s β-hCG level was 639 mIU/ml. She experienced vaginal bleeding and pain 2 weeks following ET. Upon admission, she had left lower abdominal pain with a blood pressure of 125/80 mmHg and a heart rate of 80 beats per minute. An ultrasound revealed a 23 mm × 18 mm left adnexal mass, suggestive of ectopic pregnancy, and a small amount of fluid. Endometrial thickness was 7 mm and the uterine cavity was empty. Laparoscopy was performed, which revealed a 3 cm unruptured left ampullary ectopic pregnancy. A left linear ampullary tube salpingostomy was done. Inspection of the right tube showed a bulging area in the ampullary region. Linear salpingostomy was Corresponding author: Kiandokht Kiani MSc Royan Institute Number 12 East Hafez Avenue Bani Hashem Street Resalat Highway, Tehran, Iran P.O. Box: 19395-4644 Phone/fax: +98 21 22306481 E-mail: [email protected] 1Department of Endocrinology and Female Infertility, Reproductive Biomedicine Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran 2Department of Embryology, Reproductive Biomedicine Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran