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Abdominal pregnancy after gonadotropin superovulation and intrauterine insemination: A case report
Abdominal pregnancy after gonadotropin superovulation and intrauterine insemination: A case report Wen-Fang Cheng, MD, Hong-Nerng Ho, MD, Yu-Shih Yang, MD, PhD, and Su-Cheng Huang, MD Taipei, Taiwan, Republic of China An abdominal pregnancy after superovulation with human menopausal and chorionic gonadotropins followed by intrauterine insemination of the husband's sperm is reported. The incidence of ectopic pregnancy increases with administration of human menopausal, and chorionic gonadotropins. However, the role of human menopausal and chorionic gonadotropins as a cause of abdominal pregnancy has not been delineated. It appears that ultrasonography has become one of the most important aids in the diagnosis of early abdominal pregnancy. (AM J OBSTET GYNECOL 1994;171:1394-5.)
Key words: Abdominal pregnancy, gonadotropin, superovulation, intrauterine insemination, ultrasonography
Ectopic pregnancy continues to be a major complication of assisted reproductive techniques. However, to our knowledge, few cases of abdominal pregnancy have occurred after these procedures. I. 2 We report the first case of abdominal pregnancy after treatment wi~h human menopausal and chorionic gonadotropin followed by intrauterine insemination of the husband's sperm.
Case report A 28-year-old woman had primary infertility of unknown cause for 2 years. She received superovulation with human menopausal gonadotropin (Humegon, Organon, Oss, The Netherlands) and chorionic gonadotropin (Pregnyl, Organon) at a private clinic. Artificial insemination of husband's sperm was performed later. The urine pregnancy test was negative on day 29 of that cycle. Vaginal bleeding occurred the next day and persisted for 4 days. The duration and amount of bleeding were the same as in her previous cycles. Another course of superovulation with the same regimen was given immediately. Unsatisfactory follicular growth was noted in this second course. Basal body temperature was found to be elevated on day 10. Two days later she received another artificial insemination of husband's sperm. Her urine pregnancy test result was positive at day 30. Because of acute lower abdominal pain 3 weeks later she was brought to our emergency department. Physical examination revealed an acutely ill pregnant woman with a tender abdomen. No intrauterine gestational sac From the Department of Ob;tetrl[; and Gynecology, School of Medicme and Hospital, NatIOnal Taiwan Unlverslfy. ReceIVed for publicatwn JallWlry 28, 1994; revzsed April 25, 1994; accepted May 13, 1994. Reprint requests: Hong-Nerng Ho, MD,Department of Obstetrics and Gynecology, Natzonal Taiwan Umverslty HOlp!tal, No.7, ChungShan South Road, Taipe!, Talwan, 10002, Republzc of Chma. Copyright © 1994 by Mosby-Year Book, Inc. 0002-9378194 $3.00 + 0 611/57529
1394
was found by ultrasonographic examination. Culdocentesis obtained 3 ml of noncoagulated blood. Emergency laparotomy was performed because of internal bleeding related to ectopic pregnancy. During laparotomy hemoperitoneum (about 2500 ml) was found. An intact amniotic sac with a fetus 4.5 em in length and at about the eleventh gestational week (Fig. 1) was noted in the cul-de-sac. The placenta was implanted over the lower posterior wall of the uterus, right uterosacral ligament, and cul-de-sac. The fetus and partial placenta were removed and bleeding was controlled. Bilateral fallopian tubes and uterus were carefully explored and no rupture site was noted. Except for some endometriotic spots over the anterior wall of uterus, there was neither tubal blockage nor any evidence of pelvic inflammatory disease. Eight days after operation the patient was discharged in good condition.
Comment To our knowledge, this is the first case of abdominal pregnancy reported after ovulation induction with human menopausal and chorionic gonadotropins followed by artificial insemination of husband's sperm. The incidence of ectopic pregnancy is slightly increased in patients who undergo superovulation induction because of previous pelvic inflammatory disease or tubal problems. However, the current case gave no evidence of tubal problems, except for some endometriotic spots over the anterior wall of uterus. How could this abdominal pregnancy have occurred? In theory, it may have resulted from one of the following conditions. (1) Undetectable anomalies of tubal motility or intraluminal structure because of mild endometriosis can account for the alternation of fertilized ovum transport with prior tubal pregnancy and secondary peritoneal implantation. (2) The patient ovulated and the oocytes escaped capture in the fallopian tube. The oocyte eventually
Volume 171. Number 5 Am J Obstet Gynecol
Cheng et al.
1395
Fig. 1. Fetus found in cul-de-sac measures 4.5 em. Gestational age was about 11 weeks (by length of fetus).
became fertilized in the cul-de-sac instead of in the fallopian tube. The size of this fetus (at about 11 weeks of gestation) was compatible with the gestational age counted from the date of first intrauterine insemination of husband's sperm but not with that from the date of second procedure. Our explanation is that she was pregnant after the first attempt. The vaginal bleeding, which mimicked menstruation, might have been the sign of tubal abortion. Whether the administration of gonadotropin resulted in the abdominal pregnancy needs to be further clarified. Because artificial insemination of husband's sperm after superovulation is usually used in
patients with unexplained infertility, we would emphasize that any patients who receive assisted reproductive techniques should be cataloged as at high risk for ectopic pregnancy. Serial ultrasonographic examinations in early pregnancy are recommended. REFERENCES 1. Saracoglu FO, Goksin E, Durukan T. Abdominal pregnancy following gonadotropin treatment. AM J OBSrET GYNECOL 1985; 153:804-5. 2. Oehninger S, Kreiner D, Bass MJ, Rosenwaks Z. Abdominal pregnancy after in vitro fertilization and embryo transfer. Obstet Gynecol 1988;72:499-503.
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Key words: Abdominal pregnancy, gonadotropin, superovulation, intrauterine insemination, ultrasonography
Ectopic pregnancy continues to be a major complication of assisted reproductive techniques. However, to our knowledge, few cases of abdominal pregnancy have occurred after these procedures. I. 2 We report the first case of abdominal pregnancy after treatment wi~h human menopausal and chorionic gonadotropin followed by intrauterine insemination of the husband's sperm.
Case report A 28-year-old woman had primary infertility of unknown cause for 2 years. She received superovulation with human menopausal gonadotropin (Humegon, Organon, Oss, The Netherlands) and chorionic gonadotropin (Pregnyl, Organon) at a private clinic. Artificial insemination of husband's sperm was performed later. The urine pregnancy test was negative on day 29 of that cycle. Vaginal bleeding occurred the next day and persisted for 4 days. The duration and amount of bleeding were the same as in her previous cycles. Another course of superovulation with the same regimen was given immediately. Unsatisfactory follicular growth was noted in this second course. Basal body temperature was found to be elevated on day 10. Two days later she received another artificial insemination of husband's sperm. Her urine pregnancy test result was positive at day 30. Because of acute lower abdominal pain 3 weeks later she was brought to our emergency department. Physical examination revealed an acutely ill pregnant woman with a tender abdomen. No intrauterine gestational sac From the Department of Ob;tetrl[; and Gynecology, School of Medicme and Hospital, NatIOnal Taiwan Unlverslfy. ReceIVed for publicatwn JallWlry 28, 1994; revzsed April 25, 1994; accepted May 13, 1994. Reprint requests: Hong-Nerng Ho, MD,Department of Obstetrics and Gynecology, Natzonal Taiwan Umverslty HOlp!tal, No.7, ChungShan South Road, Taipe!, Talwan, 10002, Republzc of Chma. Copyright © 1994 by Mosby-Year Book, Inc. 0002-9378194 $3.00 + 0 611/57529
1394
was found by ultrasonographic examination. Culdocentesis obtained 3 ml of noncoagulated blood. Emergency laparotomy was performed because of internal bleeding related to ectopic pregnancy. During laparotomy hemoperitoneum (about 2500 ml) was found. An intact amniotic sac with a fetus 4.5 em in length and at about the eleventh gestational week (Fig. 1) was noted in the cul-de-sac. The placenta was implanted over the lower posterior wall of the uterus, right uterosacral ligament, and cul-de-sac. The fetus and partial placenta were removed and bleeding was controlled. Bilateral fallopian tubes and uterus were carefully explored and no rupture site was noted. Except for some endometriotic spots over the anterior wall of uterus, there was neither tubal blockage nor any evidence of pelvic inflammatory disease. Eight days after operation the patient was discharged in good condition.
Comment To our knowledge, this is the first case of abdominal pregnancy reported after ovulation induction with human menopausal and chorionic gonadotropins followed by artificial insemination of husband's sperm. The incidence of ectopic pregnancy is slightly increased in patients who undergo superovulation induction because of previous pelvic inflammatory disease or tubal problems. However, the current case gave no evidence of tubal problems, except for some endometriotic spots over the anterior wall of uterus. How could this abdominal pregnancy have occurred? In theory, it may have resulted from one of the following conditions. (1) Undetectable anomalies of tubal motility or intraluminal structure because of mild endometriosis can account for the alternation of fertilized ovum transport with prior tubal pregnancy and secondary peritoneal implantation. (2) The patient ovulated and the oocytes escaped capture in the fallopian tube. The oocyte eventually
Volume 171. Number 5 Am J Obstet Gynecol
Cheng et al.
1395
Fig. 1. Fetus found in cul-de-sac measures 4.5 em. Gestational age was about 11 weeks (by length of fetus).
became fertilized in the cul-de-sac instead of in the fallopian tube. The size of this fetus (at about 11 weeks of gestation) was compatible with the gestational age counted from the date of first intrauterine insemination of husband's sperm but not with that from the date of second procedure. Our explanation is that she was pregnant after the first attempt. The vaginal bleeding, which mimicked menstruation, might have been the sign of tubal abortion. Whether the administration of gonadotropin resulted in the abdominal pregnancy needs to be further clarified. Because artificial insemination of husband's sperm after superovulation is usually used in
patients with unexplained infertility, we would emphasize that any patients who receive assisted reproductive techniques should be cataloged as at high risk for ectopic pregnancy. Serial ultrasonographic examinations in early pregnancy are recommended. REFERENCES 1. Saracoglu FO, Goksin E, Durukan T. Abdominal pregnancy following gonadotropin treatment. AM J OBSrET GYNECOL 1985; 153:804-5. 2. Oehninger S, Kreiner D, Bass MJ, Rosenwaks Z. Abdominal pregnancy after in vitro fertilization and embryo transfer. Obstet Gynecol 1988;72:499-503.
1·800·55·MOSBY This number links you to the full text of literally every article ever published in Mosby journals. MOSBY Document Express TM, a rapid response information retrieval service, provides quick turnaround, 24-hour availability, and speedy delivery methods. For inquiries and pricing information, call our toll-free, 24-hour order line: 1-800-55·MOSBY; outside the U.S. : 415-259-5046; fax : 415-259-4019; E-mail: [email protected]. MOSBY Document Express"
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In
cooperallOn
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Dynamzc InformatlOn Corp.