- Email: [email protected]
Fertility before and after surgery for primary ovarian pregnancy
,:icommunications"·in-brief FERTILITY AND STERILITY
Vol. 55, No.1, January 1991
Copyright© 1991 The American Fertility Society
Printed on acid-free paper in U.S.A.
Fertility before and after surgery for primary ovarian pregnancy
Abraham Golan, M.D.* Arie Raziel, M.D. Menachem Neuman, M.D.
David Schneider, M.D. Ian Bukovsky, M.D. Eliahu Caspi, M.D.
Department of Obstetrics and Gynecology, Assaf Harofe Medical Centre, Zeri/in, Affiliated with Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
The incidence of tubal pregnancy appears to have increased dramatically in the last decade. Concomitantly, there is also a rise in the incidence of primary ovarian pregnancy. Whereas it is known that the fertility of tubal pregnancy patients is compromised, both before the extrauterine pregnancy and definitely postoperatively, information concerning past fertility of primary ovarian pregnancy patients is inconclusive, and there is no knowledge whatsoever as to their future reproductive performance.
MATERIALS AND METHODS
The medical records of 637 patients diagnosed and treated as ectopic pregnancies in the department of Obstetrics and Gynecology at Assaf Harofe Medical Center were reviewed. Of these, 21 were diagnosed as primary ovarian pregnancy, confirmed by histopathology in accordance with Spiegelberg's criteria: (1) The tube, including the fimbria ovarica, on the affected side must be intact; (2) The gestational sac must occupy the normal position of the ovary; (3) The gestational sac must be connected to the uterus by utero-ovarian ligament; and (4) Ovarian tissue must be histologically identified in the wall of the sac. All the patients were interviewed and their reproductive performance Received April 9, 1990; revised and accepted August 23, 1990. *Reprint requests: Abraham Golan, M.D., Department of Obstetrics and Gynecology, AssafHarofe Medical Centre, Zerifin, 70300, Israel.
200
Golan et al.
Communications-in-brief
before and after the occurrence of the ovarian pregnancy was recorded.
RESULTS
The mean age ofthe patients was 28 years (range 20 to 34 years), their mean gravidity 2.7 (range 1 to 6), and mean parity 2.3 (range 1 to 4). Two patients suffered from long-standing infertility; the rest (19 patients) were all parous women. Seven abortions were reported, four early spontaneous, and three induced abortions. All19 previously fertile patients had an intrauterine device (IUD) in utero when admitted to hospital for the primary ovarian pregnancy. Pelvic adhesions were identified during surgery in only 3 patients. None gave a history of pelvic inflammatory disease (PID). Of these 19 patients, 5 were lost for follow-up, and 6 were not interested in future conceiving (2 underwent tubal ligation at surgery, 1 used oral contraception, and 3 continued to use the IUD). Eight patients were interested in future fertility. Of these, 7 had an uneventful intrauterine pregnancy, 6 within 18 months and one after 3 years. One of these 7 patients had an additional intrauterine pregnancy, unfortunately terminating as an early spontaneous abortion. Interestingly, in one of the patients in which the IUD was not removed from the uterus at the initial surgery for primary ovarian pregnancy, a contralateral tubal pregnancy occurred a year later, necessitating a laparotomy and a right dorsal salpingotomy. Fertility and Sterility
DISCUSSION
Fertility potential of patients with tubal pregnancy is reported to be low. 1 This is correct before the occurrence of the ectopic gestation, and the existence of a history and evidence of past PID in these cases further supports this observation. Matseonane2 and Bobrow and Bell3 found 42% and 56% incidence of PID in their ectopic pregnancy patients. The fact that after surgery for tubal pregnancy reproductive performance further drops is even more substantiated. Even if the tube is spared, conservative tubal surgery or even merely tubal expression or handling may further damage this already affected delicate organ. This does not seem to be the case in ovarian pregnancy. The relatively high parity of our patients is also supported by others (2 to 5 years). The vast majority of our patients (90%) were known to be fertile and they all carried an IUD. Hallatt4 also observed the good fertility of patients with primary ovarian pregnancy. In his study, however, only 20% of the patients carried an IUD. As in our series, the incidence of PID in Hallatt's report was low (8%). Grimes et al. 5 found a 45.8% incidence of PID in his primary ovarian pregnancy patients and thought that PID is a predisposing factor in primary ovarian pregnancy as in tubal pregnancy. Except for Portunado et al. 6 that reported two intrauterine pregnancies occurring within 18 months in two patients that underwent surgery for primary ovarian pregnancy, no reports exist in the literature concerning subsequent fertility after surgery for primary ovarian pregnancy. In our series, seven of the eight (87.5%) fertile patients desiring fertility conceived (1 patient con-
Vol. 55, No.1, January 1991
ceived twice), all pregnancies intrauterine. Ofthese nine pregnancies, eight (89%) were intrauterine and one was tubal. A tubal pregnancy occurred in one of the three patients using an IUD after the operation. Because the IUD is a predisposing factor for tubal pregnancy as for primary ovarian pregnancy, one wonders if the use of the IUD should not be contraindicated in primary ovarian pregnancy patients. No repeat ovarian pregnancy occurred, and none are reported in the literature. Although the series is small and the figures are insufficient to provide firm proof, we feel that this clearly demonstrates the tendency of fertility to remain unharmed after primary ovarian pregnancy and its treatment. SUMMARY
Primary ovarian pregnancy usually occurs in parous fertile women. It is an accidental event probably related to the presence of the IUD affecting implantation rather than an indicator of altered fertility. Reproductive performance postoperatively remains unmodified. REFERENCES 1. Schoen JA, Nowak RJ: Repeat ectopic pregnancy: a 16 year clinical survey. Obstet Gynecol45:542, 1975 2. Matseonane SL: Ectopic pregnancy: an 11 year study. Am J Diagn Gynecol Obstet 1:331, 1979 3. Bobrow ML, Bell HG: Ectopic pregnancy: a 16 year survey of 905 cases. Obstet Gynecol 20:500, 1962 4. Hallatt JG: Primary ovarian pregnancy: a report of twentyfive cases. Am J Obstet Gynecol143:55, 1982 5. Grimes HG, Nosal RA, Gallagher JC: Ovarian pregnancy: a series of 24 cases. Obstet Gynecol61:174, 1983 6. Portuondo JA, Ochoa C, Gomez BJ, Uribarren A: Fertility and contraception of 6 patients with ovarian pregnancy. Int J Fertil 29:254, 1984
Golan et al.
Communications-in-brief
201
Vol. 55, No.1, January 1991
Copyright© 1991 The American Fertility Society
Printed on acid-free paper in U.S.A.
Fertility before and after surgery for primary ovarian pregnancy
Abraham Golan, M.D.* Arie Raziel, M.D. Menachem Neuman, M.D.
David Schneider, M.D. Ian Bukovsky, M.D. Eliahu Caspi, M.D.
Department of Obstetrics and Gynecology, Assaf Harofe Medical Centre, Zeri/in, Affiliated with Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
The incidence of tubal pregnancy appears to have increased dramatically in the last decade. Concomitantly, there is also a rise in the incidence of primary ovarian pregnancy. Whereas it is known that the fertility of tubal pregnancy patients is compromised, both before the extrauterine pregnancy and definitely postoperatively, information concerning past fertility of primary ovarian pregnancy patients is inconclusive, and there is no knowledge whatsoever as to their future reproductive performance.
MATERIALS AND METHODS
The medical records of 637 patients diagnosed and treated as ectopic pregnancies in the department of Obstetrics and Gynecology at Assaf Harofe Medical Center were reviewed. Of these, 21 were diagnosed as primary ovarian pregnancy, confirmed by histopathology in accordance with Spiegelberg's criteria: (1) The tube, including the fimbria ovarica, on the affected side must be intact; (2) The gestational sac must occupy the normal position of the ovary; (3) The gestational sac must be connected to the uterus by utero-ovarian ligament; and (4) Ovarian tissue must be histologically identified in the wall of the sac. All the patients were interviewed and their reproductive performance Received April 9, 1990; revised and accepted August 23, 1990. *Reprint requests: Abraham Golan, M.D., Department of Obstetrics and Gynecology, AssafHarofe Medical Centre, Zerifin, 70300, Israel.
200
Golan et al.
Communications-in-brief
before and after the occurrence of the ovarian pregnancy was recorded.
RESULTS
The mean age ofthe patients was 28 years (range 20 to 34 years), their mean gravidity 2.7 (range 1 to 6), and mean parity 2.3 (range 1 to 4). Two patients suffered from long-standing infertility; the rest (19 patients) were all parous women. Seven abortions were reported, four early spontaneous, and three induced abortions. All19 previously fertile patients had an intrauterine device (IUD) in utero when admitted to hospital for the primary ovarian pregnancy. Pelvic adhesions were identified during surgery in only 3 patients. None gave a history of pelvic inflammatory disease (PID). Of these 19 patients, 5 were lost for follow-up, and 6 were not interested in future conceiving (2 underwent tubal ligation at surgery, 1 used oral contraception, and 3 continued to use the IUD). Eight patients were interested in future fertility. Of these, 7 had an uneventful intrauterine pregnancy, 6 within 18 months and one after 3 years. One of these 7 patients had an additional intrauterine pregnancy, unfortunately terminating as an early spontaneous abortion. Interestingly, in one of the patients in which the IUD was not removed from the uterus at the initial surgery for primary ovarian pregnancy, a contralateral tubal pregnancy occurred a year later, necessitating a laparotomy and a right dorsal salpingotomy. Fertility and Sterility
DISCUSSION
Fertility potential of patients with tubal pregnancy is reported to be low. 1 This is correct before the occurrence of the ectopic gestation, and the existence of a history and evidence of past PID in these cases further supports this observation. Matseonane2 and Bobrow and Bell3 found 42% and 56% incidence of PID in their ectopic pregnancy patients. The fact that after surgery for tubal pregnancy reproductive performance further drops is even more substantiated. Even if the tube is spared, conservative tubal surgery or even merely tubal expression or handling may further damage this already affected delicate organ. This does not seem to be the case in ovarian pregnancy. The relatively high parity of our patients is also supported by others (2 to 5 years). The vast majority of our patients (90%) were known to be fertile and they all carried an IUD. Hallatt4 also observed the good fertility of patients with primary ovarian pregnancy. In his study, however, only 20% of the patients carried an IUD. As in our series, the incidence of PID in Hallatt's report was low (8%). Grimes et al. 5 found a 45.8% incidence of PID in his primary ovarian pregnancy patients and thought that PID is a predisposing factor in primary ovarian pregnancy as in tubal pregnancy. Except for Portunado et al. 6 that reported two intrauterine pregnancies occurring within 18 months in two patients that underwent surgery for primary ovarian pregnancy, no reports exist in the literature concerning subsequent fertility after surgery for primary ovarian pregnancy. In our series, seven of the eight (87.5%) fertile patients desiring fertility conceived (1 patient con-
Vol. 55, No.1, January 1991
ceived twice), all pregnancies intrauterine. Ofthese nine pregnancies, eight (89%) were intrauterine and one was tubal. A tubal pregnancy occurred in one of the three patients using an IUD after the operation. Because the IUD is a predisposing factor for tubal pregnancy as for primary ovarian pregnancy, one wonders if the use of the IUD should not be contraindicated in primary ovarian pregnancy patients. No repeat ovarian pregnancy occurred, and none are reported in the literature. Although the series is small and the figures are insufficient to provide firm proof, we feel that this clearly demonstrates the tendency of fertility to remain unharmed after primary ovarian pregnancy and its treatment. SUMMARY
Primary ovarian pregnancy usually occurs in parous fertile women. It is an accidental event probably related to the presence of the IUD affecting implantation rather than an indicator of altered fertility. Reproductive performance postoperatively remains unmodified. REFERENCES 1. Schoen JA, Nowak RJ: Repeat ectopic pregnancy: a 16 year clinical survey. Obstet Gynecol45:542, 1975 2. Matseonane SL: Ectopic pregnancy: an 11 year study. Am J Diagn Gynecol Obstet 1:331, 1979 3. Bobrow ML, Bell HG: Ectopic pregnancy: a 16 year survey of 905 cases. Obstet Gynecol 20:500, 1962 4. Hallatt JG: Primary ovarian pregnancy: a report of twentyfive cases. Am J Obstet Gynecol143:55, 1982 5. Grimes HG, Nosal RA, Gallagher JC: Ovarian pregnancy: a series of 24 cases. Obstet Gynecol61:174, 1983 6. Portuondo JA, Ochoa C, Gomez BJ, Uribarren A: Fertility and contraception of 6 patients with ovarian pregnancy. Int J Fertil 29:254, 1984
Golan et al.
Communications-in-brief
201