{"paper_id":"a4d812a5-80b0-4be0-8447-9c7a5bfef610","body_text":"Ectopic pregnancy is an important cause of maternal morbidity and mortality, with an\nincidence oscillating between 1% - 2% of all reported pregnancies. Previous ectopic\npregnancy, genital infection, pelvic inflammatory disease, tubal disease, abdominal\nsurgery and smoking are directly associated with future ectopic pregnancies ( Farquhar, 2005 ), while other risk factors such\nas assisted reproductive technology (ART) may be indirectly associated with this\ncondition. Bilateral ectopic pregnancy is a rare condition, with an estimated\nprevalence of 1/200000 spontaneous pregnancies ( Polat  et al. , 2014 ). Tubal disease has been identified\nas one of the most significant risk factors for tubal pregnancy ( Rosman  et al ., 2009 ). The\nincidence of tubal disease in the donor egg recipient population is thought to be\nsignificantly lower than in the standard IVF population, which would presumably lead\nto a lower rate of ectopic pregnancies in this group of patients. However this issue\nis controversial ( Rosman  et al .,\n2009 ). Herein we aim to describe a case of bilateral ectopic pregnancy\ndiagnosed one week apart in a patient who performed  In Vitro \nFertilization (IVF) with donor eggs.\n\nA 43-year-old woman, Caucasian, living in the south of Brazil, sought an assisted\nreproduction center because of her desire to gestate. Faced with a history of\nendometriosis associated with decreased ovarian reserve due to her age, the patient\nunderwent ART. She referred to have performed a laparoscopy due to infertility\npreviously, when bilateral tubal permeability was identified. Initially, she began\novarian stimulation, but her cycle was canceled due to poor response. After two\nfailed ovarian stimulations, she entered the \"egg-sharing program\". At that time,\nthe egg-sharing program was the only allowed method of receiving egg donation in\nBrazil. Nowadays, a patient can spontaneously donate eggs. The selected donor was 34\nyears old and patient received nine mature oocytes from her. Four oocytes fertilized\nand two freshly fertilized embryos were transferred on cleavage state (D3), under\nultrasonographic guidance. The endometrium thickness at the day of transference was\n9.6 mm. As the standard laboratory protocol, embryos were loaded and transferred in\n5 µL of culture medium (Global medium, Brussels/Belgium). The couple had no\nsurplus embryos to freeze. The patient conceived and the Human chorionic\ngonadotrophin, Beta fraction (βhCG) level was 76.4 mIU/mL on the\n12 th  day after transfer.\nOn the 25 th  day after transfer, before performing ultrasound control,\npatient sought medical help with abdominal pain and vaginal bleeding,\nhemodynamically stable. A transvaginal pelvic ultrasound examination revealed an\nempty uterus without any adnexal masses and an important amount of fluid collection\nwas presented in the pouch of Douglas. The medical team decided to perform a\ndiagnostic laparoscopy. Surgery revealed hemoperitoneum of approximately 800 mL.\nThere was an ovarian ectopic pregnancy on the left ovary ( Figure 1 ), measuring about 20 millimeters in diameter. Active\nbleeding was identified and the surgeons performed excision of ectopic tissue with\npreservation of the affected ovary. The right ovary was of usual aspect and normal\ntubes were identified on both sides. Patient was discharged in good general\ncondition on the same day. After 8 days, patient reported a new acute abdominal\ndiscomfort. A transvaginal ultrasound examination revealed an empty uterus again,\nbut with a right side adnexal mass of 20 millimeters along with an important amount\nof free fluid in the pouch of Douglas. She was hemodynamically stable, and a new\nlaparoscopy was performed. At this time, laparoscopy revealed hemoperitoneum of\napproximately 900mL. There was an ectopic pregnancy with active bleeding on the\nright tube and salpingectomy was performed ( Figure\n2 ). The postoperative follow-up was uneventful, and the patient was\ndischarged on the same day. The pathology report confirmed the diagnosis of\nbilateral ectopic pregnancies, showing blood clot admixed with chorionic villi in\nthe tissue removed from the left ovary and right tube. After having passed through\nthe disorder of the event, patient chose not to perform IVF again. Nowadays patient\nopted for adoption and is currently satisfied with her decision.\nFigure 1 Left ovarian ectopic pregnancy 25 days after embryo transfer\nLeft ovarian ectopic pregnancy 25 days after embryo transfer\nFigure 2 Right tubal ectopic pregnancy 33 days after embryo transfer\nRight tubal ectopic pregnancy 33 days after embryo transfer\n\nThis study presented the case of a patient with bilateral ectopic pregnancy with a\none-week interval between the diagnoses after IVF. It is known that the prevalence\nof ectopic pregnancy following IVF ranges between 2.1% and 9.4% of all clinical\npregnancies ( Azem  et al. \n1993 ;  Edelstein & Morgan, 1989 ),\nwith an increase in incidence probably related to high prevalence of tubal disease,\nprevious abdominal surgery and pelvic inflammatory disease. Studies have found that\nART procedures are also independently related to ectopic pregnancy ( Clayton  et al ., 2006 ). The\nincidence of tubal disease in the donor egg recipient population is thought to be\nsignificantly lower than in the standard IVF population.  Clayton  et al . (2006)  reviewed population-based\ndata of pregnancies conceived with ART in United States clinics between 1999 and\n2001. They demonstrated a significantly lower ectopic pregnancy rate in the fresh\ndonor egg recipient population compared with the fresh non-donor IVF population\n(1.4%  vs.  2.2%; odds ratio 0.63, 95% confidence interval\n0.54-0.75).\nSome studies have shown that ovulation induction, especially with clomiphene citrate,\nwas an independent risk factor of ectopic pregnancy ( Cohen  et al ., 1986 ;  Marchbanks  et al ., 1985 ;  Verhulst  et al ., 1993 ) and IVF did not\nincrease further risk ( Fernandez  et\nal. , 1991 ). The contributing risk factors for the occurrence\nof ectopic pregnancy following IVF includes multiple embryo transfer and loading\nembryo(s) in a high volume of culture medium ( Klipstein & Oskowitz, 2000 ;  Nama\n& Manyonda, 2009 ). Bilateral ectopic pregnancy is the rarest kind of\nectopic pregnancy with an estimated prevalence of 1/200000 spontaneous pregnancies\n( Polat  et al ., 2014 ).\nAlso, multiple ovulations after induction could lead to multiple pregnancies,\nincluding bilateral ectopic pregnancies ( De Los Rios\n et al ., 2007 ). Since most of the cases of bilateral\nectopic pregnancy are identified by laparoscopy ( Zhu\n et al ., 2014 ), the inspection of both fallopian\ntubes should not be forgotten during surgery ( Ayoubi\n& Fanchin, 2003 ).\nIn our patient, careful inspection of both fallopian tubes was performed, and no\nsigns of a developing ectopic pregnancy in the contralateral fallopian tube was\nseen, probably because it was still too underdeveloped to be diagnosed by\nlaparoscopy at that moment.  Mock  et\nal . (2001)  proposed to perform a systematic second\nsonography within one week when an ectopic pregnancy is medically or surgically\ntreated. This protocol aimed to diagnose heterotopic pregnancy and reduce the need\nfor emergency reintervention. Such protocol could also be applied for evaluation of\ncontralateral adnexal masses. When assessing treatment options, the physician's\nexperience, the clinical presentation and fertility expectation should be considered\n( Polat  et al .,\n2014 ).\nMedical treatment with methotrexate (a folic acid antagonist highly toxic to rapidly\nreplicating tissues) can be attempted when the patient is hemodynamically stable\nwith no evidence of acute intraperitoneal bleeding, serum β-HCG level less\nthan 5000mIU/ml, absence of fetal cardiac activity and ectopic mass measuring less\nthan 4cm in diameter (Practice Committee of American Society for Reproductive\nMedicine, 2008;  Lipscomb  et al .,\n1998 ). Treatment options must be fully explained and detailed before\ntreatment decision. In conclusion, we have reported a case of bilateral ectopic\npregnancy presented within one-week apart from the first surgery. The clinician\nshould be aware that the treatment of one ectopic pregnancy does not preclude the\noccurrence of a second ectopic pregnancy in the same patient and should pay\nattention to the intra-operatory inspection of both side fallopian tubes in any\nectopic pregnancy case ( Zhu  et al .,\n2014 ). Routine ultrasound after ectopic pregnancy treatment may be\nreasonable, especially in high risk patients.","source_license":"CC-BY-4.0","license_restricted":false}