Sestre Milosrdnice University hospital and Institute of Clinical Medical Research
Abstract
Unilateral twin tubal gestations are extremely rare with a reported incidence of 1 per 200 ectopic pregnancies. In recent years, the incidence of heterotopic pregnancy associated with in vitro fertilization and embryo transfer (IVF-ET) has risen to 1%-3% of achieved pregnancies. We report a very rare case of a 32-year-old woman with 6-year primary infertility with unilateral twin tubal pregnancy and subsequent heterotopic pregnancy following two IVF treatments. Her gynecologic history was notable for previous distal occlusion of the left fallopian tube treated by laparoscopic reconstructive surgery. After ovulation induction and IVF with ET of two embryos, transvaginal sonography at 6 weeks revealed two separate gestational sacs in the left adnexal mass. Emergency laparoscopy showed unruptured ampullar pregnancy and salpingectomy was carried out. On second IVF two years later, after ovulation induction and ET of three embryos, endovaginal sonography at 6 weeks revealed only one intrauterine sac. One week later, the patient complained of intermittent episodes of lower abdominal pain in the right quadrant. Ultrasound confirmed intrauterine pregnancy and revealed right tubal gestational sac. Laparoscopy showed unruptured right ampullar pregnancy and salpingectomy was performed. Histology of salpingectomy specimens showed signs of chronic infection in both tubes. The intrauterine pregnancy progressed to term when a healthy infant was delivered vaginally. Gynecologists should always consider the possibility of ectopic pregnancy in pregnancies following IVF-ET, particularly in cases with tubal disease and abdominal pain.Jednostrana blizanačka tubarna trudnoća je iznimno rijetka s pojavnošću od 1:200 ektopičnih trudnoća. Pojavnost heterotopične trudnoće u postupku izvantjelesne oplodnje je posljednjih godina u porastu i kreće se od 1% do 3% postignutih trudnoća. Prikazujemo vrlo rijedak slučaj 32-godišnje žene sa 6-godišnjom primarnom neplodnošću s jednostranom, blizanačkom trudnoćom u jajovodu i slijedećom heterotopičnom trudnoćom nakon dva postupka izvantjelesne oplodnje. Anamnestički je ranije utvrđeno terminalno začepljenje lijevog jajovoda uz rekonstrukcijski zahvat na njemu. Nakon indukcije ovulacije i postupka izvantjelesne oplodnje te prijenosa 2 zametka, sa 6 tjedana trudnoće transvaginalnim ultrazvukom otkrivene su 2 gestacijske vreće u predjelu lijevih adneksa. Pri laparoskopiji je prikazana nerupturirana tubarna trudnoća i odstranjen je lijevi jajovod. Pri drugom pokusaju izvantjelesne oplodnje 2 godine kasnije nakon indukcije ovulacije i prijenosa 2 zametka, sa 6 tjedana trudnoće transvaginalnim ultrazvukom prikazana je intrauterina trudnoća. Tjedan dana kasnije bolesnica je dobila povremene bolove u donjem dijelu trbuha desno. Ultrazvučno je potvrđena intrauterina trudnoća, a otkrivena trudnoća u desnom jajovodu. Laparoskopski je prikazana nerupturirana desnostrana tubarna trudnoća i odstranjen je jajovod. Patohistološki su kod oba jajovoda nađeni znaci kronične upale. Intrauterina trudnoća je napredovala do termina kada je vaginalno porođeno zdravo dijete. Svaki bi ginekolog trebao razmišljati o mogućnosti izvanmaternične trudnoće nakon postupka izvantjelesne oplodnje, a naročito u slučajevima oštećenih jajovoda i bolova u trbuhu
