April 8, 2020
Author Name: Dr. Jigyasa Singh Mentor Name: Dr. Gaurav Satyadeo Sharma on April 08, 2020
Let’s start with basics first. What is IVF? In-vitro fertilization (IVF) or Test tube baby is a process in which embryo is prepared with fertilization of egg with sperm outside the womb and is transferred inside the female uterus after preparing endometrial lining of the uterus at a particular day of menstrual cycle.
Ectopic or Extra-uterine pregnancy is the implantation of embryo anywhere except in the endometrial lining of the uterine cavity. Ectopic pregnancy can lead to life threatening complications if it is not diagnosed and treated at an early stage. It is a challenge to diagnose it at an early stage and requires expertise.
It is strange coincidence that the first successful IVF pregnancy was an ectopic pregnancy!!! The incidence is 2.1% to 9.4% of all clinical pregnancies resulting from ART (assisted reproductive technique). Decline in incidence is seen with frozen embryo transfers. The incidence of ectopic pregnancy in natural conception is 1-2 %
In some cases infertility can be a cause of ectopic pregnancy while in some cases infertility can result due to ectopic pregnancy.There are many things associated with ectopic pregnancy like embrio transfer technique, fallopian tube pathology and pelvic inflammatory disorders.
Maternal age– Incidence is increased from 1.4% at the age of 21 years to 6.9% in women aged 44 years or more. This is mainly attributed to increase in chromosomal abnormalities in trophoblastic tissue and age-related changes in tubal function.
Cigarette smoking– Increases the risk following IVF treatment of about 3 times compared to non-smokers.
Previous Extrauterine pregnancy- The recurrence rate ranges from 15% to 20% in the case of one pregnancy and it increases to 32% in cases with two previous such pregnancies. But if there is one normal pregnancy after an ectopic pregnancy then it reduces the chances of subsequent pregnancy.
Tubal pathology– Hydrosalpinx is a main cause of tubal infertility and is also associated with a negative impact on the outcome of IVF treatment.
Previous Tubal surgery– The level of risk of ectopic pregnancy depends on the degree of damage to tubes and the extent of anatomic distortion of the tubes. In some cases it has been seen that altered tubal motility and developmental anomalies of the fallopian tube can also cause ectopic pregnancy.
One theory is that hydrostatic force generated by transfer medium can pull the embryo in the fallopian tube. Other prominent theory is that gravitational pull causes the embryos to enter the hanging tubes. Sometimes the uterine contractions causes reflux expulsion of the embryo into the fallopian tubes. Faulty transfer technique can also increase the chances of ectopic pregnancy. Different hormonal milieus in IVF cycles like higher circulating concentrations of oestradiol leads to a reverse migratory process of the transferred embryos.
What can be done to reduce the incidence of ectopic pregnancy?
• Embryos should be placed between 5 mm to 10 mm from the fundus.
• The transfer volume of culture media containing embryos should be optimal (preferably less than 80 µl).
• There is a recommendation that tubes be occluded at the level of the utero-tubal junction.
• To transfer Day 5 (blastocyst stage) embryos and to do frozen embryo transfers.
The incidence of ectopic pregnancy can lead to serious clinical and psychological trauma to the patient and so it should be diagnosed at the earliest for better prognosis.
The diagnosis is made by physical signs and symptoms like abdominal pain with vaginal bleeding with haemodynamic instability.
The laboratory test of serial quantitative measurements of serum β-hCG in combination withTransvaginal sonography. Ultrasonograpy will reveal absent intrauterine gestational sac while beta hcg levels will be lower than the range seen for similar gestational age. Gestational sac is usually seen at beta hcg levels of more than 1500 IU/L
Treatment is both medical and surgical.
• In medical treatment we use Injection Methotrexate with the dose of 1mg/kg intramuscularly.
• Post treatment follow up is by monitoring falling serum beta-hcg levels and doses could be repeated if desired value is not achieved. Patients are advised to avoid becoming pregnant for six months and avoid excessive alcohol and sunlight exposure.
• Surgical treatment is done in hemodynamically unstable patients with ruptured ectopic pregnancy and hemoperitoneum or blood collection in peritoneal cavity. Preferred is Laparoscopic surgery with minimal invasion and better post-operative recovery. Laparotomy is done if patient is hemodynamically unstable with huge hemoperitoneum and if expertise is not available.
So coming back to the big question – can IVF cause ectopic pregnancy?
The answer is NO. The incidence of ectopic pregnancy in IVF and natural conception is almost same if IVF is done in experienced hands and with due precautions. We agree In vitro fertilization procedure does increase the chances of Extrauterine pregnancy if due precaution is not taken but with modern technologies and excellent expertise this incidence can be reduced to minimal with a best outcome.
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