Journals | Policy | Permission

Journal of Medical Cases

Case Report

Volume 7, Number 4, April 2016, pages 150-152

A Case of Ruptured Ovarian Ectopic After Embryo Transfer With Low Serum hCG and Fertility Conserving Laparoscopy

Ovarian pregnancy is a rare form of ectopic pregnancy that remains a diagnostic enigma. Incidence reported includes 0.5-3% of all ectopic pregnancies [1]. We report an interesting case of ruptured ovarian pregnancy after in vitro fertilization (IVF) after embryo transfer with low serum beta-hCG levels in a patient presenting with an acute abdomen and successfully treated by fertility-conserving laparoscopy.

A 39-year-old nulliparous female presented to a tertiary women’s hospital complaining of severe epigastric pain and bloating. She has no significant past medical history or previous surgery. Her last menstrual period was 4 weeks ago with regular 28 days cycles. The patient was followed up for primary subfertility and recently underwent IVF treatment with embryo transfer 3 weeks ago. Initial serum beta-hCG after embryo transfer was low at 5.4 IU/L.

On physical examination, she reported a body temperature of 37.2 °C, blood pressure reading of 156/80 mm Hg and pulse rate of 87 beats/min. Abdominal examination elicited generalized severe lower abdominal tenderness with voluntary guarding and rebound positive on palpation. Speculum examination revealed no vaginal bleeding. Per vaginal examination was unremarkable. Cervical excitation was negative.

Subsequent urine pregnancy test was positive. Blood investigations indicated a hemoglobin level of 10.9 g/dL and white cell count of 14.5 × 10⁹/L. Serum beta-hCG was elevated at 1,528 IU/L. Trans abdominal ultrasound (Fig. 1) revealed a large amount of echogenic fluid in pelvis with a complex mass measuring 9.8 × 8.9 × 3.8 cm seen in the midline in the pouch of Douglas. No intrauterine gestational sac was seen. Both ovaries were not well seen due to the presence of hemoperitoneum.

Click for large image

Figure 1. Transabdominal ultrasound showing with a midline complex mass measuring 9.8 × 3.8 cm with hemoperitoneum.

A diagnosis of ruptured ectopic pregnancy was suspected. Consequently, the patient underwent an emergency diagnostic and therapeutic laparoscopy. Intra-operatively, a small 2 × 2 cm ruptured right ovarian ectopic pregnancy was seen with active hemorrhage seen. One and a half liter of hemoperitoneum was present. The uterus and bilateral tubes were normal. A wedge resection of the right ovarian ectopic was performed (Figs. 2 and 3) and hemoperitoneum evacuated. Ovarian tissue sent for histopathology reported hemorrhage, chorionic villi and trophoblastic attached which confirmed the diagnosis of a ruptured ovarian ectopic. Post-operatively, the patient remained stable and was discharged from hospital 2 days later. Post-operative hCG level was negative after follow-up.

Click for large image

Figure 2. Diagnostic laparoscopy with ruptured right ovarian ectopic.

Click for large image

Figure 3. Wedge resection of ovarian ectopic with hemostasis.

Risk factors for ovarian ectopic include previous adnexal surgery, pelvic inflammatory disease, use of intrauterine devices (IUDs), endometriosis, and previous fertility treatment including IVF which our patient had recently undergone. Other differential diagnosis also includes hemorrhagic corpus luteum and endometrioma.

Correct diagnosis of ectopic pregnancy is made on patient history, clinical acumen, serum beta-hCG levels and pelvic ultrasound. Preoperative diagnosis is often difficult, challenging and unpredictable. In our case, the ovarian ectopic was initially missed on trans abdominal ultrasound concealed by massive hemoperitoneum and diagnosed intra-operatively by laparoscopy.

Ectopic pregnancy cannot be excluded in patients after IVF treatment despite low serum beta- hCG levels after embryo transfer. These patients may present with an acute abdomen that require close surveillance. Low serum beta-hCG levels may also be misleading as ruptured ectopic pregnancies have been reported in cases with decreasing beta-hCG levels [2].

Ovarian pregnancy occurs when the ovum is not separated from the ovary during ovulation and is fertilized by sperm in the peritoneal cavity over the ovary and implanted [3]. Definite diagnosis is the fulfillment of all four histological and anatomical criteria that Spiegelberg described in 1878 with the following [4]. 1) The fallopian tube on the involved side is intact. 2) The gestational sac is located in the region of the ovary. 3) The ectopic pregnancy is attached to the uterus by the ovarian ligament. 4) Ovarian tissue in the wall of the gestational sac is proven histologically. Our case fulfilled these criteria with negative beta-hCG levels on follow-up.

The management of an ectopic pregnancy includes medical treatment with methotrexate or surgery by laparotomy or laparoscopy. Methotrexate was not suitable in our case as the ultrasound features of a large 9.8 cm midline complex mass with hemoperitoneum were contraindicated. Laparoscopic management of ovarian ectopic includes oophorectomy, enucleation of gestational sac and wedge resection for fertility conservation [5]. This technique allows preservation of reproductive capability which is ideal for patients who want to conceive post-operatively. Laparoscopy remains the ideal treatment for diagnosis and treatment as it is associated with less operative time, lower blood loss, shorter hospitalization and quicker recovery compared to laparotomy [6].

In conclusion, ovarian ectopic pregnancy remains a rare occurrence with diagnostic challenges. Diagnosis of ovarian ectopic is made on patient history, clinical acumen, serum beta-hCG levels and pelvic ultrasound. Ectopic pregnancy must be suspected in patients presenting with abdominal pain after IVF treatment despite low serum beta-hCG levels. Laparoscopic management can be successfully used for fertility conservation.

Conflict of Interest

None.

Author Contributions

All authors contributed equally to writing the manuscript.

1. Grimes HG, Nosal RA, Gallagher JC. Ovarian pregnancy: a series of 24 cases. Obstet Gynecol. 1983;61(2):174-180.
   pubmed
2. Brennan DF, Kwatra S, Kelly M, Dunn M. Chronic ectopic pregnancy - two cases of acute rupture despite negative beta hCG. J Emerg Med. 2000;19(3):249-254.
   doi
3. Var T, Tonguc EA, Akan E, Batioglu S, Akbay S. Laparoscopic conservative approach to ovarian pregnancies: two cases. Arch Gynecol Obstet. 2009;280(1):123-125.
   doi pubmed
4. Plotti F, Di Giovanni A, Oliva C, Battaglia F, Plotti G. Bilateral ovarian pregnancy after intrauterine insemination and controlled ovarian stimulation. Fertil Steril. 2008;90(5):2015 e2013-2015.
5. Odejinmi F, Rizzuto MI, Macrae R, Olowu O, Hussain M. Diagnosis and laparoscopic management of 12 consecutive cases of ovarian pregnancy and review of literature. J Minim Invasive Gynecol. 2009;16(3):354-359.
   doi pubmed
6. Alkatout I, Stuhlmann-Laeisz C, Mettler L, Jonat W, Schollmeyer T. Organ-preserving management of ovarian pregnancies by laparoscopic approach. Fertil Steril. 2011;95(8):2467-2470 e2461-2462.

This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Journal of Medical Cases is published by Elmer Press Inc.