European Journal of Obstetrics & Gynecology and Reproductive Biology 158 (2011) 8789

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European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Clinical analysis of ovarian pregnancy: a report of 49 cases

Hong-Jun Choi a, Kyong-Shil Im b, Hyun-Joo Jung b, Kyung-Taek Lim a,
Jung-Eun Mok a, Yong-Soon Kwon a,*
a
Department of Obstetrics and Gynecology, College of Medicine, University of Kwandong, Cheil General Hospital and Womens Healthcare Center, 1-19 Mukjeong-dong, Jung-gu,
Seoul 100380, Republic of Korea
b
Department of Anesthesiology and Pain Medicine, College of Medicine, Catholic University Seoul, Republic of Korea

A R T I C L E I N F O A B S T R A C T

Article history: Objective: To clinically analyze cases of ectopic ovarian pregnancy and to generate data regarding the
Received 5 November 2010 evaluation and management of suspected ectopic ovarian pregnancies.
Received in revised form 8 March 2011 Study design: We retrospectively analyzed 49 ovarian pregnancies that were surgically treated at Cheil
Accepted 25 April 2011
General Hospital and Womens Healthcare Center between January 1996 and December 2009. We
analyzed patient age, parity, symptoms, risk factors, preoperative diagnosis, and ovarian pregnancy type.
Keywords: Results: During the study period, the incidence of ovarian pregnancy was 1.59% of all ectopic pregnancies
Ovarian pregnancy
(49/3081); 45/49 (91.8%) were primary ovarian pregnancies. At the time of diagnosis, mean age was 30.7
Clinical analysis
Risk factor
years (SD: 4.4 years) and mean parity was 0.63 (SD: 0.8). The most common presenting symptoms were
abdominal pain (42.9%) and vaginal bleeding (28.6%). The most common sonographic ndings were uid
surrounding the ovarian pregnancy and ovarian enlargement. In regard to surgical treatment, ovarian wedge
resection was most often performed (85.7% of cases), followed by oophorectomy (8.2% of cases). The most
common risk factors were endometriosis (16 patients) and a history of abdominal surgery (19 patients).
Conclusions: Ovarian pregnancies are extremely rare and difcult to diagnose both pre- and intra-
operatively. Our data may assist surgeons in understanding the clinical presentation of ovarian
pregnancy and in counseling patients. Larger studies are warranted to gather more data on this rare form
of ectopic pregnancy.
2011 Elsevier Ireland Ltd. All rights reserved.

1. Introduction advent of laparoscopy and surgical experience have increased

Ovarian pregnancies account for 0.53% of all ectopic pregnan-
cies [13]. The rst case was reported by Saint Maurice in 1682 [4].
Recently the incidence has likely increased due to improved
diagnosis and the invention of assisted reproductive technology
(ART) [5]. Spiegelberg described four criteria for the diagnosis of
ovarian pregnancy: (1) fallopian tubes including mbria must be
intact and separate from the ovary; (2) the pregnancy must occupy
the normal position of the ovary; (3) the ovary must be attached to
the uterus through the utero-ovarian ligament; and (4) there must
be ovarian tissue attached to the pregnancy in the specimen [6].
Although early diagnosis of ectopic pregnancy has become more
feasible due to sensitive assays for human chorionic gonadotropin
(hCG) and ultrasonography, it remains a diagnostic challenge.
In the past, the traditional treatment for ovarian pregnancy was
oophorectomy or salpingo-oophorectomy by laparotomy. The
laparoscopic management of ovarian pregnancy, including wedge
resection, removal of only the gestational products, and injection of
chemotherapeutic agents.
Due to the extreme rarity of this type of ectopic pregnancy, the
risk factors that apply to tubal pregnancies such as endometriosis
and previous pelvic infection have not been shown to be clearly
related to ovarian pregnancies.
There are few reports that include signicant numbers of
ovarian pregnancies. To the best of our knowledge, our study has
the greatest number of cases ever published. In this clinical
analysis, we describe our experience with 49 cases of ovarian
pregnancy that were diagnosed and treated at our hospital over a
14-year period. We evaluate the prevalence, common clinical
presentations, risk factors, and sonographic ndings.
2. Material and methods

We retrospectively reviewed the medical records of 49 cases of

* Corresponding author. Current address: Department of Obstetrics and
Gynecology, Ulsan University Hospital, University of Ulsan College of Medicine,
290-3 Joenha-dong, Dong-gu Ulsan, Korea zip code: 682-714.
E-mail address: kbongchun@hanmail.net (Y.-S. Kwon).
ovarian pregnancy diagnosed and treated at Cheil General Hospital
and Womens Healthcare Center between January 1996 and
December 2009. We collected information on patient age, parity,
chief complaint, risk factors, preoperative diagnosis, sonographic

0301-2115/$ see front matter 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ejogrb.2011.04.015
88 H.-J. Choi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 158 (2011) 8789

Table 1 Table 3
Demographic characteristics. Intraoperative and pathological characteristics.
Mean age 30.7, SD: 4.4 years Operation method Laparoscopy Laparotomy
Mean gravidity 2.5, SD: 1.5 (N = 43) (N = 6)
Mean parity 0.6, SD: 0.8
Preoperative diagnosis Number (%) Ovarian wedge resection 37 (86.0%) 5 (83.3%)
Ovarian pregnancy 8 (16.3%) Oophorectomy 4 (9.3%) 0
Tubal ectopic pregnancy 33 (67.3%) Salpingo-oophorectomy 0 1 (16.7%)
Adnexal mass 6 (12.2%) Ovarian wedge resection 2 (4.7%) 0
Heterotopic pregnancy 1 (2.0%) with salpingectomy
Ovarian pregnancy site Number (%)
Previous ectopic pregnancy Right 21 (42.9%)
Yes 6 (12.2%) Left 27 (57.1%)
No 43 (87.8%)
Ovarian pregnancy type
SD, standard deviation. Primary ovarian pregnancy 45 (91.8%)
Combined ovarian pregnancy 3 (6.1%)
Heterotopic pregnancy 1 (2.0%)

nding at diagnosis, operative method, and ovarian pregnancy Combined ovarian pregnancy: mixed type between tubal and ovarian pregnancy.
type. In each case, the diagnosis of ovarian pregnancy was
established by review of pathology reports. Our nal histopatho-
logic diagnosis was based on the Spiegelberg criteria. Table 4
Risk factors.
To analyze presenting symptoms, we gathered information
about abdominal pain, nausea, vomiting, vaginal bleeding, and Numbers
shock. To analyze risk factors, we gathered information about a Present IUD use 2
history of intrauterine device (IUD) use, abdominal surgery, pelvic History of abdominal surgery 19
endometriosis, pelvic inammatory disease, ovulation induction, Endometriosis 16
and in vitro fertilization (IVF). PID 4
Ovulation induction 4
IVF 8
3. Results Others 4
None 12
A total of 3081 ectopic pregnancies were treated at Cheil Others: huge uterine myoma 2 cases, bicornuate uterus 1 case, arcuate uterus
General Hospital & Womens Healthcare Center from January 1996 1 case.
to December 2009 (from 1996 to 2009, from 107,170 deliveries at
Cheil General Hospital and Womens Healthcare Center). Of those,
49 (1.59%) were ovarian pregnancies. Most patients (43 patients, 87.8%) underwent laparoscopic
At the time of diagnosis, the mean age was 30.7 years (SD: surgery; only 6 (12.2%) underwent laparotomy. Surgical treatment
4.4), mean gravidity was 2.53, and mean parity was 0.63. In regard consisted of an ovarian wedge resection in 85.7% (42/49), an
to possible risk factors, 6 patients had a history of ectopic pregnancy. oophorectomy in 8.2% (4/49), a wedge resection with salpingect-
The majority of preoperative diagnoses were tubal ectopic pregnancy omy in 4.1% (2/49), and a salpingo-oophorectomy in 2.0% (1/49)
(67.3%) followed by ovarian pregnancy (16.3%) (Table 1). (Table 3).
The most common chief complaints were abdominal pain Of the risk factors analyzed, the most common were
(42.9%) and vaginal bleeding (28.6%). Five asymptomatic patients endometriosis (16 cases) and a history of abdominal surgery (19
were incidentally discovered to have ovarian pregnancies during cases). Only 2 patients had used an IUD and only 4 patients had a
post-IVF monitoring. Four cases were discovered in asymptomatic history of pelvic inammatory disease (PID). Twelve patients had
patients presenting for a pregnancy test. Six cases were diagnosed no known risk factors (Table 4).
as adnexal masses.
Ultrasonography revealed an enlarged ovary in 33 cases (67.3%) 4. Comments
and a uid collection surrounding the ovary in 24 cases (48.9%)
(Table 2). Although ovarian pregnancy is a rare form of ectopic pregnancy,
its true incidence is likely underestimated because some number
Table 2 of suspected tubal pregnancies that are treated medically without
clinical symptoms and ultrasound ndings. laparoscopic inspection are in fact early ovarian pregnancies.
Furthermore, the incidence is thought to vary by population. Few
Chief complaints Number (%)
reports have been published that include a signicant number of
Abdominal pain 21 (42.9%) ovarian pregnancies. We analyzed 3081 cases of ectopic pregnancy
Vaginal bleeding 14 (28.6%)
diagnosed at our hospital over 14 years and 49 of 3081 cases of
Adnexal mass 3 (6.1%)
Shock 1 (2.0%) ectopic pregnancy were diagnosed as ovarian pregnancy (1.59%).
Vomiting 1 (2.0%) This incidence is similar to that of other current reports [13].
Asymptomatic 9 (18.4%) As with tubal pregnancies, ovarian pregnancies can involve
Skipped menstruation 4 (8.2%)
multiple or heterotopic gestations. This series identied 3 cases
Post IVF follow-up 5 (10.2%)
(6.1%) of combined ovarian pregnancy, and only 1 case of
Ultrasound ndings heterotopic pregnancy (Table 3). The incidence of ectopic
Fluid collection surrounding ovary 24 (48.9%)
pregnancy is on the rise due to increasing maternal age, tubal
Enlarged ovary 33 (67.3%)
Gestational sac only 16 (32.7%) reconstruction surgery, use of ovulation induction, and use ART
Fetal pole 7 (14.3%) such as IVF and embryo transfer (ET). Unfortunately, there are few
No visible fetal pole 26 (53.1%) data on the epidemiology of ovarian pregnancies.
IVF: in vitro fertilization. Mean diameter of enlarged ovary: 41.63 mm (range: 22 Although the precise etiology of ovarian pregnancy is not
110). known, hypotheses include reverse migration of the embryo after
 H.-J. Choi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 158 (2011) 8789
deep deposition in the uterine cavity [7], use of large volumes of
culture uid [8], and tubal pathology such as from PID. In the
literature, possible risk factors include IUD use, previous laparoto-
my or laparoscopic surgery, endometriosis, use of ART, and uterine
anomalies. In our series, just two factors, a history of abdominal
surgery and pelvic endometriosis, were associated with ovarian
pregnancy (Table 4).
The classic presenting symptoms of ectopic pregnancy are
abdominal pain and vaginal bleeding, which were also the most
common symptoms in our data. As for other ectopic pregnancies, a
combination of these symptoms along with a history of antecedent
amenorrhea, elevated b-hCG level, and an empty uterus on
ultrasound should trigger the investigation for an ectopic
pregnancy.
In general, the important diagnostic tool for ovarian pregnancy is
an ultrasound. An echogenic ring around the ovary along with a yolk
sac or fetal parts are important sonographic indicators [1012].
Sergent et al. [13] reported that ultrasound diagnosis of ovarian
pregnancies is rare, because it is difcult to diagnose preoperatively
an ovarian pregnancy when an embryo is not found by ultrasound.
Though rare, the presence of a yolk sac or fetal pole in the ovary aids
in diagnosis [14]. In our series, 23 cases had gestational sac-like
masses visible on ultrasound, while 26 cases had no such ndings. Of
those 23 cases, 7 involved a visible fetal pole within the mass, 1 of
which had a visible fetal heart beat. A uid collection surrounded the
ovary on ultrasound in 24 of our cases (49.0%), and the involved
ovary was enlarged in 33 cases (Table 2).
Compared to preoperative diagnosis, ovarian pregnancies are
twice as likely to be diagnosed during surgery, such as for a
ruptured corpus luteum or tubal ectopic pregnancy, or following
pathologic review of an apparent hemorrhagic ovarian cyst (up to
72% of some case series) [1517]. In our series, the cases that were
misdiagnosed preoperatively included 33 cases of tubal pregnancy,
6 cases of an adnexal mass, and 1 case of heterotopic pregnancy
(Table 1).
The traditional treatments for ovarian pregnancy are oopho-
rectomy or salpingo-oophorectomy. If the patient wishes to
maintain fertility, more conservative surgical management could
be performed, such as wedge resection or removal of only the
gestational products. In our series, in terms of surgical procedures,
42 (85.7%) underwent ovarian wedge resection, 4 (8.2%) under-
went oophorectomy, 2 (4.1%) underwent wedge resection with
salpingectomy, and 1 (2.0%) underwent salpingo-oophorectomy.
Also, of the 49 women in this series, laparotomy was performed in
6 (12.2%) and laparoscopy was performed in 43 (87.8%). Improve-
ments in laparoscopic surgery have increased the rate of these
more conservative ovarian surgeries [18], because the benets of
laparoscopy include a shorter hospital stay and more rapid return
to normal activities.
A review of the literature shows that IUD was reported as the
only factor signicantly associated with ectopic pregnancy
[3,17,19]. The IUD may cause mild inammation, resulting in
deciliation of the endosalpinx and therefore delayed ovum
transport, leading to ectopic implantation [20]. This nding both
conrms the role of IUD in the etiology of ectopic pregnancy [21]
and suggests that there may be tubal factors involved in the
etiology of ovarian pregnancy [22]. In our series, total IUD users
were 656 women who were diagnosed as having an ectopic
pregnancy and surgically treated in our institute during the study
period. Six hundred and two of 3081 women with ectopic
pregnancy (19.7%) had a tubal pregnancy, which was relatively
lower percentage but was a rate approximately similar to the
previous reports.
89
In contrast to tubal pregnancies, our series of 49 patients with
ovarian pregnancy showed IUD use in 2 parous women (4.1%).
Therefore we suggest that it is controversial that IUD use has any
association with ovarian pregnancy. Further study is warranted to
determine the IUD role in developing an ovarian pregnancy.
In conclusion, ovarian pregnancy is unlikely to be diagnosed
preoperatively due to its rarity, lack of typical presenting
symptoms, and lack of known risk factors. Based on current
research, if an ectopic pregnancy is suspected in a patient with
endometriosis or a history of abdominal surgery, ultrasonograph-
ic evidence of a uid collection surrounding the ovary or an
enlarged ovary are helpful diagnostic clues to aid in the
preoperative diagnosis of ovarian pregnancy. Further studies
are warranted to improve our ability to diagnose ovarian
pregnancy and to clarify the most appropriate management
strategies.
Conict of interest statement
No Conict of interest statement was provided by the authors.
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