Laparoscopic, Endoscopic and Robotic Surgery 1 (2018) 70e73

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Laparoscopic management of an ectopic pregnancy after in vitro

fertilization and embryo transfer at CHRACERH: A case report

Belinga Etienne a, b gory a, *,
, Noa Ndoua Claude Cyrille a, Ayissi Gre
Kasia Onana Yves Bertrand a, Kasia Jean-Marie a, b
a
Department of Gynecology and Obstetrics, Faculty of Medicine and Biomedical Science, University of Yaounde I, Yaounde, Cameroon
b
Hospital Center for Research and Application in Endoscopic Surgery and Human Reproduction, Yaounde, Cameroon

a r t i c l e i n f o

Article history: We report a case of a laparoscopic management of an ectopic

Received 29 June 2018
Received in revised form
2 August 2018
Accepted 22 August 2018
Available online 10 September 2018
Keywords:
Ectopic pregnancy
Laparoscopic management
In vitro fertilization
Embryo transfer
1. Introduction
Initially, in vitro fertilization and embryo transfer (IVF-ET) was
designed to solve tubal factors infertility (TFI) by placing the em-
bryo(s) within the uterine cavity. However, in some cases, an
ectopic implantation occurs as the embryo can enter the tube.
Ectopic pregnancy (EP) is the location of the pregnancy outside the
intrauterine cavity. The prevalence of EP following assisted repro-
ductive technology (ART) ranges between 2.1% and 8.6% of all
pregnancies and it can reach up to 11% in women with tubal factors
infertility history.1
Following IVF-ET, either the infertility history of the patient or
specific factors related to IVF-ET techniques, including high volume
of transfer media, multiple embryo transfer, and controlled ovarian
stimulation (COS) can increase the risk of EP.2
It is a tragic even in a woman's reproductive life, especially after
suffering a long and difficult course of treatment for infertility. It
can be treated surgically, medically and occasionally by observation
alone. However, the use of conservative approaches necessitates
early diagnosis of EP.3
* Corresponding author: Department of Gynecology and Obstetrics, Faculty of
Medicine and Biomedical Sciences, University of Yaounde  I, Yaounde, Cameroon.
gory).
E-mail address: ayissigregory@yahoo.fr (A. Gre
pregnancy after IVF-ET in Cameroon, at the Hospital Center for
Research and Application in Endoscopic Surgery and Human
Reproduction (CHRACERH) in which we discuss the etiologic factors.
2. Case presentation
A 34-year-old patient Gravida 1 Para 1 010, with a past history of
one spontaneous miscarriage, and laparotomy indicated for ovarian
cyst nine years ago, followed-up at CHRACERH since 2 years, for
couple infertility of mixed origin evolving since 12 years; with tubal
factors infertility (bilateral hydrosalpinx), a low ovarian reserve
(AMH: 0.98 ng/L) and severe oligoasthenospermia in the husband.
The infectious assessment showed a polymicrobial pelvic infection
with Chlamydia trachomatis, Mycoplasma hominis and Gardenella
vaginalis, for which a treatment of the couple with josamycin,
metronidazol and secnidazol was done. She underwent a diag-
nostic laparoscopy prior to the in vitro fertilization (IVF) where a
pelvic adhesiolysis and a simple opening of the hydrosalpinx were
done. She was admitted in IVF and stimulated by the long agonist
protocol. Twelve oocytes were retrieved and 3 embryos implanted
on the July 8, 2017. A quantitative hCG test was positive seven days
post implantation and she was hospitalized for the monitoring of
the post IVF pregnancy, and put under B9 vitamin and injectable
progesterone. At day 18 post implantation, an endovaginal ultra-
sound didn't find a gestational sac inside the uterus. At day 22 post
implantation, the onset of breakthrough bleeding associated with a
pain in the left iliac fossa, motivated the request of an endovaginal
ultrasound, which showed an unruptured ectopic pregnancy in the
left fallopian tube (Fig. 1). The management consisted on a lapa-
roscopic treatment. The findings were: a left fissured ampullary
ectopic pregnancy (Fig. 2); a moderate right hydrosapinx and pelvic
adhesions (Fig. 3); numerous endometrial implants in the pelvis,
which was the evidence of an ectopic endometriosis (Fig. 4). Pelvic
adhesiolysis (Fig. 5), retrograde left salpingectomy (Fig. 6) and right
tubal exclusion (Fig. 7) were performed to avoid the risk of ectopic
pregnancy on it. The pathologic examination of the excised tubal
stump reveal trophoblasic tissues. The postoperative course was
uneventful.

https://doi.org/10.1016/j.lers.2018.08.001
2468-9009/Crown Copyright © 2018 Published by Elsevier B.V. on behalf of Sir Run Run Shaw Hospital affiliated to Zhejiang University School of Medicine. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 
B. Etienne et al. / Laparoscopic, Endoscopic and Robotic Surgery 1 (2018) 70e73 71

Fig. 1 Echographic aspects of the tubal EP.

Fig. 2 Left ampullary EP. Fig. 3 Pelvic adhesions.

72 
B. Etienne et al. / Laparoscopic, Endoscopic and Robotic Surgery 1 (2018) 70e73

Fig. 7 Right tubal exclusion.

Fig. 4 Pelvic endometrial implants.

3. Discussion

Ectopic pregnancy is a dramatic life threatening event in a

woman reproductive life, especially after a long, expensive and
difficult course of treatment for infertility. The prevalence of EP
pregnancy after IVF in Cameroon remains unknown, but Nigeria
Okohue et al have found a prevalence of 7.8% after IVF,4 while in
general population in the same country, EP rate was 1.74%.8 These
data obtained from an African population close to the cameroonian
one, follow the global trend that says that EP accounts around
1%e2% of all natural conceptions, and this prevalence increases
following assisted reproductive techniques, to range between 2.1%
and 8.6%.1
In this case, the patient had major risk factors for ectopic
pregnancy, related both to the history of infertility and IVF-ET.
Indeed she had a past history of pelvic inflammatory disease
(PID) at Chlamydia trachomatis. PID is the most common sexually
transmitted infection worldwide,5 and the immune response to PID
could result in tubal occlusion, EP and infertility.6,7
Our patient had a secondary reconstitution of the hydrosalpinx
playing a significant role in the occurrence of ectopic pregnancy in
our case. Indeed, in IVF-ET, the detrimental effects of hydrosalpinx
Fig. 5 Adhesiolysis.
may be due to its mechanical effects, embryo and gametotoxicity,

Fig. 6 Left salpingectomy.

 
B. Etienne et al. / Laparoscopic, Endoscopic and Robotic Surgery 1 (2018) 70e73
alterations of the expressions of molecules that normally inhibit the
blastocyst implantation in fallopian tube, and in endometrial
receptivity markers leading to EP.8 In cases of tubal infertility with
and without hydrosalpinx, a meta-analysis about pregnancy rates
after IVF done by Camus et al. showed that, the presence of
hydrosalpinx could obviously lower pregnancy rates: in group
without hydrosalpinx, the tubal sterility is 31.2%, while in the group
with hydrosalpinx, that rate is 19.7% (OR: 0.64; 95% CI: 0.56e0.74).9
Similarly, in the group with hydrosalpinx, the implantation rate and
the delivery rate per transfer were only around 60% of those in the
group without hydrosalpinx (implantation: 8.5% and 13.7%,
respectively; delivery: 13.4% and 23.4%). The higher incidence of
early pregnancy loss could also be observed in the hydrosalpinx
group (43.7% vs 31.1% in the control group). Thus clearly confirming
negatives effects of hydrosalpinx in IVF-ET pregnancies.9
The COS which is a cause of increase or recurrence of hydro-
salpinx in IVF-ET may also have played a crucial role in the occur-
rence of the ectopic pregnancy. The alteration in the endocrine
milieu in the stimulated/fresh cycle following COS, may be a po-
tential risk factor for the development of EP during IVF-ET. Shao
et al have shown that higher circulating concentrations of oestra-
diol (E2) during stimulated cycles, could be associated with a
reverse migratory process of the transferred embryo(s).10 These
data were supported by Wang et al who showed that COS in pa-
tients with polycystic ovarian syndrome (PCOS) was related to a
higher risk rate of EP in fresh cycles (AOR 3.06; 95% CI: 1.34e6.96)
but not with frozen-thawed embryo transfer cycles.11 In further
analysis of the cases of EP in the non-PCOS patients, women with E2
levels > 4085 pg/mL had double greater risk of developing EP (95%
CI: 1.19e3.35). Hence, it was suggested that the observed higher
prevalence of EP during COS could be associated with the hyper-
physiologic levels of E2 related to PCOS and/or ovulation induc-
tion.11 The endometriosis discovered at laparoscopy, multiple
embryos transfer, and the transfer technique used are all major risk
factors that may have played a role in the occurrence of ectopic
pregnancy in our case.1
Surgery, medicine or occasional observation could treat EP. The
traditional treatment for tubal pregnancy is laparotomy and sal-
pingectomy. But laparoscopy has been widely used since the last
two decades. Several studies reported the successful laparoscopic
management of ectopic pregnancies12e14 but none were from
Central Africa, particularly in Cameroon. In our case we did a
retrograde salpingectomy with a contralateral tubal exclusion to
avoid risk of interstitial pregnancy,15 and because the woman wants
to attempt another IVF-ET. As the shorter postoperative recovery
time and lower morbidity, laparoscopic surgery is the preferred
approach in haemodynamically stable patients and has largely
replaced the need for laparotomy due to shorter postoperative re-
covery time and lower morbidity. However, persistent tropho-
blastic tissues is more common with salpingostomy with a relative
risk of 15 (95% CI: 2.0e113.4) for persistence.16,17
4. Conclusion
We reported a successful laparoscopic management of an
ampullary pregnancy following IVF-ET at CHRACERH. It appears
73
that, patients with a history of tubal infertility should be given
special attention in IVF-ET, because IVF-ET itself leads to an increase
in the risk of ectopic pregnancy. The condition for laparoscopic
treatment is early diagnosis of ectopic pregnancies thanks to ul-
trasound and hCG. However, the risk of persistence of trophoblastic
tissues and ectopic pregnancy remains significant in the conser-
vatory approach.
Acknowledgments
The authors would like to thank Professor Jean-Marie Kasia,
Administrator and General Manager of CHRACERH; Head of the
Department of Obstetrics and Gynecology at the Faculty of Medi-
cine and Biomedical Sciences of the University of Yaounde I (FMSB)
for the educational and human support.
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