Case report

A 27 year old woman was treated at Furness General Hospital fertility clinic since three years when she presented with four years history of primary infertility. She was diagnosed to have bilateral hydrosalpinx at laparoscopy, which was treated by bilateral fimbrial salpingostomy together with adhesiolysis for pelvic adhesions. Dye test confirmed bilateral tubal patency. Patient had ovulatory progesterone and partner had a normal seminal analysis. She had 12 cycles of controlled ovulation induction and 3 stimulated intrauterine insemination (IUI) cycles all of which were not successful. She was referred for IVF/ET, before which bilateral laparoscopic salpingectomy for small bilateral hydrosalpinges was carried out to improve her chances of implantation at IVF.

She presented to Furness General Hospital with lower abdominal pain over the last 2 days. She denied orthostatic symptoms. Four weeks earlier she had undergone the first IVF/ET cycle, during which time she had 2 embryos transferred into her uterus. The patient was normotensive and on pelvic examination she had a slightly enlarged uterus with a closed cervix and a tender right adnexum. Her haemoglobin concentration was 10 g/dL. Serum B human chorionic gonadotropin (BhCG) was 9612 IU/L, scan suspected a right cornual ectopic pregnancy with empty uterine cavity, 1.7×2 cm eccentric mixed echogenic shadow on the right cornu and mild pelvic collection.

Arrangements were made for emergency laparoscopy and possible laparotomy. Four units of blood were prepared. Laparoscopy confirmed an intact right cornual ectopic pregnancy sac protruding through a dehiscent right cornu together with 200 ml of blood in the pouch of Douglas (Figure 1).

Figure 1

Figure 1: Intact right cornual gestation sac protruding through a dehiscent right uterine cornu seen at laparoscopy.

Ectopic sac was pulled gently with a grasping forceps and the bleeding area of the myometrium was coagulated using bipolar diathermy forceps. Haemostasis was secured. 72 mg of systemic methotrexate was given. Her postoperative course was uncomplicated. She was discharged home four days later. BhCG was repeated which dropped back to normal after 2 weeks. Histopathology confirmed cornual ectopic pregnancy.

Discussion

A cornual gestation is one of the most hazardous types of ectopic gestation with high mortality. Cornual ectopic pregnancy is difficult to diagnose and management options are always challenging. IVF/ET post bilateral salpingectomy can predispose to interstitial or cornual pregnancy ₅.

This patient had laparoscopic bilateral fimbrial salpingostomies for bilateral small hydrosalpinges to increase her chances of conception with controlled ovulation induction and IUI. Aboulghar et al reported that in selected cases of small thin walled hydrosalpinges with healthy mucosa, good results can be achieved by fimbrial salpingostomy or fimbrioplasty performed by experienced surgeon ₆. Unfortunately this patient failed to conceive with the above assisted reproductive treatment and she was referred for IVF.

She had laparoscopic bilateral salpingectomy prior to IVF to increase her chances of pregnancy. Murray et al reported that the presence of hydrosalpinx during an IVF/ET cycle results in significant decrease in implantation rates and pregnancy rate₇. Surgical treatment of hydrosalpinges before IVF/ET cycles improves implantation rates.

Both surgical and medical treatments for cornual gestation exist, each is not without its shortcomings. Medical treatment is associated with failure rates that may result in uterine rupture and catastrophic haemorrhage. Surgical treatment that involves hysterectomy causes a loss of future childbearing capability. Surgical treatment that involves resection of the involved cornual region is associated with decreased fertility rates and increased rates of uterine rupture in future pregnancies ₈.

Different modalities of surgical intervention for cornual gestation were reported in the literature . Laparotomy with cornual resection was traditionally performed in ruptured corunal pregnancy when the patient is haemodynamically unstable. Recently, more conservative operations have been developed, and operative laparoscopy had provided yet another management option. Grobman & Milad had treated a case of a large cornual ectopic pregnancy by conservative laparoscopy₉. However, Morita et al reported a case of cornual pregnancy successfully treated laparoscopically with fibrin glue haemostasis after coagulation of the bleeding area of the myometrium with bipolar diathermy₁₀. Laparoscopic cornuostomy and cornual resection were reported previously for the treatment of interstitial ectopic pregnancy ₁₁,₁₂. Laparoscopic and ultrasound-guided transcervical evacuation of cornual ectopic pregnancy was also ₁₃.

Combined laparoscopy and dilatation and evacuation together with post operative methotrexate injection used to treat cornual pregnancy was reported by Ross et al ₈. We treated this patient conservatively by laparoscopy to avoid any possible future compromise to her reproductive function.

We combined the conservative laparoscopic approach with systemic methotrexate, thinking that some of the trophoblast might still be in the cornu due to the high primary BhCG. However, follow up was essential in this case in order to make sure that the BhCG was declining. Even intrauterine pregnancy post bilateral salpingectomy is at risk of bilateral cornual uterine dehiscence which indicates that bilateral salpingectomy is not an entirely safe procedure ₁₄.

Up to our knowledge, this case of intact cornual ectopic sac with cornual dehiscence conceived by IVF/ET post bilateral salpingecomy, treated by combined conservative laparoscopic approach and systemic methotrexate is the first case reported in the literature. We concluded that bilateral salpingectomy for hydrosalpinges prior to IVF, is not an entirely safe procedure. Close monitoring of pregnancies conceived by IVF/ET following bilateral salpingectomy is essential to prevent a deleterious delay in treatment of a cornual pregnancy. Combined conservative laparoscopic approach together with systemic methotrexate for an intact cornual ectopic sac, can be a good treatment option for women who wish to preserve fertility.

Currently there is insufficient evidence to recommend any single treatment modality for cornual gestation, and the decision should be based on such factors as clinical presentation, surgeon's expertise, side effects, overall cost and patient's preference.

Correspondence to

Dr. Shamma Al Inizi, 10 Bracken Close, Sale, Cheshire M33 5EX UK Tel +447821708743 Email address: shammainizi@hotmail.com