Ovarian Ectopic Pregnancy: A Case Report

Fertility management including Assisted Reproductive Technology is a well-recognized risk factor for Ectopic pregnancy. Ovarian pregnancy is a very rare complication of both spontaneous and ART-induced pregnancies. The incidence of spontaneous primary ovarian pregnancy ranges from 1:7000 to 1:40,000 pregnancies accounting for 0.5 % - 3.6 % of all ectopic pregnancies [1,2] . General risk factors of ovarian ectopic pregnancy are tubal pathology, previous gynecologic surgery, pelvic inflammatory diseases

-A 31 years old lady, known to have Primary male factor infertility for 18 years. The couple had multiple cycles of ICSI/ IVF with no resultant pregnancy.
-She was not having any medical or surgical history, but she had a BMI of 37(obesity class ii).
-she did not have any previous history of PID, Tubal Surgery, and Ovarian Surgery. -27 eggs were retrieved, 21 were injected with sperm, and out of them three were fertilized with intra-cytoplasmic sperm injection; 2 grade one blastocysts developed (4 cell stage) which were transferred intrauterine on day 5. Progesterone support is used for the luteal phase. -Intra Operatively Uterus was Grossly normal and blood & clots were filling the Pouch of Douglas and the lower part of the pelvis. Both tubes were identified and found normal. The right ovary was normal although the left ovary was seen with ruptured ectopic pregnancy.
Ectopic pregnancy was removed with hydro dissection and tractioncounter traction technique with ovarian tissue preservation.
Hemostasis was secured.

Abstract
Fertility management including Assisted Reproductive Technology is a well-recognized risk factor for Ectopic pregnancy. Ovarian pregnancy is a very rare complication of both spontaneous and ART-induced pregnancies. The incidence of spontaneous primary ovarian pregnancy ranges from 1:7000 to 1:40,000 pregnancies accounting for 0.5 % -3.6 % of all ectopic pregnancies [1,2]. General risk factors of ovarian ectopic pregnancy are tubal pathology, previous gynecologic surgery, pelvic inflammatory diseases, and Intrauterine contraceptive device use.
Laparoscopic management with resection of ovarian pregnancy while preserving ovarian tissue is considered the gold standard treatment; however, successful medical management with methotrexate has been reported14

Discussion
Ovarian pregnancy is a rare variant of non-tubal ectopic pregnancy which can be either spontaneous or ART-induced. (1) One study among IVF patients showed a higher frequency of ovarian pregnancy comprising 4.5 %-6 % of Ectopic pregnancies, However, there may be a detection bias since IVF pregnancies are usually monitored earlier and more carefully than natural pregnancies; and therefore, short-lived IVF-induced ovarian pregnancies have a higher likelihood of being detected.
The mechanisms behind ovarian pregnancy are not completely understood; however, can be classified as primary and secondary. In Regarding the symptoms of Ovarian pregnancy, it is usually similar to tubal pregnancy symptoms like abdominal pain, vaginal bleeding, and delayed menses; however asymptomatic ovarian pregnancies have been described in the literature. [6] the diagnostic criteria for ovarian pregnancy have been established by A german gynecologist. the criteria depend on the intraoperative findings: (1) the gestational sac is in the same position as the ovary.
(2) the ovary is connected to the uterus by the utero-ovarian ligament.
(3) intact fallopian tube on the ipsilateral side.
(4) the ovarian tissue is present in the wall of the gestational sac. Some study results showed more ectopic pregnancies among patients with peak serum estradiol concentration exceeding 4085 pg./mL (15,000 pmol/L) [10] A possible mechanism for the effect of high estradiol level is provided by the following observations: it affects the normal physiology of the fallopian tube including impaired protein secretion, ciliary motion frequency, embryonic motility, and implantation, which increased the likelihood of extrauterine implantation.
Oliveira et al 18 described a possible association between blastocyst transfer and intraovarian implantation, as they had no cases of ovarian pregnancies following the transfer of embryos on days 2nd and 3rd.

[11]
By ultrasonography, the ovarian Ectopic Pregnancy mimics corpus luteum, hemorrhagic cyst, and endometriotic cyst of the ovary which delay the diagnosis of ovarian pregnancy, as serum βhCG level and imaging are of limited contribution to the diagnosis of ovarian pregnancy. The American Society for Reproductive Medicine recommends a surgical intervention in any case of suspected ovarian pregnancy, which may begin as explorative laparoscopy for suspected extra-uterine pregnancy.
If ovarian ectopic has been diagnosed the management may include salpingo-oophorectomy, oophorectomy, wedge resection, and removal of gestational product with ovarian tissue preservation.
Laparoscopic management with resection of ovarian gestation and preservation of ovarian tissue is considered the gold standard treatment; however medical management with methotrexate has been reported. [12] the use of MTX to treat ovarian pregnancy is not as well established,

Conclusion
Ovarian ectopic pregnancy poses an ethical and diagnostic dilemma because of the scarcity of clinical presentation and diagnosis. As most of the patients are presenting and diagnosed late, Methotrexate will not be a viable treatment option in most of these cases, therefore Surgical management and removal of the Ectopic is the gold standard modality where experts are available.

Ethical approval:
We obtained permission &amp; a consent from the patients to publish this report with the pictures anonymously and ethical approval was granted by the Ethics Committee of the hospitals.