To the Editor:
We thank Cepni et al. for sharing their recent case series, “An alternative treatment option in tubal ectopic pregnancies with fetal heartbeat: aspiration of the embryo followed by single-dose methotrexate administration” (1). This was of great interest to us, as we have used a similar aspiration and instillation technique using hyperosmolar glucose to treat a heterotopic pregnancy created after in vitro fertilization (IVF).
Our patient was a 29-year-old nulligravida with longstanding infertility and a history of stage IV endometriosis and severe pelvic adhesive disease. She underwent IVF with a transfer of 2 blastocysts. She presented 20 days after transfer (5+4 weeks estimated gestational age) for ultrasound and was diagnosed with a heterotopic pregnancy. Options including surgical intervention, systemic methotrexate, and adnexal aspiration with instillation of hyperosmolar glucose and/or methotrexate were discussed. The patient strongly desired to preserve the intrauterine pregnancy and wished to avoid surgical intervention. We performed transvaginal ultrasound-guided aspiration of the ectopic gestational sac, followed by instillation of hyperosmolar (50%) glucose. Pathology revealed fetal tissue within the aspirated material. The patient tolerated the procedure well and delivered a term infant via cesarean section.
Aspiration of an ectopic pregnancy with instillation of hyperosmolar glucose has rarely been reported (2), but it appears to be an effective treatment modality for a select group of patients with early heterotopic or possibly even ectopic pregnancies. Particularly in cases of heterotopic pregnancy – where patients may be anxious to minimize any possible risk to the intrauterine pregnancy – aspiration and local instillation of hyperosmolar glucose may be an attractive therapeutic option.
Nanette L. Rollene, M.D.
Division of Reproductive Endocrinology
Naval Medical Center
Jani R. Jensen, M.D.
Reproductive Endocrinology and Infertility
1. Cepni I, et al. An alternative treatment option in tubal ectopic pregnancies with fetal heartbeat: aspiration of the embryo followed by a single-dose methotrexate administration. Fertil Steril 2011;96:79-83.
2. Goldberg JM, Bedaiwy MA. Transvaginal local injection of hyperosmolar glucose for the treatment of heterotopic pregnancies. Obstet Gynecol 2006;107(2 Pt 2):509-10.
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.09.027
The Authors Respond:
We are pleased to hear that Rollene and Jensen treated a heterotopic pregnancy without the need for salpingostomy or salpingotomy. We had a similar patient who had tubal heterotopic pregnancy (HP) treated conservatively with transvaginal ultrasound-guided aspiration of the fluid in the gestational sac and instillation of hyperosmolar glucose (1). According to the preliminary data of our unpublished studies aspiration of fetal tissues give better results than aspiration and instillation of only the fluid. Aspiration of fetal tissues may seem difficult although it is not much different than oocyte pick-up procedure. The most important limitation of our technique is ectopic gestations older than 8 weeks where ossification begins, since the ossified structures may obstruct the aspiration needle and the operation would probably be ineffective. However, considering that ectopic pregnancies are mostly diagnosed around 6 to 8 weeks, our technique has a wide array of usages.
The use of hyperosmolar glucose may be safer than methotrexate (MTX) since MTX may have some adverse effects. If used in combination with aspiration of the fetal tissues, hyperosmolar glucose may eliminate the need for MTX even in non-heterotopic cases. However the success of the two methods should be compared in further studies.
Onur Guralp, M.D.
Hazel Gurleyen, M.D.
Ismail Cepni, M.D.
Department of Obstetrics and Gynecology
Cerrahpasa School of Medicine
1. Ocal P, Erkan S, Cepni I, Idil MH. Transvaginal ultrasound-guided aspiration and instillation of hyperosmolar glucose for treatment of unruptured tubal heterotopic pregnancy. Arch Gynecol Obstet. 2007 Sep;276(3):281-3.
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.09.026