,......
FERTILITY AND STERILITY Copyright © 1979 The American Fertility Society
Vol. 32, No, 1, July 1979 Printed in U.SA.
THE INTRAUTERINE DEVICE AND OVARIAN PREGNANCY
MARK I. EVANS, M.D.* NEIL S. ANGERMAN, M.D., PH.D. WILLIAM D. MORAVEC, M.D. SAMIR N. HAJJ, M.D., F.A.C.O.G.
Department of Obstetrics and Gynecology, The University of Chicago Pritzker School of Medicine, The Chicago Lying-In Hospital, Chicago, Illinois 60637
Within a I-year period, three patients presenting to the University of Chicago, Chicago Lying-In Hospital with a complaint of lower abdominal pain were diagnosed at laparotomy to have ovarian pregnancies according to the criteria of Spiegelberg. All of the patients were at the time using the Copper-7 intrauterine device for contraception. There are now 50 known cases of ovarian pregnancies in patients using the intrauterine device (IUD). The characteristics of these patients do not differ markedly from those previously reported in studies on tubal pregnancies, with and without the IUD, but the presentation of patients tends to be more variable than in tubal pregnancies. The increasing incidence noted here, in a population already known to be particularly prone to pelvic inflammatory disease and therefore ectopic pregnancies in general, lends further credence to a questioning of the desirability of the IUD in such a population. Fertil Steril32:31, 1979
In recent years reports of primary ovarian pregnancy have become more numerous. Most estimates have placed the incidence at about 1125,000 to 1140,000 of all pregnancies and approximately 1% of ectopic gestations. l With increasing utilization ofthe intrauterine device (IUD) for contraception, much interest has also been focused on patients who become pregnant while using the IUD.2 Several authors have suggested that the IUD, while being adequately effective against intrauterine pregnancy, is of questionable efficacy in preventing ectopic pregnancy in general and perhaps ovarian pregnancy in particular. l - 4 The criteria for the diagnosis of ovarian pregnancy were set forth in 1878 by Spiegelberg.5 Although the criteria have been modified throughout the years, they do provide a basis for establishing
the diagnosis. They are as follows: (1) the fallopian tube on the affected side must be normal with no evidence of gestation in it; (2) the gestational sac must occupy the normal position of the ovary; (3) the sac must be connected to the uterus by the ovarian ligament; and (4) ovarian tissue must be histologically demonstrable in the wall ofthe sac. This report describes three patients in whom ovarian pregnancy was diagnosed according to the criteria of Spiegelberg. All were treated at the University of Chicago, Chicago Lying-In Hospital within 1 year (1977) and had an IUD in place at the time of conception. The characteristics of these pregnancies are compared with those of other published cases. CASE REPORTS
Patient 1
Received December 26, 1978; revised February 8, 1979; accepted February 21, 1979. *Reprint requests: Mark I. Evans, M.D., Department of Obstetrics and Gynecology, The University of Chicago Pri tzker School of Medicine, 5841 South Maryland Avenue, Chicago, Ill. 60637.
B. W. was an 18-year-old gravida 1, para 0 black female who was seen for lower abdominal pain of 1 day's duration. History of Present Illness. The patient's last
31
32
EVANS ETAL.
normal menstrual period had occurred on January 10, 1977. She underwent a suction abortion on February 10, 1977. At the same time a Copper-7 IUD was removed which had been in situ for 1 year. She was asymptomatic until the day of admission (March 17, 1977), when she experienced bilateral lower abdominal pain. The past medical history was noncontributory. Physical Examination. The patient was a welldeveloped female in moderate abdominal distress. Blood pressure was 112170 lying, 90/60 sitting. Pulse was 116 lying, 150 sitting. Her temperature was 37.3° C. Results of the cardiovascular and chest examinations were normal. The abdomen showed diffuse lower abdominal tenderness with guarding and rebound tenderness. Pelvic examination revealed a normal-sized uterus with marked bilateral adnexal tenderness. Culdocentesis yielded unclotted blood. Laboratory Data. The white blood count was 8.4 x 10 3 /cu mm; hemoglobin, 13.0 gm/100 ml; hematocrit, 39.1%. Electrolytes, kidney, and liver function tests were within normal limits. A chest x-ray was normal. Hospital Course. At laparotomy, approximately 400 ml of blood were found in the abdomen along with what was thought to be a right ruptured corpus luteum. The uterus and both fallopian tubes were normal. A right ovarian wedge resection was performed. The patient had an unremarkable postoperative course. Pathologic Findings. The operative specimen revealed a ruptured right ovarian ectopic pregnancy.
Patient 2 M. L. was a 35-year-old gravida 2, para 2 white female who was seen for lower abdominal pain of 2 weeks' duration. History of Present Illness. The patient's last normal menstrual period had occurred on May 14, 1977. A menstrual period in the middle of June 1977 consisted of spotting for 2 weeks. Three weeks prior to admission (on July 10, 1977), she developed lower abdominal pain, predominantly on the left side. She was treated with Keflex for pelvic infection. A Copper-7 IUD was in place. This form of contraception had been used for 4 years, being changed at 2-year intervals. The IUD was removed when the local physician detected a leftsided pelvic mass. The patient was referred to the university center where the pelvic mass was
July 1979 confirmed. The past medical history was noncontributory. Physical Examination. The patient was a welldeveloped and well-nourished female in mild distress with lower abdominal pain. Blood pressure was 130/80; pulse, 90; respiration, 20. Her temperature was 37° C. The heart and lungs were unremarkable. The abdomen was tender to deep palpation in the lower quadrants, especially the left. No rebound tenderness was elicited. Pelvic examination revealed a normal-sized uterus; a tender, 10-cm left adnexal mass was present. The right adnexum was unremarkable. LaboratoryData. The white blood count was 11.3 x 103 /cu mm; hemoglobin, 12.0 gm/100 ml; hematocrit, 35.6%. Electrolytes, kidney, and liver function tests were within normal limits. A chest x-ray and electrocardiogram were normal. Hospital Course. At laparotomy the uterus was unremarkable, as were the tubes. The left ovary was replaced by a bluish cystic mass nearly 8 cm in diameter. The right ovary contained a hemorrhagic corpus luteum cyst. A total abdominal hysterectomy, left salpingo-oophorectomy, and right ovarian cystectomy were performed. The patient did well postoperatively. Pathologic Findings. The operative specimens revealed a left ovarian pregnancy with degenerated cystic corpus luteum. The right ovary contained a hemorhagic corpus luteum cyst (Fig. 1).
Patient 3 M. M. was a 22-year-old gravida 1, para 0 white female who was seen for lower abdominal pain of 2lh months' duration. History of Present Illness. The patient's last normal menstrual period had occurred on September 17, 1977. She had experienced spotting on October 15, 1977. She was seen for lower abdominal pain at the end of October and was told she had an infected uterus. A Copper-7 IUD which had been in situ for 1 year was removed, and she was treated with tetracycline. She continued to have lower abdominal pain and had a very heavy 5-day menstrual period starting on November 13, 1977. She was seen by a different physician at the end of November and was found to have a 4 x 5 cm tender left adnexal mass. A pregnancy test was positive. She was hospitalized, and a diagnostic laparotomy revealed a 4 x 5 cm hemorrhagic left ovarian cyst with no blood in the abdomen or any other abnormal findings. Dilatation and curettage was productive of scant tissue and interpreted as an
r-
-----~---------~~~
Vol. 32, No.1
THE INTRAUTERINE DEVICE AND OVARIAN PREGNANCY
33
FIG. 1. Representative section from a patient with an ovarian pregnancy. CL, Corpus luteum; TB, trophoblastic tissue.
Arias-Stella reaction. The patient continued to have lower abdominal pain with an enlarging left adnexal mass that persisted throughout late December 1977. The patient was readmitted to the hospital for definitive treatment. The past medical history was noncontributory. Physical Examination. The patient was a welldeveloped female in no apparent distress. Blood pressure was 100/60; pulse, 82; respiration, 18. Her temperature was 36.6° C. Results of the cardiovascular and chest examinations were normal. The abdomen was tender in the left lower quadrant with fullness in the suprapubic area. There was no rebound tenderness. An 8-cm left adnexal mass was present. Laboratory Data. The white blood count was 8.9 x 10 3 /cu mm; hemoglobin, 13.0 gm/100 ml; hematocrit, 38%. Electrolytes, kidney and liver function tests, and clotting studies were within normal limits. A chest x-ray and electrocardiogram were normal. Hospital Course. At surgical exploration the uterus and tubes were noted to be normal. The right ovary was unremarkable; the left ovary contained a hemorrhagic cyst nearly 7 cm in diameter. A left ovarian cystectomy and incidental appendectomy were performed. The patient had an unremarkable postoperative course. Pathologic Findings. The operative specimen
revealed an ovarian pregnancy and corpus luteum of the left ovary. DISCUSSION
Recently published statistics have suggested that IUDs are extremely effective in preventing intrauterine implantation of embryos but may not influence in any dramatic way the likelihood of implanted ectopic gestation as compared with those women using no contraception. 2 , 6, 7 It has been proposed that the IUD acts as a foreign body in the uterus, causing enzymatic changes in the endometrium that may prevent implantation. 2 However, such an alteration may not extend through the fallopian tubes or to the ovaries. A proportional increase in the incidence of ectopic pregnancies in IUD failures could thus be predicted in view of the reduction in the incidence of intrauterine pregnancies. Within 8 years prior to 1977, only two ovarian pregnancies were seen at the Chicago Lying-In Hospital. Neither patient was using contraception. During the same period 3.9% of all ectopic pregnancies occurred in patients using an IUD.8 More recent surveys have found as much as a 21% association,9 and it appears that the IUD cannot prevent ectopic pregnancy.2, 6, 7 ~ Three of the fifty known cases of ovarian pregnancy with the IUD (6%) have been treated at a
l
EVANS ET AL.
34
July 1979
TABLE 1. Comparison of Data in IUD-Related Ovarian and Tubal Pregnancies and Non-IUD Ectopic Pregnancies Hallatt' Without IUD
Mean age % Nulliparous % Primiparous
Duration of usage Less than 1 yr 1-2 yr 2-3yr More than 3 yr Prior abortions Abdominal pain Vaginal bleeding
With IUD
30.2 30
28.5 11
35%
34.3% 31.4% 1O.(}% 24.3% 31.(}%
single hospital within 1 year (data and references are available from author). Pelvic inflammatory disease is common in the population of the Chicago Lying-In Hospital, and pelvic inflammatory disease with the IUD may predispose to ovarian ectopic pregnancy even without the IUD.lO All of the patients treated at the Chicago Lying-In Hospital were using the Cu-7. Laufer et al.,9 Berger and Blechner,11 and Gray and Ruffalo 12 have recently reported similar experiences with Cu-7 IUDs. The vast majority of cases in the literature have involved patients using the Lippes Loop. When experience with the Cu-7 increases, however, there may be no differences. The proportions generally seem to correspond with the frequency of use of the type of IUD in the general population. There appear to be no major differences in several parameters for these patients as compared with a very large series of ectopic pregnancies, with and without IUDs, seen at the University of Southern California and previous experience at the University of Chicago (Table 1).7,8 It is of interest that in the first two series, nearly one-third of the patients had undergone prior abortions (16.7% in this series) and that other indices related to duration of use and parity among the groups were comparable (X- not significant). Two factors do seem to be particularly consistent with IUD-associated ovarian pregnancy. Abdominal pain was the major presenting symptom in 95.3% of patients, and pregnancy teets, when done with even fairly crude techniques, were also positive in 87% of patients. The high incidence of positive pregnancy tests may reflect a greater ability of the ovary to incorporate trophoblastic tissue in comparison with the fallopian tube. In the previous series of ectopic gestations at the Chicago Lying-In Hospital, 73.5% of patients had a positive pregnancy test by slide latex agglutination. s Pritchard and MacDonald,13 however, have stated.
Helvacioglu et al.·
This series (ovarian pregnancy with IUD)
28 25.0 31.7
34.9% 96.7%
26.3 18.8 18.8 34.8% 34.8% 21.7% 8.7% 16.7% 95.3% 47.fHo
that in general a positive test may be observed for tubal pregnancies in as few as 50% of patients. One particularly striking feature is the lack of amenorrhea in many of the patients. Nearly onehalf (46%) of the patients had no menstrual irregularities. Findings on pelvic examinations were also variable. Often a mass was felt in one adnexum which proved to be a cyst, and the pregnancy was implanted in the opposite ovary.14. 15 Interpretation of the data presented must necessarily be subjective, since no controls are available to compare the incidence of ovarian pregnancy and the IUD. However, it is known that populations in which there is a high incidence of pelvic inflammatory disease also have an increased risk of ectopic pregnancy.I6-1S The ovarian pregnancies reported here may reflect a predisposition of the population in addition to an increased likelihood of ectopic pregnancy with the IUD. The combination of these factors raises further questions about the desirability of the IUD as a means of contraception in such a population.
I
I,
I"
I
I \
REFERENCES 1. Lehfeldt H, Tietze C, Gorstein F: Ovarian pregnancy and the intrauterine contraceptive device. Am J Obstet Gynecol 108:1105, 1970 2. Perlmutter JF: Pregnancy and the IUD. J Reprod Med 20:133, 1978 3. Seward PN, Israel R, Ballard CA: Ectopic pregnancy and intrauterine contraception: a definitive relationship. Obstet Gynecol 40:214, 1972 4. Tatum HJ, Schmidt FH: Contraception and sterilization practices and extrauterine pregnancy: a realistic perspective. Fertil Steril 28:407, 1977 5. Spiegelberg 0: Zur casuistik den ovrialschwangenschaft. Arch Gynaekol 13:73, 1878 6. Beral V: An epidemiological study of recent trends in ectopic pregnancy. Br J Obstet Gynaecol 82:775,1975 7. Hallatt JG: Ectopic pregnancy associated with the intrauterine device: a study of seventy cases. Am J Obstet Gynecol 125:754, 1976
j
Vol. 32, No.1
THE INTRAUTERINE DEVICE AND OVARIAN PREGNANCY
8. Helvacioglu A, Long EM, Yang SL: Recent experience with ectopic pregnancy at Chicago Lying-In Hospital-an eight year review. J Reprod Med 22:87,1979 9. Laufer N, Zilberman R, Anteby SV: Ectopic pregnancy and intrauterine device. Harefuah 94:71, 1978 10. Haii SN: Does sterilization prevent pelvic infection? J Reprod Med 20:289, 1978 11. Berger B, Blechner IN: Ovarian pregnancy associated with Copper 7 intrauterine device. Obstet Gynecol 52:597, 1978 12. Gray CL, Ruffalo EH: Ovarian pregnancy associated with intrauterine contraceptive devices. Am J Obstet Gynecol 132:134, 1978 13. Pritchard JA, MacDonald PC: Williams Obstetrics, 15th Edition. New York, Appleton-Century-Crofts, 1976, p 440
35
14. Graff G, Lancet M, Czernobilsky B: Ovarian pregnancy with IUD's in situ. Obstet Gynecol 40:535, 1972 15. Varga L, Obolenski W, Scheidegger S: Ovarian pregnancy and the IUD, a case report. Int J Fertil 17:142, 1972 16. Westrom L, Bengtsson LP, Mardh PA: The risk of pelvic inflammatory disease in women using intrauterine contraceptive devices as compared to nonusers. Lancet 2:221, 1976 17. Eschenbach DA, Harnisch JP, Holmes KK: Pathogenesis of acute pelvic inflammatory disease: role of contraception and other risk factors. Am J Obstet GynecoI128:838, 1977 18. Ory HW: A review of the ,association between intrauterine devices and acute pelvic inflammatory disease. J Reprod Med 20:200, 1978
FERTILITY AND STERILITY Copyright © 1979 The American Fertility Society
Vol. 32, No, 1, July 1979 Printed in U.SA.
THE INTRAUTERINE DEVICE AND OVARIAN PREGNANCY
MARK I. EVANS, M.D.* NEIL S. ANGERMAN, M.D., PH.D. WILLIAM D. MORAVEC, M.D. SAMIR N. HAJJ, M.D., F.A.C.O.G.
Department of Obstetrics and Gynecology, The University of Chicago Pritzker School of Medicine, The Chicago Lying-In Hospital, Chicago, Illinois 60637
Within a I-year period, three patients presenting to the University of Chicago, Chicago Lying-In Hospital with a complaint of lower abdominal pain were diagnosed at laparotomy to have ovarian pregnancies according to the criteria of Spiegelberg. All of the patients were at the time using the Copper-7 intrauterine device for contraception. There are now 50 known cases of ovarian pregnancies in patients using the intrauterine device (IUD). The characteristics of these patients do not differ markedly from those previously reported in studies on tubal pregnancies, with and without the IUD, but the presentation of patients tends to be more variable than in tubal pregnancies. The increasing incidence noted here, in a population already known to be particularly prone to pelvic inflammatory disease and therefore ectopic pregnancies in general, lends further credence to a questioning of the desirability of the IUD in such a population. Fertil Steril32:31, 1979
In recent years reports of primary ovarian pregnancy have become more numerous. Most estimates have placed the incidence at about 1125,000 to 1140,000 of all pregnancies and approximately 1% of ectopic gestations. l With increasing utilization ofthe intrauterine device (IUD) for contraception, much interest has also been focused on patients who become pregnant while using the IUD.2 Several authors have suggested that the IUD, while being adequately effective against intrauterine pregnancy, is of questionable efficacy in preventing ectopic pregnancy in general and perhaps ovarian pregnancy in particular. l - 4 The criteria for the diagnosis of ovarian pregnancy were set forth in 1878 by Spiegelberg.5 Although the criteria have been modified throughout the years, they do provide a basis for establishing
the diagnosis. They are as follows: (1) the fallopian tube on the affected side must be normal with no evidence of gestation in it; (2) the gestational sac must occupy the normal position of the ovary; (3) the sac must be connected to the uterus by the ovarian ligament; and (4) ovarian tissue must be histologically demonstrable in the wall ofthe sac. This report describes three patients in whom ovarian pregnancy was diagnosed according to the criteria of Spiegelberg. All were treated at the University of Chicago, Chicago Lying-In Hospital within 1 year (1977) and had an IUD in place at the time of conception. The characteristics of these pregnancies are compared with those of other published cases. CASE REPORTS
Patient 1
Received December 26, 1978; revised February 8, 1979; accepted February 21, 1979. *Reprint requests: Mark I. Evans, M.D., Department of Obstetrics and Gynecology, The University of Chicago Pri tzker School of Medicine, 5841 South Maryland Avenue, Chicago, Ill. 60637.
B. W. was an 18-year-old gravida 1, para 0 black female who was seen for lower abdominal pain of 1 day's duration. History of Present Illness. The patient's last
31
32
EVANS ETAL.
normal menstrual period had occurred on January 10, 1977. She underwent a suction abortion on February 10, 1977. At the same time a Copper-7 IUD was removed which had been in situ for 1 year. She was asymptomatic until the day of admission (March 17, 1977), when she experienced bilateral lower abdominal pain. The past medical history was noncontributory. Physical Examination. The patient was a welldeveloped female in moderate abdominal distress. Blood pressure was 112170 lying, 90/60 sitting. Pulse was 116 lying, 150 sitting. Her temperature was 37.3° C. Results of the cardiovascular and chest examinations were normal. The abdomen showed diffuse lower abdominal tenderness with guarding and rebound tenderness. Pelvic examination revealed a normal-sized uterus with marked bilateral adnexal tenderness. Culdocentesis yielded unclotted blood. Laboratory Data. The white blood count was 8.4 x 10 3 /cu mm; hemoglobin, 13.0 gm/100 ml; hematocrit, 39.1%. Electrolytes, kidney, and liver function tests were within normal limits. A chest x-ray was normal. Hospital Course. At laparotomy, approximately 400 ml of blood were found in the abdomen along with what was thought to be a right ruptured corpus luteum. The uterus and both fallopian tubes were normal. A right ovarian wedge resection was performed. The patient had an unremarkable postoperative course. Pathologic Findings. The operative specimen revealed a ruptured right ovarian ectopic pregnancy.
Patient 2 M. L. was a 35-year-old gravida 2, para 2 white female who was seen for lower abdominal pain of 2 weeks' duration. History of Present Illness. The patient's last normal menstrual period had occurred on May 14, 1977. A menstrual period in the middle of June 1977 consisted of spotting for 2 weeks. Three weeks prior to admission (on July 10, 1977), she developed lower abdominal pain, predominantly on the left side. She was treated with Keflex for pelvic infection. A Copper-7 IUD was in place. This form of contraception had been used for 4 years, being changed at 2-year intervals. The IUD was removed when the local physician detected a leftsided pelvic mass. The patient was referred to the university center where the pelvic mass was
July 1979 confirmed. The past medical history was noncontributory. Physical Examination. The patient was a welldeveloped and well-nourished female in mild distress with lower abdominal pain. Blood pressure was 130/80; pulse, 90; respiration, 20. Her temperature was 37° C. The heart and lungs were unremarkable. The abdomen was tender to deep palpation in the lower quadrants, especially the left. No rebound tenderness was elicited. Pelvic examination revealed a normal-sized uterus; a tender, 10-cm left adnexal mass was present. The right adnexum was unremarkable. LaboratoryData. The white blood count was 11.3 x 103 /cu mm; hemoglobin, 12.0 gm/100 ml; hematocrit, 35.6%. Electrolytes, kidney, and liver function tests were within normal limits. A chest x-ray and electrocardiogram were normal. Hospital Course. At laparotomy the uterus was unremarkable, as were the tubes. The left ovary was replaced by a bluish cystic mass nearly 8 cm in diameter. The right ovary contained a hemorrhagic corpus luteum cyst. A total abdominal hysterectomy, left salpingo-oophorectomy, and right ovarian cystectomy were performed. The patient did well postoperatively. Pathologic Findings. The operative specimens revealed a left ovarian pregnancy with degenerated cystic corpus luteum. The right ovary contained a hemorhagic corpus luteum cyst (Fig. 1).
Patient 3 M. M. was a 22-year-old gravida 1, para 0 white female who was seen for lower abdominal pain of 2lh months' duration. History of Present Illness. The patient's last normal menstrual period had occurred on September 17, 1977. She had experienced spotting on October 15, 1977. She was seen for lower abdominal pain at the end of October and was told she had an infected uterus. A Copper-7 IUD which had been in situ for 1 year was removed, and she was treated with tetracycline. She continued to have lower abdominal pain and had a very heavy 5-day menstrual period starting on November 13, 1977. She was seen by a different physician at the end of November and was found to have a 4 x 5 cm tender left adnexal mass. A pregnancy test was positive. She was hospitalized, and a diagnostic laparotomy revealed a 4 x 5 cm hemorrhagic left ovarian cyst with no blood in the abdomen or any other abnormal findings. Dilatation and curettage was productive of scant tissue and interpreted as an
r-
-----~---------~~~
Vol. 32, No.1
THE INTRAUTERINE DEVICE AND OVARIAN PREGNANCY
33
FIG. 1. Representative section from a patient with an ovarian pregnancy. CL, Corpus luteum; TB, trophoblastic tissue.
Arias-Stella reaction. The patient continued to have lower abdominal pain with an enlarging left adnexal mass that persisted throughout late December 1977. The patient was readmitted to the hospital for definitive treatment. The past medical history was noncontributory. Physical Examination. The patient was a welldeveloped female in no apparent distress. Blood pressure was 100/60; pulse, 82; respiration, 18. Her temperature was 36.6° C. Results of the cardiovascular and chest examinations were normal. The abdomen was tender in the left lower quadrant with fullness in the suprapubic area. There was no rebound tenderness. An 8-cm left adnexal mass was present. Laboratory Data. The white blood count was 8.9 x 10 3 /cu mm; hemoglobin, 13.0 gm/100 ml; hematocrit, 38%. Electrolytes, kidney and liver function tests, and clotting studies were within normal limits. A chest x-ray and electrocardiogram were normal. Hospital Course. At surgical exploration the uterus and tubes were noted to be normal. The right ovary was unremarkable; the left ovary contained a hemorrhagic cyst nearly 7 cm in diameter. A left ovarian cystectomy and incidental appendectomy were performed. The patient had an unremarkable postoperative course. Pathologic Findings. The operative specimen
revealed an ovarian pregnancy and corpus luteum of the left ovary. DISCUSSION
Recently published statistics have suggested that IUDs are extremely effective in preventing intrauterine implantation of embryos but may not influence in any dramatic way the likelihood of implanted ectopic gestation as compared with those women using no contraception. 2 , 6, 7 It has been proposed that the IUD acts as a foreign body in the uterus, causing enzymatic changes in the endometrium that may prevent implantation. 2 However, such an alteration may not extend through the fallopian tubes or to the ovaries. A proportional increase in the incidence of ectopic pregnancies in IUD failures could thus be predicted in view of the reduction in the incidence of intrauterine pregnancies. Within 8 years prior to 1977, only two ovarian pregnancies were seen at the Chicago Lying-In Hospital. Neither patient was using contraception. During the same period 3.9% of all ectopic pregnancies occurred in patients using an IUD.8 More recent surveys have found as much as a 21% association,9 and it appears that the IUD cannot prevent ectopic pregnancy.2, 6, 7 ~ Three of the fifty known cases of ovarian pregnancy with the IUD (6%) have been treated at a
l
EVANS ET AL.
34
July 1979
TABLE 1. Comparison of Data in IUD-Related Ovarian and Tubal Pregnancies and Non-IUD Ectopic Pregnancies Hallatt' Without IUD
Mean age % Nulliparous % Primiparous
Duration of usage Less than 1 yr 1-2 yr 2-3yr More than 3 yr Prior abortions Abdominal pain Vaginal bleeding
With IUD
30.2 30
28.5 11
35%
34.3% 31.4% 1O.(}% 24.3% 31.(}%
single hospital within 1 year (data and references are available from author). Pelvic inflammatory disease is common in the population of the Chicago Lying-In Hospital, and pelvic inflammatory disease with the IUD may predispose to ovarian ectopic pregnancy even without the IUD.lO All of the patients treated at the Chicago Lying-In Hospital were using the Cu-7. Laufer et al.,9 Berger and Blechner,11 and Gray and Ruffalo 12 have recently reported similar experiences with Cu-7 IUDs. The vast majority of cases in the literature have involved patients using the Lippes Loop. When experience with the Cu-7 increases, however, there may be no differences. The proportions generally seem to correspond with the frequency of use of the type of IUD in the general population. There appear to be no major differences in several parameters for these patients as compared with a very large series of ectopic pregnancies, with and without IUDs, seen at the University of Southern California and previous experience at the University of Chicago (Table 1).7,8 It is of interest that in the first two series, nearly one-third of the patients had undergone prior abortions (16.7% in this series) and that other indices related to duration of use and parity among the groups were comparable (X- not significant). Two factors do seem to be particularly consistent with IUD-associated ovarian pregnancy. Abdominal pain was the major presenting symptom in 95.3% of patients, and pregnancy teets, when done with even fairly crude techniques, were also positive in 87% of patients. The high incidence of positive pregnancy tests may reflect a greater ability of the ovary to incorporate trophoblastic tissue in comparison with the fallopian tube. In the previous series of ectopic gestations at the Chicago Lying-In Hospital, 73.5% of patients had a positive pregnancy test by slide latex agglutination. s Pritchard and MacDonald,13 however, have stated.
Helvacioglu et al.·
This series (ovarian pregnancy with IUD)
28 25.0 31.7
34.9% 96.7%
26.3 18.8 18.8 34.8% 34.8% 21.7% 8.7% 16.7% 95.3% 47.fHo
that in general a positive test may be observed for tubal pregnancies in as few as 50% of patients. One particularly striking feature is the lack of amenorrhea in many of the patients. Nearly onehalf (46%) of the patients had no menstrual irregularities. Findings on pelvic examinations were also variable. Often a mass was felt in one adnexum which proved to be a cyst, and the pregnancy was implanted in the opposite ovary.14. 15 Interpretation of the data presented must necessarily be subjective, since no controls are available to compare the incidence of ovarian pregnancy and the IUD. However, it is known that populations in which there is a high incidence of pelvic inflammatory disease also have an increased risk of ectopic pregnancy.I6-1S The ovarian pregnancies reported here may reflect a predisposition of the population in addition to an increased likelihood of ectopic pregnancy with the IUD. The combination of these factors raises further questions about the desirability of the IUD as a means of contraception in such a population.
I
I,
I"
I
I \
REFERENCES 1. Lehfeldt H, Tietze C, Gorstein F: Ovarian pregnancy and the intrauterine contraceptive device. Am J Obstet Gynecol 108:1105, 1970 2. Perlmutter JF: Pregnancy and the IUD. J Reprod Med 20:133, 1978 3. Seward PN, Israel R, Ballard CA: Ectopic pregnancy and intrauterine contraception: a definitive relationship. Obstet Gynecol 40:214, 1972 4. Tatum HJ, Schmidt FH: Contraception and sterilization practices and extrauterine pregnancy: a realistic perspective. Fertil Steril 28:407, 1977 5. Spiegelberg 0: Zur casuistik den ovrialschwangenschaft. Arch Gynaekol 13:73, 1878 6. Beral V: An epidemiological study of recent trends in ectopic pregnancy. Br J Obstet Gynaecol 82:775,1975 7. Hallatt JG: Ectopic pregnancy associated with the intrauterine device: a study of seventy cases. Am J Obstet Gynecol 125:754, 1976
j
Vol. 32, No.1
THE INTRAUTERINE DEVICE AND OVARIAN PREGNANCY
8. Helvacioglu A, Long EM, Yang SL: Recent experience with ectopic pregnancy at Chicago Lying-In Hospital-an eight year review. J Reprod Med 22:87,1979 9. Laufer N, Zilberman R, Anteby SV: Ectopic pregnancy and intrauterine device. Harefuah 94:71, 1978 10. Haii SN: Does sterilization prevent pelvic infection? J Reprod Med 20:289, 1978 11. Berger B, Blechner IN: Ovarian pregnancy associated with Copper 7 intrauterine device. Obstet Gynecol 52:597, 1978 12. Gray CL, Ruffalo EH: Ovarian pregnancy associated with intrauterine contraceptive devices. Am J Obstet Gynecol 132:134, 1978 13. Pritchard JA, MacDonald PC: Williams Obstetrics, 15th Edition. New York, Appleton-Century-Crofts, 1976, p 440
35
14. Graff G, Lancet M, Czernobilsky B: Ovarian pregnancy with IUD's in situ. Obstet Gynecol 40:535, 1972 15. Varga L, Obolenski W, Scheidegger S: Ovarian pregnancy and the IUD, a case report. Int J Fertil 17:142, 1972 16. Westrom L, Bengtsson LP, Mardh PA: The risk of pelvic inflammatory disease in women using intrauterine contraceptive devices as compared to nonusers. Lancet 2:221, 1976 17. Eschenbach DA, Harnisch JP, Holmes KK: Pathogenesis of acute pelvic inflammatory disease: role of contraception and other risk factors. Am J Obstet GynecoI128:838, 1977 18. Ory HW: A review of the ,association between intrauterine devices and acute pelvic inflammatory disease. J Reprod Med 20:200, 1978
