**1. Introduction**

44 Ectopic Pregnancy – Modern Diagnosis and Management

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trachomatis genital infection induced by a vaccine based on the major outer membrane multi-epitope human papillomavirus major capsid protein L1. *Vaccine*

Sullivan E, van der Poel S, on behalf of I, Who. 2009. The International Committee for Monitoring Assisted Reproductive Technology (ICMART) and the World Health Organization (WHO) Revised Glossary on ART Terminology, 2009. *Hum.* 

> Ectopic pregnancy represents a rare pregnancy complication. In the last 20 years, with the use of IVF, heterotopic pregnancies have become more frequent, while this percentage differs between IVF programs. Many factors contribute to this, like the active management of hydrosalpinx or treatment of Chlamydia infection before starting a cycle. Although, *in vitro* fertilization is an expensive treatment, ectopic complication adds to this cost.

> Not a lot of studies exist for ectopic pregnancy after IVF. Most of them are case reports. Not a standard way exists, for dealing with heterotopic pregnancies, even in the era of modern laparoscopy. Not a lot of research has been performed on molecules that involved. Studies have tried to associate certain techniques during IVF, with this entity, but with controversial results. There is no standard form for diagnosing, dealing and presenting heterotopic pregnancies. Most of them are diagnosed when ruptured. Because it is rare event, costeffectiveness studies could not be performed and this complication is added to the overall IVF. Knowledge, on this field, is taken from the management of ectopic pregnancies in the general population, even if these present at a lower percentage.

> The purpose of the study is to systematically evaluate studies on molecular aspects of ectopic pregnancy, the ART techniques that are associated with ectopic pregnancy, the diagnosis of this entity and finally present case reports of heterotopic pregnancies and their management. At the end, cost-effectiveness models from the general population will be presented in parallel with systematic examination of these studies. Finally, new research targets will be pointed.

<sup>\*1</sup>Dimitrios Peschos1, Mynbaev Ospan2, Eliseeva Marina2, Ioannis Verginadis1, Yannis Simos1, Tsirkas Panagiotis3, Spyridon Karkabounas1, Vicky Kalfakakou1, Angelos Evangelou1 and Ioannis P. Kosmas1,3

*<sup>1</sup>Laboratory of Physiology, Faculty of Medicine, University of Ioannina, Ioannina, Greece 2Centre of Obstetrics, Gynaecology & Perinatology, Moscow State University of Medicine & Dentistry, Moscow, Russia* 

*<sup>3</sup>Department of Obstetrics and Gynecology, Ioannina State General Hospital G Chatzikosta, Ioannina, Greece*

Ectopic Pregnancy and Assisted Reproductive Technologies: A Systematic Review 47

Fig. 2. Type of study per tissue used when examining biological factors in ectopic pregnancy fallopian tube samples, 1 used human endometrium and fallopian tube, 2 used human placental tissue, 1 used ovarian, prostate, endometrial, tubal and semen, 1 used trophoblast, 2 used serum samples, 1 used transervical specimens and one used stimulated cervical mononuclear cell supernatants. The type of study per tissue used can be seen in Fig 2. 4 (20%) of the studies were published in American Journal of Reproductive Immunology, 2 (10%) in Human Reproduction and from 1 (5%) in Molecular Human Reproduction, Reproduction, Reproductive Biology & Endocrinology, Reproductive Sciences, Biology of Reproduction, Cellular Microbiology, Clinical and Vaccine Immunology, European Journal of Obstetrics & Gynecology, Histochemistry & Cellular Biology, Infection and Immunity, The Journal of Immunology, The Journal of Infectious Diseases ,The Journal of Clinical Endocrinology & Metabolism, The Medical Hypothesis journal. The distribution of type of study per Journal is seen in Fig 3. Eight studies (40%) did not mentioned their controls, four studies (20%) used normal pregnant patients and intrauterine pregnancy, and from one study (5%) used women with no infection and without infertility problem, normal desidual tissue, normal endometrium and normal Fallopian tube, normal pregnant patient peripheral blood, spontaneous abortion,, tissue from women undergoing tubal ligation with segmental

resection and women with viable and non-viable intrauterine pregnancy.

source of each study per Journal published is seen on Fig 4.

Samples size examined ranged from 3 (in each group) to 144. Disease distribution examined presented as: ectopic pregnancy (8/40%), spontaneous abortion and ectopic pregnancy (2/10%), Chlamydia infection (2/10%), Chlamydia infection in patients with no infertility compared with women with Chlamydia and tubal damage, ectopic pregnancy and decidualized endometrium, ectopic pregnancy and blighted ovum, ectopic pregnancy and Chlamydia infection, pelvic inflammatory disease and ectopic pregnancy, post IVF ectopic pregnancy, viable ectopic pregnancy while 1 (5%) did not mentioned disease. Funding
