Heterotopic Triplet Pregnancy after In Vitro Fertilization with Favorable Outcome of the Intrauterine Twin Pregnancy Subsequent to Surgical Treatment of the Tubal Pregnancy

Heterotopic triplet pregnancy is an exceptionally rare medical condition. The broad use of assisted reproductive technologies has contributed to the increase of ectopic and subsequently heterotopic pregnancy rate, masking a life-threatening condition for the gravid and the intrauterine pregnancy. We describe a case of a woman with heterotopic triplets at 9+4 gestational week following transfer of three embryos obtained by in vitro fertilization techniques. The ectopic tubal pregnancy was ruptured and salpingectomy was performed by laparotomy. The intrauterine pregnancy progressed to the delivery by cesarean section of two healthy twins at 36+2 gestational age. Heterotopic triplets with tubal ectopic are a special diagnostic and therapeutic challenge for the obstetrician. High index of suspicion and timely treatment by laparotomy or laparoscopy can preserve the intrauterine gestation with a successful outcome of the pregnancy. 1. Introduction Heterotopic pregnancy (HP) is a rare medical condition in obstetrics. It is characterized by the presence of coexistent intrauterine and ectopic pregnancy. The most frequent implantation site of the ectopic pregnancy is in the fallopian tube, most commonly in its ampullary segment (80%) [1]. The incidence of heterotopic pregnancy is around 1/30,000 (1/10000 to 1/50000) in spontaneous pregnancies [1, 10]. In pregnancies resulting from assisted reproduction techniques, the incidence is greater, ranging from 1/100 to 1/3,600, nearly as high as 1% in some series [1]. Overall, the incidence of heterotopic pregnancy nowadays is estimated around 1/7000 [2] to 1/15000 live births (0,8% calculated risk) in contrast with the indisputably lower incidence of 1？:？30.000 in 1948 [3]. The big difference in these percentages is attributed to the higher incidence of pelvic inflammatory disease (PID) observed currently resulting in tubal damage as well as ovarian stimulation and transfer of many embryos in the range of the broad use of assisted reproductive technology (ART) techniques [1]. There has also been a 5.9-fold increase in triplet conception between 1971–1977 and 1998, attributable to ART extended use, too [4]. Heterotopic triplets are even more uncommon and cases with tubal ectopic and coexisting twin intrauterine pregnancy are limited. This medical condition can be hazardous to the intrauterine pregnancy and mother’s life as well. We present the case of a following in vitro fertilization (IVF) combined intrauterine twin and tubal pregnancy which was ruptured and successfully surgically treated with preservation of the