Synchronous intrauterine and ectopic pregnancy associated with clomiphene citrate

Although synchronous intrauterine and ectopic pregnancies associated with the use of clomiphene citrate for infertility are rare, the actual incidence might, in fact, be considerably higher than previously thought. The cornerstone for ruling out an extrauterine gestation is the presence of sonographic evidence of an intrauterine pregnancy, as the possibility of concomitant intrauterine and extrauterine gestation is perceived to be statistically rare. This has resulted in an unacceptably high incidence of negative ultrasound interpretations. During a recent 12 month period, four women treated with clomiphene citrate for infertility were diagnosed as having concomitant intrauterine and ectopic pregnancies. Three had pelvic sonograms that were erroneous for the extrauterine component. However, successful evacuation of the products of ectopic gestation was performed in each, despite an immediate preoperative false-negative ultrasound report. Three of the women delivered healthy normal infants at full term, and the fourth woman spontaneously aborted the products of the concomitant intrauterine gestation. All four did well postoperatively, and no gross complications were encountered. Reassessment of ultrasound diagnostic criteria and the use of more sensitive methods, such as endovaginal ultrasound in high risk patients, are indicated for any symptomatic patient using clomiphene citrate for infertility. Awareness of the prevalence of this entity and the limitations of ultrasound will lead to prompt intervention and improved survival rates.