Pregnancy can occur unexpectedly in an infertile woman.
A 29 year old woman married for 9 years, came with secondary infertility. She had a history of spontaneous conception in 2002 which ended in missed abortion at around 8 weeks of gestation needing dilatation and curettage in a private hospital. There was no suggestive family or personal history. Husband was apparently healthy and his seminogram revealed no abnormality. She had regular 28-30 days cycle with average flow and mild dysmenorrhea.
Routine blood examination was within normal limits. Initial endocrine workup showed mild hyperprolactinemia (serum prolactin: 44.2 ng/mL) and mild hypothyroidism (TSH 5.03 iu/mL). She was treated with bromocriptin and thyroxine. After three months of treatment her prolactin and TSH levels dropped down to near normal.
A hysterosalpingogram (HSG) was advised after the next period and was done on 22nd Otober, 2003 after 3 days of cessation of menstruation. Report showed a filling defect near the fundus of the uterus encroaching more on to the right cornu (Figure 1). However both the tubes were patent and there was free spillage of dye on both sides. In order to find out the exact nature of the filling defect a transvaginal sonography (TVS) was done on 25th October, 2003.
To our utter surprise, the vaginal sonography reported the uterine filling defect as a 6 weeks gestational sac. On explaining the fetal risk due to radiation exposure and to teratogenic iodine containing contrast medium the patient consented to pregnancy termination which was done by 600 mg mifepristone orally followed 24 hours later by 600 mg misoprostol vaginally. Complete evacuation was confirmed by sonography after 11 days.
HSG is one of the basic investigations in the management of infertility. The investigation of a case of persisting infertility can never be said to be complete without HSG 1. In addition to determining whether the tubes are open or blocked the test can reveal the presence of polyps, fibroid tumor or scar tissue2.
Presence of pregnancy came as a shocking news to us as well as to the infertile couple. On retrospection and close enquiry with the patient it appears that the patient conceived spontaneously in the previous cycle, may be due to correction of endocrine problems. The three days of bleeding, which was more scanty than her usual flow, was actually implantation bleeding which she mistook as normal menstruation. Thus the developing fetus was inadvertently exposed not only to radiation but also to teratogenic iodine containing contrast medium. On explanation about the risk to the developing fetus the couple consented for the termination of pregnancy.
