A 30-year-old female came to our practice complaining of primary infertility over the last 4 years. Her history indicated that in 2014, tuberculotic peritonitis had been diagnosed and treated laparoscopically, following which she received TB chemotherapy for 6 months. In 2016, the right Fallopian tube was laparoscopically resected and a pathology examination confirmed the tuberculotic nature of the lesions. Afterward, TB chemotherapy was reinstated for another year. Wishing to become pregnant, she requested IVF. Before carrying out the procedure, both a tuberculin skin test (TST) and chest computed tomography (CT) were carried out. The TST showed a water bubble after 72 h, and the CT scan showed streaking on the medial segment of the middle lobe of the right lung and a protuberance under an enlarged lymph node.
In view of her having twice received anti-TB treatment, it was decided not to repeat that treatment; ovarian stimulation was initiated following administration of a short-acting depot gonadotropin-releasing hormone analogue for pituitary suppression. Because of the husband's asthenospermia, the intracytoplasmic sperm injection technique was used. On the third day after fertilization, two grade II embryos were transferred, and three others were frozen.
Eleven days after the embryo transfer, the patient complained of diarrhea. At that time, her serum hormone levels were as follows: beta-human chorionic gonadotropin (beta-HCG), 49.5 mlU/mL; oestradiol (E 2) 80.8 pg/mL; and progesterone (P) 12.8 ng/mL The symptoms improved following intravenous fluids and antibiotics. On day 14 after the transfer, the patient presented with intermittent fever, from 37.8 to 38.5 C, and a cough; she again received symptomatic treatment. On day 18 the patient's body temperature rose once more to 38.9 C. At this point serum, blood levels were beta-HCG 371.6 mIU/mL, E 2 235.2, and P 14.2 pg/mL A routine blood test showed the following: white blood cells (WBC) 20.34 x 106/mL; neutrophil ratio 83.7%; hemoglobin 103 g/L; and erythrocyte sedimentation rate 110 mm/h. Transvaginal sonography (TVS) revealed no clear echo indicating the presence of the pregnant sac in the uterine cavity or the annex area. After a review of the patient's history, a TB recurrence was suspected and confirmed by the Gansu Province TB specialized hospital.
The patient received a four-drug chemotherapy, but still had a low fever. On day 28, a new TVS showed that there was no pregnancy sac in the uterine cavity, but a cyst image about 11 x 10 mm appeared at the level of the cervix; no definite embryo image or heartbeats could be detected. Also, a low-density mass measuring 79 x 70 mm became visible on the right ovary. At this point a diagnosis of cervical pregnancy was suspected, combined with a right ovarian tuberculotic cyst.
A decision was then made to terminate the pregnancy, and the gestational sac was injected with 50 mg of methotrexate through the cervical canal; in addition, 50 mg of mifepristone tablets were administered three times daily. 4 days later, the gestational sac was expelled. A pathological examination confirmed that it was indeed a cervical pregnancy. 1 week later, she underwent laparoscopy for the right salpingectomy and oophorectomy. The specimen contained about 150 mL of purulent discharge, which was sent for culture; the cystic wall was sent for histologic examination. Pathology demonstrated chronic nonspecific inflammation in the oviduct and ovarian suppurative inflammation. Cultures for acid-fast bacilli were negative.