Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-cd9895bd7-gbm5v Total loading time: 0 Render date: 2024-12-23T06:28:55.673Z Has data issue: false hasContentIssue false

Chapter 4 - Ectopic Pregnancy

from Part I - ANTEPARTUM

Published online by Cambridge University Press:  07 May 2010

John Patrick O'Grady ,
Martin L. Gimovsky ,
Lucy A. Bayer-Zwirello  and
Kevin Giordano
By
Samantha F. Butts  and
David B. Seifer
John Patrick O'Grady
Affiliation:
Tufts University, Massachusetts
Samantha F. Butts
Affiliation:
Assistant Professor, Department of Obstetrics and Gynecology Division of Infant and Reproductive Endocrinology University of Pennsylvania Medical School Philadelphia, Pennsylvania
David B. Seifer
Affiliation:
Professor, Department of Obstetrics, Gynecology, and Reproductive Sciences Mount Sinai School of Medicine New York
Get access

Summary

This chapter provides a comprehensive discussion of the contemporary approach to ectopic pregnancy. It reviews the diagnosis and treatment options and the epidemiology and pathophysiology of ectopic pregnancy. Abnormalities of tubal function and ovum quality or an altered hormonal milieu may each contribute to the development of an ectopic pregnancy. Some of the most significant risk factors for the development of ectopic pregnancy include history of pelvic inflammatory disease (PID), prior fallopian tube surgery, increasing age, and a history of infertility. Prior tubal surgery results in an increased risk of ectopic implantation. Although surgery remains the mainstay of treatment for ectopic pregnancy, medical management is a widely used alternative. Methotrexate therapy for ectopic pregnancy is a widely used medical alternative to surgery. The use of proteomics to aid in the detection of early ectopic pregnancy is an active area of research.

Keywords

ectopic pregnancyfallopian tube surgerymedical managementmethotrexate therapypelvic inflammatory disease
Type
Chapter
Information
Operative Obstetrics , pp. 69 - 88
Publisher: Cambridge University Press
Print publication year: 2008

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Goldner, TE, Lawson, HW, Xia, Z, Atrash, HK. Surveillance for ectopic pregnancy – United States, 1970–1989. MMWR 1993;73–82.Google ScholarPubMed
Current Trends Ectopic Pregnancy – United States, 1990–1992. MMWR Weekly 1995;44:46–48.
Chang, J, Elam-Evans, LD, Berg, CJ, Herndon, J, Flowers, L, Seed, KA, Syverson, CJ.Pregnancy- Related Mortality Surveillance – United States, 1991–1999. MMWR Surveillance Summaries 2004;52:1–8.Google Scholar
Russell, JB.The etiology of ectopic pregnancy. Clin Obstet Gynecol 1993; 81:287–292.Google Scholar
Elias, S, LeBeau, M, Simpson, J, Martin, AO. Chromosome analysis of ectopic human conceptuses. Am J Obstet Gynecol 1981 Nov; 141(6):698–703.CrossRefGoogle Scholar
Budowick, M, Johnson, TR Jr, GenadryR, Parmley TH R, Parmley TH, Woodruff, JD. The histopathology of the developing tubal ectopic pregnancy. Fertil Steril 1980 Aug;34(2):169–171.CrossRefGoogle Scholar
Pauerstein, CJ, Croxatto, HB, Eddy, CA, Ramzy, I, Walters, MD.Anatomy and pathology of tubal pregnancy. Obstet Gynecol 1986 Mar;67(3):301–308.Google Scholar
Stock, RJ.Tubal pregnancy-associated histopathology. Obstet Gynecol Clin North Am 1991;18:73–94.Google ScholarPubMed
Robertson, J, Hogston, P, Ward, M. Gonococcal and chlamydial antibodies in ectopic and intrauterine pregnancy. Br J Obstet Gynaecol 1988;95:711–716.CrossRefGoogle ScholarPubMed
Svensson, L, Mardh, PA, Ahlgren, M, Nordenskjold, F.Ectopic pregnancy and antibodies to Chlamydia trachomatis. Fertil Steril 1985 Sep;44(3):313–317.CrossRefGoogle Scholar
Westrom, L, Bengtsson, LPH, Mardh, PA.Incidence, trends, and risks of ectopic pregnancy in a population of women. Br Med J 1981;282:15–18.CrossRefGoogle Scholar
Westrom, L.Effect of acute pelvic inflammatory disease on infertility. Am J Obstet Gynecol 1975;121:707–713.CrossRefGoogle Scholar
Berek, JS, Adashi, EY, Hillard, PA, eds. Novak's Gynecology, 12th ed. Baltimore, Williams and Wilkins, 1996.Google Scholar
Butts, S, Sammel, M, Hummel, A, Chittams, J, Barnhart, K.Risk factors and clinical features of recurrent ectopic pregnancy: A case-control study. Fertil Steril 2003;80:1340–1344.CrossRefGoogle ScholarPubMed
Uotila, J, Heinonen, PK, Punnonen, R.Reproductive outcome after multiple ectopic pregnancies. Intl J Fertil 1989;34:102–105.Google ScholarPubMed
Glock, JL, Loy, RA, Brumsted, JR.Reproductive performance following a second ectopic gestation. Intl J Gynaecol Obstet 1993;43:191–194.CrossRefGoogle ScholarPubMed
Speroff, L, Fritz, M, eds. Clinical Gynecologic Endocrinology and Infertility, 7th edition. Baltimore, Lippincott Williams and Wilkins, 2004.Google Scholar
Furlong, LA.Ectopic pregnancy risk when contraception fails: A review. J Reprod Med 2002;47:881–885.Google ScholarPubMed
Peterson, HB, Xia, Z, Hughes, JM, Wilcox, LS, Tylor, LR, Trussell, J. The risk of pregnancy after tubal sterilization: Findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol 1996; 174;1161–1168.CrossRefGoogle ScholarPubMed
Sheikh, A, Yussman, M.Ruptured ectopic pregnancy after bilateral laparoscopic tubal fulguration. Am J Obstet Gynecol 1976;125:569.CrossRefGoogle ScholarPubMed
Chi, IC, Laufe, , Gardner, SD, Tolbert, MA. An epidemiologic study of risk factors associated with pregnancy following female sterilization. Am J Obstet Gynecol 1980 Mar;136(6):768–773.CrossRefGoogle Scholar
McClausland, A.High rate of ectopic pregnancy following laparoscopic tubal coagulation failures. Am J Obstet Gynecol 1980;136:97–101.CrossRefGoogle Scholar
Holt, VL, Chu, J, Daling, JR, Stergachis, AS, Weiss, NS. Tubal sterilization and subsequent ectopic preg-nancy: A case-control study. JAMA 1991 Jul;266(2):242–246.CrossRefGoogle Scholar
Wolf, GC, Thompson, JN. Female sterilization and subsequent ectopic pregnancy. Obstet Gynecol 1980;55:17–19.Google ScholarPubMed
Russell, JB, DeCherney, AH, Laufer, N, Polan, ML, Naftolin, F.Neosalpingostomy: Comparison of 24- and 72-month follow-up time shows increased pregnancy rate. Fertil Steril 1986 Feb;45(2):296–298.CrossRefGoogle Scholar
Henderson, S.The reversibility of female sterilization with the use of microsurgery: A report on 102 patients with more than one year of follow-up. Am J Obstet Gynecol 1984;149:57–61.CrossRefGoogle ScholarPubMed
Caspi, E, Halperin, Y.Surgical management for periadnexal adhesions. Intl J Fertil 1981;26:49–52.Google ScholarPubMed
Ni, HY, Daling, JR, Chu, J, Stergachis, A, Voigt, LF, Weiss, NS. Previous abdominal surgery and tubal pregnancy. Obstet Gynecol 1990 Jun;75(6):919–922.Google Scholar
McBain, JC, Evan, JH, Pepperell, RJ, Robinson, HP, Smith, MA, Brown, JB. An unexpectedly high rate of ectopic pregnancy following the induction of ovulation with human pituitary and chorionic gonadotropin. Br J Obstet Gynaecol 1980 Jan;87(1):5–9.CrossRefGoogle Scholar
Gemzell, C, Buillome, J, Wang, CF. Ectopic pregnancy following treatment with human gonado-tropins. Am J Obstet Gynecol 1982;143:761–765.CrossRefGoogle Scholar
Yang, CP, Chow, WH, Daling, JR, Weiss, NS, Moore, . Does prior infertility increase the risk of tubal pregnancy?Fertil Steril 1987 Jul;48(1):62–66.CrossRefGoogle Scholar
Fernandez, H, Coste, J, Job-Spira, N.Controlled ovarian hyperstimulation as a risk factor for ectopic pregnancy. Obstet Gynecol 1991;78:656–659.Google ScholarPubMed
Steptoe, PC, Edwards, RG. Reimplantation of a human embryo with subsequent tubal pregnancy. Lancet 1976;1:880–882.CrossRefGoogle ScholarPubMed
Cohen, J, Mayaux, MJ, Guihard-Moscato, ML, Schwartz, D. In-vitro fertilization and embryo transfer: A collaborative study of 1163 pregnancies on the incidence and risk factors of ectopic pregnancies. Hum Reprod 1986 Jun;1(4):255–258.CrossRefGoogle Scholar
In vitro fertilization-embryo transfer (IVF-ET) in the United States: 1990 results from the IVF-ET Registry. Medical Research International and the Society for Assisted Reproductive Technology, The American Fertility Society. Fertil Steril 1992 Jan;57(1):15–24. Erratum in: Fertil Steril 1993 Jan;59(1):250.
Herman, A, Ron-El R, , Golan, A, Weinraub, Z, Bukovsky, I, Caspi, E.The role of tubal pathology and other parameters in ectopic pregnancies occurring in in vitro fertilization and embryo transfer. Fertil Steril 1990 Nov;54(5):864–868. PMID: 2226919.CrossRefGoogle Scholar
Farquhar, CM.Ectopic pregnancy. Lancet 2005;366:583–591.CrossRefGoogle ScholarPubMed
Makinen, JI, Erkkola, RU, Laippala, PJ. Causes of the increase in the incidence of ectopic pregnancy: A study on 1017 patients from 1966 to 1985 in Turku, Finland. Am J Obstet Gynecol 1989;160:642–646.CrossRefGoogle ScholarPubMed
Pulkkienen, M, Talo, A.Tubal physiologic consideration in ectopic pregnancy. Clin Obstet Gynecol 1987;30:164–172.CrossRefGoogle Scholar
Dorfman, SF.Epidemiology of ectopic pregnancy. Clin Obstet Gynecol 1987;30:173–180.CrossRefGoogle ScholarPubMed
Yeko, TR, Handler, A.The effect of aging on tubal function and ectopic pregnancy. Semin Reprod Endocrinol 1991;9:215–220.CrossRefGoogle Scholar
Ankum, WM, Mol, BWJ, Veen, F, Bossuyt, PM. Risk factors for ectopic pregnancy: A meta-analysis. Fertil Steril 1996;65:1093–1099.CrossRefGoogle ScholarPubMed
Campbell, OM, Gray, RH. Smoking and ectopic pregnancy: Multinational case-control study. In: Rosenberg MJ, ed. Smoking and Reproductive Health. Littleton, MA: PSG Publishing Company, 1987; pp. 70–75.Google Scholar
Chow, WH, Daling, FJ, Weiss, NS, Voigt, LF. Maternal cigarette smoking and tubal pregnancy. Obstet Gynecol 1988;71:167–70.Google ScholarPubMed
Handler, A, Davis, F, Ferre, C, Yeko, T.The relationship of smoking and ectopic pregnancy. Am J Public Health 1989;79:1239–1242.CrossRefGoogle ScholarPubMed
NatofskyJG, JG,LenseJ, J,MayerJC, JC,Yeko, TR.Ultrasound-guided injection of ectopic pregnancy. Clin Obstet Gynecol 1999;42:39–47.CrossRefGoogle ScholarPubMed
Storring, PL, Gaines-Das, RE, Bangham, DR. International Reference Preparation of Human Chorionic Gonadotropin for Immunoassay: Potency estimates in various bioassays and protein binding assay systems, and International Reference Preparations of the alpha and beta subunits of human chorionic gonadotropin for immunoassay. J Endocrinol 1980 Feb;84(2):295–310.CrossRefGoogle Scholar
Pittaway, , Reisch, RL, Wentz, AC. Doubling times of human chorionic gonadotropin increase in early viable intrauterine pregnancies. Am J Obstet Gynecol 1985;152:299–302.CrossRefGoogle ScholarPubMed
Batzer, FR, Schlaff, S, Goldfarb, A.Serial B subunit: hCG doubling times as a prognostication of pregnancy outcome in an infertile population. Fertil Steril 1981;35:307–312.CrossRefGoogle Scholar
Kadar, N, Romero, R.Serial human chorionic gonadotropin measurements in ectopic pregnancy. Am J Obstet Gynecol 1988;158:1239–1240.CrossRefGoogle ScholarPubMed
Kadar, N, Romero, R.Observations on the log human chorionic gonadotropin-time relationship in early pregnancy and its practical implications. Am J Obstet Gynecol 1987;157:73–78.CrossRefGoogle ScholarPubMed
Kader, N, Caldwell, BU, Romero, R.A method of screening for ectopic pregnancy and its indications. Obstet Gynecol 1981;58:162–166.Google Scholar
Barnhart, KT, Sammel, MD, Rinaudo, PF, Zhou, L.Hummel, AC, Guo, W.Symptomatic patients with an early viable intrauterine pregnancy: hCG curves redefined. Obstet and Gynecol 2004;104:50–55.CrossRefGoogle ScholarPubMed
Jain, KA, Hamper, UM, Saunders, RC. Comparison of transvaginal and transabdominal sonography in the detection of early pregnancy and its complications. Am J Radiol 1988;151:1139–43.Google ScholarPubMed
Pennell, RG, Baltarowich, OH, Kurtz, AB et al. Complicated first-trimester pregnancies: Evaluation with endovaginal ultrasound versus transabdominal technique. Radiology 1987;165:79–83.CrossRefGoogle ScholarPubMed
Timor-Tritsch, IE, Yen, MN, Peisner, DB, Lester, KB, Slavik, BS. The use of transvaginal ultrasound in the diagnosis of ectopic pregnancy. Am J Obstet Gynecol 1989;161:157–61.CrossRefGoogle Scholar
Goldstein, SR, Snyder, JR, Welson, C, Danon, M.Very early pregnancy detection with endovaginal ultrasound. Obstet Gynecol 1988;72:200–204.Google ScholarPubMed
Barnhart, KT, Mennuti, MT, Benjamin, I, Jacobson, S, Goodman, D, Coutifaris, C.Prompt diagnosis of ectopic pregnancy in an emergency department setting. Obstet Gynecol 1994;84:1010–1015.Google Scholar
Aleem, FA, DeFazio, M, Gintautas, J.Endovaginal sonography for the early diagnosis of intrauterine and ectopic pregnancies. Hum Reprod 1990;5:755–758.CrossRefGoogle ScholarPubMed
RottemS, S,ThalerI, I,LevronJ, J,Peretz, BA, ItskovitzJ, J,Brandes, JM. Criteria for transvaginal sonographic diagnosis of ectopic pregnancy. J Clin Ultrasound 1990;18:274–279.CrossRefGoogle ScholarPubMed
Mateer, JR, Valley, VT, Aiman, EJ, Phelan, MB, Thoma, ME, Kefer, MP. Outcome analysis of a protocol including bedside endovaginal sonography in patients at risk for ectopic pregnancy. Ann Emerg Med 1996;27:283–289.CrossRefGoogle ScholarPubMed
Cacciatore, G, Stenman, UH, Ylostalo, P.Diagnosis of ectopic pregnancy by vaginal ultrasonography in combination with a discriminatory serum B-hCG level of 1000 IU/L. Br J Obstet Gynaecol 1990;97:904–908.CrossRefGoogle Scholar
Emerson, DS, Cartier, MS, Altieri, et al. Diagnostic efficacy of endovaginal color Doppler flow imaging in an ectopic pregnancy screening program. Radiology 1992;183:413–420.CrossRefGoogle Scholar
Pellerito, JS, Taylor, KJW, Quedens-Case C, , et al. Ectopic pregnancy: Evaluation with endovaginal color flow imaging. Radiology 1992;183:407–411.CrossRefGoogle ScholarPubMed
Barnhart, KT, Simhan, H, Kamelle, SA. Diagnostic accuracy of ultrasound above and below the beta hCG discriminatory zone. Obstet Gynecol 1999;94:583–587.Google ScholarPubMed
Spandorfer, SD, Menzin, AW, Barnhart, KT, Livolsi, VA, Pfeifer, SM. Gynecology: Efficacy of frozen-section evaluation of uterine curettings in the diagnosis of ectopic pregnancy. Am J Obstet Gynecol 1996;175:603–605.CrossRefGoogle Scholar
Barnhart, KT, Gracia, CG, Reindl, B, Wheeler, JE. Usefulness of Pipelle endometrial biopsy in the diagnosis of women at risk for ectopic pregnancy. Am J Obstet Gynecol 2003;188:906–909.
Barnhart, KT, Katz, I, Hummel, A, Gracia, CR. Presumed diagnosis of ectopic pregnancy. Obstet Gynecol 2002;100:505–510.Google ScholarPubMed
Ailawadi, M., Lorch, SA, Barnhart, KT. Cost-effectiveness of presumptively medically treating women at risk for ectopic pregnancy compared with first performing a dilatation and curettage. Fertil Steril 2005;83:376–382.CrossRefGoogle ScholarPubMed
Brumstead, J, Kessler, C, Gibson, D, et al. A comparison of laparoscopy and laparotomy for the treatment of ectopic pregnancy. Obstet Gynecol 1988;71:889–892.Google Scholar
Vermesh, M, Silva, PD, Rosen, GF, et al. Management of unruptured ectopic gestation by linear salpingostomy: A prospective randomized clinical trial of laparoscopy versus laparotomy. Obstet Gynecol 1989;73:400–404.Google ScholarPubMed
Lundorff, P, Hahlin, M, Kallfelt, B, et al. Laparoscopic surgery in tubal pregnancy: A randomized trial versus laparotomy. Acta Obstet Gynecol Scand 1992;70:343–348.CrossRefGoogle Scholar
Seifer, DB, Gutmann, JN, Doyle, MB, Jones, EE, Diamond, MP, DeCherney, AH. Persistent ectopic pregnancy following laparoscopic linear salpingostomy. Obstet Gynecol 1990;76:1121–1125.Google ScholarPubMed
Seifer, DB, Diamond, MP, DeCherney, AH. Persistent ectopic pregnancy. Obstet Gynecol Clin North Am 1991;18:153–159.Google ScholarPubMed
Seifer, DB, Gutmann, JN, Grant, WD, Kamps, CA, DeCherney, AH. Comparison of persistent ectopic after laparoscopic salpingostomy versus salpingostomy at laparotomy for ectopic pregnancy. Obstet Gynecol 1993;81:378–382.Google ScholarPubMed
Gracia, CG, Brown, MD, Barnhart, KT. Prophylactic methotrexate after linear salpingostomy: A decision analysis. Fertil Steril 2001;76:1191–1195.CrossRefGoogle ScholarPubMed
Hajenius, PJ, Mol, BW, Ankum, WM, Veen, F, Bossuyt, PM, Lammes, FB. Clearance curves of serum human chorionic gonadotropin for the diagnosis of persistent trophoblast. Hum Reprod 1995;10:683–687.CrossRefGoogle Scholar
Spandorfer, SD, Sawin, SW, Benjamin, I, Barnhart, KT. Postoperative day 1 serum human chorionic gonadotropin level as a predictor of persistent ectopic pregnancy after conservative surgical management. Fertil Steril 1997;68:430–434.CrossRefGoogle ScholarPubMed
Graczykowski, JW, Mishelle, DR. Methotrexate prophylaxis for persistent ectopic pregnancy after conservative treatment by salpingostomy. Obstet Gynecol 1997;89:118–122.CrossRefGoogle ScholarPubMed
Tulandi, T, Saleh, A.Surgical management of ectopic pregnancy. Clin Obstet Gynecol 1999;42:31–38.CrossRefGoogle ScholarPubMed
Ory, SJ, Nnandi, E, Herrmann, R, O'Brien, PS, Melton, LJ. Fertility after ectopic pregnancy. Fertil Steril 1993;60:231–235.CrossRefGoogle ScholarPubMed
Tuomivaara, L, Kauppila, A.Radical or conservative surgery for ectopic pregnancy? A follow-up study of fertility of 323 patients. Fertil Steril 1988;50:580–583.CrossRefGoogle ScholarPubMed
Seifer, DB, Silva, PD, Grainger, DA, Barber, SR, Grant, WD, Gutmann, JN. Reproductive potential after treatment for persistent ectopic pregnancy. Fertil Steril 1994;62:194–196.CrossRefGoogle ScholarPubMed
Hajenius, PJ, Mol, BW, Bossuyt, PM, Ankum, WM, Veen, F.Interventions for tubal ectopic pregnancy. Cochrane Database Syst Rev:CD00324, 2000.CrossRefGoogle ScholarPubMed
Lipscomb, GH, Stovall, TG, Ling, FW. Nonsurgical treatment of ectopic pregnancy. N Engl J Med 2000;343:1325–1329.CrossRefGoogle ScholarPubMed
Practice Bulletin No 3.: Medical Management of Tubal Pregnancy. Washington, DC, American College of Obstetricians and Gynecologists, 1998.
Libscomb, GH, et al. Predictors of success of methotrexate treatment in women with tubal ectopic pregnancy. N Engl J Med 1999;341:1974–1978.CrossRefGoogle Scholar
Barnhart, KT, Gosman, G, Ashby, R, Sammel, M.The medical management of ectopic pregnancy: A meta-analysis comparing “single dose” and “multidose” regimens. Obstet Gynecol 2003;101:778–784.Google ScholarPubMed
Isaacs, JD, McGeheee, RP, Cowan, BD. Life-threatening neutropenia following methotrexate treatment of ectopic pregnancy: A report of two cases. Obstet Gynecol 1996;88:694–696.CrossRefGoogle ScholarPubMed
Gervaise, A, Masson, L, Tayrac, R, Frydman, R, Fernandez, H.Reproductive outcome after methotrexate treatment of tubal pregnancies. Fertil Steril 2004;82:304–308.CrossRefGoogle ScholarPubMed
Oloffson, JI, Poromaa, IS, Ottander, U, Kjellberg, L, Damber, MG. Clinical and pregnancy outcome following ectopic pregnancy: A prospective study comparing expectancy, surgery and systemic methotrexate treatment. Acta Obstet Gynecol Scand 2001;80:744–749.CrossRefGoogle Scholar
Shalev, E, Peleg, D, Tsabari, A, Romano, S, Bustan, M.Spontaneous resolution of ectopic pregnancy tubal pregnancy: Natural history. Fertil Steril 1995;63:15–19.CrossRefGoogle ScholarPubMed
Doubilet, PM, Benson, CB, Frates, MC, Ginsberg, E.Sonographically guided minimally invasive treatment of unusual ectopic pregnancies. J Ultrasound Med 2004;23:359–370.CrossRefGoogle ScholarPubMed
Strohmer, H, Obruca, A, Lehner, R, Egarter, C, Husslein, P, Feichtinger, W.Successful treatment of a heterotopic pregnancy by sonographically guided instillation of hyperosmolar glucose. Fertil Steril 1998;69:149–151.CrossRefGoogle ScholarPubMed
Lau, S, Tulandi, T.Conservative medical and surgical management of interstitial ectopic pregnancy. Fertil Steril 1999;72:207–215.CrossRefGoogle ScholarPubMed
Boyko, TR, O'Brien, JF. Cervical pregnancy: A case report. Ann Emerg Med 2001;38:177–180.CrossRefGoogle ScholarPubMed
Jabara, S, Barnhart, KT. Is Rh immune globulin needed in early first-trimester abortion? A review. Am J Obstet Gynecol 2003188:623–627.
Practice Bulletin No. 4: Prevention of Rh(D) Alloimmunization. Washington, DC, American College of Obstetricians and Gynecologists, 1999.
Gerton, GL, Fan, XJ, Sammel, M, Hummel, A, Strauss, JF, Barnhart, K.A serum proteomics approach to the diagnosis of ectopic pregnancy. Ann NY Acad Sci 2004;1022:306–316.CrossRefGoogle Scholar
Agarwal, SK, Wisot, AL, Garzo, G, Meldrum, DR.Cornual pregnancies in patients with prior salpin-gectomy undergoing in vitro fertilization and em-bryo transfer. Fertil Steril 1996 Mar;65(3): 659–60.CrossRefGoogle Scholar

Save book to Kindle

To save this book to your Kindle, first ensure [email protected] is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×