bilateral ectopic pregnancy is a rare condition and is divided in two subgroups , primary and secondary , based on history of assisted reproductive technology . a 30 year old primigravid woman with history of infertility and ovulation induction presented to a hospital in kashan in year 2013 . she had vaginal bleeding , abdominal pain and ultrasound findings suggested early pregnancy . due to high titer of -hcg , gestational trophoblastic disease was proposed and d8c was done in referral and admission to gyneco - oncology ward in tehran . repeat sonography suggested ectopic pregnancy in left side and repeat -hcg level showed an increase of 19435 miu / ml . bilateral ectopic gestation should be considered as a rare differential diagnosis for ectopic pregnancy . in this study , the implantation and development of fertilized ovum outside the uterine cavity is observed in approximately 2% of all pregnancies . over 95% of ectopic pregnancies because of the increase in incidence of sexually transmitted diseases , tubal surgery and more frequent use of ovulation induction and assisted reproductive technologies ( art ) , the incidence of ectopic pregnancies has grown in the last 30 years according to many reports from developed countries . ectopic pregnancy is still the leading cause of pregnancy - related deaths in developed countries ( 1 ) . however , bilateral tubal pregnancy is a rare clinical condition which occurs in only 1 per 200,000 pregnancies . this condition is divided in two subgroups , primary and secondary , and because of different physiopathological mechanisms , these two entities should be studied separately . however , as studies have shown , the cause of bilateral ectopic pregnancy after art is clearly different from spontaneous cases . clinical and paraclinical findings of this condition are the same as unilateral ectopic pregnancy so the distinct diagnosis is difficult ( 2 ) . in the present article , a case of bilateral tubal pregnancy a 30 year old primigravid woman has been hospitalized in kashan in year 2013 due to minimal vaginal bleeding and low abdominal pain . she had been under different treatments including sequential treatment with clomiphene , fsh and hmg in previous cycle . her last menstrual period was 8 weeks ago . in admission , vital signs were normal . the first transvaginal ultrasound revealed a suspicious gestational sac without yolk sac in uterus and normal adnexal area was reported . due to high level of -hcg ( 16000 miu / ml ) , without normal viable intrauterine pregnancy , dilatation and curettage had been done to clarify existence of intrauterine pregnancy or its complications or ep . due to high level of -hcg , gestational trophoblastic neoplasm was considered in differential diagnosis besides ectopic pregnancy and it resulted in gyneco - oncology consultation . the rise of -hcg level to 21770 miu / ml , 9 days after operation resulted in referral and admission of patients to gynecology - oncology ward of our center in tehran . positive findings in this admission to gynecooncology ward in tehran were low abdominal pain , minimal vaginal bleeding with stable vital signs similar to the ones observed in previous admission . through re - checking the -hcg level , titer of 19435 miu / ml was observed . the next ultrasound reported a normal uterus with endometrial thickening up to 11 mm , a heterogeneous mass measuring 49 mm in left adnex , suspicious to ectopic pregnancy and two simple cysts , 69 mm in left ovary and 50 mm in right ovary . there was no free fluid in the pelvic cavity . because of persistently high level of -hcg , surgical intervention was done . atypical findings and diagnosis of gtn besides fp led to choice of laparatomy instead of laparascopy . surgical findings were two bluish , 5 cm in left side and 2 cm in right side , swelling in both ampullary parts of fallopian tubes with minimal bleeding from fimbria . two simple cysts , about 5 cm in right ovary and 4 cm in left ovary were seen . bilateral salpingostomy was performed and some trophoblastic - like tissue was extracted and sent for pathologic evaluation separately . the patient received 50 mg / m intramuscular methotrexate due to bipateral fp and non - radical approach . secondary bilateral ectopic pregnancy is a condition with localization of trophoblastic tissue in both tubes , following a kind of manipulation in physiology such as through the use of art drugs . the classic triad of pain , vaginal bleeding and missed period was present , similar to unilateral ectopic pregnancy . in a study , 19 secondary bilateral tubal pregnancy cases were reviewed in an attempt to examine the symptoms and signs . diagnosis in this group was done due to discrepancy between sonography and -hcg level . in 6 out of 19 ( 31.6% ) cases , due to involvement of both fallopian tubes , probability of rupture is higher in comparison to unilateral ectopic gestation ( 2 ) . in the case of the present study , as a secondary bilateral ectopic gestation , high level of -hcg without intrauterine pregnancy suggested ectopic gestation and atypical high titer of hcg resulted in referral to a tertiary gyneco - oncology ward . in review of studies , mean gestational age at the time of diagnosis was about 6.7 weeks ( 5 - 9 weeks ) after the last menstruation ( 2 ) . sonographic findings and -hcg level , usually , do n't lead to a correct diagnosis of bilateral ectopic pregnancy . due to ample amount of -hcg during normal gestation , its level is not diagnostic ( 13 ) . in a review of hcg level in 16 cases of secondary bilateral tubal pregnancy , mean level of -hcg was 20878 miu / ml with a wide range of 27 - 226768 miu / ml . three cases out of 16 revealed -hcg titers of 13296 , 62520 and 226768 miu / ml ( 2 , 47 ) . in unilateral ectopic pregnancy , there is lower level of -hcg . in contrast to normal pregnancy with predictable range of -hcg in each week of gestation , in ectopic pregnancy it is more variable ( 2 , 3 ) . in our case , empty uterus coexisting with high level of -hcg suggested gestational trophoblastic disease ( gtn ) and ectopic pregnancy was less probable due to high atypical titer 21770 miu / ml hcg . high level of -hcg titer in bilateral ectopic gestation , such as above 10,000 in 3 case reports and our case and even 226768 miu / ml in a case report , proposed gtn as a reasonable differential diagnosis . however , pre - operative diagnosis of secondary bilateral ectopic pregnancy was made just in 10% of patients ( 2 ) . in our case , bilateral rupture of tubes was rare . in 5 out of 19 cases in a review of secondary bilateral ectopic pregnancy , unilateral tubal rupture in operative field bilateral unruptured tubal pregnancy in ampulary portion of tubes was seen . in our case , left tube was more distended , about 5 cm and right tube was 2 cm . in the review of bilateral tubal gestation in literature including primary and secondary cases , left tubal pregnancy was larger and more prone to rupture in comparison to right one . an attempt was made to review cases of medical literature which the side and size of rupture in bilateral tubal gestation was defined ( table 1 ) . medical treatment of these patients is not fully studied when pre - operative diagnosis is made . there are three surgical approaches for ectopic pregnancy : salpingotomy , salpingostomy and radical salpingectomy . regarding the future plan of fertility procedures , conservation or resection of fallopian tubes might be planned in the operation field ( 1 , 2 , 810 ) . in this case , size of right and left tube distention according to surgical findings in cases with bilateral ectopic pregnancy bilateral ectopic gestation , although rare , should be regarded as the differential diagnosis for ectopic pregnancy , especially in assisted reproductive technology cases and high titers of -hcg ( more than 100000 ) . left tubal side of bilateral tubal pregnancy was more probable to rupture and it revealed bigger size in review of cases .
backgroundbilateral ectopic pregnancy is a rare condition and is divided in two subgroups , primary and secondary , based on history of assisted reproductive technology.case presentationa 30 year old primigravid woman with history of infertility and ovulation induction presented to a hospital in kashan in year 2013 . 
 she had vaginal bleeding , abdominal pain and ultrasound findings suggested early pregnancy . due to high titer of -hcg , gestational trophoblastic disease was proposed and d8c was done in referral and admission to gyneco - oncology ward in tehran . 
 repeat sonography suggested ectopic pregnancy in left side and repeat -hcg level showed an increase of 19435 miu / ml . 
 laparotomy findings revealed bilateral ampullary ectopic pregnancy . 
 bilateral salpingostomy followed by one course of methotrexate was prescribed.conclusionbilateral ectopic gestation should be considered as a rare differential diagnosis for ectopic pregnancy . in this study , 
 bigger size and rupture in left side was observed .