Severe spontaneous hemoperitoneum in pregnancy may be linked to in vitro fertilization in patients with endometriosis: a systematic review

Obstetricians should be alert to severe spontaneous hemoperitoneum in pregnancy, which although very rare, is potentially fatal. In vitro fertilization in women with severe endometriosis may be a risk factor.

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Volume 106, Issue 3, Pages 692-703


Ivo A. Brosens, M.D., Ph.D., Marit C. Lier, M.D., Velja Mijatovic, M.D., Ph.D., Marwan Habiba, Ph.D., Giuseppe Benagiano, M.D., Ph.D.



To evaluate existing evidence of a possible association in women with endometriosis between controlled ovarian hyperstimulation plus embryo transfer (COH-ET) and the occurrence of spontaneous hemoperitoneum in pregnancy (SHiP).


Comprehensive review.


Not applicable.




An electronic literature search up to February 2016 was conducted using Scopus and PubMed.

Main Outcome Measure(s)

The role of COH-ET in SHiP.


Controlled ovarian hyperstimulation plus embryo transfer may increase the severity or incidence of the rare condition known as SHiP. An analysis of published cases shows that bleeding often occurs from multiple or diffuse sites, mainly situated in the posterior pelvic cavity, making it difficult to control without interfering with the pregnancy itself. Spontaneous hemoperitoneum in pregnancy is linked to adverse perinatal outcomes, including stillbirth, neonatal mortality, and very low or low birth weight. In 14 cases a biopsy of the bleeding site was obtained, and in all cases, even in the absence of visible endometriosis, decidualization was documented. At present, the relatively small number of cases published prevents firm conclusions, although they are highly suggestive of a link between COH-ET in women with endometriosis and the occurrence and seriousness of SHiP.


Spontaneous hemoperitoneum in pregnancy is a rare but potentially fatal complication for the pregnant woman and her unborn child. In vitro fertilization in women with severe endometriosis may be a risk factor for SHiP.

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Fertility and Sterility

Editorial Office, American Society for Reproductive Medicine

Fertility and Sterility® is an international journal for obstetricians, gynecologists, reproductive endocrinologists, urologists, basic scientists and others who treat and investigate problems of infertility and human reproductive disorders.