Ectopic pregnancy Quiz: Ace Your Exams

A 35-year-old woman presents to the emergency department with severe right-sided lower abdominal pain. She also has mild vaginal bleeding that she believes is the start of her menstrual period as her last cycle began 6 weeks ago. She currently uses a levonorgestrel-intrauterine device (LNG-IUD) for contraception and is sexually active with a single male partner. She has a history of a laparoscopic cholecystectomy 2 years ago for acute cholecystitis and an asymptomatic chlamydia infection 11 years ago that was diagnosed on routine screening and treated with antibiotics. She takes no oral medication. She drinks one glass of wine per night but does not smoke or use illicit substances. Temperature is 37.0 °C (98.6 °F), heart rate is 94 bpm, respirations are 19/min, and blood pressure is 122/80 mmHg. Body mass index is 32 kg/m². The physical exam is notable for significant right lower quadrant tenderness, a closed cervical os with a small amount of blood in the vaginal vault, and right adnexal tenderness on a bimanual exam. Human chorionic gonadotropin (hCG) level is 4,230 mIU/mL (reference range: <5 mIU/mL). Transvaginal ultrasound reveals the absence of an intrauterine gestational sac with a complex 2 cm right-sided adnexal mass. Which of the following clinical factors most likely increased this patient’s risk of developing the current condition?