Reproductive outcome after methotrexate treatment of tubal pregnancies

Tubal Pathologies and Fertility Outcomes: A Review

Anomalies of the fallopian tubes represent one of the most significant elements that might contribute to reproductive issues. They can be inherited or acquired; they are among the most important problems of the profession. Although there is much discussion regarding which therapies for each tubal disease are the most effective and result in the best long-term reproductive outcomes. During the evaluation of an infertile couple, certain anomalies of the fallopian tubes are frequently discovered. These abnormalities were thought, for a long time, to not have an influence on fertility; however, in recent years, researchers have discovered that they seem to play a crucial role in fertility problems. Couples in industrialized countries are postponing childbearing, which raises the risk of women developing tubal diseases before they are ready to become pregnant. These disorders may have a negative impact on a woman's ability to get pregnant. The goals of this study are to conduct research to gain a deeper understanding of the recent advancements that have been made in the field of tubal diseases and to carry out an evaluation of the medical conducts that have the best fertility outcomes. We searched both Medline and PubMed, paying special attention to the most relevant articles that have been added to either database over the course of the last six years.

The Use of Single Dose Methotrexate in the Management of Ectopic Pregnancy and Pregnancy of Unknown Location: 10 Years’ Experience in a Tertiary Center

Objective

To study factors associated with the success of single dose methotrexate (MTX) treatment in women with ectopic pregnancy.

Methods

This is a retrospective study of women (n=110) with ectopic pregnancy and treated with single dose of MTX. The clinical presentations, transvaginal sonography (TVS) findings, pretreatment beta-human chorionic gonadotropin (β-HCG), and progesterone values were compared between the treatment success (Group S) and treatment failure (Group F) groups.

Results

The overall success rate of treatment with single dose of MTX was 75.45%. The majority of patients in both groups presented with pain and bleeding (~55%), and bleeding only was the presenting symptom in about 20% of patients. Only 3 patients (3.61%) in Group S required a repeat dose of MTX. In contrast, 51.8% of the Group F patients required a repeat dose. The mean pretreatment β-HCG level was 2.3 times higher in Group F than in Group S (1734±1684 vs 4036±2940 IU/L). The data showed a β-HCG level of 3924IU/L as a suitable cut-off value with 76.19% sensitivity and 62.5% specificity to predict MTX treatment success. History of ectopic pregnancy had no relation with success/treatment failure or a repeat dose. None of the TVS findings were related to the outcome of the treatment, whereas pretreatment HCG level was a significant predictor.

Conclusion

The single dose MTX treatment was successful in 75.45% (83/110) of cases, with 3.61% (3/83) requiring a repeat dose of the drug. Pretreatment β-HCG level is a significant predictor of the treatment outcome.

Cervical Ectopic Pregnancy in a 23 Year Old with Uterus Didelphys

Ectopic pregnancy remains an important diagnosis for the emergency physician to recognize, accounting for up to 2% of all pregnancies and associated with significant morbidity and mortality. Ectopic pregnancies can implant in various sites outside of the uterus, one of the rarest of which is in the cervix. Cervical ectopics account for less than 1% of ectopic pregnancies, but are associated with higher rates of significant bleeding than others.1–2 Uterine anomalies are a predisposing factor for ectopic pregnancies. This case highlights the management of a cervical ectopic pregnancy in a 23 year old with a history of uterine didelphys.

The impact of expectant management, systemic methotrexate and surgery on subsequent pregnancy outcomes in tubal ectopic pregnancy

BACKGROUND

The most common treatment modalities of ectopic pregnancy may influence long-term subsequent fertility outcomes in women who previously treated for ectopic pregnancy.

AIMS

Our objective was to compare long-term subsequent fertility outcomes after treatment with expectant management, systemic methotrexate (MTX) and surgery in tubal ectopic pregnancy.

METHODS

We searched our database for all women diagnosed with tubal ectopic pregnancy between January 2007 and January 2011 who were managed expectantly, with systemic MTX and with surgery. Treatment success and spontaneous pregnancy rates were compared in patients who desire to conceive following a tubal pregnancy.

RESULTS

One hundred twelve of 151 women desired to conceive following tubal ectopic pregnancy. Twenty-seven of 112 (24.1 %) patients were managed expectantly. Fifty-three (47.3 %) and 32 (28.5 %) patients were managed with systemic MTX or surgery, respectively. All patients in expectant and surgery groups were managed successfully. Two (3.7 %) patients had surgery after failed treatment with systemic MTX. Spontaneous intrauterine pregnancy rates were 62.9 % in expectantly managed women, 58.4 % in women with systemic MTX and 68.7 % in women with surgery (p > 0.05).

CONCLUSIONS

Treatment of ectopic pregnancy with either expectant management or systemic MTX is equally effective as compared to surgery. Spontaneous intrauterine pregnancy rates were comparable in expectant management, systemic methotrexate and surgery.

Ovarian reserve and subsequent assisted reproduction outcomes after methotrexate therapy for ectopic pregnancy or pregnancy of unknown location

OBJECTIVE

To assess ovarian reserve after methotrexate treatment for ectopic pregnancy or pregnancy of unknown location after assisted reproductive technology (ART).

DESIGN

Retrospective cohort study.

SETTING

Large ART practice.

PATIENT(S)

Women receiving methotrexate or surgery after ART.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Follicle-stimulating hormone (FSH), antral follicle count (AFC), and oocyte yield compared between women treated with methotrexate or surgery, with secondary outcomes of clinical pregnancy and live birth.

RESULT(S)

There were 153 patients in the methotrexate group and 36 patients in the surgery group. Neither group demonstrated differences in ovarian reserve or oocyte yield in a comparison of the before and after treatment values. The change in ovarian reserve and oocyte yield after treatment were similar between the two groups. The number of doses of methotrexate was not correlated with changes in ovarian reserve, indicating no dose-dependent effect. Time between treatment and repeat ART was not correlated with outcomes. Live birth in subsequent cycles was similar in the two groups.

CONCLUSION(S)

Ovarian reserve and subsequent ART cycle outcomes were reassuring after methotrexate or surgical management of ectopic pregnancy. No adverse impact of methotrexate was detected in this large fertility cohort as has been previously described elsewhere.

Low-dose methotrexate treatment in ectopic pregnancy: a retrospective analysis of 164 ectopic pregnancies treated between 2000 and 2008

PURPOSE

Ectopic pregnancy is an acute, potentially life-threatening condition. The aim of this study was to compare the results of surgery and methotrexate treatment in women with ectopic pregnancy, along with a review of the literature.

METHODS

164 women with ectopic pregnancy, treated from 2000 to 2008 at the university gynecology department, were examined in a retrospective analysis. Patients with diagnosed ectopic pregnancy underwent one of the following treatments: Salpingotomy, salpingectomy or administration of a single dose of 30 mg methotrexate. The main outcome measures were treatment success rate, rate of patients wishing to have children after the ectopic pregnancy, and rates of pregnancy, live births, recurrent ectopic pregnancy, miscarriage, use of assisted reproduction and side effects.

RESULTS

There were no significant differences in success rates between the groups (methotrexate 83.9 %, salpingotomy 88.2 %, salpingectomy 96.8 %). Significantly more patients in the salpingotomy group wished to become pregnant afterward than in the salpingectomy group. No significant differences were observed between the groups in the rates of intrauterine pregnancy, live births, recurrences, miscarriages, or side effects.

CONCLUSIONS

With defined inclusion criteria, similar results can be achieved with low-dose single administration of 30 mg methotrexate in comparison with surgical treatment for ectopic pregnancy. On the basis of the data presented here, further research to establish optimal dosages for methotrexate is needed.

Ultrasound monitoring in patients undergoing in-vitro fertilization after methotrexate treatment for ectopic pregnancy

OBJECTIVES

To compare sonographic characteristics of the endometrium and follicles during in-vitro fertilization (IVF) before and after methotrexate (MTX) treatment for ectopic pregnancy.

METHODS

This retrospective study, conducted at Conception Hospital from January 2000 to July 2007, included all patients diagnosed with an ectopic pregnancy resulting from IVF treatment that was treated with MTX and who then underwent another IVF cycle. We compared the number and size of follicles and the endometrial thickness and quality on the day of human chorionic gonadotropin injection in the cycles before and after the MTX treatment to determine whether MTX had any effect.

RESULTS

Eleven patients were included in the study. The median interval between the IVF cycle resulting in ectopic pregnancy and the first IVF cycle after MTX therapy was 180 (range, 150-900) days. There was no statistically significant difference between the before and after MTX treatment groups with respect to number of follicles (14 (3-20) vs. 9 (4-16), P = 0.12), follicle size (16.5 (14.7-21.7) mm vs. 17.8 (14.9-19.8) mm, P = 0.37), endometrial thickness (10.0 (9.5-12.0) mm vs. 10.0 (7.5-14.0) mm, P = 0.31) or endometrial quality (P = 0.32). Four women became pregnant during the IVF cycle following MTX treatment.

CONCLUSIONS

Ultrasound monitoring showed no modification of the characteristics of the endometrium or follicles during IVF after MTX treatment for ectopic pregnancy.

Combined local and systemic methotrexate treatment of viable ectopic pregnancy: outcomes of 31 cases

PURPOSE

Medical treatment of viable unruptured ectopic pregnancies by systemic methotrexate (MTX) is controversial due to elevated failure rates. This study describes a combined local and systemic MTX administration and compares the outcomes between viable ectopics in different locations.

METHODS

This retrospective study evaluated 31 patients treated with combined local (sonographically guided) and systemic MTX for viable, unruptured ectopic pregnancies. Success was defined by pregnancy resolution without surgical intervention. Details on subsequent pregnancies were obtained via telephone questionnaires.

RESULTS

The ectopic pregnancies were located in the fallopian tube (n = 23), cesarean section scar (n = 5), and intramural portion of the tube (interstitial pregnancy) (n = 3). beta-Human chorionic gonadotropin levels and gestational weeks were similar. The combined treatment was successful in 73.9%, 100%, and 66.7% of cases, respectively (p > 0.05). Details regarding reproductive outcomes were available for 28 women (90.3%). Eighteen of the 24 women attempting to conceive became pregnant, and 15 of these had at least one live birth. There were three subsequent tubal pregnancies, all in patients with previous tubal pregnancies.

CONCLUSION

Combined MTX administration is effective and safe for treating viable cesarean scar pregnancies but is less successful for viable tubal or interstitial pregnancies. Reproductive outcomes following the combined MTX treatment are comparable to other treatment modalities for ectopic pregnancy.

Does methotrexate treatment for ectopic pregnancy influence the patient's performance during a subsequent in vitro fertilization/embryo transfer cycle?

In a study on the influence of methotrexate (MTX) treatment on ovarian stimulation characteristics during the subsequent IVF cycle, 14 patients admitted to our department with the diagnosis of ectopic pregnancy and successfully treated with MTX were evaluated. No differences were observed in ovarian stimulation characteristics between the IVF cycle that had resulted in the ectopic pregnancy and the IVF cycle that followed MTX treatment. Treating ectopic pregnancy with MTX has no influence on patients' performance in the following IVF cycle.

The nonsurgical management of ectopic pregnancy

PURPOSE OF REVIEW

This review discusses the diagnosis and nonsurgical management of ectopic pregnancy.

RECENT FINDINGS

In the majority of cases the diagnosis of ectopic pregnancy should be made on transvaginal ultrasonography. Those for which the diagnosis is not made on the first scan may initially be classified as pregnancies of unknown location. There are now a number of strategies and mathematical models to predict ectopic pregnancy in this pregnancy of unknown location population. Reported success rates for expectant and medical management of ectopic pregnancy vary due to different inclusion criteria. A number of predictors of success have been studied: maternal age, previous obstetric history, gestational age, ultrasound features, human chorionic gonadotrophin levels, progesterone levels and the change in human chorionic gonadotrophin over time. At present the initial human chorionic gonadotrophin level probably remains the single most important predictor of success. Nonsurgical management is also particularly important for nontubal ectopic pregnancies: interstitial, cervical and caesarean section scar pregnancies.

SUMMARY

The majority of ectopic pregnancies can be visualized by ultrasound and so can be considered for conservative treatment. Nonsurgical management can be safe and effective. Appropriate selection criteria remain an issue, however, and a consensus needs to be reached on the predictors of success and failure to optimize management.

The non-surgical management of ectopic pregnancy

Ectopic pregnancy can now be detected at earlier gestations in asymptomatic women. As a consequence conservative treatment strategies may be more appropriate than surgical intervention. This review aims to discuss the diagnosis and the non-surgical management options for ectopic pregnancy, in particular expectant management and the use of methotrexate.