Effect of methotrexate exposure on subsequent fertility in women undergoing controlled ovarian stimulation

Ovarian reserve in children with juvenile idiopathic arthritis using biologic disease-modifying anti-rheumatic drugs

BACKGROUND/OBJECTIVES

The aim of the study is to assess the effect of juvenile idiopathic arthritis (JIA) and biologic disease-modifying anti-rheumatic drugs (bDMARDs) on ovarian reserve in children.

MATERIALS AND METHODS

A cross-sectional study was performed from March 2021 to March 2022 and included 81 patients with JIA and 49 healthy children. Serum anti-Mullerian hormone (AMH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol levels were analyzed using electrochemiluminescence methods.

RESULTS

The mean of current age (13.5 ± 3.2 vs. 14.4 ± 2.4 years), height standard deviation score (SDS) (- 0.35 ± 1.18 vs. - 0.44 ± 0.94), body mass index SDS (0.12 ± 1.33 vs. 0.25 ± 1.28), and the median weight SDS (- 0.13 (- 2.27-3.23) vs. - 0.52 (- 3.4-3.3)) were similar in JIA patients and controls (p > 0.05). Patients with JIA were divided into two groups according to their treatment regimens: treated with methotrexate (MTX) (biologic naive) (n = 32) and treated with MTX plus bDMARDs (n = 49). No significant differences were detected between the 3 groups regarding menarche age, menstrual cycle length, and flow duration (for all p > 0.05). The median serum concentration of AMH was 2.94 (1.12-7.88) ng/ml in the control group, 3.02 (0.36-8.54) ng/ml in the biologic naïve group, and 3.01 (0.99-8.26) ng/ml in the MTX plus bDMARD group. There were no significant differences between 3 groups according to serum AMH, FSH, LH, and estradiol levels (p > 0.05).

CONCLUSION

Biologic DMARDs are reassuring in terms of ovarian reserve in girls with JIA and demonstrate that AMH is unaffected by treatment. Prospective studies with larger sample sizes are needed to confirm our findings and to evaluate the impact on the future fertility of patients. Key Points • Although biologic disease-modifying anti-rheumatic drugs (bDMARDs) are being game-changing treatment options in juvenile idiopathic arthritis, their effect on fertility and ovarian reserve is one of the most discussed issues. • In addition to treatment used, autoimmune diseases might also have a negative effect on fertility. • In this cross-sectional study, we found that anti-Mullerian hormone level of patients who were on bDMARDs, patients who were on methotrexate, and healthy controls were similar. • Our results suggest that bDMARDs are reassuring in terms of ovarian reserve in girls with JIA and demonstrate that AMH is unaffected by treatment.

Efficacy of transvaginal ultrasound-guided local injections of absolute ethanol for ectopic pregnancies with intrauterine implantation sites

BACKGROUND

Cervical pregnancies, interstitial tubal pregnancies, and cesarean scar pregnancies, which are ectopic pregnancies with intrauterine implantation sites exhibit increasing trends with the recent widespread use of assisted reproductive technologies and increased rate of cesarean deliveries. The development of high-sensitivity human chorionic gonadotropin testing reagents and the increased precision of transvaginal ultrasonic tomography have made early diagnosis possible and have enabled treatment. Removal of ectopic pregnancies using methotrexate therapy and/or uterine artery embolization has been reported. However, delayed resumption of infertility treatments after methotrexate therapy is indicated, and negative effects on the next pregnancy after uterine artery embolization have been reported.

AIM

To examine the efficacy and safety of ultrasound-guided topical absolute ethanol injection in ectopic pregnancies with an intrauterine implantation site.

METHODS

In this study, we retrospectively examined the medical records of 21 patients who were diagnosed with an ectopic pregnancy with an intrauterine implantation site at our hospital, between April 2010 and December 2018, and underwent transvaginal ultrasound-guided local injections of absolute ethanol to determine the treatment outcomes. We evaluated the treatment methods, treatment outcomes, presence of bleeding requiring hemostasis measures and blood transfusion, complications, and treatment periods. Successful treatment was defined as the completion of treatment using transvaginal ultrasound-guided local injections of absolute ethanol alone.

RESULTS

There were 21 total cases comprising 10 cervical pregnancies, 10 interstitial tubal pregnancies, and 1 cesarean scar pregnancy. All patients completed treatment with this method. No massive hemorrhaging or serious adverse reactions were observed during treatment. The mean gestation ages at the time of diagnosis were 5.9 wk (SD, ± 0.9 wk) for cervical and 6.9 wk (SD, ± 2.1 wk) for interstitial tubal pregnancies. The total ethanol doses were 4.8 mL (SD, ± 2.2 mL) for cervical pregnancies and 3.3 mL (SD, ± 2.2 mL) for interstitial pregnancies. The treatment period was 28.5 days (SD, ± 11.7 d) for cervical pregnancies and 30.0 ± 8.1 d for interstitial pregnancies. Positive correlations were observed between the blood β- human chorionic gonadotropin level at the beginning of treatment and the total ethanol dose (r = 0.75; P = 0.00008), as well as between the total ethanol dose and treatment period (r = 0.48; P = 0.026).

CONCLUSION

Transvaginal ultrasound-guided local injections of absolute ethanol could become a new option for intrauterine ectopic pregnancies when fertility preservation is desired.

Ultrasound-guided local ethanol injection for fertility-preserving cervical pregnancy accompanied by fetal heartbeat: Two case reports

BACKGROUND

The incidence of cervical pregnancy is increasing due to the recent widespread application of assisted reproductive technology. Although hysterectomy has been a treatment option, high-sensitivity human chorionic gonadotropin testing and improved accuracy of transvaginal ultrasound imaging have increased possibility of uterine preservation. Dilation and curettage with methotrexate therapy and uterine artery embolization have been reported as treatments with fertility preservation; however, certain disadvantages limit their use.

CASE SUMMARY

In our two reported cases, we avoided massive bleeding and immediately resumed infertility treatment using ultrasound-guided local ethanol injection for cervical pregnancies with fetal heartbeats.

CONCLUSION

This treatment may be a new fertility-preserving option for cervical pregnancy.

Pregnancy outcomes in patients with rheumatoid arthritis who discontinue methotrexate treatment to conceive

INTRODUCTION/OBJECTIVES

Rheumatoid arthritis (RA) develops at reproductive age. Methotrexate (MTX), the anchor drug for RA treatment, is contraindicated during pregnancy. We investigated pregnancy outcomes in RA patients in whom MTX was withdrawn.

METHOD

Pregnancy outcomes, RA treatment, and infertility factors were examined in patients with RA who discontinued MTX prior to attempting conception. The Mann-Whitney U test and Fisher's exact test were used to evaluate differences between the groups.

RESULTS

Of the 52 patients enrolled in this study, 33 gave birth after discontinuing MTX and 19 did not. The age at MTX discontinuation was significantly different between the childbirth and non-childbirth groups (p = 0.0258). The use of non-steroidal anti-inflammatory drugs (NSAIDs) and salazosulfapyridine was significantly different between the groups (p = 0.0079 and p = 0.0438, respectively). Patients whose time from MTX discontinuation to pregnancy was longer than 12 months had a longer previous MTX administration period (p = 0.0182) and were older at the time of pregnancy (p = 0.0128) than those whose was shorter.

CONCLUSIONS

The results suggest that to ensure successful childbirth in women with RA, the decision to conceive should be made at the youngest possible age, NSAIDs should not be used, and a shorter duration of MTX treatment should be considered before pregnancy. Nevertheless, additional studies with larger sample sizes are warranted to analyse the effects of other factors on pregnancies in patients with RA.

KEY POINTS

• Patients with RA who plan to conceive must discontinue MTX therapy. • To achieve successful pregnancy outcomes, female patients with RA should become pregnant when they are young, discontinue NSAIDs prior to conception, and shorten their durations of MTX therapy before attempting pregnancy.

Persistent follicular granulosa cell senescence and apoptosis induced by methotrexate leading to oocyte dysfunction and aberrant embryo development

Evidence from clinical cases indicates an association between the low success rate of in vitro fertilization (IVF) and ovarian injury due to previous methotrexate (MTX) administration. Therefore, it is necessary to develop and propose reasonable clinical drug guidelines to improve the quality of oocytes and the development of embryos before pregnancy. In this study, we established a mouse model with previous MTX exposure to validate the effects of MTX on reproductive function in female mice. We observed that MTX administration could result in a decrease in the success rate of fertilization and an aberrant embryonic development in both natural fertilization and IVF, even after completion of five to six ovulation cycles after MTX withdrawal. Further research revealed senescence and apoptosis of follicular granulosa cells (GCs), accompanied by arrested follicle development and aberrant estradiol and anti‐Mullerian hormone levels. Supportive evidence indicated that MTX administration induced senescence and apoptosis of human GCs in vitro, and the effects were consistent with the high levels of p21, p53, and oxidative stress. We further demonstrated that folic acid (FA) could improve oocyte function and embryonic development in vivo and in vitro by protecting GCs against apoptosis and senescence. Based on these findings, we propose the implementation of extended intervals between MTX exposure and conception or IVF and recommend FA as a special dietary supplement during this interval period; however, prospective inquiry in humans is necessary to further understand the relationship between MTX and FA recovery.

Methotrexate impaired in-vivo matured mouse oocyte quality and the possible mechanisms

Background

Methotrexate (MTX) is an antifolate agent which is widely used in clinic for treating malignancies, rheumatoid arthritis and ectopic pregnancy. As reported, MTX has side effects on gastrointestinal system, nervous system and reproductive system, while its potential damages on oocyte quality are still unclear. It is known that oocyte quality is essential for healthy conception and the forthcoming embryo development. Thus, this work studied the effects of MTX on the oocyte quality.

Results

We established MTX model mice by single treatment with 5 mg/Kg MTX. Both morphological and molecular biology studies were performed to assess the in-vivo matured oocytes quality and to analyze the related mechanisms. The in-vivo matured oocytes from MTX-treated mice had poor in-vitro fertilization ability, and the resulting embryo formation rates and blastocyst quality were lower than the control group. We found that the in-vivo matured MTX-treated mouse oocytes displayed abnormal transcript expressions for genes of key enzymes in the folate cycles. MTX increased the rate of abnormal chromosome alignment and affected the regulation of chromosome separation via disrupting the spindle morphology and reducing the mRNA expressions of MAD2 and Sgo1. MTX reduced the DNA methylation levels in the in-vivo matured oocytes, and further studies showed that MTX altered the expressions of DNMT1 and DNMT 3b, and may also affect the levels of the methyl donor and its metabolite.

Conclusions

MTX impaired the in-vivo matured mouse oocyte quality by disturbing folate metabolism and affecting chromosome stability and methylation modification.

Safety of fertility treatments in women with systemic autoimmune diseases (SADs)

Introduction: Systemic Autoimmune Diseases (SADs) include systemic lupus erythematosus, antiphospholipid antibody syndrome, rheumatoid arthritis, systemic sclerosis, Sjogren's syndrome, mixed connective tissue disease, idiopathic inflammatory myopathies and vasculitis. SADs often occur in women of childbearing age and can affect fertility. Both infertility treatments and fertility preservation techniques are thus often indicated. Areas covered: The literature regarding the safety of fertility-related drugs for both fertility preservation and infertility treatment in patients affected by SADs was reviewed. Based on current knowledge, all the options for fertility preservation should be contemplated in patients with SADs who are at risk for fertility loss, including GnRH analogue administration, oocyte/embryo vitrification and ovarian tissue cryopreservation. Similarly, if pregnancy is not contraindicated in a patient with a SAD, neither should be any fertility treatment. Expert opinion: Women with SADs should postpone conception until a stable disease has been achieved for at least 6 months. When infertility treatments are needed, women with antiphospholipid antibodies should receive concomitant anticoagulation. If in vitro fertilization/intra-cytoplasmic sperm injection and embryo transfer is required, ovarian hyperstimulation and the inherent risk of thrombosis should be eliminated by GnRH-agonist trigger and cycle segmentation. Counselling about adherence to anti-rheumatic therapy to prevent disease exacerbations is also critical.

Characteristics related to early secondary amenorrhoea and pregnancy among women diagnosed with systemic lupus erythematosus: an analysis using the GOAL study

Objective

Systemic lupus erythematosus (SLE) disproportionately affects women and often develops during their reproductive years. Research suggests that some women who receive cyclophosphamide as treatment for SLE experience earlier decline in menstrual function, but reproductive health among women with SLE who have not taken this drug is less well understood. This study aims to better understand the relation between SLE and reproduction by assessing early secondary amenorrhoea and pregnancy in women treated with and without cyclophosphamide from a population-based cohort with large numbers of African-Americans.

Methods

Female patients with SLE, ages 20–40 at time of diagnosis, who were 40 years or older at the time of the survey were included in this analysis (N=147). Participants in the Georgians Organized Against Lupus (GOAL) study were asked about their reproductive histories including early secondary amenorrhoea, defined as loss of menstruation before age 40.

Results

Women who were cyclophosphamide naïve had an increased prevalence of early secondary amenorrhoea compared with population estimates, 13–17% compared with 1–5%. Factors associated with early secondary amenorrhoea in women not treated with cyclophosphamide were marital status and receipt of a kidney transplant. Treatment with cyclophosphamide doubled the prevalence after adjustment for patient characteristics. Over 88% of women reported being pregnant at least once, and about 83% of these had a child, but the majority of pregnancies occurred before diagnosis.

Conclusions

SLE diagnosed in early adulthood may affect women's reproductive health even if they are not treated with cyclophosphamide. Better understanding of other factors related to reproductive health in this population will improve clinicians' and patients' abilities to make treatment and family planning decisions.

Endometrial changes after methotrexate treatment: Relation with multiple nabothian cysts and future pregnancies

A clinical study was conducted in order to validate the effect of methotrexate on 30 patients with ectopic pregnancy (EP). A typical ultrasound appearance of multiple cysts of Naboth in the cervix was observed on six cases that are studied below. Endometrial sample with endogyn was retrieved from the six cases after the treatment with methotrexate was complete. The cytological results were studied and there were many changes found in the endometrial cells, in their cores, and some inflammatory cells as well. Two out of the six cases studied show more profound evidence. The cellular appearance of the endometrium after the treatment is discussed, in relation to the presence of multiple Nabothian cysts, as a result of inflammatory reaction, and the possibility of any influence in the capacity for a future pregnancy.

Methotrexate treatment for ectopic pregnancy after assisted reproductive technology: A case-control study

OBJECTIVES

Ectopic pregnancy (EP) occurs in 2% to 5.6% of pregnancies achieved by assisted reproductive technology (ART). EP treatment options include medical treatment by uses of methotrexate (MTX) systemic injection. The objective of this study was to compare MTX treatment effectiveness for EP occurring spontaneously or following ART.

METHODS

A case-control study performed in the department of obstetrics and gynecology at a tertiary health care center in France. Twenty EP achieved by ART (ART group) and 60 spontaneous EP (SEP group) received MTX treatment between January 2002 and May 2012. The main outcome measures were MTX treatment failure rates, number of MTX injections administered and recovery time.

RESULTS

MTX treatment failure rates observed in ART and SEP groups were similar (3/20 [15%] versus 10/60 [17%]: OR=0.88 [0.22-3.58]). Mean duration of recovery time in patients with successful MTX treatment did not differ between ART and SEP groups (33±14 days versus 28±13 days, P=0.39). A second MTX injection was required more frequently in ART group than in SEP group (10/20 [50%] versus 10/60 [17%]: OR=5 [1.65-15.15]).

CONCLUSIONS

It is concluded that MTX treatment is equally effective for spontaneous EP and EP achieved by ART, two injections of MTX being more frequently required in case of ART.

Methotrexate does not affect ovarian reserve or subsequent assisted reproductive technology outcomes

PURPOSE

The purpose of this research was to study whether methotrexate (MTX) as treatment for ectopic pregnancy (EP) impacts the future fertility of women undergoing assisted reproductive technology (ART) METHODS: In a systematic review and multi-center retrospective cohort from four academic and private fertility centers, 214 women underwent an ART cycle before and after receiving MTX as treatment for an EP. Measures of ovarian reserve and responsiveness and rates of clinical pregnancy (CP) and live birth (LB) were compared in the ART cycles prior and subsequent to MTX.

RESULTS

Seven studies were identified in the systematic review, and primary data from four institutions was included in the final analysis. Women were significantly older in post-MTX cycles (35.3 vs 34.7 years). There were no differences in follicle stimulating hormone, antral follicle count, duration of stimulation, oocytes retrieved, or fertilization rate between pre- and post-MTX cycles. However, post-MTX cycles received a significantly higher total dose of gonadotropins (4206 vs 3961 IU). Overall, 42 % of women achieved a CP and 35 % achieved a LB in the post-MTX ART cycle, which is similar to national statistics. Although no factors were identified that were predictive of LB in young women, the number of oocytes retrieved in the previous ART cycle and current AFC were predictive of LB (AUC 0.76, 0.75) for the older women.

CONCLUSIONS

MTX does not influence ovarian reserve, response to gonadotropin stimulation, and CP or LB rate after ART. MTX remains a safe and effective treatment option for women with asymptomatic EPs.

Immunosuppressive drugs and fertility

Immunosuppressive drugs are used in the treatment of inflammatory and autoimmune diseases, as well as in transplantation. Frequently prescribed in young people, these treatments may have deleterious effects on fertility, pregnancy outcomes and the unborn child. This review aims to summarize the main gonadal side effects of immunosuppressants, to detail the effects on fertility and pregnancy of each class of drug, and to provide recommendations on the management of patients who are seen prior to starting or who are already receiving immunosuppressive treatment, allowing them in due course to bear children. The recommendations for use are established with a rather low level of proof, which needs to be taken into account in the patient management. Methotrexate, mycophenolate, and le- and teri-flunomide, cyclophosphamide, mitoxanthrone are contraindicated if pregnancy is desired due to their teratogenic effects, as well as gonadotoxic effects in the case of cyclophosphamide. Anti-TNF-alpha and mTOR-inhibitors are to be used cautiously if pregnancy is desired, since experience using these drugs is still relatively scarce. Azathioprine, glucocorticoids, mesalazine, anticalcineurins such as cyclosporine and tacrolimus, ß-interferon, glatiramer-acetate and chloroquine can be used during pregnancy, bearing in mind however that side effects may still occur. Experience is limited concerning natalizumab, fingolimod, dimethyl-fumarate and induction treatments. Conclusion: At the time of prescription, patients must be informed of the possible consequences of immunosuppressants on fertility and of the need for contraception. Pregnancy must be planned and the treatment modified if necessary in a pre-conception time period adapted to the half-life of the drug, imperatively in relation with the prescriber of the immunosuppressive drugs.

Ectopic pregnancy secondary to in vitro fertilisation-embryo transfer: pathogenic mechanisms and management strategies

BACKGROUND

Ectopic pregnancy (EP) is the leading cause of maternal morbidity and mortality during the first trimester and the incidence increases dramatically with in vitro fertilisation and embryo transfer (IVF-ET). The co-existence of an EP with a viable intrauterine pregnancy (IUP) is known as heterotopic pregnancy (HP) affecting about 1% of patients during assisted conception. EP/HP can cause significant morbidity and occasional mortality and represent diagnostic and therapeutic challenges, particularly during fertility treatment. Many risk factors related to IVF-ET techniques and the cause of infertility have been documented. The combination of transvaginal ultrasound (TVS) and serum human chorionic gonadotrophin (hCG) is the most reliable diagnostic tool, with early diagnosis of EP/HP permitting conservative management. This review describes the risk factors, diagnostic modalities and treatment approaches of EP/HP during IVF-ET and also their impact on subsequent fertility treatment.

METHODS

The scientific literature was searched for studies investigating EP/HP during IVF-ET. Publications in English and within the past 6 years were mostly selected.

RESULTS

A history of tubal infertility, pelvic inflammatory disease and specific aspects of embryo transfer technique are the most significant risk factors for later EP. Early measurement of serum hCG and performance of TVS by an expert operator as early as gestational week 5 can identify cases of possible EP. These women should be closely monitored with repeated ultrasound and hCG measurement until a diagnosis is reached. Treatment must be customised to the clinical condition and future fertility requirements of the patient. In cases of HP, the viable IUP can be preserved in the majority of cases but requires early detection of HP. No apparent negative impact of the different treatment approaches for EP/HP on subsequent IVF-ET, except for risk of recurrence.

CONCLUSIONS

EP/HP are tragic events in a couple's reproductive life, and the earlier the diagnosis the better the prognosis. Due to the increase incidence following IVF-ET, there is a compelling need to develop a diagnostic biomarker/algorithm that can predict pregnancy outcome with high sensitivity and specificity before IVF-ET to prevent and/or properly manage those who are at higher risk of EP/HP.

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.

Do you need to definitively diagnose the location of a pregnancy of unknown location? The case for "yes"

Pregnancy of unknown location (PUL) is a common diagnostic challenge. The primary diagnostic goal is to ensure that the PUL is nonviable prior to proceeding with any invasive procedures. In nonviable PUL, there are several diagnostic and treatment strategies, which are generally quite safe. However, the management option that provides the most definite diagnosis is uterine curettage. We advocate use of uterine curettage in all cases of nonviable PUL because it limits exposure to a chemotherapeutic agent to only those who need it and it allows for the most accurate information for counseling the patient on prognosis of future pregnancies.

Medical management of ectopic pregnancy: a comparison of regimens

Medical management has become increasingly popular in the treatment of ectopic pregnancy. Given its convenience, for many it is used as a first-line treatment, however, this is not always the optimal choice for the patient. It is important to understand the options for medical treatment and when it is appropriate to treat a particular patient with medical management, or when one should opt for surgical management. This review outlines the different regimens for methotrexate administration and the associated risks and benefits to medical management.

Protective effect of calcium folinate against methotrexate-induced endosalpinx damage in rats

The aim of this study was to evaluate the protective effect of calcium folinate (CF) applied in 10% of the methotrexate (MTX) dosage against morphologic and steroid-receptor damage induced by MTX in rat endosalpinx. The result indicated that endosalpingitis, the ultrastructural damage of endosalpinx, and a change in estrogen and P receptor expression induced by low- and high-dose MTX in endosalpinx can be reversed completely and partly (B1, B2) by combined treatment with CF, suggesting that CF combined with MTX protects against the side effects induced by MTX.

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.