Fertility outcomes subsequent to treatment of tubal ectopic pregnancy in younger Turkish women

The effects of conservative and surgical approaches in tubal ectopic pregnancy on fertility

BACKGROUND

Medical treatment, expectant approaches, and surgical treatment options are available in the treatment of ectopic pregnancy. Regardless of the treatment, in addition to its effectiveness, the main concern is to limit the risk of relapse and preserve fertility.

OBJECTIVES

Determine the impact of medical or surgical treatment for ectopic pregnancy on future fertility.

DESIGN

Retrospective.

SETTING

Department of obstrtrics and gynecolgy at Ankara Etlik Zübeyde Hanım Women's Health Training and Research Hospital, Ankara, Turkey.

PATIENTS AND METHODS

Patients who were treated for ectopic pregnancy between June 2016 and November 2019 were allocated into two groups. Expectant approach or medical treatment by methotrexate constituted the conservative treatment group while salpingectomy by laparoscopy indicated the surgical treatment group.

MAIN OUTCOME MEASURES

Fertility rates within two years following treatment were evaluated according to treatment options.

SAMPLE SIZE

202 patients.

RESULTS

Of the 202 patients, 128 had medical treatment and 74 patients had surgical treatment for ectopic pregnancy. Of 272 diagnosed with ectopic pregnancy, 70 were excluded for various reasons. Parity and unemployment rate was significantly higher in the surgical treatment (P=.006 and P=.12, respectively). Moreover, ectopic mass size and serum β-hCG levels were significantly higher in the surgical treatment group (P<.001 and P<.001, respectively). There were no significant differences between the conservative and surgical treatment groups in time to pregnancy (17.0 months vs 19.0 months, P=.255). Similarly, there was no significant difference between the conservative and surgical treatment groups with respect to history of infertility (P=.12). There were no significant differences between the conservative and surgical treatment groups in terms of live birth (51.6% vs 44.6%) and ectopic pregnancy (2.3% vs 1.4%) (P=.72 for both). There was no significant difference between the conservative and surgical treatment groups with respect to infertility rate (35.9% vs 41.9%, P=.72) and admittance to the IVF program (3.9% vs 6.8%, P=.39) following ectopic pregnancy treatment.

CONCLUSIONS

Reproductive outcomes did not differ significantly in women undergoing expectant management, medical treatment, and surgery for ectopic pregnancy. This finding suggests that clinicians should not hesitate to act in favor of surgical treatment for ectopic pregnancy even if there were concerns for future fertility.

LIMITATIONS

Retrospective study.

The impact of systemic methotrexate and surgical management on fertility preservation in tubal ectopic pregnancy among Saudi women

BACKGROUND

The impact of various management plans on subsequent fertility after tubal ectopic pregnancy (EP) is not well known. The objective of the present study was an evaluation of the subsequent fertility outcome among women with EP managed either surgical or medical with systemic methotrexate or medical management followed by surgical one.

PATIENTS AND METHODS

A retrospective cohort study was done by reviewing of medical records of all women diagnosed with EP at King Faisal Military Hospital, Southern Region, Saudi Arabia throughout the period from January 2015 to December 2016 provided that they were hemodynamic stable, with starting βhCG level less than 10000 IU/L, and adnexal mass less than 5 cm. These cases were followed for four years from January 2017 to December 2020.

RESULTS

The study included 85 women with EP. Their mean age was 31.3 ± 6.7 years. Medical management (systemic Methotrexate) was followed in 48.2% of cases whereas surgical management was applied for 43.5% of them while medical management followed by surgical one was seen in 8.2% of cases. Complete follow-up throughout 2017-2020 was available for 52 women. A history of recurrent EP was observed among 3 women (5.8%). Most of them (75%) had a viable pregnancy. There was no statistically significant association between the method of management of EP and subsequent fertility, although the rate of normal pregnancy (intrauterine viable pregnancy ≥ 24 weeks which is the age of viability at our hospital) was higher among those managed surgically or by medical followed by surgical management than those managed medical only (84.6% and 100% vs. 62.5%).

CONCLUSION

Although the normal pregnancy rate was higher among those managed surgically or by medical followed by surgical management than those managed medically only, this was not statistically significant.

Reproductive outcomes of ectopic pregnancy with conservative and surgical treatment: A systematic review and meta-analysis

BACKGROUND

Ectopic pregnancy (EP), one of the most common gynecological emergencies, is the major cause of maternal death in the first trimester and increases the incidence of infertility and repeat ectopic pregnancy (REP). The aim of this study was to compare the effects of different treatment methods for tubal EP on natural pregnancy outcomes.

METHODS

We systematically searched PubMed, Embase, Cochrane Library, Web of Science, and Clinical Trials for observational studies on EP (published until October 30,2022 in English) comparing methotrexate (MTX) versus surgery, MTX versus salpingostomy, MTX versus salpingectomy, salpingostomy versus salpingectomy, and MTX versus expectant treatment. Our main endpoints included subsequent natural intrauterine pregnancy (IUP) and REP. We assessed the pooled data using Review Manager software (version 5.3) with a random effects model.

RESULTS

Of 1274 identified articles, 20 were eligible and 3530 participants were included in our analysis. There was a significant difference in the odds of subsequent IUP in tubal EP patients who underwent MTX compared with those who were treated with surgery [odds ratios (OR) = 1.52, 95% confidence interval (CI):1.20-1.92]. No significant difference was found in the odds of REP between the 2 groups (OR = 1.12, 95% confidence interval [CI]: 0.84-1.51). There was no significant difference in the odds of subsequent IUP and REP in patients after MTX compared to those after salpingostomy (OR = 1.04,95% CI: 0.79-1.38; OR = 1.10, 95% CI: 0.64-1.90). There was a significant difference in the odds of subsequent IUP in patients after MTX compared with those after salpingectomy (OR = 2.11, 95% CI: 1.52-2.93). No significant difference was found in the odds of REP between the 2 groups (OR = 0.98, 95% CI: 0.57-1.71). There was a significant difference in the odds of subsequent IUP between patients who underwent salpingostomy and those who underwent salpingectomy (OR = 1.61, 95% CI: 1.29-2.01). No significant difference was found in the odds of REP between the 2 groups (OR = 1.21, 95% CI: 0.62-2.37). There was no significant difference in the odds of subsequent IUP and REP in patients after MTX compared with those after expectant treatment (OR = 1.25, 95% CI: 0.64-2.45; OR = 0.69, 95% CI: 0.09-5.55).

CONCLUSION

For hemodynamically stable tubal EP patients, MTX has advantages over surgery, particularly salpingectomy, in improving natural pregnancy outcomes. However, MTX is not inferior to salpingostomy and expectant treatment.

Tubal ectopic pregnancy: a retrospective cohort study on clinical characteristics, treatment options and reproductive outcomes within 5 years

PURPOSE

To investigate the association between different treatments of tubal ectopic pregnancy (EP) -expectant management, methotrexate (MTX), selected or recommended laparoscopic surgery-and the subsequent reproductive outcomes.

METHODS

We conducted a retrospective cohort study including 228 EPs. The patients were divided into four treatment groups: 28 (12.3%) with expectant management successfully, 60 (26.3%) with MTX successfully, 140 patients with laparoscopic salpingectomy, of which 47 (20.6%) were assigned to selected surgery group because they opted for surgical treatment versus MTX, 93 (40.8%) were assigned to recommended surgery group as recommended by the attending physician.

RESULTS

The recommended surgery group had the lowest rate of intrauterine pregnancy (IUP) (77.42%) and live birth (LB) (72.04%), while the incidence of recurrent EP (REP) (20.43%) was the highest, but the statistical differences were not significant. We did not observe significant differences of the EP-IUP time interval, rates of LB and miscarriage (MIS) between the four groups. Compared to the MTX group, recommended surgery was negatively associated with IUP (adjusted OR, 95%CI: 0.34, 0.11-1.03) and LB (0.35, 0.14-0.92), while it had higher risk for REP (3.48, 1.03-11.74) in the subsequent pregnancy. Further, compared to selective surgery group, recommended surgery was negatively associated with IUP (0.15, 0.03-0.68) and LB (0.23, 0.07-0.74), while it had higher risk for REP (6.83, 1.43-32.67) in the subsequent pregnancy. Expectant treatment was negatively associated with assisted reproductive technology (ART) (0.08, 0.02-0.40) compared with MTX. Of the185 patients who had LBs, all adverse outcomes were not statistically different between the four groups.

CONCLUSION

Patients with recommended laparoscopic salpingectomy had worse reproductive outcomes than the other treatment groups. The disease status of EP may play an important role in the association rather than the surgery alone.

Comparisons of Fertility Outcomes Following a Salpingectomy and a Salpingotomy with or Without Suturing for a Tubal Ectopic Pregnancy

Objective

This study aimed to compare fertility outcomes in patients who underwent different laparoscopic surgeries and to determine the most beneficial surgical treatment for tubal ectopic pregnancy (EP) patients who wished to become pregnant in the future.

Methods

In this retrospective study, patients aged 18–36 years, who had been diagnosed with a tubal EP in our hospital, were enrolled. Based on the treatment methods, the patients were divided into three groups, ie a salpingectomy group, a salpingotomy with suturing group and a salpingotomy without suturing group. The follow-up time for the enrolled patients was more than three years. Serum beta (β)-human chorionic gonadotropin (β-HCG) levels were monitored after surgery. The intrauterine pregnancy (IUP) rate at 12, 24 and 36 months postoperatively, and recurrent EP rate were compared.

Results

The median time for β-HCG level returning to normal in the salpingectomy group was much shorter than in the salpingotomy with suturing or salpingotomy without suturing groups (P < 0.001). The 12, 24 and 36-month IUP rates among the three groups were not significantly different. A recurrent EP was found in only one patient in the salpingotomy with suturing group and two patients in the salpingotomy without suturing group.

Conclusion

In this study, we found that salpingectomy and salpingotomy with or without suturing methods reflected no significant differences in fertility outcomes for tubal EP patients.

Factors Associated with Ruptured Ectopic Pregnancy: A 10-Year Review at a District Hospital in Ghana

Background

Approximately 1–2% of all pregnancies are ectopic. Despite a decline in ectopic pregnancy-related mortality, there is still a paucity of information on the factors associated with clinical presentation and outcomes in Sub-Saharan Africa which is essential in determining the most appropriate treatment modalities.

Methods

We performed a ten-year retrospective chart review of cases of ectopic pregnancies managed at the Lekma hospital and assessed them for peculiar risk factors, clinical presentation, and outcomes. Associations between patients' sociodemographic characteristics, clinical presentation, and treatment outcome were evaluated using multiple logistic regression and reported as adjusted odds ratios (AOR). The confidence interval (CI) was set at 95%, and a p value <0.05 were considered significant.

Results

Over the ten-year period, there were 115 ectopic pregnancies and 14,450 deliveries (7.9/1,000). The mean age ± standard deviation of the 115 patients was 27.61 ± 5.56. More than half of the patients were single (59/115, 51.3%). The majority (71.3%) of the patients presented with a ruptured ectopic pregnancy. After adjusting for covariates, the odds of an ectopic pregnancy presenting as ruptured among single patients was 2.63 times higher than that of married patients (AOR = 3.63, 95% CI: 1.33–9.93, p=0.01). Ectopic pregnancies located in the isthmic region of the tube had a 77% lower odds of presenting as ruptured than those located in the ampullary region (AOR = 0.23, 95% CI: 0.07–0.74, p=0.01). The odds of rupturing were 1.69 times increased for every additional week after the missed period (AOR = 2.69, 95% CI: 1.56–4.64, p < 0.01). No mortalities were reported as a result of an ectopic pregnancy.

Conclusion

Most of the cases of ectopic pregnancy presented ruptured. Marital status and period of amenorrhoea were significantly associated with rupture.

Preliminary hysteroscopic tubal hydrotubation improves fertility outcomes after laparoscopic salpingotomy for tubal ampullary pregnancy

Background

Salpingotomy may change the anatomical structure and patency of the fallopian tube, which may affect the fallopian function. This study is to investigate the clinical efficacy of preliminary hysteroscopic tubal hydrotubation (HTH) after laparoscopic salpingotomy for tubal ampullary pregnancy.

Methods

A retrospective study was carried out, 140 women underwent laparoscopic salpingotomy for ampullary pregnancy from March 2013 to March 2017. Some patients received HTH in the 1st month and hysterosalpingography (HSG) in the 3rd month after salpingotomy (HTH group; n = 95), and some patients only received HSG in the 3rd month after salpingotomy (control group; n = 45). Clinical data, tubal patency and fertility outcome were evaluated after follow-up of 15 months.

Results

The tubal patency rate of the operated side was significantly higher in the HTH group than that in the control group (89.47% vs 68.89%, P < 0.05). The intrauterine pregnancy (IUP) rate was significantly higher in the HTH group (76.47% vs 51.11%, P < 0.05), and the recurrent ectopic pregnancy rate in the operated side was significantly lower in the HTH group than in the control group (9.41% vs 22.22%, P < 0.05). Logistic regression analysis showed that the positive factor for IUP was HTH (OR = 3.109, 95% CI 1.439–6.714, P = 0.004), while the negative factors were history of pelvic inflammatory disease (PID) (OR = 0.167, 95% CI 0.074–0.377, P < 0.001) and history of tubal infertility (OR = 0.286, 95% CI 0.113–0.723, P < 0.05).

Conclusion

Preliminary HTH after laparoscopic salpingotomy for ampullary pregnancy could improve reproductive function and lead to a better fertility outcome. Patients without history of PID or tubal infertility may be the most suitable ones for HTH after salpingotomy.

Fertility outcomes subsequent to medical and surgical treatment for ectopic pregnancy: A retrospective cohort study in Iran

Background

Ectopic pregnancy (EP) and its treatment methods may affect subsequent fertility outcomes.

Objective

To compare methotrexate (MTX), laparoscopic salpingostomy, and salpingectomy methods of EP treatment and their effects on fertility outcomes.

Materials and Methods

This retrospective cohort study was performed on women receiving a definitive diagnosis of tubular EP from 2014 to 2017 at Arash Medical Center, Tehran, Iran. In total, 194 women were studied, of which 64 were treated with MTX, 52 underwent salpingostomy, and 78 underwent salpingectomy, depending on their clinical status. Basic information, obstetrics history, and major outcomes of the treatment after an 18-month follow-up, including recurrence of EP, miscarriage, and successful intrauterine pregnancy (IUP), were recorded and variables were compared among the three groups.

Results

There was no significant difference in fertility outcomes among the three groups. Among the studied variables, predictors of successful IUP after EP treatment were multiparity (Hazard Ratio (HR): 1.37; 95%CI: 1.06-1.77), no history of miscarriage (HR: 2.37; 95%CI: 1.01-5.56), and a higher number of live births (HR: 1.54; 95%CI: 1.01-2.37). On the other hand, predictors of EP recurrence included nulliparity (HR: 1.61; 95%CI: 1.02-2.53) and a lower number of live births (HR: 3.84; 95%CI: 1.43-10.98). The effect of other factors, including the utilized therapeutic modalities, was not statistically significant.

Conclusion

The current study results demonstrated that after an 18-month follow-up, fertility outcomes, including recurrence of EP and successful IUP, were not significantly different among the subjects with EP treated with MTX, salpingostomy, or salpingectomy. Further studies with long-term follow-ups are recommended.

A Systematic Review and Meta-analysis of Surgical Treatment of Ectopic Pregnancy with Salpingectomy versus Salpingostomy

OBJECTIVE

To evaluate the fertility outcomes of salpingectomy compared with those of salpingostomy among patients treated for tubal ectopic pregnancies, including a separate analysis of women with risk factors along with a review of the surgical technique.

DATA SOURCES

Systematic review and meta-analysis from 1990 to the present through PubMed, Embase, CINAHL, and Ovid MEDLINE. The search string included "tubal pregnancy" or "ectopic" as well as "salpingectomy" and various terms describing salpingotomy.

METHODS OF STUDY SELECTION

Articles studying women who underwent surgical management of an ectopic pregnancy and the contrasted outcomes of salpingectomy vs salpingostomy were reviewed. The primary outcomes included subsequent intrauterine pregnancy (IUP) and repeat ectopic pregnancy (REP).

TABULATION, INTEGRATION, AND RESULTS

Two randomized controlled trials (RCTs), which consisted mostly of patients classified as low risk, and patients from 16 cohort studies were included. In the RCTs, there was no significant difference in the odds of subsequent IUP in patients who underwent a salpingectomy compared with those who were treated with salpingotomy (odds ratio [OR] 0.97; 95% confidence interval [CI], 0.71-1.33). However, a significant and clinically meaningful difference was noted in the cohort studies, with the patients having a lower chance of IUP after salpingectomy (OR 0.45; 95% CI, 0.39-0.52). No significant difference was noted in the OR for a REP in the randomized trials (OR 0.77; 95% CI, 0.41-1.47), but the patients followed in the cohort studies had a cumulatively higher risk of REP after a salpingostomy (OR 0.73; 95% CI, 0.60-0.90). The subgroup analysis examining women within the studies with risk factors for tubal pathology found an even more impressive lowering in the odds of a subsequent IUP in patients classified as at-risk who were treated with salpingectomy (OR 0.30; 95% CI, 0.17-0.54), with a change in the direction of the odds for an REP rate favoring those who were treated with salpingostomy (OR 1.96; 95% CI, 0.88-4.35).

CONCLUSION

Salpingectomy has clear advantages over salpingostomy, and RCTs consisting mainly of patients classified as low risk show no difference in outcomes between salpingectomy and salpingostomy. However, in cohort studies inclusive of all patients, the likelihood of a subsequent spontaneous IUP is decreased in patients treated with salpingectomy, and salpingostomies may be especially underused in women with risk factors for tubal disease.

Fertility and reproductive outcome after tubal ectopic pregnancy: comparison among methotrexate, surgery and expectant management

Purpose

To compare fertility and reproductive outcome after surgical, medical, and expectant management for tubal ectopic pregnancy (EP).

Methods

133 of 228 patients, who were managed between January 2012 and December 2017 for a tubal EP, tried to conceive immediately after treatment: 86 out of 173 (49.7%) underwent surgical treatment; 38 (21.9%) were treated with methotrexate (MTX), and 49 (28.3%) had expectant management. Clinical data were retrieved by medical records, fertility outcomes were obtained by phone follow-up. The cumulative incidence (CI) of intrauterine clinical pregnancy (CP), miscarriage, live birth (LB), and recurrent EP, and the time between treatment and first intrauterine CP were compared between women treated with MTX, surgery and expectant management.

Results

The CI of intrauterine CP starting from 12 months after the EP was 65.3% for the expectant management, 55.3% for the MTX group, and 39.5% for surgery (p = 0.012). Post-hoc analysis showed expectant management having higher intrauterine CP and LB, and shorter time between treatment and first intrauterine CP compared to surgery (p < 0.05). The CI of recurrent EP was comparable between the 3 groups. The analysis stratified per βhCG cut-off of 1745 mUI/mL and EP mass cut-off of 25 mm reported consistent results.

Conclusions

Women successfully managed by expectation appear to have better reproductive outcomes compared to women who underwent surgery, with the shortest time to achieve a subsequent intrauterine CP. Therefore, if safely applicable the expectant management should be considered in the case of tubal EP. The fact that the chosen treatment was primarily guided by the βhCG value and EP mass diameter based on the protocol, which is intrinsically related to the characteristics of the EP, represents the main limitation of the present study. Indeed, we cannot completely exclude that the observed differences between treatments are related to the EP itself instead of the treatment.

Risk factors and clinical characteristics of recurrent ectopic pregnancy: A case-control study

OBJECTIVE

To compare signs and symptoms between patients with recurrent ectopic pregnancies (REP) and primary ectopic pregnancies (PEP) and to identify potential risk factors of REP.

MATERIALS AND METHODS

Data from 2014 to 2016 were analyzed. The study included 81 women each diagnosed with REP and PEP with no recurrence of ectopic pregnancy (EP) before January 2019. Information, including historical factors and findings at presentation of both group were collected. Data were compared between the two groups. Associations between REP and the risk factors were analyzed by logistic regression.

RESULTS

The findings revealed that compared to the patients in the PEP group, REP patients had significantly lower education (P = 0.001), higher proportion of previous infertility (P < 0.001) and different methods of PEP treatment (P = 0.001). Clinical data of the last operation revealed significantly higher occurrences of pelvic and peritubal adhesions (P < 0.05). Further multiple regression analysis showed that lower educational background (odds ratio [OR] = 4.183 95% confidence interval [CI] 1.311-13.344 P = 0.016), nulliparity (OR = 12.312 95% CI 3.382-44.824 P < 0.001), history of salpingotomy (OR = 7.129 95% CI 1.022-49.748 P < 0.05) and abortion (OR for one abortion = 21.576, P = 0.001; OR for two abortions =36.794, P < 0.001; OR for three abortions or more = 119.013, P < 0.001) were significant risk factors for REP.

CONCLUSION

Active education on contraception is required for patients with lower educational level and history of abortion. Different plans should be formulated for patients with EP. For EP patients wanting fertility, the risk between fertility preservation and REP needs to be evaluated as reproductive function cannot be pursued blindly while ignoring the risk of recurrence.

From β-hCG values to counseling in tubal pregnancy: what do women want?

Tubal pregnancy represents an entity that every gynecologist will encounter during professional life. Because of the high prevalence among the pregnant population, standardized protocols are needed in order to choose the optimal strategy for each case. Accurate ultrasound pictures are supporting a more precise diagnosis of ectopic tubal pregnancy, the evolution of which should be closely monitored in follow-up with serial β-hCG values. Laparoscopy, intramuscular methotrexate, and active expectant management are all involved, however, tailoring the best treatment to the patient's needs is the challenge to focus on. This manuscript describes how in routinary practice an evidence-based diagnostic process should be the key factor to go for the best possible management. When possible, a longsighted less invasive approach should be preferred, aiming to preserve the patient's fertility for years to come. An optimal choice of the management should involve the patient or the couple in the decision-making process to reach the ultimate goal of compliance.

A new tubal classification system for fertility prognosis after laparoscopic salpingostomy for tubal pregnancy

OBJECTIVE

To assess the objectivity and accuracy of a new system that predicts the pregnancy outcomes in patients with tubal pregnancy after laparoscopic salpingostomy.

STUDY DESIGN

480 tubal pregnancy patients were retrospectively stratified as mild, moderate, or severe group according to the new tubal classification system in which pelvic adhesions, tubal morphology, structure, and patency were included. The follow-up was performed for 24 months to determine spontaneous pregnancy outcomes.

RESULTS

The tubal classification was significantly associated with intrauterine pregnancy rates (mild 70.9% vs. moderate 66.0% vs. severe 41.8%, P=0.001) and recurrent ectopic pregnancy rates (mild 2.8% vs. moderate 4.2% vs. severe 10.9%, P=0.047). The 24-month cumulative rate of intrauterine pregnancy was 73.5% in the mild group, 68.5% in the moderate group, and 45.8% in the severe group (P=0.002). The 24-month cumulative repeat ectopic pregnancy rate was 6.6% in the mild group, 9.1% in the moderate group, and 15% in the severe group (P=0.154). In Cox multivariate regression analysis, a lack of a history of infertility [hazard ratio (HR)=0.633, P=0.001] and tubal scoring (mild HR=2.408, P=0.008; moderate HR=2.147, P=0.010) were significantly associated with a higher rate of spontaneous intrauterine pregnancy. Having a history of infertility (HR=0.351, P=0.037) and no prior abdominopelvic surgery (HR=2.907, P=0.014) were significantly associated with a lower ectopic pregnancy rate.

CONCLUSION

The new tubal classification system significantly correlated with spontaneous pregnancy outcomes in patients with tubal pregnancy following laparoscopic salpingostomy.

Comparison of the Fertility Outcome of Salpingotomy and Salpingectomy in Women with Tubal Pregnancy: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare the natural fertility outcomes of salpingotomy and salpingectomy among women treated for tubal pregnancy.

METHODS

An online database search including PubMed, Embase, CENTRAL and Web of Science was performed to identify studies comparing salpingotomy and salpingectomy to treat women with tubal pregnancy. The search included papers published after the databases were established until May 2015. Two reviewers independently screened literature according to the inclusion and exclusion criteria and then extracted data and assessed the methodological quality of all of the included studies. The meta-analysis was conducted using RevMan 5.3 software. The registration number is CRD42015017545 in PROSPERO.

RESULTS

Two randomized controlled trials (RCTs) and eight cohort studies, including a total of 1,229 patients, were znalyzed. The meta-analysis of the RCT subgroup indicated that there was no statistically significant difference in IUP rates (RR = 1.04, 95% CI = 0.89-1.21, P = 0.61) nor the repeat ectopic pregnancy (REP) rate (RR = 1.30, 95% CI = 0.72-2.38, P = 0.39) between the salpingotomy and salpingectomy group. In contrast, the cohort study subgroup analysis revealed that the IUP rate was higher in the salpingotomy group compared with the salpingectomy group (RR = 1.24, 95% CI = 1.08-1.42, P = 0.002); Salpingotomy also increased the risk of REP rate (RR = 2.27, 95% CI = 1.12-4.58, P = 0.02). The persistent ectopic pregnancy (PEP) occurred more frequently in the salpingotomy group than the salpingectomy group (RR = 11.61, 95% CI = 3.17-42.46, P = 0.0002). An IUP would be more likely to occur after salpingotomy than salpingectomy when the follow-up time was more than 36 months (RR = 1.16, 95% CI = 1.02-1.32, P = 0.03). The IUP rate (RR = 1.13, 95% CI = 1.01-1.26, P = 0.03), and the REP rate (RR = 1.62, 95% CI = 1.02-2.56, P = 0.04) was higher after salpingotomy than salpingectomy among patients from Europe compared with those from America.

CONCLUSIONS

Based on the available evidence, we believe that for patients with a healthy contralateral tube operated for tubal pregnancy, the subsequent fertility after salpingectomy and salpingotomy are similar in the long term. The fertility prospects will not be improved via salpingotomy compared with salpingectomy.

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.

Fertility outcome analysis after surgical management of tubal ectopic pregnancy: a retrospective cohort study

OBJECTIVES

To compare the subsequent fertility and risk of recurrence of an ectopic pregnancy (EP) in women who had had an EP, according to the type of surgical treatment they received--that is, salpingectomy, salpingostomy or tubal anastomosis.

METHODS

A retrospective cohort study was carried out between January 2003 and September 2011 of 618 patients admitted to hospital with tubal EP and who had received surgical treatment (salpingectomy, n=434; salpingostomy, n=112; and tube anastomosis, n=72). Main outcomes included the first intrauterine pregnancy (IUP) and recurrent EP.

RESULTS

The crude IUP rates up to 24 months after surgery were 55.5% for salpingectomy, 50.9% for salpingostomy and 40.3% for tubal anastomosis treatments. In the multivariate-adjusted model, with the patients receiving salpingectomy as the reference group, HR for patients after salpingostomy and tubal anastomosis treatments for IUP were 0.912 (95% CI 0.762 to 2.017) and 0.619 (95% CI 0.328 to 0.927), respectively. The 2-year cumulative recurrent EP rates were found to be 8.1% for salpingectomy, 6.3% for salpingostomy and 16.7% for tubal anastomosis treatments. Taking the patients receiving salpingectomy as the reference group, the patients who received tubal anastomosis had a positively higher risk of recurrent EP (HR=2.280; 95% CI 1.121 to 4.636) in univariate analysis. Adjustment for other potential confounders only slightly attenuated the HR.

CONCLUSIONS

The patients with an EP receiving tubal anastomosis treatments appeared to have a lower 2-year rate of IUP and a higher risk of recurrent EP after adjustment for other potential risk factors.

Laparoscopic management of interstitial pregnancy and fertility outcomes after ipsilateral salpingectomy - three case reports

Background: Interstitial pregnancy after ipsilateral salpingectomy is a rare event with potentially serious consequences. Optimal management strategy remains uncertain and debated. In addition, fertility sparing is determinant of the treatment choice.

Cases: Here, we report three cases of interstitial pregnancy occurring after homolateral salpingectomy. We expose the therapeutic option held in all three situations, which associated laparoscopic procedure followed by intramuscular methotrexate injection with successful outcome for all patients. We also report the fertility outcome for the first patient, discussing the timing and mode of delivery. Cesarean section at term was performed for this patient.

Conclusion: In these three situations, we obtained a successful result using a minimally invasive surgical approach combined with systemic methotrexate injection. Cesarean section at term for subsequent intrauterine pregnancy seems to be the safest delivery strategy, although no clear data exist in literature.

Fallopian tube: Its role in infertility and gynecological oncology

Disorders of the fallopian tube play a very important role in both infertility and gynaecological oncology. Tubal factor infertility is considered among the leading causes of female factor infertility. Many tubal disorders are related to infertility including congenital anomalies, acute and chronic inflammatory diseases, endometriosis and other pathologies that result in partial or total fallopian tube obstruction. In the field of gynaecological oncology, ovarian surface epithelial tumors remain one of the most fatal malignancies in women worldwide carrying the worst prognosis among female genital malignancies. For decades, the cell of origin of epithelial tumors has remained controversial and was largely believed to be surface ovarian epithelium. Recently several studies suggested that there is a major role of the fallopian tube in the development of ovarian surface epithelial tumors, mainly high grade serous carcinoma and other tumour types. In this article we review the role of the fallopian tube in both infertility and gynaecological oncology.