Hysterosalpingographic evaluation of tubal patency after ectopic pregnancy

Methotrexate local injection for unruptured tubal pregnancy: an alternative to laparotomy?

Fifty-nine women with early unruptured tubal pregnancy were treated by a single local injection of methotrexate at laparoscopy. All 59 patients underwent the procedure without any adverse reaction, 47 (80%) of them needing no laparotomy. Twelve patients required a laparotomy for reasons such as rising beta-hCG levels and abdominal pain with or without rising levels of beta-hCG. Only one patient ruptured the tube. None of the women needed a blood transfusion. We found tubal patency in 19 out of 21 patients at follow up hysterosalpingography. Eleven pregnancies were subsequently reported, one of them tubal. The appearance of the injected tube was absolutely normal in three patients, one at cesarean section and two at repeated laparoscopy. No peritubal adhesions were observed. We suggest that this new technique is a safe and effective alternative to laparotomy in a patient with an early unruptured tubal pregnancy.

Conservative treatment of ectopic pregnancy

As a conservative nonsurgical treatment of an early ectopic pregnancy, local prostaglandin, parenteral or local methotrexate, local hyperosmolar glucose, and also expectant management have been used successfully in selected cases. The success rate of conservative treatment has been 71%-100% and that of tubal patency after different kinds of conservative treatment 72-93% of patients. In the present study of expectant management in early ectopic pregnancy in patients with decreasing serum hCG levels, spontaneous resolution was observed in 64.6% of patients and in the total series of 207 ectopic pregnancies in 15.0% of patients. Expectant management of early ectopic pregnancy is recommended when emergency surgery is not needed on admission and the serum hCG level is decreasing as noted in two consecutive estimations with an interval of 1-2 days.

Nonsurgical management of tubal pregnancy. Necessity in view of the changing clinical appearance

The incidence of ectopic pregnancy is definitely increasing. Ectopic pregnancies are diagnosed earlier these days because of the improvement in diagnostic means and the increasing awareness of the condition. It seems that there is a dramatic change in the clinical presentation of this disease; it used to be a grave and life-threatening condition, and now it is a more benign presentation. The vast majority of the diagnosed ectopic pregnancies are unruptured. This has stimulated various investigators to attempt nonsurgical methods of treatment such as systemic administration of methotrexate or RU 486 (mifepristone) or local injection of methotrexate, potassium chloride, or prostaglandins under laparoscopic or ultrasonographic guidance. Most of these conservative, nonsurgical measures proved efficient in 80% to 90% of cases. Expectant management, which was practiced in some cases, proved to be equally successful. We believe that the ideal mode of treatment in early unruptured ectopic pregnancy is still to be determined. The answer probably lies in proper selection.

Reproductive performance after methotrexate treatment of ectopic pregnancy

The purpose of this study was to examine return of reproductive potential, hysterosalpingographic findings, and time to conception in patients treated with methotrexate and citrovorum factor for unruptured ectopic pregnancy. Fifty-seven patients with unruptured ectopic pregnancies less than 3.0 cm in greatest dimension were treated with methotrexate and citrovorum factor. The mean time from resolution of the ectopic pregnancy to return of menses was 26.0 (0 to 157) days. Forty-four patients were available for follow-up (2 to 15 months). Nineteen of 23 patients who had hysterosalpingograms demonstrated patency in the ipsilateral tube. Fourteen patients desired pregnancy; 11 of 14 (78.6%) were successful, with 10 of 11 (90.9%) having an intrauterine pregnancy, whereas one of 14 (9.1%) were extrauterine gestations. The mean time from first attempt to achieving pregnancy was 2.3 (1 to 4) months. We conclude that methotrexate and citrovorum factor treatment of unruptured ectopic pregnancy is associated with subsequent tubal patency and does not impair return of menses. Most importantly, the pregnancy rates after this form of therapy appear to be better than those achieved by traditional surgical methods, and are comparable to results after laparoscopic salpingostomy.

First successful intrauterine pregnancy after treatment of tubal pregnancy with prostaglandin F2 alpha

A total of 41 patients with tubal pregnancies were treated by means of prostaglandin F2 alpha injected transabdominally into the fallopian tube. Hysterosalpingography showed tubal patency in 12 of 14 women. One intrauterine pregnancy most likely occurred via the prostaglandin-treated tube 3 months after treatment.

Fertility after ectopic pregnancy

In the period July 1983 to March 1985, 264 women had surgery for ectopic pregnancy at Grady Memorial Hospital; 76 had postoperative hysterosalpingograms. Of these, 55 (76.4%) women were followed up for 3 to 41 months (mean, 23.8) to determine subsequent fertility. During the follow-up period, 30 pregnancies occurred among the 55 patients; 24 were intrauterine and 6 were repeat ectopic pregnancies. In the surgical group of 39 patients with salpingectomy, 60.8% of those desiring pregnancy achieved an intrauterine pregnancy. Of the 12 patients with salpingostomy, the three who desired pregnancy achieved it (100%). In the tubal abortion group, the two women desiring pregnancy conceived (100%). There were six repeat ectopic pregnancies (10.9%). Of the ectopic pregnancies, one occurred in the salpingectomy group (2.6%), four in the salpingostomy group (33.3%), and one in the tubal abortion group (25%). Five of the six ectopic gestations were found in the contralateral fallopian tube. Hysterosalpingographic evidence of contralateral tubal patency was a good prognostic indicator for subsequent intrauterine pregnancy. By contrast, one half of study patients with findings suggesting tubal occlusion still achieved an intrauterine pregnancy.

Laparoscopic treatment of ectopic pregnancy

Over the last decade and a half the success and safety of endoscopic surgery for ectopic pregnancy has been established. Shapiro and Adler (1973) reported laparoscopic salpingectomy using electrocoagulation followed by excision. Soderstrom (1981) followed with the snare technique of salpingectomy. Valle and Lifchez (1983) reported tubal patency rates approaching and attaining 100% following salpingostomy in the sole oviduct during laparotomy encouraged continued laparoscopic approach. DeCherney (1981) described linear salpingostomy via a cutting current in 18 women with an intrauterine pregnancy rate of 50% 1 year afterwards. No spontaneous abortions or repeat ectopics were reported. Pouly et al (1986) described laparoscopic salpingostomy in 321 women with a resultant 64% intrauterine pregnancy and 22% repeat ectopic rate. These studies support the realization that previous surgical approaches per laparotomy for ectopic pregnancy may be achieved endoscopically, but intraoperative and postoperative complications have occurred. As noted by Kelly et al (1979) and Richards (1984) these consist mainly of persistent or delayed haemorrhage along with continued trophoblastic growth. Haemorrhage is most often a result of failed salpingostomy in larger ectopics. Continued trophoblastic development requiring repeat surgical exploration due to incomplete removal of tissue has been reported by Pouly (1986) in as many as 5% of cases. This rare but reported consequence signals the importance of following quantitative HCG concentrations into the negative range. Occasionally HCG levels remain elevated more than 30 days postoperatively with eventual resolution; Cartwright et al (1986) claim that tubal patency rates appear to be unaffected by this prolonged clearance of tissue. Despite infrequent morbidity, laparoscopic treatment of ectopic pregnancy, in comparison to laparotomy, significantly shortens hospital stays, operating time, convalescence and postoperative analgesic requirements (Brumsted et al, 1988). Endoscopic surgery also reduces postoperative formation of pelvic adhesions (Fayez and Schneider, 1987). As familiarity and technical expertise with endoscopy continues to increase, exploratory laparotomy may be considered too radical an approach to ectopic pregnancy treatment regardless of the procedure performed.