Radical or conservative surgery for ectopic pregnancy? A follow-up study of fertility of 323 patients

Isolated Fallopian Tube Torsion: Diagnosis and Management of a Gynecologic Emergency

Isolated fallopian tube torsion (IFTT) is a rare gynecologic emergency that requires a high index of suspicion and immediate surgical intervention. IFTT is rarely diagnosed preoperatively due to the lack of pathognomonic signs and symptoms. A 15-year-old female with no medical history presented with acute lower abdominal pain, nausea, and a physical exam significant for diffuse abdominal tenderness to palpation. Ultrasound revealed a large cystic adnexal mass with patent vascular flow to the ipsilateral ovary. Vital signs were stable and laboratory evaluation was unremarkable. Due to an uncertain diagnosis and suspicion of incomplete ovarian torsion, a laparoscopy was performed, which revealed an IFTT and ipsilateral hemorrhagic ovarian cyst. Treatment consisted of unilateral salpingectomy with cystectomy. IFTT is a surgical emergency with nonspecific signs and symptoms. A high degree of clinical suspicion is needed for prompt management. Diagnostic laparoscopy can be a useful tool in the setting of an uncertain diagnosis.

Could serum β-hCG levels and gestational age be the indicative factors for the prediction of the degree of trophoblastic invasion into tubal wall in unruptured ampullary pregnancies?

OBJECTIVE

To evaluate the predictive value of gestational age and maternal serum β-hCG concentration for the determination of the depth of trophoblastic invasion into the tubal wall.

METHODS

This is a retrospective trial conducted on women with a diagnosis of ampullary pregnancy (71) who were submitted to salpingectomy. Serum β-hCG measurements were obtained at the initial admission of hospital. Histological investigation was performed by a single well-experienced pathologist who was blind to the clinical and laboratory characteristics of the patients. Ampullary pregnancy was classified histologically according to the depth of trophoblastic infiltration into tubal wall: trophoblast limited to the tubal mucosa (stage I), extended to muscularis layer (stage II) and complete tubal wall infiltration up to serosal layer (stage III).

RESULTS

There was a significant difference in maternal serum β-hCG concentrations regarding the histological stages of trophoblastic invasion. The serum β-hCG concentrations that the best predicted for stage III trophoblastic invasion was 6,475 mIU/ml, with a sensitivity of 100 %, a specificity of 92 %.

CONCLUSION

The depth of trophoblastic tissue infiltration into tubal wall is correlated with serum β-hCG levels, but not with gestational age. These findings may explain the reason for conservative management failure of EP in women with high β-hCG concentrations.

Fertility after tubal ectopic pregnancy: results of a population-based study

OBJECTIVE

To assess the reproductive outcome after an ectopic pregnancy (EP) based on the type of treatment used, and to identify predictive factors of spontaneous fertility.

DESIGN

Observational population based-study.

SETTING

Regional sistry.

PATIENT(S)

One thousand sixty-four women registered from 1992 to 2008.

INTERVENTION(S)

Laparoscopic (radical or conservative), or medical treatment.

MAIN OUTCOME MEASURE(S)

Epidemiologic characteristics, clinical presentation, treatments performed, reproductive outcome, recurrence.

RESULT(S)

The 24-month cumulative rate of intrauterine pregnancy (IUP) was 67% after salpingectomy, 76% after salpingostomy, and 76% after medical treatment. IUP rate was lower after radical treatment compared with conservative treatments in univariable analysis. In multivariate analysis, IUP rate was significantly lower for patients >35 years old or with history of infertility or tubal disease. For them, IUP rate was significantly higher after conservative treatment compared with salpingectomy. The 2-year cumulative rate of recurrences was 18.5% after salpingostomy or salpingectomy and 25.5% after medical treatment. History of infertility or of previous live birth would be protective, in contrast to history of voluntary termination of pregnancy.

CONCLUSION(S)

Conservative strategy seems to be preferred, whenever possible, to preserve patients' fertility without increasing the risk of recurrence. The choice between conservative treatments does not rely on subsequent fertility, but more likely on their own indications and therapeutic effectiveness. Risk factors of recurrence could be considered for secondary prevention.

[Risk factors for recurrence of ectopic pregnancy]

OBJECTIVES

Investigate and identify the risk factors influencing the recurrence of ectopic pregnancies.

PATIENTS AND METHODS

The Auvergne ectopic pregnancy registry data were analyzed from 1992 to 2008. The appearance of a recurrence was studied among 1108 women from 18 to 44 years old, who attempted to conceive again.

RESULTS

One hundred and sixteen repeated ectopic pregnancies occurred (10.5 %) during the period under study. The rate of recurrence was significantly higher among women who had a history of voluntary termination of pregnancy (P=0.01). Conversely, fewer recurrences (P=0.01 and 0.0478) occurred among women having a history of infertility or previous live birth. The treatment for ectopic pregnancy, whether it is conservative or radical laparoscopic, or medical with methotrexate did not significantly influence the recurrence rate (P=0.86).

CONCLUSION

Reproductive history appears to involve the risk of repeated ectopic pregnancy and must be taken into account in their secondary prevention. As for the choice of treatment, the risk of recurrence does not seem to constitute a decisive argument.

[Fertility after ectopic pregnancy]

BACKGROUND

The subsequent fertility of women who had experienced ectopic pregnancy (EP) is the best criteria of the effectiveness of the treatment. In the absence of randomised trials comparing laparotomy, laparoscopy, medical treatment by methotrexate (MTX) and expectative, the only way to compare treatments is to make use of data from observational studies.

METHODS

The databases consulted were Medline, Cochrane Library, National Guideline Clearinghouse and Health Technology Assessment Database. Keywords used for research: fertility; ectopic pregnancy; expectative; methotrexate; salpingectomy; salpingotomy.

RESULTS

Twenty-four papers of randomised control trial (RCT) or observational studies were analysed. No difference between laparotomy and laparoscopy for fertility was found. Tubal suture does not modify the subsequent fertility. The risk of normal pregnancy or ectopic recurrence is similar between salpingotomy or salpingectomy when controlateral tube is normal. Conversely, in case of altered tube, the fertility appears higher after conservative treatment. Between conservative treatments, surgical or medical, no difference appears.

CONCLUSIONS

Conservative surgical treatment is the gold standard. However, the fertility seems similar with the other treatments. Three ongoing RCT could answer to the three main questions: Which is the best fertility between medical and conservative surgical treatment? Which is the best fertility between radical and conservative surgical treatment? Which is the best fertility between MTX and expectative?

Analysis of metallothionein, RCAS1 immunoreactivity regarding immune cell concentration in the endometrium and tubal mucosa in ectopic pregnancy during the course of tubal rupture

INTRODUCTION

Tubal rupture seems to be linked to a disturbance in maternal immune response and trophoblast cell invasion. The immunomodulating activity of endometrial cells is necessary for the coexistence of activated immune cells and endometrial cells. RCAS1 and metallothionein (MT) participate in this process.

MATERIAL AND METHODS

Tissue samples derived from fallopian tubes and endometrium were collected during one surgical procedure and divided into three groups: unruptured ectopic pregnancy (EP) without bleeding, unruptured EP with hemorrhage into the peritoneal cavity, and ruptured tubal pregnancy. Immunoreactivity of MT, RCAS1, CD56, CD3, CD69 and CD25 were assessed by immunohistochemical methods.

RESULTS

The number of CD3+ and CD56+ cells as well as CD69 antigen immunoreactivity in ruptured tubal mucosa of EP were statistically significantly higher than those measured for unruptured EP without bleeding, while at the same time the number of CD56+ cells in endometrium was statistically significantly lower. The growth of immune cell numbers in tubal mucosa during tubal rupture was not associated with an adequate MT and RCAS1 level.

CONCLUSION

Tubal perforation seems to be linked to a concentration of immune cells and a growth of their activity without an adequate increase of the level of proteins compensating for immune cell response.

Reproductive outcome after methotrexate treatment of tubal pregnancies

OBJECTIVE

To evaluate reproductive outcome after ectopic pregnancy (EP) treated with methotrexate (MTX) and to assess the relative contribution of various risk factors to future fertility.

DESIGN

Telephone follow-up interviews in a cohort of patients treated for EP.

SETTING

University hospital.

PATIENT(S)

A cohort of 158 patients treated with MTX for tubal pregnancies between April 1991 and March 1999.

INTERVENTION(S)

Assessment of fertility outcomes.

MAIN OUTCOME MEASURE(S)

Cumulative pregnancy rates for intrauterine and ectopic pregnancies.

RESULT(S)

Thirty-two patients (20.2%) were lost to follow-up. Of 126 patients, 93 (73.8%) sought to become pregnant, and of these 93 women, 76 (81.7%) did. Sixty-four pregnancies were spontaneous, and 12 resulted from in vitro fertilization (IVF). No pregnancies occurred in the group not trying to become pregnant. Of the 64 spontaneous pregnancies, 52 (81.2%) were intrauterine, with 12 (18.7%) resulting in miscarriages, and 12 (18.7%) were recurrent ectopic pregnancies. The cumulative intrauterine pregnancy rate was 57.5% after 1 year and 66.9% after 2 years. The cumulative ectopic pregnancy rate was 15.4% after 1 year and 23.7% after 2 years. After adjusting for factors associated with fertility with a Cox regression, only one factor was associated with poor reproductive performance: previous history of infertility.

CONCLUSION(S)

Within 1 year of seeking to become pregnant, more than half the women previously treated medically for EP conceived and had ongoing pregnancies. Our analysis indicates that fertility depends more on the patients' previous medical history than on her treatment for EP.

[Fertility after ectopic pregnancy: the population-based register of the urban area around Lille, Northern France]

The aims of this work were the evaluation of the reproductive outcome after ectopic pregnancy, and the assessment of the role of infertility risk factors and treatment's strategy. All patients in the population-based register of the urban area around Lille, Northern France, were followed-up. 345 women treated between April 1994 and March 1997, who were trying to become pregnant were interviewed by telephone every 6 months and then every year. The cumulative pregnancy rates were calculated by the Kaplan-Meier estimation. Associations between infertility risk factors and intrauterine pregnancy were tested by the logrank test, and by a Cox model for multivariate analysis. The mean duration of follow-up was 22 months, and 228 (66%) women had obtained a new pregnancy at the time of the analysis. 23 (10%) of the first pregnancies were recurrences. For women for whom EP occurred with an IUCD (17 patients), the 1 year intrauterine pregnancy (IUP) reached 67%. For the others, the 1 year IUP rate was 56%, and reached 67% after 2 years. After adjusting factors associated with fertility with a Cox regression, 3 factors seemed to lower reproductive performances: age > 35 years, previous history of infertility, and anterior tubal damage. More than half the women treated for EP obtained spontaneously a normally progressive pregnancy after 1 year. Reproductive performances are associated with characteristics of the patients, but do not depend on radical or conservative treatment.

Ectopic pregnancy from surgical emergency to medical management

During the past 25 years, the incidence of ectopic pregnancy has progressively increased while the morbidity and mortality have substantially decreased, and the treatment has progressed from salpingectomy by laparotomy to conservative surgery by laparoscopy and more recently to medical therapy. This therapeutic transition from surgical emergency to medical management has been attributed to early diagnosis through the use of sensitive assays for hCG and the high definition of vaginal ultrasound. By using these sensitive diagnostic tools, we are now able to select those patients who are most likely to respond to medical management versus those who are at high risk of rupture and require surgery. Besides being less invasive and associated with significantly lower risks, medical therapy with methotrexate results in significant cost savings, which have been calculated to be approximately $3,000 per treated patient. Our goal is to identify those patients with ectopic pregnancy who are most likely to respond to methotrexate therapy and least likely to develop significant side effects. Recent studies have helped us define the predictors of success with methotrexate treatment in women with ectopic pregnancy. The reported success rates of treating ectopic pregnancy with methotrexate vary from 71% to 100%. The highest success rates have been reported from institutions that have detailed diagnostic and therapeutic protocols, readily available assays for serum hCG levels, high-resolution vaginal probe ultrasound, and support staff that can closely monitor clinical response. The importance of developing specific protocols to create a clinical environment that supports the effective use of medical therapy for ectopic pregnancy is confirmed by the associated cost savings, decreased morbidity, and patient preference. Modern diagnostic advances and minimally invasive treatments coupled with improved success rates for assisted reproductive technologies should reduce the morbidity and mortality associated with ectopic pregnancy and offer the affected couple a much more optimistic outlook for subsequent reproductive potential.

Survival analysis of fertility after ectopic pregnancy

OBJECTIVE

To evaluate the reproductive outcome after ectopic pregnancy and to assess the contribution of risk factors to future fertility.

DESIGN

Prospective follow-up in a population-based sample.

SETTING

Register of ectopic pregnancies established in an urban area around Lille, France.

PATIENT(S)

Three hundred and twenty-eight women treated between April 1994 and March 1997 who had not been using an IUCD at the time of the ectopic pregnancy and were trying to become pregnant.

INTERVENTION(S)

Interviews by telephone every 6 months for 2 years and once yearly thereafter.

MAIN OUTCOME MEASURE(S)

Cumulative pregnancy rate.

RESULT(S)

Two hundred fifteen (65.5%) women became pregnant after a mean of 5 months. One hundred eighty-two (84.7%) pregnancies were intrauterine; 22 (10.2%) were recurrent ectopic pregnancies; and in 11 women (5.1%), it was too early to define implantation. The cumulative intrauterine pregnancy rate was 56% at 1 year and 67% at 2 years. After applying Cox regression, three factors associated with fertility seemed to decrease reproductive performance: age > 35 years, history of infertility, and anterior tubal damage .

CONCLUSION(S)

More than half of the women treated for ectopic pregnancy spontaneously conceived and had a normally progressive pregnancy at 1 year. Fertility depends more on established patient characteristics than characteristics of ectopic pregnancy itself or treatment thereof.

Fertility following radical, conservative-surgical or medical treatment for tubal pregnancy: a population-based study

OBJECTIVE

To investigate the factors influencing the choice of treatment for ectopic pregnancy and to compare the subsequent fertility rates of radical, conservative-surgical or medical treatments.

DESIGN

Population-based study of 835 ectopic pregnancies registered between 1992 and 1996.

SETTING

Auvergne Ectopic Pregnancy Register (France).

SAMPLE

Four hundred and seventy-six women with tubal ectopic pregnancy who were not using contraception at the time of conception. Subsequent fertility was studied for the 291 women who attempted to conceive again.

METHODS

Comparison of reproductive outcomes according to ectopic pregnancy treatment. Cumulative fertility curves were calculated by the Kaplan-Meier estimator and compared by log rank test for univariate analysis and by Cox regression to take into account confounding variables.

MAIN OUTCOME MEASURE

Recurrence and fertility rates after ectopic pregnancy.

RESULTS

The first treatment given was 'radical' for 178 women (37%), 'conservative-surgical' for 262 (55%), and 'medical' for 35 (8%). The treatment failed in 1% for radical treatment, 5% for conservative-surgical treatment, and 36% for medical treatment. The two-year cumulative rate of recurrence was 27% with no significant difference between treatments. For women with previous infertility factors (in particular diseased contralateral tube), the treatments differed significantly, with the rate of intrauterine pregnancy lower for radical treatment and higher for medical treatment than for conservative-surgical treatment. For women with no infertility factor, there was no significant difference between treatments.

CONCLUSIONS

These results should be confirmed in a controlled trial. The results of this study provide the elements necessary to plan such a trial.

Fertility outcome following combined methotrexate treatment of unruptured extrauterine pregnancy

OBJECTIVE

To assess the effectiveness of systemic treatment with methotrexate in combination with local injection for unruptured tubal pregnancy, and to evaluate reproductive function following treatment.

DESIGN

Prospective, open clinical study.

SETTING

University clinic.

POPULATION

Sixty-seven women with unruptured tubal pregnancy.

METHODS

Systemic methotrexate (intramuscular methotrexate 0.5 mg/kg for up to five days) in combination with local application of 12.5 mg methotrexate via laparoscopy.

MAIN OUTCOME MEASURES

The subsequent surgical intervention required and future fertility.

RESULTS

In 89.6% of women no further surgical intervention was required and 47 women (81%) experienced subsequently an intrauterine pregnancy. In 39 of 40 women who underwent hysterosalpingography following treatment, patency of the affected tube was observed.

CONCLUSIONS

Combined local and systemic methotrexate treatment for unruptured tubal pregnancy seems to be more effective than each therapeutic modality alone.

Ectopic pregnancy

Ectopic pregnancy occurs in approximately 2% of all pregnancies in the United States, and is the nation's leading cause of first trimester maternal death. Its incidence has increased sixfold in the past 25 years, despite significant improvements in techniques for early diagnosis and management. This article reviews the epidemiology, risk factors, and common clinical presentations of ectopic pregnancy. Both traditional and newly developed strategies for diagnosis and management are described. The primary care physician is in an excellent position to screen for and diagnose ectopic pregnancy, and to counsel patients regarding treatment options and future risks. With the increasing trend toward outpatient nonsurgical management of ectopics, it is expected that the roll of the primary care physician in managing patients with ectopic pregnancy will continue to increase.

Complications of laparoscopy. Strategies for prevention and cure

With a detailed knowledge of pelvic anatomy, familiarity with the many laparoscopic instruments, and attention to the details of good technique, many of the complications of laparoscopy described in this article can be avoided. The information presented complements that in the other articles in this issue and briefly summarizes many salient lessons already published in other excellent texts. The focus is on the most common laparoscopic complications, namely, those associated with insufflation and trocar insertion, such as vascular injury and bowel perforation. Other complications that may arise during adhesiolysis, removal of and bleeding from an ectopic pregnancy, and specimen removal from the abdomen are also discussed.

Current status of surgical and nonsurgical management of ectopic pregnancy

OBJECTIVES

To review the efficacy, safety, costs, and subsequent reproductive outcome of surgical and nonsurgical management of ectopic pregnancy (EP).

DESIGN

Pertinent studies were identified through computer Medline search. The rates of intrauterine pregnancy (IUP) and EP were calculated from the raw data in the original publications so that the denominator would be consistent.

RESULT(S)

The efficacy of laparoscopic treatment of EP is similar to that by laparotomy. The rate of persistent EP after conservative surgery ranges from 3% to 20%. Based on a review of 1,514 patients attempting to conceive after linear salpingostomy, the IUP and recurrent EP rates were 61.4% and 15.4%, respectively, among patients who had laparotomy, and 61% and 15.5%, respectively, among patients who had laparoscopic procedure. Of 3,584 patients who had partial or total salpingectomy, the subsequent IUP rate was 38.1% and the recurrent EP rate was 9.8%. Of 540 patients treated with a single-dose methotrexate, 84% did not require further treatment and, among 215 patients who attempted to conceive, 54% had subsequent IUP and 8% had recurrent EP. The success rate of expectant management was 69.2% in 347 patients reviewed.

CONCLUSION(S)

There is no difference in the reproductive outcome after treatment of EP by laparotomy and by laparoscopy. Salpingostomy is associated with higher subsequent IUP and recurrent EP rates compared with salpingectomy. Methotrexate is a viable alternative to laparoscopic salpingostomy for a selected group of patients.

Laparoscopic surgical treatment of ectopic pregnancy: salpingectomy or salpingostomy?

There is a widespread belief that salpingostomy is the treatment of choice for ectopic pregnancy. The ability to treat most ectopic pregnancies via a laparoscopic approach has been a major advance in gynaecological surgery. Despite the well publicized benefits of laparoscopy over laparotomy only 50% of patients with ectopic pregnancies in Australia presently benefit from this surgical advance. Although it is clear that laparoscopic treatments are preferable to laparotomy there is no consensus on whether salpingectomy or salpingostomy should be performed, despite over 40 years of research since the introduction of conservative tubal treatment. A systematic review of laparoscopic surgical treatment is needed and could be incorporated into the Cochrane Collaboration. A prospective clinical study, with long-term follow-up, needs to be performed to evaluate fertility prognosis and complications after laparoscopic salpingectomy versus salpingostomy.

Endoscopic surgery in gynecologic practice

In recent decades, the operative approach for several gynecologic diseases has changed from laparotomy to laparoscopy. New techniques and indications are continuously being developed. Laparoscopy offers a lot of advantages for the patient, but still a lot of additional data are required to determine the exact indications. Operative laparoscopy requires not only skill and experience, but also specialized equipment and paramedical staff. The most important topics for the gynecologist will be reviewed in this article.

Systemic treatment of ectopic pregnancies with single-dose methotrexate

STUDY OBJECTIVE

To evaluate the success rate, side effects, reproductive outcome, and possible pitfalls of systemic low-dose methotrexate (MTX) for treatment of ectopic pregnancy (EP).

DESIGN

Longitudinal, nonrandomized trial Setting. Department of Obstetrics and Gynaecology at a teaching hospital in Germany.

PATIENTS AND INTERVENTIONS

Forty women with EP were treated with a single dose of MTX 20 to 40 mg intravenously. The highest pretreatment human chorionic gonadotropin (hCG) titer was 21,100 mIU/ml.

MEASUREMENTS AND MAIN RESULTS

Thirty-seven patients (92.5%) were treated successfully. Thirty-four (85%) received a single dose of MTX. Six (15%) required a second dose about a week later. Three patients (7. 5%) required surgical intervention. Serum MTX levels decreased below 0.1 micromol/L (45.4 microg/L) within 24 hours. In 53.8% of women hCG levels decreased directly after treatment; in 46.2% levels increased within the first 5 days after treatment.

CONCLUSIONS

In selected patients, systemic low-dose MTX is an effective way to treat EP, and has no demonstrable side effects.

Ectopic pregnancy

Ectopic pregnancy remains a diagnostic and management challenge for nurse practitioners. The incidence and physiology of ectopic pregnancy, the current research on risk factors, detection methods, and management techniques, and counseling strategies are reviewed in this article. In addition, a protocol for nurse practitioners to improve the management and possibly lessen the serious impact of this challenging complication of pregnancy will be discussed.

Fertility after ectopic pregnancy

OBJECTIVES

To compare pregnancy rates (PRs) after radical or conservative surgical treatment for tubal pregnancy over a 12.5-year interval (minimum of 3 years) and to assess the relative contribution of various risk factors to future fertility performance.

DESIGN

A retrospective cohort study examining the influence of various risk factors on PRs with stepwise discriminant analysis using a jackknife-type validation program.

PATIENTS

Eighty-eight Olmsted County, Minnesota, women who presented over a 10-year interval with their first ectopic pregnancy (EP), undergoing either radical or conservative surgery at laparotomy, who actively attempted conception after surgery and who were available for follow-up at Mayo Clinic.

MAIN OUTCOME MEASURES

The primary end point for analysis was the occurrence of a livebirth or EP at 3 years of follow-up after the index EP.

RESULTS

No difference in PR was identified in patients treated with radical or conservative surgery. Patients who underwent conservative surgery had a higher risk of subsequent EP. Patients with a prior history of infertility had significantly reduced fertility potential.

CONCLUSIONS

Prior history of infertility was the most significant determinant for fertility potential after surgical treatment for EP. Patients with prior infertility had markedly impaired fertility after surgical treatment of EP, and outcome was not influenced by choice of surgical procedures. Patients without prior infertility had comparable encouraging fertility potential with both conservative and radical therapy. These findings have relevance for future management of infertility in affected patients.

Fertility outcome after conservative surgical treatment of ectopic pregnancy evaluated in a randomized trial

OBJECTIVE

To evaluate the fertility outcome after laparoscopic surgery for ectopic pregnancy.

DESIGN

A randomized trial versus laparotomy was performed between May 1987 and June 1989.

SETTING

The study was conducted in a clinical university center, the Sahlgrens Hospital.

PATIENTS

A group of 105 patients with tubal pregnancy were stratified with regard to risk determinants and age and randomized to laparoscopy or laparotomy. Eighty-seven patients who desired pregnancy were evaluated for subsequent fertility outcome.

INTERVENTIONS

Linear salpingotomy was performed in both surgical groups.

MAIN OUTCOME MEASURE

We evaluated the fertility outcome after laparoscopic salpingotomy for comparison with the outcome after laparotomy.

RESULTS

There was no difference between the groups in the overall fertility outcome. A substantially higher proportion of patients in the laparotomy group were subjected to adhesiolysis performed at a second-look laparoscopy.

CONCLUSIONS

The fertility prospects are not impaired by laparoscopic surgery. Adhesiolysis at a second-look laparoscopy, especially after laparotomy, might be beneficial in selected cases and may serve to improve subsequent fertility.

Advancing conservative treatment of ectopic pregnancy--laparoscopic and "non-surgical" management

Improvements in diagnostic measures have contributed to the earlier diagnosis of ectopic pregnancy which in turn has led to the development of new and alternative methods of managing tubal pregnancies. Laparoscopic salpingotomy offers advantages such as a reduction in operating time and shorter hospital stays and convalescence as compared with conventional abdominal surgery. Furthermore, neither the frequency of persistent trophoblasts nor of second operations is increased, and the subsequent fertility rate is at least equal to that after laparotomy. "Non-surgical" treatment of ectopic pregnancy, such as systemic administration of methotrexate and laparoscopic/transvaginal ultrasonic--guided local injection of methotrexate, prostaglandins or hyperosmolar glucose, are attractive alternative methods in selected cases. These methods are safe and effective and have a high success rate and promising results for fertility. Laparoscopy is preferred to conventional abdominal surgery for the treatment of ectopic pregnancy. In selected cases, "non-surgical" treatment can be an attractive alternative therapy.

Ectopic pregnancy and infertility following treatment of infertile couples: a follow-up of 929 cases

A follow-up analysis was made of 929 infertile couples, with special attention paid to ectopic pregnancy. The conception rate was 46%, and 9% of the pregnancies were ectopic. Previous ectopic pregnancy, an industrial occupation and smoking reduced the fecundity and increased the risk of ectopic pregnancy. Tubal damage as a verified reason for infertility and its treatment also increased the risk of ectopic pregnancy. Stepwise logistic regression analysis showed the strongest association with ectopic pregnancy to exist in the case of women with a previous ectopic pregnancy (9.9-fold risk) rather than women with primary infertility. Treatment of tubal damage by salpingostomy entailed a 6.0-fold risk and treatment by other methods a 2.8-fold risk. Women working in industry had a 3.5-fold risk of ectopic pregnancy compared with those in other professions.

Multifactorial analysis of fertility after conservative laparoscopic treatment of ectopic pregnancy in a series of 223 patients

OBJECTIVES

To lay down the criteria to clearly define whether conservative or radical laparoscopic treatment should be adopted in cases of ectopic pregnancies (EP).

DESIGN

Retrospective, noncomparative.

SETTING

At the University Hospital of Clermont Ferrand and the La Pergola Clinic at Vichy from July 1974 to December 1987.

PATIENTS

This study was carried out in 223 patients who had been treated laparoscopically for EP and who desired future childbearing and who were not lost to follow-up.

MAIN OUTCOME MEASURES

The measures chosen to achieve the objective included age, parity, size of hematosalpinx, volume of hemoperitoneum, tubal rupture, location, intrauterine device, ipsilateral and contralateral adhesions, and patient's previous history of salpingitis, EP, solitary tube, and tubal infertility.

RESULTS

The general intrauterine pregnancy rate was 67% (149 patients) and the recurrence rate 12% (27 patients). The results according to the studied factors demonstrated that age, parity, and the type of the EP have no influence on the postectopic fertility. The history of the patient, ipsilateral adhesions, or contralateral tubal status significantly reduce the future fertility prognosis and risk of recurrence.

CONCLUSIONS

From a multivariable analysis, the authors propose a scoring system to choose the most suitable treatment to preserve fertility and to reduce the risk of recurrence ranging from laparoscopic conservative treatment to laparoscopic salpingectomy with contralateral sterilization.

Present day endoscopic surgery in gynecology

The last ten years have been characterized by a tremendous change in laparoscopy. Initially used exclusively for diagnosis, laparoscopy is now a surgical method in its own right and plays a strategic role. Long-term evaluation of results for various pathologies (such as ectopic pregnancy and tubo-peritoneal sterility) means that just one laparoscopic procedure can be used for diagnosis, selection of the best therapeutic approach and also for treatment in those cases where laparoscopy is the optimum choice. Other more recent indications (including hysterectomy, lymphadenectomy etc.) which are now possible thanks to recent technological developments (such as clips and mechanical sutures) need long-term analysis of their results.

Treatment of tubal pregnancy by laparoscope-guided injection of prostaglandin F2 alpha

Twenty-six cases of unruptured tubal pregnancy were treated by laparoscope-guided injection of prostaglandin (PG) F2 alpha into the affected tube and the ovary containing the corpus luteum. Preoperative serum human chorionic gonadotropin (hCG) levels were 22 to 2,050 IU/L (mean 328 IU/L). The procedure was successful in 24 patients (92%), as indicated by reduction of hCG values to less than 20 IU/L. The remaining 2 cases showed an initial fall in hCG after injection and thereafter a plateau phase indicating the persistence of trophoblast. In both cases, a second surgical intervention was necessary. The total subsequent conception rate among 19 women desiring pregnancy was 90% (17/19). The intrauterine conception rate was 58% (11/19), and the repeat rate of ectopic pregnancy was 32% (6/19). Two-thirds (12/19) of the subsequent pregnancies occurred within 6 months "at risk" for conception. It is concluded that local injection of PGF2 alpha represents an attractive method for termination of selected cases of tubal pregnancy, preferentially in subjects with low trophoblastic activity.

Reproductive outcome after laparoscopic salpingectomy for tubal pregnancy

Since 1983, we have performed laparoscopic salpingectomy as a routine procedure for ectopic pregnancy (EP) in cases where conservative management is impossible or contraindicated. The main indications are a ruptured tubal gestation, a pathological tube, a history of tuboplasty, and an ipsilateral recurrence. This technique is simple, quick, and safe. Reproductive outcome after laparoscopic total salpingectomy for EP was evaluated in 125 cases between January 1983 and December 1987. The pregnancy rate was 33.6%. In our population, there was a high proportion of patients with a pathological or absent contralateral tube (74.4%). In patients with a normal contralateral tube (32 cases), the live birth rate (46.9%) was greater but not significantly than in patients (39 cases) with a patent but pathological tube (25.6%). In vitro fertilization (IVF) was performed in 59 patients; clinical pregnancy was obtained in 40.7% of cases. These encouraging results lead us rapidly to consider IVF in patients with a pathological contralateral tube.