Fertility after radical surgery for tubal pregnancy

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Ectopic pregnancy after infertility treatment

Early pregnancy complications are more common in women who conceive after infertility treatment. Most of these occur before 12 weeks of gestation and include miscarriage, vaginal bleeding, intrauterine hematoma, vanishing twin, and ectopic pregnancy (EP). The incidence of EPs following infertility treatment is much higher compared with that in spontaneous pregnancies. The occurrence of an EP is very distressing to an infertile couple, who has lots of hopes pinned on the treatment outcome, especially because of the cost incurred and the physical and mental trauma both have gone through during the treatment process. The association between infertility and EP is complex, as it can be a consequence of infertility as well as a cause. The two principal risk factors for an EP are genital tract infections and tubal surgeries. Though several etiologies are proposed, but patients with tubal factor infertility are at an increased risk of an EP. Earlier diagnosis of EP helps to improve prognosis and optimize subsequent fertility. It is pivotal to evaluate the likelihood of subsequent occurrence of an EP and be too vigilant when treating. The correct choice of the treatment modality should be made to prevent the recurrence. The early prediction of the pregnancy outcome therefore has great importance for both the couple and clinician. Today with the help of sensitive beta human chorionic gonadotropin (β-hCG) assays and transvaginal sonography, one can diagnose an EP prior to symptoms, and conservative treatment for the preservation of the fallopian tube is possible. Conservative management in the form of expectant and medical management should be considered as a first-line treatment modality, provided that the overall clinical picture suggests that it is safe to do so. If not, laparoscopic management of EPs appears to be the favored approach of management as compared to laparotomy.

Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Società Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Società Italiana di Chirurgia (SIC), Società Italiana di Chirurgia d'Urgenza e del Trauma (SICUT), Società Italiana di Chirurgia nell'Ospedalità Privata (SICOP), and the European Association for Endoscopic Surgery (EAES)

BACKGROUND

In January 2010, the SICE (Italian Society of Endoscopic Surgery), under the auspices of the EAES, decided to revisit the clinical recommendations for the role of laparoscopy in abdominal emergencies in adults, with the primary intent being to update the 2006 EAES indications and supplement the existing guidelines on specific diseases.

METHODS

Other Italian surgical societies were invited into the Consensus to form a panel of 12 expert surgeons. In order to get a multidisciplinary panel, other stakeholders involved in abdominal emergencies were invited along with a patient's association. In November 2010, the panel met in Rome to discuss each chapter according to the Delphi method, producing key statements with a grade of recommendations followed by commentary to explain the rationale and the level of evidence behind the statements. Thereafter, the statements were presented to the Annual Congress of the EAES in June 2011.

RESULTS

A thorough literature review was necessary to assess whether the recommendations issued in 2006 are still current. In many cases new studies allowed us to better clarify some issues (such as for diverticulitis, small bowel obstruction, pancreatitis, hernias, trauma), to confirm the key role of laparoscopy (such as for cholecystitis, gynecological disorders, nonspecific abdominal pain, appendicitis), but occasionally previous strong recommendations have to be challenged after review of recent research (such as for perforated peptic ulcer).

CONCLUSIONS

Every surgeon has to develop his or her own approach, taking into account the clinical situation, her/his proficiency (and the experience of the team) with the various techniques, and the specific organizational setting in which she/he is working. This guideline has been developed bearing in mind that every surgeon could use the data reported to support her/his judgment.

Fertility outcomes following expectant management of tubal ectopic pregnancy

OBJECTIVES

To evaluate fertility outcome after the expectant management of tubal ectopic pregnancy.

METHODS

Our dedicated early pregnancy database was searched for all women diagnosed with a tubal ectopic pregnancy between January 1999 and June 2003 who were either managed expectantly or underwent a salpingectomy. They were contacted to enquire about their ability to conceive following the ectopic pregnancy and about the outcomes of any subsequent pregnancies.

RESULTS

Four hundred and forty-four women had a diagnosis of tubal ectopic pregnancy, and 173 (39%) were successfully contacted. A total of 146/173 (84.4%; 95% CI, 79-89.8%) tried for another pregnancy: 49/59 (83.1%; 95% CI, 73.4-92.6%) in the expectant management and 97/114 (85.1%; 95% CI, 78.4-91.6%) in the salpingectomy group (P > 0.05). Spontaneous intrauterine pregnancy occurred in 41/49 (83.7%; 95% CI, 73.3-94.2%) women managed expectantly and in 62/97 (63.9%; 95% CI, 54.4-73.5%) women managed surgically (odds ratio 2.89; 95% CI, 1.22-6.86%). The risk of recurrent ectopic pregnancy was not significantly different between the two management groups.

CONCLUSIONS

Fertility outcomes following the expectant management of tubal ectopic pregnancy are comparable to those following salpingectomy.

Laparoscopy for abdominal emergencies

BACKGROUND

Emergency laparoscopic exploration can be used to identify the causative pathology of acute abdominal pain. Laparoscopic surgery also allows treatment of many intraabdominal disorders. This report was prepared to describe the effectiveness of laparoscopic surgery compared to laparotomy or nonoperative treatment.

METHODS

A panel of European experts in abdominal and gynecological surgery was assembled and participated in a consensus conference using Delphi methods. The aim was to develop evidence-based recommendations for the most common diseases that may cause acute abdominal pain.

RECOMMENDATIONS

Laparoscopic surgery was found to be clearly superior for patients with a presumable diagnosis of perforated peptic ulcer, acute cholecystitis, appendicitis, or pelvic inflammatory disease. In the emergency setting, laparoscopy is of unclear or limited value if adhesive bowel obstruction, acute diverticulitis, nonbiliary pancreatitis, hernia incarceration, or mesenteric ischemia are suspected. In stable patients with acute abdominal pain, noninvasive diagnostics should be fully exhausted before considering explorative surgery. However, diagnostic laparoscopy may be useful if no diagnosis can be found by conventional diagnostics. More clinical data are needed on the use of laparoscopy after blunt or penetrating trauma of the abdomen.

CONCLUSIONS

Due to diagnostic and therapeutic advantages, laparoscopic surgery is useful for the majority of conditions underlying acute abdominal pain, but noninvasive diagnostic aids should be exhausted first. Depending on symptom severity, laparoscopy should be advocated if routine diagnostic procedures have failed to yield results.

Diagnosis and treatment of ectopic pregnancy

Ectopic pregnancy is a life- and fertility-threatening condition that is commonly seen in Canadian emergency departments. Increases in the availability and use of hormonal markers, coupled with advances in formal and emergency ultrasonography have changed the diagnostic approach to the patient in the emergency department with first-trimester bleeding or pain. Ultrasonography should be the initial investigation for symptomatic women in their first trimester; when the results are indeterminate, the serum beta human chorionic gonadotropin (beta-hCG) concentration should be measured. Serial measurement of beta-hCG and progesterone concentrations may be useful when the diagnosis remains unclear. Advances in surgical and medical therapy for ectopic pregnancy have allowed the proliferation of minimally invasive or noninvasive treatment. Guidelines for laparoscopy and for methotrexate therapy are provided.

Ectopic pregnancies after infertility treatment: modern diagnosis and therapeutic strategy

Ectopic pregnancy (EP) is a major event in a woman's reproductive life. It complicates infertility treatment and must be recognized early to simplify the treatment strategy, which must always be directed towards optimizing subsequent fertility. Epidemiological findings indicate that tubal history and smoking are the principal risk factors of those EP that are considered reproductive (rather than contraceptive) failures. Adding together the attributable risks for EP allows the construction of a risk scale to determine its probability for any given patient. This risk calculation makes it easier to establish a diagnostic strategy that uses abdominal and transvaginal ultrasound and hCG assays. Progesterone assays are useful only for determining the activity of the pregnancy but do not help to identify its site. Conservative treatment is to be preferred unless the EP occurs on a known hydrosalpinx. All the treatment trials and the Cochrane database meta-analysis show that medical treatment with methotrexate, preferably multidose, is equivalent in efficacy to conservative treatment with laparoscopy in the populations studied. Heterotopic pregnancies, which occur most often after assisted reproduction technology (1-3%), should preferably be treated by salpingectomy except in interstitial sites. There is no consensus that IVF is indicated after EP. The patient's age is probably the determining factor: fertility treatment should not be delayed to an age where the results would be altered, especially with the risk of a recurrent EP.

Early and late half-life of human chorionic gonadotropin as a predictor of persistent trophoblast after laparoscopic conservative surgery for tubal pregnancy

BACKGROUND

To determine if the early or late half-lives (T0.5) of human chorionic gonadotropin (hCG) can identify patients with persistent trophoblastic activity after conservative surgery for tubal pregnancy.

DESIGN

Prospective cohort study.

SETTING

Department of obstetrics and gynecology of a university hospital.

METHODS

All patients with a tubal pregnancy treated by laparoscopic salpingostomy between June 1997 and September 2000 were enrolled in the study. Postoperative sequential hCG sampling was performed at days 0, 2 (+/- 1) and 7 (+/- 2) and followed until levels were undetectable. Taking the biexponential hCG declining curve as a model, we calculated the early (days 0-2) and late (days 2-7) T0.5 hCG values.

MAIN OUTCOME MEASURE

To assess success or failure of surgical treatment.

RESULTS

Seventy-three patients with an ectopic pregnancy were managed by conservative surgery. Early and late T0.5 allowed us to identify 2/10 and 9/10 women, respectively, with persistent trophoblast. Late T0.5 levels revealed two patients with false-positive values, but one patient showed a secondary increase in hCG after day 7 (false-negative) despite a normal late T0.5.

CONCLUSIONS

Early and late half-lives of hCG do not identify all women at risk for persistent ectopic pregnancy. To exclude persistent trophoblast, postoperative serum hCG determination should be performed until levels are undetectable.

[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.

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.