Microsurgical resection of nonocclusive salpingitis isthmica nodosa is beneficial

OBJECTIVE: To determine the effect of microsurgical resection and tubocornual anastomosis (TCA) of nonocclusive salpingitis isthmica nodosa (SIN) on fertility and risk for ectopic pregnancy (EP). DESIGN: Prospective cohort. SETTING: University-affiliated tertiary fertility clinic. PATIENT(S): Infertile women with hysterosalpingography evidence of SIN in patent fallopian tubes. INTERVENTION(S): Microsurgical resection and TCA for nonocclusive SIN. MAIN OUTCOME MEASURE(S): Occurrence of IUP and EP after TCA; comparison of duration of infertility preceding TCA with time to intrauterine pregnancy (IUP) after TCA; and comparison of numbers of women who conceived an EP before and after TCA. RESULT(S): Twelve (46%) of the women had IUPs with a mean time to pregnancy of 10.5 months, which is significantly shorter than the preceding period of infertility. Three women experienced EPs after TCA, which is reduced compared with the number of women with an EP preceding the TCA. CONCLUSION(S): The significant decrease in time to conceive an IUP after surgery as compared with the duration of infertility before surgery and the apparent reduction in risk for EP after surgery demonstrate the benefit of TCA for resection of nonocclusive SIN.     

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.     

甲氨蝶呤治疗输卵管妊娠后的生殖状态

目的 总结甲氨蝶呤(MTX)治疗输卵管妊娠后的生殖状态。方法 收集我院1997年3月-2002年8月确诊为输卵管妊娠并符合保守条件的患者6l例，应用MTX全身治疗，对其中46例随诊1-7年。结果 MTX治疗后宫内妊娠率71．7％，异位妊娠率8．7％。初孕即为输卵管妊娠者，保守治疗后宫内妊娠率为74．2％，再次异位妊娠率6．5％；第2次为输卵管妊娠者，保守治疗后宫内妊娠率为58．3％，再次异位妊娠率16．7％；第3次为输卵管妊娠者，保守治疗后无妊娠。结论 选择合适的早期患者采用MTX治疗是安全、价廉、可靠的治疗方法，也可获得满意的远期生殖状态。     

Treatment of tubal ectopic pregnancy by salpingotomy with or without tubal suturing and salpingectomy

Thirty-four women with unruptured tubal ectopic pregnancy (EP) were randomly assigned to undergo salpingotomy without tubal suturing (n = 15) or salpingotomy with tubal suturing (n = 19). The reproductive performance of these patients was compared with 24 patients who underwent salpingectomy for their EP (historical control). Using life table analysis, the cumulative probability of intrauterine pregnancy (IUP) at 12 and 24 months was 45% and 45% after salpingotomy without tubal suturing and 21% and 47% after salpingotomy with tubal suturing, respectively. The cumulative probability of IUP after salpingectomy (21% and 26% at 12 and 24 months, respectively) was significantly lower than after salpingotomy with or without tubal suturing. There was no difference in the cumulative probability of EP after salpingotomy with or without tubal suturing, but it was significantly higher than after salpingectomy. In 18 women who subsequently underwent laparoscopy or laparotomy, no significant difference was found between the degree of adhesions after salpingotomy with or without tubal suturing. These findings suggest that IUP after conservative treatment is higher than after salpingectomy, but recurrent EP is also higher. Intrauterine pregnancy occurs earlier after salpingotomy without tubal suturing than after salpingotomy with tubal suturing. This might be because of rapid return of tubal function after healing by secondary intention.     

Role of laparoscopic salpingostomy in the treatment of hydrosalpinx

OBJECTIVE: To determine pregnancy rates after laparoscopic salpingostomy in occlusive distal tubal disease. To evaluate the relative impact of various historical, physical, and operative factors on pregnancy outcome using a multivariate statistical analysis. DESIGN: Prospective cohort. SETTING: University-affiliated tertiary care infertility clinic. PATIENT(S): One hundred thirty-nine infertile women with occlusive distal tube disease. INTERVENTION(S): Laparoscopic salpingostomy. MAIN OUTCOME MEASURE(S): The occurrence of intrauterine (IUP) and ectopic pregnancy (EP). RESULT(S): The overall IUP and EP rates were 24.5% and 16.5%, respectively. Analysis of historical variables, assessed independently, demonstrated a significantly higher IUP rate with a positive history of gonorrhea and a significantly higher EP rate with a positive history of pelvic inflammatory disease, lack of history of intrauterine device (IUD) usage, or the performance of a bilateral procedure. The logistic regression model to predict intrauterine pregnancy had an overall predictive value of 77.5% and included the following significant variables: secondary infertility, positive history of gonorrhea, and the operative finding of moderate periadnexal adhesions. The logistic regression model to predict ectopic pregnancy had an overall predictive value of 89.0% and included the following significant variables: previous ectopic pregnancy, negative history of IUD use, positive history of PID, a bilateral procedure, and perihepatic adhesions. CONCLUSION(S): Operative laparoscopy may be effective for the correction of hydrosalpinges in selected patients. The probability of achieving an intrauterine or an ectopic pregnancy can be predicted based on combinations of significant variables.     

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 after ectopic pregnancy. III. The prognostic role of antecedents

Fertility after conservative laparoscopic treatment for ectopic pregnancy (EP) was studies in 223 patients based on the existence of either past EP, salpingitis, having a single tube, or sterility. These factors impact significantly on fertility rate. The global fertility rate is statistically much higher for patients who do not fit into any of these categories (group a-101 patients) compared to patients with 1 or more criteria (group B-122 patients). For each group, the compared intrauterine pregnancy rate is 90% (91 cases) for group A and 42.6% (52 cases) for group B (p001). The compared ectopic recurrence rate is 5% (5 cases) in group A and 18% (22 cases) in group B (0.001p0.01). The rate of sterility was only 5% (5 cases) in group A as compared to 39.4% (48 cases) in group b (p0.001). Moreover, the fertility rate for patients with 1 or more of the above mentioned criteria is significantly much lower that that of patients without any of the factors examined. This is a significant difference when intrauterine rate, ectopic recurrence rate, and sterility rate are each examined separately. A positive past history for these criteria also affects cumulative intrauterine pregnancy (IUP) rate. For all patients, cumulative IUP rate is 54.60% at 2 years. For patients in group A, this rate increased up to 75.70%. For patients with 1 of these factors, the cumulative IUP rate is only between 12.90% and 25.50%. Finally, these factors delay the onset of subsequent intrauterine pregnancy. Globally, 70% of all IUP occurred with 2 years after the conservative laparoscopic treatment for EP. This rate is 83.20% for patients without any of these factors and 50% for those with at least 1 factor. (author's modified)     

甲氨蝶呤治疗输卵管妊娠后的再孕率分析

目的 总结甲氨蝶呤（MTX）治疗输卵管妊娠后的再孕率。方法 收集我院1985年3月至1999年8月确诊为未破裂输卵管妊娠、有生育要求的患者129例,中期60例为MTX全身治疗成功,69例为患侧输卵管切除,按每5年1个时间段回顾分析,随诊1－15年。结果 MTX治疗者,宫内妊娠73％（44例）,异位妊娠8％（5例）;输卵管切除者,宫内妊娠70％（48例）,异位妊娠4％（3例）。两者比较,差异无显著性（P＞0．05）。结论 MTX保守治疗的效果和一侧输卵管切除术相似,没有提高再孕率。     

Use of a single random serum progesterone value as a diagnostic aid for ectopic pregnancy

We evaluated the usefulness of serum progesterone (P) determinations in differentiating between ectopic pregnancy (EP), normal intrauterine pregnancy (IUP), and abnormal IUP. Values were obtained from 233 samples from 54 patients with IUP, 100 samples from 26 patients with abnormal IUP, and 125 samples from 46 patients with EP. Although mean values from all three groups were significantly different, we could not detect a single value that readily predicted both the presence and absence of EP. Only 2% of patients with EP (excluding those having undergone ovulation induction) had a P greater than 20 ng/mL and only 2% of patients with IUP had a value less than 10 ng/mL. Thirty-one percent of IUP, 23% of abnormal IUP, and 52% of EP had values that fell between 10 and 20 ng/mL, which limits the clinical usefulness of this test.     

Maternal serum vascular endothelial growth factor levels in early ectopic and intrauterine pregnancies after in vitro fertilization treatment

OBJECTIVE: To determine whether serum levels of vascular endothelial growth factor (VEGF) 11 days after a day-3 embryo transfer were predictive of outcome, in women with normal intrauterine pregnancy (IUP), first-trimester miscarriage (SAB), biochemical (BC), and ectopic pregnancy (EP) after IVF therapy. DESIGN: Retrospective analysis. SETTING: University hospital IVF unit. PATIENT(S): One hundred eight women who underwent IVF therapy and who were subsequently diagnosed with EP, BC, SAB, or a normal IUP (27 in each category). INTERVENTION(S): Serum samples were obtained at 11 days after a day-3 embryo transfer. MAIN OUTCOME MEASURE(S): Serum concentrations of VEGF, P, and beta-hCG. RESULT(S): Serum concentrations of VEGF were similar in women with BC and EP and higher than in women with normal IUP and SAB (571.8 +/- 61.8, 604.4 +/- 73.4 vs. 448.9 +/- 39.9, 461.8 +/- 39.2 pg/mL, respectively). Also, serum beta-hCG and P levels were significantly higher in women with a normal IUP and SAB. Using a cutoff concentration of >700 pg/mL for VEGF, an EP could be distinguished from an IUP (normal and SAB), with a positive predictive value of 64% and a negative predictive value of 71%. CONCLUSION(S): Elevated maternal serum levels of VEGF, as early as 11 days after embryo transfer, are associated with ectopic pregnancies after IVF.     

Reproductive outcome after laparoscopic myomectomy for intramural myomas in infertile women with or without associated infertility factors

Aims:   To evaluate reproductive outcome after laparoscopic myomectomy for intramural myomas in infertile women with or without associated infertility factors.
Methods:   A retrospective study was carried out in 30 infertile women with intramural myomas measuring ≥50 mm in diameter and treated using laparoscopy.
Results:   The overall rate of spontaneous intrauterine pregnancy was 50.0% (15 patients). Of 13 patients with infertility factors associated with the uterine myomas, three (23.1%) became pregnant, whereas 12 of 17 patients (70.6%) with no other associated infertility factor became pregnant. No uterine ruptures were observed. All pregnancies were spontaneous and 13 occurred within 1 year of the operation. In the 10 patients who gave birth by Cesarean section, no adhesions were found on the myomectomy scar.
Conclusions:   On the basis of these results, laparoscopic surgery for myomas appears to offer comparable results to laparotomy. In infertile patients with intramural myoma, pregnancy rates are affected by the presence of other infertility factors associated with the uterine myomas. (Reprod Med Biol 2006; 5 : 31–35)     

Serum progesterone and 17-hydroxyprogesterone in the diagnosis of ectopic pregnancies and the value of progesterone replacement in intrauterine pregnancies when serum progesterone levels are low.

The corpus luteum function was evaluated in patients with surgically confirmed ectopic pregnancy (EP) in a multicenter study. In addition, the minimal threshold of serum progesterone (P) concentration required for salvaging intrauterine pregnancies (IUP) was also examined. Results show that single P or 17-OHP measurements are not diagnostic for EP, since mean P levels in EP were similar to those with spontaneous abortion though significantly lower than those in controls. 17-OHP levels in EP overlapped in 50% with IUP, and the mean levels were significantly lower only at 6-7 weeks. The 17-OHP levels when compared to hCG supports the view that corpus luteum defect is primary. In IUP, P levels < 8 ng/ml still were associated with viable (60%) pregnancy; thus no minimal threshold could be established.     

Does prior infertility increase the risk of tubal pregnancy?

One hundred forty-nine patients who underwent surgery for tubal pregnancy at five hospitals in Seattle (WA) between 1975 and 1979 were interviewed to determine the risk factors for this disorder. Their responses were compared with those of 706 control women who had conceived an intrauterine pregnancy during the same time period during which the tubal pregnancies occurred. A higher proportion of cases reported a history of infertility (attempt to conceive without success for a period of at least 1 year) than controls (relative risk [RR] = 2.5; 95% confidence interval [CI] = 1.7-3.7). Women who were diagnosed in the investigation of their infertility as having tubal or ovulatory dysfunction had relative risks of tubal pregnancy of 5.8 (95% CI = 2.1-16.4) and 3.4 (95% CI = 1.3-8.5), respectively. The average time over which subjects had attempted to conceive before index pregnancies that were planned was longer among cases (15.4 months) than among controls (6.9 months). These results support the hypothesis that a history of infertility predisposes women to an increased risk of tubal pregnancy. The authors also found that, among infertile women, about twice as many cases (14.3%) as controls (6.8%) were current fertility drug users (RR = 3.1; 95% CI = 1.1-9.1), which suggests that the use of fertility drug(s) may further increase the risk of tubal pregnancy.     

Combined use of progesterone and human chorionic gonadotropin determinations for differential diagnosis of very early pregnancy

Progesterone (P) level and daily change in human chorionic gonadotropin (hCG) were determined in the serum of 307 patients with suspected ectopic pregnancy (EP). Of the viable intrauterine pregnancies (IUP), 99% had P values above 30 nmol/L, whereas 75% of the EP and 81% of the spontaneous abortions had P values less than 30 nmol/L. Among the viable IUP, 95% had normal hCG increases, whereas 89% of the EP and 99% of the spontaneous abortions had abnormal hCG increases. A P value less than 30 nmol/L combined with an abnormal hCG increase had a positive predictive value for pathological pregnancy of 1.0. Consequently, in such cases, further invasive diagnostic or therapeutic measures can be taken with a low risk of jeopardizing a viable IUP.     

Pregnancy and adoption among infertile women following ovulation induction and intrauterine insemination

Using a retrospective cohort study, 214 clinically diagnosed infertile women who underwent ovulation induction and intrauterine insemination between 1991 and 1994 at a hospital-based centre of reproductive medicine, were followed up 5 years after treatment to assess their overall health, pregnancy and adoption status. Multivariate logistic regression analysis was used to estimate odds ratios and 95% confidence intervals for these outcomes, adjusted for age, education, infertility diagnosis, infertility status, parity, number of prior intrauterine insemination cycles, pregnancy following intrauterine insemination treatment, and undergoing other assisted reproductive procedures. Significant increased likelihood of pregnancy was observed for younger women, for women with secondary versus primary infertility, and for women who underwent other assisted reproductive procedures versus those who did not. Significant decreased likelihood of adoption was observed for women with a lower versus a higher educational level, for women with secondary versus primary infertility, and for parous versus nulliparous women. Although the analyses were mostly based on self-reported data, infertile women may adopt or conceive with or without assisted reproductive techniques resulting in minimal change in overall health, and eventually adjust to infertility treatment and its aftermath.     

Serum activin A levels are lower in tubal than intrauterine spontaneously conceived pregnancies

Objective.?To measure serum activin A levels together with progesterone and hCG, in women with overt clinical signs and symptoms of ectopic pregnancy (EP) and, in gestational age-matched intrauterine pregnancy (IUP).

Design.?Retrospective case–control study.

Setting.?Department of Pediatrics, Obstetrics and Reproductive Medicine, Section of Obstetrics and Gynecology, University of Siena, Siena, Italy.

Population.?The study group was composed by 30 women with an EP; the control group was composed by 30 women with a sonographic evidence of a single spontaneous IUP.

Methods.?Clinical examination; transvaginal ultrasound scan; hCG, progesterone and activin-A measurements; laparoscopy; uterine curettage; histological examination.

Main Outcome Measure.?Pregnancy outcome; sensitivity and specificity of hCG, progesterone, and activin A for EP.

Results.?Serum hCG levels did not differ significantly between tubal EP and IUP, while P concentrations were significantly (P?<?0.001) lower in tubal EP than IUP. Serum levels of activin A were significantly (P?<?0.0001) lower in tubal EP than in IUP and, at the cutoff 0.43 ng/mL achieved a sensitivity of 96.7% and a specificity of 100% for EP.

Conclusion.?Activin A secretion in EP is reduced and measurement of its serume levels may have the potential clinical advantage to signal the presence of EP.     

Fertility after laparoscopic management of gynecologic emergencies: the experience of a developing country

The objectives of this study were to estimate the pregnancy rate after the surgical treatment of ectopic pregnancy (EP), adnexal torsion, ruptured ovarian cyst, and acute pelvic inflammatory disease (PID) within 1 year of operative laparoscopy (LAS) or laparotomy (LAP) and to define different factors that would affect this pregnancy rate in women desiring fertility. The study was based on a prospective longitudinal interventional non-randomized study and was set in a tertiary care university hospital. There was a total of 152 patients presenting with gynecologic emergencies. Transvaginal ultrasonography (TVS) was performed in all cases. The patients were divided into two groups. Diagnostic laparoscopy was performed to confirm the diagnosis in 77 cases (group A), which was followed by operative laparoscopic procedures accordingly. In 75 cases (group B), laparotomy was performed from the start. In both groups, the procedures were performed based on microsurgical principles and intraperitoneal drains were inserted. The main outcome measures were the rate of intrauterine or EP, or infertility within 1 year of the procedure. Positive TVS findings were seen in all cases. EP was diagnosed in 60 (78%) and 52 (69%) patients, while twisted adnexa was diagnosed in 7 (9%) and 12 (16%) patients in both groups, respectively. Ruptured ovarian cyst was diagnosed in 6 (7.8%) and 5 (6.7%) cases, whereas PID was diagnosed in 4 (5.2%) and 6 (8%) patients in both groups, respectively. On follow-up after 1 year, fertility was significantly higher in the LAS group (p=0.001), as 45 (58.4%) and 24 (32%) patients, respectively, fell pregnant. In patients desiring further fertility, both laparoscopy and laparotomy can achieve fertility preservation following basic microsurgical principles, with a significant superiority of the laparoscopic approach. High fertility is achieved in patients younger than 30 years of age, in multiparous women, if the contralateral tube is free, if concomitant adhesiolysis is performed, and after salpingotomy operation for treating EP.     

Microsurgery for tubal infertility

In vitro fertilization/embryo transfer (IVF/ART) results have shown significant improvements during the last decade. In the United States the rate of live births per cycle improved gradually to become 27% in 2001. Assisted reproductive techniques (ARTs) are increasingly being used for the treatment of tubal factor infertility. In this review the data are derived largely from our department, where we have treated sufficient numbers of patients and have maintained substantial consistency in our surgical techniques. This 3-part review demonstrates a high success rate of intrauterine pregnancy (IUP) after anastomosis for sterilization reversal. This rate, for those who are < 35 years of age at the time of reversal, is >70%, with most pregnancies occurring within 18 months after surgery. Those who are 35 years of age or more will have a 55% rate of IUP. We note, too, the satisfactory IUP rate (50%) after tubocornual anastomosis for proximal tubal disease. We document the beneficial role of laparoscopic salpingoovariolysis, fimbrioplasty and salpingostomy performed during the initial diagnostic laparoscopy. The IUP rates after salpingoovariolysis and fimbrioplasty are 60% and 50%, respectively. The rates of IUP for salpingostomy are modest in comparison, yet they are 25% for liberal use of salpingostomy during the preliminary laparoscopy. Salpingostomy also provides a beneficial effect upon embryo implantation in both in vivo and in vitro attempts at conception. This stresses the need for an appropriate preliminary investigation and for the subsequent diagnostic laparoscopy to be performed at a center able to perform these procedures. The evidence suggests that surgery should retain its place in the treatment of tubal infertility. Surgery and ART are complementary approaches that can be used singly or in combination to improve the outcome for couples with tubal infertility.     

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

ObjectiveTo 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 SourcesSystematic 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 SelectionArticles 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 ResultsTwo 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).ConclusionSalpingectomy 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.     

Recent declining trend in ectopic pregnancy in France: evidence of two clinicoepidemiologic entities

OBJECTIVE: To assess the recent incidence of ectopic pregnancy (EP) in France (1992-1997) and to relate this incidence to trends in risk factors and use of contraception. DESIGN: Population register-based study. SETTING: Auvergne EP register (central France). PATIENT(S): Women aged 15-44 years with EP in the Auvergne region. MAIN OUTCOME MEASURE(S): Rates of EP, frequencies of exposure to risk factors, and sales of contraceptive methods in 1992-1997. RESULT(S): The overall EP rate decreased 13.7%, from 96.4 per 100,000 women aged 15-44 in 1992 to 83.2 per 100,000 in 1997. The rate of EP associated with reproductive failure remained stable, but the rate of EP associated with contraceptive failure (mostly intrauterine device failure) decreased 26.6%. The trends in the prevalence of the main risk factors for EP and sales of contraceptive methods are concordant with the changes in EP rates: Risk factor prevalence did not change over time, but intrauterine device sales in the area declined in parallel. CONCLUSION(S): The rates of EP as the result of contraceptive failure and as a result of reproductive failure evolve differently in the population and should not be confused in epidemiologic studies. This finding, along with published evidence that the two types of EP have different risk factors, location, prognosis, and perception by women, indicates that they are two distinct clinical entities possibly requiring different management.