Factors determining fertility after conservative or radical surgical treatment for ectopic pregnancy

Objective: To examine factors determining choice of radical or conservative surgical procedure for tubal ectopic pregnancy and subsequent pregnancy rates.Design: A retrospective study collating information from the operative notes and previous gynecologic history associated with the choice of procedure and pregnancy rates and outcome over 3 years after a primary tubal ectopic pregnancy.Patient(s): Thirty-four women who had undergone conservative (tube sparing) and 56 who had undergone radical (salpingectomy) surgical treatment for tubal ectopic pregnancy at least 3 years before the study.Main Outcome Measure(s): The main outcome measure was the occurrence of a pregnancy (live birth, miscarriage, or ectopic pregnancy) over 3 years after the ectopic pregnancy.Result(s): The type of surgery performed was not affected by a previous history of infertility, known pelvic inflammatory disease, the presence of tubal adhesions, or abnormalities on the contralateral tube. Intrauterine pregnancy was not more likely after conservative treatment of ectopic pregnancy but, equally important, the risk of a further ectopic pregnancy was not increased. The single factor that was clearly associated with future fertility problems was a past history of infertility.Conclusion(s): Better results may be obtained by careful selection of operative procedure based on history and findings at the time of surgery.     

Persistent ectopic pregnancy following conservative surgery for tubal pregnancy

Objective To audit the incidence and management of persistent ectopic pregnancy following conservative tubal surgery performed at laparotomy and via the laparoscope.
Design A retrospective analysis of the case records. Setting The Birmingham and Midland Hospital for Women.
Participants Two hundred and fourteen women who received surgical treatment for ectopic pregnancy between October 1991 and December 1994.
Results Of the 85 women who underwent conservative tubal surgery, nine were diagnosed as having persistent ectopic pregnancy on the basis of hCG values. The incidence after laparoscopy was no higher than after laparotomy. A second surgical procedure was indicated in only four cases.
Conclusions Post-operative surveillance of serum hCG remains mandatory. Patients who remain symptom free may be managed conservatively The threshold for a second-look laparoscopy should be relatively high and be based on the presence of symptoms rather than changes in hCG values.     

Isthmic ectopic pregnancy and salpingitis isthmica nodosa

Two hundred eighty-five charts were reviewed from patients who underwent surgery for ectopic pregnancy. Excluded were patients with previous tubal reparative surgery, linear salpingotomy, or failed sterilization. The incidence of isthmic ectopic pregnancy in the remaining 255 cases was 15.3%. The association of salpingitis isthmica nodosa (SIN) and isthmic ectopic pregnancy was determined by review of resected tubal segments. SIN was noted in 17 of 37 cases (45.9%) of isthmic ectopic pregnancy. SIN places the patient at risk for recurrent ectopic pregnancy or infertility. Recommended conservative management of isthmic ectopic pregnancy is segmental resection with postoperative emphasis on documentation of SIN when present. Postoperative hysterosalpingography is recommended with an abnormal contralateral tube or when SIN is noted in the resected tubal segment. Management options after an isthmic ectopic pregnancy when future fertility is desired are presented.     

Cornual heterotopic pregnancy: contemporary management options

This review covers the clinical presentations, treatments, and outcomes of cornual heterotopic pregnancies reported in the literature. Infertile women with a history of ectopic pregnancy, tubal surgery, or disease are at increased risk for cornual heterotopic pregnancy when they undergo in vitro fertilization. Women who have undergone bilateral salpingectomy also seem to be predisposed to this condition when they undergo in vitro fertilization. We recommend that these patients be followed up closely after a successful in vitro fertilization cycle with monitoring of serum beta-human chorionic gonadotropin levels and serial transvaginal ultrasonography because of the high associated morbidity. Laparotomy remains the treatment of choice for rupture of a cornual heterotopic pregnancy. In the absence of cornual rupture, however, medical management is an option that eliminates the risk of surgery and anesthesia and results in outcomes similar to those associated with surgical treatment. Currently there is insufficient evidence to recommend any single treatment modality, and the decision should be based on such factors as clinical presentation, surgeon's expertise, side effects, overall cost, and the patient's preference.     

Improved fertility following conservative surgical treatment of ectopic pregnancy

Objective To evaluate fertility after salpingectomy or tubotomy for ectopic pregnancy.
Design Retrospective cohort study.
Setting Clinical University Center, Hvidovre Hospital, Copenhagen.
Population Two hundred and seventy-six women undergoing salpingectomy or tubotomy for their first ectopic pregnancy between January 1992 and January 1999 and who actively attempted to conceive were followed for a minimum of 18 months.
Methods Retrospective cohort study combined with questionnaire to compare reproductive outcome following salpingectomy or tubotomy for ectopic pregnancy. Cummulative probabilities of pregnancy for each group were calculated by the Kaplan-Meier estimator and compared by Cox regression analysis to control for potential confounders.
Main outcome measures Intrauterine pregnancy rates and recurrence rates of ectopic pregnancy after surgery for ectopic pregnancy.
Results The cumulative intrauterine pregnancy rate was significantly higher after tubotomy (88%) than after salpingectomy (66%) (log rank   P < 0.05  ) after correction for confounding factors. No difference was found in the recurrence rate of ectopic pregnancy between the treatments (16% vs 17%). In patients with contralateral tubal pathology, the chance of pregnancy was poor (hazard ratio 0.463) and the risk of recurrence was high (hazard ratio 2.25), assessed with Cox regression. The rate of persistent ectopic pregnancy was 8%.
Conclusion Conservative surgery is superior to radical surgery at preserving fertility. Conservative surgery is not followed by an increased risk of repeat ectopic pregnancy, but by the risk of persistent ectopic pregnancy, which should be taken into account when deciding on the operative procedure. Management in case of contralateral tubal pathology is disputed and should ideally be addressed in a randomised clinical trial.     

Ectopic pregnancy following the treatment of tubal infertility.

To evaluate the prognosis for the patient who becomes pregnant after infertility treatment, we analyzed the occurrence of ectopic pregnancy following reconstructive surgery and in vitro fertilization/embryo transfer (IVF/ET) for tubal infertility. The results of 474 microsurgical operations and the results of 2,119 stimulated IVF/ET cycles for tubal infertility in the Reproduction Unit of Ljubljana University Department of Obstetrics and Gynecology are presented. The ratio of patients who subsequently had only ectopic pregnancies to the number of operations was 12%. Ectopic pregnancies represented 28% of all pregnancies after surgery. In IVF/ET cycles for tubal infertility, ectopic pregnancy represented 2.8% of all pregnancies and 3 permiles of all transfers. There was one (0.5%) heterotopic pregnancy. The likelihood of live births (30%, one or more times) after surgery compensates the high risk for ectopic pregnancy. While the risk for ectopic pregnancy after IVF/ET is much lower than the risk after tubal surgery, it is still rather high compared with the risk in the normal population. In the cases with severe tubal lesions IVF/ET is preferable to tubal surgery. The results show the importance of considering ectopics when deciding upon treatment and in patients who become pregnant after treatment for tubal infertility.     

Reproductive outcome following conservative surgery for tubal pregnancy in women with a single fallopian tube

Between the years 1974 and 1980, 13 patients underwent a conservative (salpingotomy) surgical procedure for tubal pregnancy in their only fallopian tube. In this group, one patient has been lost to follow-up, and one has intentionally avoided pregnancy, although tubal patency was documented by hysterosalpingogram. All the remaining patients have had at least one term pregnancy. The diagnosis was confirmed in all instances by laparoscopy prior to laparotomy. In 11 patients, the ectopic pregnancy was unruptured. One ectopic pregnancy had ruptured and one had resulted in a tubal abortion. All patients underwent essentially the same conservative procedure, performed by the same surgical team, with close adherence to the principles of microsurgery. This technique is described in detail. Since each of these patients had only one tube, this report reaffirms the value of conservative surgery for tubal pregnancy.     

Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Tubal Stump Pregnancy

ObjectiveTo demonstrate a case of left tubal stump pregnancy successfully treated using our 2-step technique for transvaginal natural orifice transluminal endoscopic surgery (vNOTES).DesignDemonstration of the technique using surgical video footage.SettingTertiary university hospital.InterventionsA 27-year-old gravida 3 para 0 patient with a history of laparotomy, left salpingectomy owing to a ruptured tubal pregnancy, was referred to our hospital because of a pregnancy of unknown location. Her serum β human chorionic gonadotropin level was 8400 U/L, and a transvaginal ultrasound revealed an ectopic pregnancy in the left tubal stump. After discussing medical and surgical treatment options, the patient underwent a 2-step vNOTES approach. First, a diagnostic vNOTES was performed using a 5-mm trocar with autoretracting blade. After confirmation of the diagnosis, the trocar was removed, and the incision was enlarged with blunt dissection. A self-constructed pessary port was then placed through the enlarged colpotomy, and the ectopic pregnancy in the left tubal stump was excised using an advanced bipolar device. The colpotomy was closed with running resorbable sutures. The duration of the surgery was 36 minutes, and the patient was discharged on postoperative day 1 without any complications.ConclusionTubal stump pregnancy is a rare form of ectopic pregnancy with an incidence of approximately 0.4% of all ectopic pregnancies [1]. Treatment options include conservative medical management using methotrexate and surgery. Successful surgical treatment using laparoscopy has been previously reported [1,2]. This case demonstrates that vNOTES may be a minimally invasive option for the surgical treatment of tubal stump pregnancy in selected cases.     

Ectopic pregnancy

The diagnosis of ectopic pregnancy has become precise and reliable. Consequently, the management of ectopic pregnancy has progressed to the point where the physician is often able to preserve fertility. Therefore, conservative surgery is indicated if the patient desires future fertility and conditions are appropriate. The combination of ultrasound, beta-hCG pregnancy testing, and laparoscopy has led to a rising incidence of diagnosed ectopic pregnancy prior to rupture. This has greatly facilitated the use of the conservative approach to the management of tubal pregnancy. Although ectopic pregnancy can be diagnosed early and managed conservatively, it is, and will remain a potentially life-threatening disease and must be approached as such. Table 3 summarizes our proposed surgical management of tubal pregnancy. Table 4 summarizes the results of conservative surgery for tubal pregnancy.     

A Pragmatic and Evidence-Based Management of Ectopic Pregnancy

The incidence of ectopic pregnancy is approximately 2% of all pregnancies, and it remains the leading cause of death in early pregnancy. Over 95% of ectopic pregnancies are tubal pregnancies, and the remainders are nontubal pregnancies. The highest risk factor for ectopic pregnancy is a previous tubal pregnancy followed by previous tubal surgery, tubal sterilization, tubal pathology, and current intrauterine device use. The apparent increase in the incidence of nontubal ectopic pregnancy including heterotopic pregnancy may be attributed to the increasing number of pregnancies because of in vitro fertilization treatment. In most cases, an ectopic pregnancy can be treated medically with a single dose of methotrexate. Surgical treatment is still needed in women who are hemodynamically unstable and in those who do not fulfill the criteria for methotrexate treatment. Usually surgical treatment can be performed by laparoscopy and in some cases by hysteroscopy. Laparotomy is rarely needed even in women with intraperitoneal bleeding.     

Treatment of ectopic tubal pregnancies by laparoscopy

Laparoscopy as an aid to the diagnosis of ectopic tubal pregnancy has been widely accepted for several years. As a natural evolution of surgical skills, combined diagnosis and treatment of ectopic tubal pregnancy was carried out laparoscopically in nine patients in whom the diagnosis was suspected. All nine procedures were completed successfully. Intravenous sedation was used in three women and general anesthesia in six. The average hospital stay was 1.5 days, with one patient discharged on the day of surgery; one woman was hospitalized for 6 days due to symptomatic anemia. Surgical specimens were removed successfully in six patients, and the diagnosis confirmed histologically. In no instance where the specimen was left in the cul-de-sac did complications result. No complications were attributable to the procedure. The technique is safe and effective when performed by an experienced laparoscopist, and when provisions for immediate laparotomy are available. It should be noted that this procedure is not intended for patients with massive intraperitoneal bleeding or shock.     

辅助生殖技术助孕后不同步异位妊娠原因探究及文献回顾

目的:探讨辅助生殖技术(ART)能够降低异位妊娠风险的预防、治疗措施。方法:报道2例国内外少见的不同步异位妊娠病例,并结合近年来相关的5个案例进行回顾性分析。结果:不同步异位妊娠成因复杂,自然受孕及ART助孕都可发生,最迟可发生在初次异位妊娠后1个月左右,且往往需要2次手术治疗。结论:对有相应适应证的患者,输卵管抽芯切除作为预处理或冻融单囊胚移植可降低不同步异位妊娠的发生率;异位妊娠手术处理后1个月左右均需密切监测患者情况,尽早发现不同步异位妊娠病灶并给予及时处理。     

Methotrexate treatment of unruptured ectopic pregnancy: a report of 100 cases

In an ongoing clinical trial, 100 patients with an unruptured ectopic pregnancy of 3.5 cm or less in greatest dimension were treated with an outpatient protocol of methotrexate and citrovorum factor chemotherapy. Methotrexate and citrovorum were given on alternating days until the hCG titer had decreased by 15% on 2 consecutive days. The patients ranged in age from 16-40 years, gravidity from 1-8, and parity from 0-5. Twenty-three patients had a previous ectopic pregnancy. Of the 100 patients, 96 (96%) received methotrexate/citrovorum as primary therapy and four (4%) were treated for persistent hCG titers after a conservative surgical procedure. The tubal pregnancies of patient nos. 1-50 were confirmed by laparoscopy, whereas patient nos. 51-100 were diagnosed according to a nonlaparoscopic algorithm. Four patients of 100 failed medical therapy and required surgery. Of these, one had an ectopic pregnancy with cardiac activity, one ruptured after intercourse, and the remaining two cases had no specific identifiable risk factors. Of the ectopic pregnancies with cardiac activity, 80% were successfully treated. Five patients (5%) had methotrexate-related side effects, all after the fourth dose, but none required treatment for these side effects. Hysterosalpingograms done on 58 patients subsequently demonstrated tubal patency in 84.5% on the involved side. To date, 37 pregnancies have occurred in this group, of which 31 (89.2%) were intrauterine and four (10.8%) were recurrent ectopic pregnancies. We conclude that methotrexate/citrovorum is safe, effective, and helps to preserve reproductive performance when used as primary therapy for unruptured ectopic pregnancy and for treatment of persistent disease following a conservative surgical procedure.     

A twelve year analysis of non-tubal ectopic pregnancies: Do the clinical manifestations and risk factor for these rare pregnancies differ from those of tubal pregnancies?

The aim of this study was to analyze the characteristics and peculiarity of non-tubal ectopic (NTE) pregnancy presenting to a major district hospital in London, UK. Data were collected between January 2003 and July 2014. There were 850 cases of ectopic pregnancies (798 tubal pregnancies and 53 NTE pregnancies). Forty-seven of the NTE were included in the study. Data were analyzed using IBM SPSS Statistics 20. Pearson’s chi-squared analysis was used to compare statistical significance of the data collected; the level of statistical significance at which the null hypothesis was rejected was chosen as 0.05. The 31–40 year age group had the highest incidence (55 % of the cohort). Thirty-seven percent of NTE were primigravida. Most of the women presented at 6–10 weeks gestation (63 %) with abdominal and vaginal bleeding being the most common presentation in 55 % of cases. When compared with tubal ectopic pregnancy, NTE was more likely to present at later gestation of presentation (p?=?0.000), have history of assisted reproduction (p?=?0.041) and more likely to present with diarrhoea, shoulder-tip pain and syncopal attack as well having a significant amount of haemoperitoneum at surgery compared with tubal ectopic pregnancy. NTE pregnancies are likely to present most commonly at 6–10 weeks and therefore clinicians should have a high index of suspicion when treating any pregnant woman at this gestation. The later presentation of NTE pregnancies may relate to the delay in diagnosis of these rarer ectopic pregnancies; this may be attributed to the clinician having a level of suspicion that is too low, as the incidence of NTE pregnancies is becoming increasingly common. A combination of a thorough history with the presence of specific risk factors such as a history of assisted conception, pelvic surgery and pelvic inflammatory disease and symptoms such as syncope and an abnormal amount of free fluid behind the empty uterus at ultrasound should make the clinician highly suspicious of a NTE or heterotopic pregnancy.     

影响输卵管积水患者腹腔镜术后妊娠率的相关因素分析

目的:研究输卵管积水患者腹腔镜术后影响其自然妊娠率的高危因素,为患者个体化治疗提供临床依据。方法:回顾性分析我院2010年1月至2013年12月因输卵管积水行腹腔镜手术患者643例的临床资料,并对影响其自然妊娠率的因素进行单因素及多因素Logistic回归分析。结果:643例患者临床妊娠率为34.06%(219/643),正常宫内妊娠率为21.15%(136/643),流产率为3.89%(25/643),异位妊娠率为9.02%(58/643)。单因素分析结果显示,输卵管积水患者腹腔镜术后自然妊娠率与年龄、不孕年限、是否有盆腹腔手术史及盆腔输卵管病变程度有关(P0.1),与不孕类型、体质量指数、是否有异位妊娠史、单侧或双侧积水、主刀医师不同无关(P0.1);多因素分析显示,不孕年限5年(OR=1.539,P=0.008)和盆腔输卵管中、重度病变(OR=1.569,P=0.001)是输卵管积水患者腹腔镜术后影响其妊娠能力的独立危险因素。结论:在指导输卵管积水患者腹腔镜术后适时妊娠方面,应充分考虑患者的不孕年限和输卵管病变程度,实现个体化治疗,有望提高妊娠率。     

Ectopic pregnancy

Ectopic pregnancy is a implantation occurring elsewhere than in the cavity of the uterus, whereas nintynine percent of extrauterine pregnancies occur in the fallopian tube. The incidence of extrauterine pregnancy has increased from 0.5% thirty years ago, to a present day 1–2%. The most frequent cause of tubal pregnancy is previous salpingitis. Mortality rates for tubal pregnancies used to be approximately 1.7% in the 1970 s but dropped to 0.3% in 1980 s. Diagnosis: Using transvaginal ultrasound it is possible to obtain positive evidence of an ectopic pregnancy at a very early stage. In cases of hCG titers>2000 IU/l, intrauterine pregnancy can be diagnosed with certainty. The most important differential diagnosis of ectopic pregnancy is early intrauterine pregnancy. Clinical management and therapy: Regardless of the therapeutic strategy selected by the physician, informing the patient is a major aspect of the management of ectopic pregnancy. If surgery is considered appropriate, the patient must be informed about the nature, side effects and complications of the procedure. However, it should be remembered that in some cases, the actual chances of cure first become apparent at surgery. In asymptomatic patients with a serum hCG titer <1000 IU/l that is falling, it is appropriate to wait and watch. In clinically stable patients with an unruptured tubal pregnancy and steady hCG levels, systemic treatment with methotrexate might also be considered. In unruptured tubal pregnancy with a hCG titer between 1000 and 2500, a further therapeutic alternative is intratubal injection of prostaglandins, hyperosmolar glucose of NaCl. Generally speaking, the currently widespread laparoscopic surgical treatment of the fallopian tube hardly influences the risk of recurrence. If the gestational mass is larger, the serum hCG titer higher than the approximate limit of 2500 mU/ml and/or the tube already ruptured, surgery is usually required. Prevention: The most effective prevention is to avoid tubal inflammation or, in cases of preexisting inflammation, to administer effective therapy. Received: December 1998 / Accepted: 25 May 1999     

Embarazo ectópico recurrente ipsolateral

An ectopic pregnancy is a common pathology in the first trimester, with an increasing incidence due to several factors. Ruptured ectopic pregnancy is one of the most dangerous emergencies in the obstetric patient, since this is a condition responsible for most pregnancy-related deaths in the first trimester. Any woman in fertile age with vaginal bleeding and/or abdominal pain can have an ectopic pregnancy, therefore we must always be aware of it, even more so if our patient has risk factors, such as previous tubal surgery.     

New concepts in the surgical management of tubal pregnancy and the consequent postoperative results

The success following reconstructive tubal pregnancy can only be measured in terms of live births. Because the fallopian tube is not a simple conduit and has numerous complex functions, many women fail to conceive despite successful reconstructive surgery. The most effective way to prevent reocclusion or peritubal adhesion is to minimize tissue trauma. Magnification permits accurate excision and hemostasis. In this review, it has been demonstrated that tubal conservation is technically possible and safe. It is effective in increasing the number of live births postoperatively in women interested in fertility and does not increase the risk of the repaired tube for a repeat tubal gestation more than the uninvolved tube, although one of five subsequent pregnancies are again ectopic. They seem to occur equally as often in the contralateral tube as in the repaired tube. It has been shown that salpingotomy can restore tubal patency and maintain fertility. The second question was whether the number of viable pregnancies increase after conservative surgery. This question can be answered only if the repaired tube remains and the patient subsequently delivers at term. Such data have already demonstrated this outcome. Conservative operations in selected cases of tubal pregnancy seem feasible and safe and do not further impair tubal function. Because intrauterine pregnancy is more apt to occur than is repeat ectopic pregnancy, it seems logical that the involved tube should be saved whenever fertility is desired (Fig. 2). In unruptured isthmic pregnancy, Stangel and Gomel prefer segmental excision and end-to-end anastomosis during the same intervention. Gomel advocates segmental excision of the conceptus whether ruptured or not when the pregnancy is located in the isthmus or proximal half of the ampulla, and end-to-end anastomosis undertaken later as an elective procedure if necessary (Fig. 2). An ampullary gestation may be successfully treated by salpingotomy; and in the case of distal ampullary location, a tubal abortion may be performed (Fig. 2). When extensive destruction of the tube occurs, salpingectomy becomes necessary. In cases of early diagnosis of tubal gestation, conservative surgical management may be carried out via laparoscopy (Fig. 1).     

近10年输卵管妊娠临床特点、诊断和治疗的变化(附4299例报告)

目的:探讨最近10年输卵管妊娠的临床特点、发生率和诊治方法的变化。方法:回顾性分析我院过去10年输卵管妊娠病例的临床特点,并对不同的治疗方法进行比较,随访并分析影响生育的各种因素。结果:异位妊娠与同期分娩数之比从1995年的1∶7.38升高到2004年的1∶4.12。输卵管妊娠占总数的94.23%。有停经史的占86.4%,阴道流血占87.3%,腹痛占59.1%。腹腔镜治疗从1995年的1.6%上升到2005年的78.7%。较经腹手术组,腹腔镜手术具有手术时间短的优势(P<0.05)。MTX治疗成功率为91.40%,保守手术治疗成功率为96.57%。有异位妊娠史、输卵管或者盆腔手术史是影响治疗后生育的最重要因素。结论:异位妊娠发生率在升高。停经、阴道流血和腹痛是异位妊娠最主要的临床表现。腹腔镜手术、保守性手术是治疗异位妊娠的趋势。对不同患者应采取个性化的治疗方案以提高日后生育几率。     

Surgical treatment of ectopic pregnancy

In most cases of ectopic pregnancy, medical treatment with methotrexate is successful. However, some cases still require surgery and laparoscopy is an effective approach. The candidates for surgical treatment include women who are not suitable to or have failed methotrexate treatment, those with heterotopic pregnancy, or those who are hemodynamically unstable. In women of reproductive age with tubal pregnancy, salpingostomy is the preferred surgical method. Conversely, salpingectomy is a better treatment for women with severely damaged fallopian tube, recurrent ectopic pregnancy in the same tube, uncontrolled bleeding after salpingostomy, large tubal pregnancy (> 5 cm), heterotopic pregnancy, and for those who have completed their family. Similar to treatment of a tubal pregnancy, cervical and interstitial pregnancy could be treated medically first. Most abdominal pregnancies are diagnosed late in pregnancy. However, when the diagnosis is made early, laparoscopic removal of the pregnancy should be performed.