Management of tubal pregnancy with methotrexate

Summary. Ten women with tubal ectopic pregnancy were treated by the injection of methotrexate into the gestational sac under direct laparoscopic vision followed by a course of intramuscular therapy including folinic acid rescue. One course of treatment induced resolution of the extrauterine pregnancy in eight women. Complete resolution (β-hCG<10 miu/ml) was achieved within 6–47 days (mean 14·5 days). Serum β-hCG levels started to decline 3–4 days from the beginning of therapy. Length of hospital stay was 5–11 days (mean 6·4 days). Treatment failed in two patients. One woman had a laparoscopic tubal clip sterilization concomitantly with methotrexate treatment. Tubal patency was demonstrated in all the other seven women (100%) tested subsequently. There is a need to establish criteria for patient selection before methotrexate becomes a routine treatment for tubal pregnancy.     

Management of tubal pregnancy with methotrexate

Ten women with tubal ectopic pregnancy were treated by the injection of methotrexate into the gestational sac under direct laparoscopic vision followed by a course of intramuscular therapy including folinic acid rescue. One course of treatment induced resolution of the extrauterine pregnancy in eight women. Complete resolution (beta-hCG less than 10 miu/ml) was achieved within 6-47 days (mean 14.5 days). Serum beta-hCG levels started to decline 3.4 days from the beginning of therapy. Length of hospital stay was 5-11 days (mean 6.4 days). Treatment failed in two patients. One woman had a laparoscopic tubal clip sterilization concomitantly with methotrexate treatment. Tubal patency was demonstrated in all the other seven women (100%) tested subsequently. There is a need to establish criteria for patient selection before methotrexate becomes a routine treatment for tubal pregnancy.     

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.     

Sperm electron microscopy for the evaluation of in vitro fertilization failures

When performing IVF, the clinician is frequently confronted with the failure of fertilization. When the standard parameters to evaluate the male factor are "within normal limits," the conclusion is often made that the lack of fertilization is most likely due to "poor egg quality." These two cases demonstrate the fallacy of this approach and support a more rigorous evaluation of the male factor. Ultrastructural analysis of sperm is underutilized and, as demonstrated by these two cases, can play an essential role in this evaluation process.     

Critical evaluation of methods for electron microscopy of cervical mucus

The ultrastructure of cervical mucus has been studied by scanning (SEM) and transmission (TEM) electron microscopy. The images differ according to the methods used for preparation; different patterns were found in the same sample when the freeze-drying and critical point-drying methods were used for SEM. When using TEM, the specimen appeared more homogeneous, with fine fibrils and granules. This accords with the theory that the cervical mucus consists of a randomly entangled fibrillar network. Electron microscopy of cervical mucus requires preparation procedures which involve considerable risk of creating artefacts. In our experience the TEM technique produces fewer artefacts and therefore gives pictures more true to the in vivo situation.     

Scanning electron microscopy evaluation of porous and nonporous arterial substitutes

The fate of two different kinds of new small arterial substitutes, porous and nonporous, has been compared, particularly with regard to the structure of the luminal surface. Twenty-eight weavenit Dacron pyrolytic carbon coated grafts and 28 glutaraldehyde-tanned human umbilical vein segments were implanted into the carotid arteries of dogs. Grafts were removed at intervals, from ten to 120 days after implantation, and examined by scanning electron microscopy. The cumulative patency rate was 96.4 per cent for Dacron and 85.7 per cent for umbilical vein grafts. Ten days after implantation, the Dacron grafts were uniformly covered by a thin thrombus layer, while the umbilical vein grafts showed a thin network of fibrin on the central portion of the luminal surface of the graft and thrombotic deposits at the anastomoses. Thirty days after implantation, both types of prostheses showed the development of a thin fibrous tissue layer on the inner surface. Finally, at 120 days, an endothelial lining was observed.     

Treatment of tubal pregnancy by local injection of prostaglandin: selection of patients and evaluation of subsequent tubal patency

Thirty women who had a small unruptured tubal pregnancy were treated by laparoscopically guided injection of prostaglandin F2 alpha into the oviduct and into the corpus luteum. They had no side effects. The serum human chorionic gonadotropin (S-HCG) concentration decreased in 25 women to less than 20 IU/l in a median time of 8 days (range 1-45). Five women were operated on because of increasing S-HCG concentration. The median diameter of the oviduct at the site of the gestation, the tubal localisation and the gestational age was similar in the women treated by prostaglandin and those, who were operated on after failure of the procedure. Four of the 6 women, with S-HCG concentrations of more than 2000 IU/l, needed subsequent operative treatment, compared to only one of 24 with a lower concentration. The median duration of the hospital stay after treatment was 2 days for the group of women with a S-HCG concentration of less than 2000 IU/l. Hysterosalpingography 3 months after treatment showed patency on the side of the pregnancy in 12 of 14 women. Prostaglandin injection seems to be an appealing option for the treatment of selected ectopic pregnancies.     

Radionuclide evaluation of tubal function

The tubal capacity to transport radioactively labeled human albumin microspheres deposited in the vaginal fornix and cervical canal and to concentrate them on the ovarian surface was evaluated in a group of 34 patient-volunteers. One millicurie of technetium-99 was used to label human albumin microspheres of 20 mu in diameter, suspended in 1 ml of saline. The distribution of the radioactive material was imaged on a gamma camera at different intervals between 15 and 240 minutes. The radiation dose to the ovaries was estimated to be similar to that of a hysterosalpingogram. The results of the radionuclide evaluation were compared with the surgical findings at the time of laparoscopy or laparotomy performed for diagnostic or therapeutic reasons. The overall correlation was 87.1%. It would appear that as opposed to the traditional hysterosalpingogram, a radionuclide test may give a better understanding of the functional capacity of the tube and may also prove a useful method in the evaluation of the results of tubal microsurgical procedures.     

Treatment of unruptured tubal pregnancy by local injection of methotrexate under transvaginal sonographic control.

Seventeen unruptured tubal gestations were managed on an outpatient basis using local methotrexate (MTX) injection. A single 50-mg dose of MTX was injected into the gestational sac under transvaginal sonographic control. Follow-up included serial assays of the beta-subunit of human chorionic gonadotropin (beta-hCG), clinical and sonographic evaluation. Resolution was obtained in 13 out of 17 patients. The regression curve between days after treatment versus beta-hCG (y = 82.2 - 10.8x + 0.37x2) demonstrated a significant negative correlation (R2 = 0.77; R = 0.88; P less than or equal to 0.02). The mean beta-hCG level on day 15 was 3.2% +/- 3.1% of the initial value. Laparoscopy was performed in 4 patients. Pathological findings suggested that resolution was underway in these four cases despite a slow decline in beta-hCG. No systemic side effects were observed in any of the 17 patients. Long-term follow-up is needed to evaluate tubal patency and reproductive outcome. Our experience suggests that local injection of MTX may be an effective alternative for the treatment of unruptured ectopic pregnancy.     

Spontaneous bilateral tubal ectopic pregnancy and failed methotrexate therapy: A case report

Spontaneous bilateral ectopic pregnancy is extremely rare. An unsuspected case of spontaneous bilateral ectopic pregnancy with failure of single-dose methotrexate is presented. We question whether the recommended dose of methotrexate for unilateral ectopic pregnancy is adequate for bilateral tubal pregnancy.(Am J Obstet Gynecol 1997;177:1545-6.)     

Conservative nonsurgical treatment of early detected tubal pregnancies with intra-amniotic methotrexate

Four cases of early detected tubal pregnancies were managed conservatively by aspiration and administration of 20 mg methotrexate into the amniotic sac during laparoscopy. All three women for whom hysterosalpingograms are available had patent tubes on the side of the former ectopic pregnancy six months after treatment. Spontaneous menstruation occurred within six weeks after methotrexate application in all cases.     

Treatment of tubal pregnancy by local injection of methotrexate after adrenaline injection into the mesosalpinx: a report of 25 patients

Twenty-five patients with a tubal pregnancy were treated by an injection of methotrexate (MTX) into the tubal swelling after vasoconstriction of the mesosalpinx with adrenaline. Twenty-four of the 25 patients had an uneventful clinical course. In one case, the tube ruptured despite falling serum human chorionic gonadotropin (hCG) concentrations. In 17 of 24 patients, the dose of 100 mg that was locally injected was sufficient. Seven patients were given additional systemic injections. In 3 of the 4 patients with high initial serum hCG levels (greater than 10.000 mIU/mL), the clinical course was uneventful. The side effects of MTX and adrenaline were minimal. Whether this way of treatment guarantees better chances of fertility in the future is unknown. Therefore a prospective, case-controlled study comparing the fertility rates in different ways of treatment is needed.     

卵巢浆液性癌光镜与电镜酶细胞化学观察

卵巢浆液性癌是妇科常见的恶性肿瘤 ,其发病率高而存活率低 ,不易早期诊断。目前病因不清 ,有关癌细胞膜活性的研究报道甚少。我院 1999年 5月至 2 0 0 0年 1月应用光、电镜酶细胞化学方法在超微结构方面观察了肿瘤细胞膜酶的分布及酶活性变化 ,现报道如下。1　材料与方法1 1　材料与分组1 1 1　卵巢浆液性癌组 10例　研究对象来源于我院住院患者 ,年龄 35～ 5 9岁 ,平均 47 8岁 ,手术切除的标本 ,术前未行放疗或化疗。组织病理证实为浆液性癌。1 1 2　正常卵巢组 8例　为正常妇女因其它疾病手术而切除的新鲜卵巢。年龄 37～ 5 6岁 ,平均 45…     

Prenatal diagnosis of Pompe disease by electron microscopy

Introduction Pompe disease is one of the lysosomal storage disorders caused by -glucosidase deficiency. The disease is characterized by accumulation of glycogen in the lysosome. The accumulation has unique ultrastructural features, which enable a prenatal diagnosis possible by electron microscopy.Materials and methods A prenatal diagnosis of Pompe disease by electron microscopic study of chorionic villus biopsies is described in a fetus of a mother whose previous child had died of the disease.Results Electron microscopy revealed fibrocytes with typical vacuoles filled with glycogen. A prenatal diagnosis of Pompe disease was made and subsequently confirmed by the autopsy study of the abortus.Conclusion We report the usefulness of electron microscopy for prenatal diagnosis in the first trimester of Pompe disease.     

Effects of tubal sterilization

OBJECTIVE: Besides manifestations of hormonal deficits, psychological problems are also known as possible negative effects of tubal sterilization (here termed "operative contraception"--OC). It is generally assumed that the age at time of operation and the number of children play a crucial role in enabling the patient to come to terms with surgical contraception. We investigated whether these patients were satisfied and the frequency of a desire for refertilization as well as further factors possibly affecting our patients. PATIENTS AND METHODS: A standardized questionnaire was sent to 274 women in whom surgical contraception was performed from 1984 to 1990 in our hospital. Besides physical symptoms, the questions mainly inquired as to satisfaction, degree of regret and desire for refertilization. RESULTS: 5.4% of women were not satisfied with the operation. 13.7% of the patients regretted the operative contraception and 6.5% wished to have refertilization. The negative appraisal did not correlate with the number of children and age at the time of operative contraception. Altogether, satisfaction was very much greater in patients who had completed family planning than in patients who had received operative contraception for medical reasons. Appraisal of operative contraception was especially negative in women in whom the operation had been performed on the occasion of a cesarean section. CONCLUSION: Our follow-up investigation confirmed that operative contraception was experienced as being very liberating by most women and was accordingly appraised positively on the whole. The number of children and age only played a subordinate role in how patients came to terms with their situation. For a positive experience of operative contraception, the time of the operation appears to be of major importance. In particular, "favorable opportunities" on the occasion of cesarean section and the if anything doubtful need for this measure in the condition after prior cesarean sections must be avoided, since in these cases a free decision in favor of operative contraception, which the woman concerned feels to be autonomous, is not possible.