Tubal sterility. What treatment to propose: IVF or surgery?]

The results of IVF in cases of tubal sterility are compared with those of surgery (macro- or micro-surgery, coelio-surgery). This analysis includes a continuous series of 1051 attempted pregnancies in 640 women (with or mixed tubal sterility with or without endometriosis). After an average 1.64 attempts per patient, 220 women had achieved 241 pregnancies (pregnancy rate: 22.9% per puncture, 34.3% per woman). Of these 241 pregnancies, there were 172 (71.8%) which continued to term, 57 (23.6%) miscarriages and 11 (4.6%) ectopic pregnancies. The pregnancies carried to term were single pregnancies in 129 cases (74.6%), twin pregnancies in 37 cases (21.4%) and triple pregnancies in 7 cases (4%). The indication of coelio-surgery (or microsurgery) is justified in young women with no history of genital tuberculosis, tubal plasty or ectopic pregnancy and presenting with purely tubal sterility with a good prognosis. Restoration of patency after tubal sterilization remains a good indication for microsurgery in young women. In all other cases, indication is for IVF from the outset.     

Tumor markers and creatine kinase in the differential diagnosis of tubal pregnancy

In the present study we tried to evaluate the cancer marker CA 19-9, CA 12-5, CA 15-3 as well as the enzyme creatine-kinase (CK) whether they are of any diagnostic value in cases of tubal pregnancies. 15 patients with laporoscopically verified tubal pregnancy were compared with 15 patients with normal intrauterine pregnancies of the same age. Except one case of elevated CK in a patient with tubal pregnancy all other values were within the normal range. We concluded, that tumor markers and CK are inefficient for preoperative differential diagnosis in cases of tubal pregnancies.     

Antibodies to Chlamydia trachomatis and risk for tubal pregnancy

We performed a case-control study of the effect of exposure to Chlamydia trachomatis on the risk for tubal pregnancy. Sixty women with tubal pregnancies and 60 matched control women with normal second-trimester intrauterine pregnancies were studied. Cases were more likely than controls to have detectable antichlamydial IgG antibodies (82% versus 58%, p less than 0.01) and their mean titers were higher. The prevalence of IgM antibody seropositivity was not different between cases and controls (20% versus 12%, not significant). Compared with women with IgG antibody titers of less than or equal to 1:8 the relative risk for tubal pregnancy for women with titers greater than or equal to 1:128 was 6.6 (95% confidence interval, 2.0 to 21.6). Among women with tubal pregnancies, antichlamydial antibody titers of greater than or equal to 1:128 were significantly associated with pelvic adhesions and inflammatory tubal mucosal damage. Only 17.6% of women with detectable antichlamydial antibody or inflammatory tubal damage reported a history of pelvic inflammatory disease or gonorrhea.     

An analysis of factors associated with ectopic pregnancy following in vitro fertilization and embryo transfer

Five ectopic pregnancies occurred in 75 in vitro fertilization and embryo transfer (IVF-ET) pregnancies (6.7%) in Ogikubo Hospital IVF program between 1985 and 1989. The indication for IVF in 70 pregnancies was a tubal factor. Thirty cases were among 70 pregnancies with hydrosalpinx, and 40 cases were with other tubal conditions. All of the five cases had tubal disease. Four of them had hydrosalpingos. The percentage of ectopic pregnancies for the 30 pregnancies with hydrosalpinx was 13.3%, while for 40 pregnancies with other tubal conditions it was 2.5%. However, there was no significant difference between the two groups. No correlation was found in other parameters including superovulatory methods, oocyte recovery procedure, number of embryos transferred, embryo transfer procedure, and endocrine changes after embryo transfer. In this study, we were unable to identify a difference between ectopic pregnancy and intra-uterine gestation in IVF-ET. However, further study is required to clarify whether hydrosalpinx increases the risk of ectopic pregnancy in IVF-ET.     

Ovarian pregnancy associated with the intra-uterine contraceptive device. A survey of two decades

Records of 25 cases of ovarian pregnancy in the period 1965 to 1984 were reviewed. Seventeen cases (68%), had an IUCD in situ, and 15 of these had occurred during the last decade. The ratio of ovarian pregnancy to all ectopic pregnancies was 1:13 in the IUCD group versus 1:78 in the non-IUCD group (p less than 0.025). In contrast to patients with tubal pregnancies, those with ovarian pregnancy very seldom have a history of pelvic inflammatory disease (PID), infertility, or earlier pelvic operations. Subsequent fertility is good compared with patients with tubal pregnancies, for patients both with and without IUCD.     

The contribution of pathological anatomy to the diagnosis and prognosis of different forms of tubal sterility]

The histological examination made by means of tubal section allows us to predict; in a large number of cases, the functional future of the tubes after plastic surgery. The results obtained through surgical treatment of the various internal tubal occlusions can be summarised thus: a persistance of permeability is very marked in the internal tubal occlusions and more especially, in the colonisations. But on the whole, uterine pregnancies, including those with abortion, and gestations whose development is unknown, are less frequent than those obtained after surgical treatment ofr external tubal occlusions. In fact, the percentage of pregnancies after external tubal occlusions is 22%, with 18% of the pregnancies going the full term; 15% in cases of internal tubal occlusion, with only 5 pregnancies, that is 7%.     

Conservative surgery for tubal pregnancy.

Twenty-four conservative surgical procedures for unruptured tubal pregnancies were performed on 23 patients with poor past obstetric performance. All cases were diagnosed preoperatively by laparoscopy. Salpingotomy was performed in 20 cases and fimbrial expression of the ectopic pregnancy was performed in 4 cases. In the group of conservatively treated patients there were 15 live births in 11 women and 28 intrauterine pregnancies in 14 women. No ectopic pregnancies occurred in the operated tube. Early diagnosis and conservative surgical treatment of unruptured tubal pregnancy is appropriate for patients with poor reproductive histories.     

Risk factors associated with the rupture of tubal ectopic pregnancy

OBJECTIVE: To identify risk factors that may lead to the rupture of ectopic pregnancies. STUDY DESIGN: A retrospective chart review was performed on patients with ectopic pregnancies at the University of Miami/Jackson Memorial Hospital between 1/1/1995 and 3/1/2002. 738 patients were identified with ectopic pregnancies. Women with tubal rupture were compared to those without rupture. Variables analyzed were demographic data, patient-related risk factors (history of pelvic surgery, bilateral tubal ligation, history of pelvic inflammatory disease, previous ectopic pregnancy, intrauterine device use) and beta-human chorionic gonadotropin (betahCG) measurement. RESULTS: There were 439 (59%) cases with a ruptured and 299 (41%) cases with an unruptured ectopic pregnancy. Multivariate logistic regression analysis revealed that previous ectopic pregnancy (OR 2.88; 95% CI 1.92, 4.33) and betahCG level >or=5,000 mIU/ml (OR 1.85; 95% CI 1.12, 3.06) were the only significant risk factors for tubal rupture. CONCLUSION: Patients with betahCG levels >or=5,000 mIU/ml and patients with a history of a previous ectopic pregnancy are significantly more likely to experience a tubal rupture.     

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.     

Clearance pattern of maternal serum pregnancy specific beta 1-glycoprotein after treatment in active and regressed tubal pregnancy

The clearance pattern of maternal serum pregnancy specific beta 1-glycoprotein (SP1) was studied in 16 cases of tubal pregnancy (9 active and 7 regressed) after 12, 24, 48, 72, 96, 120 and 192 h following surgery. The mean values of the hormone in both groups showed a statistically highly significant difference in all measurements before and after treatment (P less than 0.001), but they followed the same exponential regression pattern. The half-life of SP1 in active tubal pregnancies after salpingectomy was 36.2 h and in regressed tubal pregnancies after salpingostomy was 37.5 h.     

Development and results of microsurgical sterility operations at the Gynecology and Obstetrics Clinics of the Brno Masaryk University

Four periods of microsurgery of tubal sterility and present approach to individual operation techniques in respect to assisted reproduction are evaluated. The evaluation concerns 240 operated women, their average was 31.8 years, 68.8 per cent women were operated for the first time. The pregnancy rate arrived at 90 pregnancies (40.8 per cent), 80 women delivered (33.3 per cent), the abortion occurred in 7 cases (2.9 per cent) and ectopic pregnancies occurred in 11 cases (4.6 per cent). By adhesiolysis we achieved 56 per cent pregnancies, by fimbrioplastics 34 per cent pregnancies and by neostomies only 27 per cent pregnancies. Tubal anastomosis (11 operations) and tubal implantations (9 operations) had no significant influence upon evaluation. Deflection from tubal implantations, anastomoses (except refertilizing ones) or neostomies (especially iterative ones) in favour of in-vitro-fertilization is evident.     

The intrauterine device and ovarian pregnancy.

Within a 1-year period, three patients presenting to the University of Chicago, Chicago Lying-In Hospital with a complaint of lower abdominal pain were diagnosed at laparotomy to have ovarian pregnancies according to the criteria of Spiegelberg. All of the patients were at the time using the Copper-7 intrauterine device for contraception. There are now 50 known cases of ovarian pregnancies in patients using the intrauterine device (IUD). The characteristics of these patients do not differ markedly from those previously reported in studies on tubal pregnancies, with and without the IUD, but the presentation of patients tends to be more variable than in tubal pregnancies. The increasing incidence noted here, in a population already known to be particularly prone to pelvic inflammatory disease and therefore ectopic pregnancies in general, lends further credence to a questioning of the desirability of the IUD in such a population.     

Different placentation patterns in viable compared with nonviable tubal pregnancy suggest a divergent clinical management.

OBJECTIVE: In contrast to tubal abortions, viable ectopic pregnancies in color Doppler ultrasonography exhibit a signal-intensive ring around the gestational sac. We investigated the underlying differences in implantation and placentation. STUDY DESIGN: Histologic sections of fallopian tubes carrying viable tubal pregnancies (13 patients) and tubal pregnancies that aborted (8 patients) were immunostained for cytokeratin, MIB-1, CD-34, and CD-68. The data were studied by computer-aided image analysis followed by statistical evaluation (Student t test, P <.05). RESULTS: In contrast to tubal abortions, viable tubal pregnancies are characterized by implantation at the mesosalpingial rather than at the antimesosalpingial side of the organ. They exhibit deeper trophoblast invasion into the thickened tubal wall, more intense trophoblast proliferation (P <.001), and increased villous vascularization (P <.001). CONCLUSION: The morphologic findings correlate with preoperative Doppler ultrasonography. They suggest that trophoblast invasion, placental growth, and the fate of tubal pregnancies depend on the implantation site. They encourage a conservative management of anti-mesosalpingially implanted, nonviable ectopic pregnancies in clinically stable patients.     

Tubal pregnancies in women using progestagen-only contraception

Previously, 10 cases of tubal pregnancy in women using progestagen-only contraception have been reported in medical journals and mention has been made of 13 unpublished cases. 9 women who had ectopic pregnancies while taking progestagen-only pills (norethisterone .3 mg) for contraception can now be added to the list. These cases were found in 4 hospitals in 3 well-defined regions in the eastern, southeastern, and western parts of Norway in less than 2 years. Statistically, 2.5 ectopic pregnancies would be expected among minipill users instead of the 9 observed in this period. It is suggested that altered tubal motility is responsible for the high incidence of ectopic pregnancies among minipill users. The hypothesis that the minipill prevents intrauterine but not extrauterine pregnancies is a possibility that is difficult to prove.     

Culdocentesis in Tubal Pregnancy

Summary: Culdocentesis was carried out in 92 suspected cases of ectopic pregnancy and was positive in 90%. Laparotomy confirmed the accuracy of culdocentesis in 97.5% of the cases of acute tubal rupture, 87.5% of tubal abortions and 80% of 'intact' tubal pregnancies.     

Ruptured heterotopic pregnancy: a report of unusual acute abdominal syndrome in two cases

A heterotopic pregnancy is in effect a multiple pregnancy with one or more intrauterine pregnancies coexisting with an ectopic pregnancy. Prompt diagnosis, rapid fluid and blood resuscitation, heart-sparing anesthesia and gentle, expeditious surgery collectively contribute to a favorable outcome for the mother and fetus in patients with a ruptured tubal pregnancy. In this report we present two cases of heterotopic pregnancies with ruptured tubal components; one spontaneous and the other one after clomiphene citrate treatment. Explorative laparotomy and salpingectomy were performed in both patients. After surgery, the intrauterine pregnancies were not damaged, and were still healthy on progression.     

Responsabilité médicale en gynécologie

One hundred and twenty cases of medical responsibility in gynaecology from January 1973 to September 1996 are reviewed. Close to 50 percent of these cases were related to recto-vaginal fistulae, pregnancy following tubal ligation, vesico-vaginal fistulae, abnormal cervical smears and salpingitis after tubal ligation. Of these cases, 31 were assessed as avoidable (25,8%). Those cases with increased rates of being avoidable included forgotten surgical swabs (75,0%), abnormal cervical smears (57,1 %), undetected ectopic pregnancies (50,0%), pregnancies following tubal ligation (40,0%), medications errors (36,4%), uterine perforation (28,6%) and those cases related to informed consent (28,6%). These avoidable accidents must be closely monitored and eventually prevented by risk management strategies including comprehensive patient information and better informed consent, documentation on the patient file and enhancement of quality assurance of the gynaecological interventions.     

Laparoscopic tubal anastomosis.

OBJECTIVES: To evaluate the pregnancy outcome after laparoscopic tubal anastomosis. METHODS: From December 1998 to December 2001, 26 patients with bilateral tubal ligation who underwent laparoscopic tubal anastomosis were prospectively evaluated. Patients' age varied from 28 to 37 years. RESULTS: Laparoscopic tubal reversal was performed in 23 patients. Bilateral reversal was possible in all but two patients. The operation time ranged from 95 to 155 min and all patients were discharged in the following morning after surgery. After 3 months, tubal patency was confirmed in 15 patients (15/23). Pregnancy rate was 56.5% (13/23), without ectopic pregnancies. The average time from tubal reversal and pregnancy was 6 months. CONCLUSIONS: In selected cases, laparoscopic tubal reversal can be offered to patients who had been submitted to tubal sterilization and desire new pregnancies. Patient selection as well as meticulous surgical technique are key factors in achieving satisfactory pregnancy rates.     

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.