Transvaginal intratubal methotrexate treatment of ectopic pregnancy.

OBJECTIVE: To evaluate the efficacy of transvaginal intratubal methotrexate (MTX) treatment of tubal ectopic pregnancy (EP). SETTING: Outpatient setting in University Hospital. PATIENTS: Forty women with early EP and rising serum beta-human chorionic gonadotropin (beta-hCG) levels. INTERVENTION: Transvaginal intratubal administration of MTX (1 mg/kg body weight). MAIN OUTCOME MEASURES: Success was defined as declining serum beta-hCG to undetectable levels, no tubal dilatation on ultrasound examination, and no further intervention was required. RESULTS: Treatment was associated with a 70% success rate. No difference was found in the success rate between women with an embryo (76.9%) and those with no embryo in their fallopian tubes (66.7%). The initial serum beta-hCG levels were also not different between patients who were successfully treated and those who failed to respond to the treatment. Despite declining serum beta-hCG levels, tubal rupture occurred in two patients. CONCLUSIONS: Treatment of EP by transvaginal MTX administration is associated with a 70% success rate. This is independent of the presence of an embryo or the initial serum beta-hCG levels. Rupture of EP can still occur despite low and declining serum beta-hCG levels.     

Laparoscopy with ultrasonographic guidance of intraamniotic methotrexate injection for ectopic pregnancy. A report of two cases

BACKGROUND: The efficacy of laparoscopic intratubal injection of methotrexate is reportedly controversial. CASES: A 29-year-old woman with an interstitial-isthmic pregnancy and a 30-year-old woman with an ampullary pregnancy surrounded by dense adhesions were treated with intraamniotic injection of methotrexate with ultrasonographically guided laparoscopy (LUS). The ectopic pregnancies resolved quickly, without further intervention. The human chorionic gonadotropin concentrations were negligible by 18 and 25 days. CONCLUSION: Intraamniotic methotrexate injection with LUS is an effective treatment for unruptured interstitial and tubal pregnancies in patients with dense adhesions.     

The treatment of unruptured tubal pregnancy with intratubal methotrexate injection under laparoscopic control

Nine patients with unruptured tubal pregnancies of 6-9 weeks' duration were treated with methotrexate intratubal injection under laparoscopic control. Urinary hCG levels decreased immediately after completion of the procedure, with a median time of 11 days (range 1-29) to resolution. Tubal patency on the side of the ectopic gestation was confirmed by hysterosalpingography 1-3 months after the procedure in all cases. This method requires a reduced methotrexate dosage compared with intramural or intravenous therapy. The indications are unruptured tubal pregnancy of 4 cm or less in diameter and urinary hCG levels of 8000 mIU/mL or lower.     

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.     

Methotrexate local injection for unruptured tubal pregnancy: an alternative to laparotomy?

Fifty-nine women with early unruptured tubal pregnancy were treated by a single local injection of methotrexate at laparoscopy. All 59 patients underwent the procedure without any adverse reaction, 47 (80%) of them needing no laparotomy. Twelve patients required a laparotomy for reasons such as rising beta-hCG levels and abdominal pain with or without rising levels of beta-hCG. Only one patient ruptured the tube. None of the women needed a blood transfusion. We found tubal patency in 19 out of 21 patients at follow up hysterosalpingography. Eleven pregnancies were subsequently reported, one of them tubal. The appearance of the injected tube was absolutely normal in three patients, one at cesarean section and two at repeated laparoscopy. No peritubal adhesions were observed. We suggest that this new technique is a safe and effective alternative to laparotomy in a patient with an early unruptured 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.     

Successful treatment of two viable tubal pregnancies by two-step local injection.

Two viable tubal pregnancies were diagnosed by transvaginal ultrasound with a serum beta-hCG level of up to 3,004 mIU/mL in Case 1 and 16,676 mIU/mL in Case 2. Under transvaginal sonographic guidance, a local injection of potassium chloride (0.5 mL = 1.0 mEq) into the embryo was performed for the purpose of embryocide. In Case 1, a follow-up of serum beta-hCG levels showed an initial plateau and subsequent regression to negative, 49 days after the local injection. However, a persistent increase in serum beta-hCG levels was noted in Case 2 for two samples at intervals of two days during follow-up, 27,800 and 36,500 mIU/mL, in spite of the fact that no fetal cardiac activity was visible. Six days later, laparoscopy was done and methotrexate, 50 mg in 6 mL of normal saline, was injected into the ampullar mass of the right fallopian tube in two divided dosages. The serum beta-hCG levels then gradually decreased and returned to negative 60 days after the methotrexate injection. For a viable ectopic pregnancy, this new modality of two-step local injection, first with potassium chloride and then with supplemental methotrexate, separately by two procedures, may offer an additional choice of conservative treatment.     

Could we treat more unruptured ectopic pregnancies with intramuscular methotrexate?

The main reason for the restricted use of methotrexate in the treatment of ectopic pregnancy (EP) obviously is the fear of tubal rupture in patients with lower abdominal pain after the administration of methotrexate. Therefore, we wanted to find out if patient characteristics at first presentation, such as age, pretreatment beta-hCG level, adnexal mass as visualized by transvaginal ultrasonography, or history of prior EP, would identify patients at risk for tubal rupture if they were hemodynamically stable and showed no signs of peritoneal irritation. We examined whether more patients could have been treated medically with methotrexate, because tubal rupture was unforeseeable at first presentation and inclusion criteria for methotrexate treatment were fulfilled. From January 1996 to August 1998, 122 patients diagnosed as having EP were treated at the Gynecologic Department of the University Hospital of Vienna. Inclusion criteria for medical treatment with intramuscular methotrexate (50 mg/ m(2) body surface area) were (1) hemodynamic stability, (2) an unruptured ectopic mass < or = 5 cm at the greatest dimension demonstrated at transvaginal ultrasonography; (3) beta-hCG level < or = 5,000 mIU/ml; (4) no cardiac activity of the extrauterine embryo; (5) wish of future fertility, and (6) informed consent. Patients with hemodynamic instability, severe abdominal pain, an ectopic mass > or = 5 cm at the greatest dimension, beta-hCG levels > or = 5,000 mIU/ml, cardiac activity of the extrauterine embryo, and no wish of future fertility, or disagreement with methotrexate treatment, primarily underwent surgery. Despite the fact that none of the above patient characteristics at first presentation identified patients at risk for tubal rupture, only 60/122 patients (49%) actually underwent medical treatment whereas our inclusion criteria would have granted medical treatment in 101/122 patients (83%). We determined the actual and maximal possible percentages of patients with unruptured EP eligible for medical treatment of EP with intramuscular single-dose methotrexate 50 mg/m(2) body surface area. Our data show that tubal rupture in hemodynamically stable patients is not foreseeable and should not lead to a restricted use of medical treatment in patients preferring methotrexate.     

Intratubal methotrexate for prevention of persistent ectopic pregnancy after salpingotomy

STUDY OBJECTIVE: To investigate whether frequency of persistent ectopic pregnancy after linear salpingotomy can be reduced by prophylactic administration of a single intraoperative injection of local methotrexate. DESIGN: Prospective, randomized, controlled trial (Canadian Task Force classification I). SETTING: University-affiliated hospital. PATIENTS: Sixty-five women with unruptured ectopic pregnancy. INTERVENTION: Laparoscopic salpingotomy with or without a single intratubal dose of methotrexate 1 mg/kg. MEASUREMENTS AND MAIN RESULTS: In the prophylaxis group, 22 patients received a single dose of intratubal methotrexate 1 mg/kg after linear salpingotomy; 43 controls had only linear salpingotomy. Six women (14%) in the control group developed persistent ectopic pregnancy, compared with none in the prophylaxis group (p <0.05). CONCLUSION: In our opinion, intratubal methotrexate injection during laparoscopic salpingotomy is a practical option for women with unruptured ectopic pregnancy.     

Treatment of ectopic pregnancy with a single intramuscular dose of methotrexate

This study evaluates the outcome of unruptured ectopic pregnancies treated with single-dose intramuscular methotrexate injection. There were 77 women with unruptured non-laparoscopically diagnosed ectopic pregnancies who were prospectively followed after receiving a single dose of 50 mg/m2 intramuscular methotrexate. Diagnosis required transvaginal ultrasound and serial quantification of beta subunit of human chorionic gonadotropin (betahCG). A repeat dose was given if the weekly drop of betahCG was less than 30%. Therapy was considered successful if complete resolution of betahCG to a level below 25 IU/L was achieved without surgical intervention. Treatment in 73 (95%) cases was successful. The mean pre-treatment level of betahCG was 2592 +/- 3771 IU/L (177-15000 IU/L), the mean diameter of ectopic mass was 2.4 +/- 1.0 cm (1.7-3.5 cm). The average resolution period was 3.2 +/- 1.0 weeks (1-6 weeks) and this significantly correlated with the pre-treatment betahCG level. With strict criteria of inclusion and follow-up, single-dose intramuscular methotrexate is a successful method for the treatment of selected cases of ectopic pregnancy.     

Current issues in medical management of ectopic pregnancy

This review focuses on current medical therapy for unruptured ectopic pregnancy. Recently emerging issues include early diagnosis, treatment costs, intratubal methotrexate injection, medical treatment of cervical and interstitial ectopic pregnancies, and future fertility potential after methotrexate therapy. In addition, new clinical practice guidelines identify optimal candidates for medical therapy.     

Transvaginal ultrasound-guided treatment of cervical pregnancy

OBJECTIVE: To describe our experience with sonographically guided injection of methotrexate and potassium chloride (KCl) to treat early cervical pregnancy. METHODS: We prospectively reviewed all cases of cervical pregnancies treated conservatively through transvaginal ultrasound-guided therapy at our institutions. Thirty-eight cases were identified, from 1993 through 2004. All cases were managed with transvaginal intra-amniotic and intrachorionic injection of 50 mg of methotrexate under ultrasound guidance. An additional intracardiac fetal injection of 2 mL KCl was given for those cervical pregnancies with documented cardiac activity. Follow-up sonographic examinations and serum beta-hCG measurements were performed twice weekly for 2 weeks after the procedure, then weekly. RESULTS: The mean initial beta-hCG level was 38,948 milli-International Units/mL and ranged from 5,608 to 103,256 milli-International Units/mL for 22 cases with fetal heart activity and from 2,765 to 18,648 milli-International Units/mL for 16 cases without. Gestational age ranged from 5.4 to 14 weeks (mean 8.8 weeks). All cervical pregnancies were successfully aborted, with an average resolution of the cervical mass in 49 days. Postoperative beta-hCG declined to less than 5 milli-International Units/mL within a mean of 38 days. A mean 4.5-year follow-up showed that, of 21 patients who desired pregnancy, 18 had achieved subsequent successful pregnancies. CONCLUSION: Cervical pregnancies can be successfully managed without surgical intervention through local injection of methotrexate and KCl. This treatment not only ablates the ectopic pregnancy but also preserves the uterus for subsequent pregnancies.     

Laparoscopic methotrexate treatment of ectopic pregnancy: feasibility, efficacy, safety and intrauterine pregnancy rates.

We set out to investigate efficacy, methotrexate (MTX) plasma concentrations, and toxicity following a single injection of MTX into the gestational site in the treatment of ectopic pregnancy. This was a non-randomised, non-blinded prospective clinical trial. Eighteen women with unruptured tubal pregnancies and in stable haemodynamic condition were studied. MTX 1 mg/kg was injected into the ectopic pregnancy guided by laparoscopy. Serum betahCG levels were estimated before MTX treatment and on days 1, 4 and 13. In 14 patients plasma MTX was determined 1 h and 6 h after the injection. We found an adequate decline in betahCG was achieved in 17 (94%) patients, and tubal surgery avoided in 15 (83%). At 6 hours following drug administration, mean plasma MTX concentration (0.36+/-0.21 microM) was only 12% of mean peak level (3.1+/-1.0 microM). Six (39%) demonstrated slightly elevated, but completely reversible liver enzymes. None reported any subjective adverse effects. At the 4-7 year follow-up nine of 12 (75%) women had delivered healthy babies. It is concluded that intratubal injection of 1 mg/kg MTX appears to be an effective and safe treatment of ectopic pregnancy.     

Alternative to surgery of treatment of unruptured interstitial pregnancy: 15 cases of medical treatment

Objective: To evaluate medical treatment of interstitial pregnancy. Methods: This series was a retrospective study of medical treatment of interstitial pregnancies which was managed in two French Departments of Obstetrics and Gynecology (Bichat public Hospital, Paris and A. Béclère public Hospital, Clamart, France). Fifteen patients with clear evidence of an unruptured interstitial pregnancy were treated by injection of methotrexate (MTX) or potassium chloride (KCL) without surgery since January 1988. The diagnosis was established either by sonography and laparoscopic confirmation in eight cases or by only transvaginal ultrasound in seven cases. Three out of 15 cases in this series, had a heterotopic pregnancy who were treated by transvaginal ultrasound-guided injection of KCL. Others received systemic MTX injection in four cases, and local MTX injection in eight cases under either laparoscopy or transvaginal ultrasound guidance. Four different protocols of MTX (Ledertrexate^R) administration was performed in this series with time: at the beginning of our experience, MTX1 protocol, 15 mg i.m. daily for 5 days was used; and after MTX2 protocol, 1 mg/kg body weight i.m. daily for 4 days; MTX3 protocol, 1 mg/kg body weight intratubal associated with 1 mg/kg body weight i.m. daily for 3 days; and now MTX4 protocol, only intratubal 1 mg/kg body weight is especially used. The success was defined as declining serum human chorionic gonadotropin (hCG) to undetectable levels, and no further surgical management was required. Outcome of subsequent fertility was also evaluated. Results: Complete resolution was obtained in 13 (86.6%) out of 15 interstitial pregnancies. Two out of 15 patients, with medical treatment's failure required secondary surgery. No severe side effects of medical treatment were observed. Follow-up hysterosalpingography was performed in 12 patients showing 91.7% tubal patency on the side of interstitial pregnancy. Outcome of intra-uterine pregnancy of the three patients who had heterotopic gestation, was two miscarriages and one delivery at term. Out of the other 12 patients in this series, nine became pregnant within 1 year: eight pregnancies at term, and one induced abortion. At present, among the last three patients, two have no desire to conceive. Conclusion: Our results suggest that unruptured interstitial pregnancies now can be managed with local MTX administration of 1 mg/kg body weight under transvaginal ultrasound or under laparoscopy procedure. This approach is particularly attractive in these patients, where the only alternative to therapy is laparotomy with cornual resection.     

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     

Predictors of methotrexate treatment failure in ectopic pregnancy

OBJECTIVE: To determine the possible predictors of methotrexate treatment failure in ectopic pregnancy. STUDY DESIGN: Fifty-eight patients diagnosed with ectopic pregnancy were treated with methotrexate (50 mg/m2). Selected variables in the history of the patients, the signs and symptoms at the time of admission, transvaginal ultrasound findings and serum beta-human chorionic gonadotropin (beta-hCG) levels on day 1 and 3 were evaluated in a logistic regression model to predict treatmentfailure, defined as tubal rupture. RESULTS: Methotrexate treatment failed in 9 cases (15.5 %). Another 9 cases (15.5%) required a second dose of methotrexate, and no treatment failures were observed in these cases. The presence of subchorionic tubal hematoma in the ectopic gestation (OR = 22.9, CI = 2.7-194.7, p = 0.004), the presence of an embryo (OR = 24, CI = 2.1-269, p = 0.01) and day 1 serum beta-hCG level > or = 3,000 mIU/mL (OR = 27.1, CI = 2.1-342.5, p = 0.01) were the main predictors of treatment failure. Follow-up serum beta-hCG levels > or =3,500 mIU/mL (OR = 42.9, CI = 4.3-421) on day 3 were significant predictors of treatment failure. Follow-up risk score was calculated as > 4 on day 3 by adding day 3 serum beta-hCG level to the admission score. Only 1 treatment failure (2.4%) occurred in 42 patients with an admission score of nil. No treatment failure occurred in 39 patients whose follow-up score was nil. The increase in admission risk (OR = 32.1, CI = 3.8-270, p = 0.001) and follow-up risk (OR = 9.2, CI = 2.4-35.2) were significant predictors of treatment failure. CONCLUSION: Transvaginal ultrasound findings are as important as serum beta-hCG level on the first day of methotrexate treatment. In unruptured cases, day 3 serum beta-hCG level is important to reevaluate the decision to continuefollow-up or perform early surgery for increased risk of treatment failure.     

The conservative management of interstitial pregnancy

OBJECTIVES: To evaluate the effectiveness of systemic methotrexate in the treatment of interstitial pregnancy. DESIGN: Prospective observational study. SETTING: An Early Pregnancy Assessment Unit in a London teaching hospital. SAMPLE: Twenty consecutive women diagnosed with an interstitial pregnancy. METHODS: Women were diagnosed with an interstitial pregnancy based on transvaginal ultrasound findings. Single dose, intramuscular methotrexate was administered on day 0. A second dose of methotrexate was given if the beta-hCG levels had not fallen by 15% between days four and seven. Weekly follow up continued until the serum beta-hCG < 5 IU. MAIN OUTCOME MEASURE: The resolution of serum beta-hCG levels without the need for surgical intervention. RESULTS: Two hundred and ninety-three ectopic gestations were diagnosed over a 42-month period. Twenty of these were interstitial in nature, with a median initial serum beta-hCG of 6452 IU. Of the 20 interstitial pregnancies, 17 cases received systemic methotrexate. Sixteen were treated successfully (94%), including all of the four cases with fetal heart activity present. A second methotrexate dose was given to six patients. Two cases were managed expectantly. Two cases underwent laparotomy and cornual resection: one elected for surgical management at the outset and one as a result of suspected ectopic rupture after two doses of methotrexate. There were no other complications. CONCLUSIONS: Systemic methotrexate is a safe and highly effective treatment for interstitial pregnancy. Surgery can be avoided in the majority of women with this condition. Early recognition of the cornual pregnancy with transvaginal ultrasound is essential.     

Medicosurgical approach to diagnosis and treatment of ectopic pregnancy.

Early ectopic pregnancy screening using vaginal ultrasonographic technology together with measurement of beta human chorionic gonadotropin (beta-hCG) and human chorionic somatomammotropin is possible within the first 2 weeks of the missing menses, prior to the appearance of symptoms. This article summarizes the main available treatment modalities, focusing primarily on the pelviscopic surgical tube-conserving approach and on instillation of intrachorionic drugs (methotrexate alone or in combination with ornipressin) and injection of prostaglandin F2 alpha. While the pelviscopic surgical approach can be applied in nearly all cases of ectopic pregnancy, irrespective of pregnancy duration, the pelviscopic medicosurgical approach is only appropriate for the treatment of early ectopic pregnancies until the 8th week of gestation in patients without fluid collection in the pouch of Douglas and beta-hCG values below 2000 mU/mL. The transvaginal intrachorionic drug instillation as a simple medicosurgical approach performed under ultrasonographic guidance without anesthesia remains restricted to the treatment of early viable ectopic pregnancy. A brief account of the expectant treatment of patients with nonviable ectopic pregnancy is given, underlining the prerequisites of decreasing beta-hCG values and the absence of fluid in the pouch of Douglas. Although spontaneous resorptions have been observed in a number of cases of the disease, no clear evidence is available on the reconstitution of tubal function and patency.     

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.     

A medical management of interstitial ectopic pregnancy: a 5-year clinical study

BACKGROUND: Medical treatment of the rare interstitial ectopic pregnancy with methotrexate has been considered an alternative to surgical resection. AIM: To determine the treatment success rate with a single-dose intravenous methotrexate/folinic acid regimen and to identify predictors of treatment outcome. METHODS: A 5-year audit (April 2000-August 2005) was carried out, collecting clinical imaging data and serum beta-human chorionic gonadotrophin (beta-hCG). Time taken for complete beta-hCG resolution was recorded, and a negative beta-hCG result was used as an endpoint of successful outcome. RESULTS: Of the 13 cases, two required urgent surgery for rupture on presentation. In the remaining 11 cases, intravenous methotrexate (300 mg) was used, with oral folinic acid rescue (15 mg x 4 doses). There were no side-effects. Complete beta-hCG resolution was achieved in 10 of the 11 medically treated cases (91% success rate), requiring 21-129 days. Successful outcome was seen with initial beta-hCG level as high as 106 634 IU/L and gestation sac as large as 6 cm and a live fetus. CONCLUSION: The methotrexate/folinic acid regimen used as a one-dose treatment is safe and effective for unruptured interstitial pregnancy, with no side-effects and the advantage of avoiding invasive surgery. Subsequent tubal patency and reproductive function are yet to be ascertained.