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Objective To compare single dose systemic methotrexate (50 mg/m 2 ) with laparoscopic surgery for the treatment of unruptured tubal pregnancy.Design An open, pragmatic, prospective randomised trial. Setting Departments of obstetrics and gynaecology at three hospitals in Auckland, New Zealand.Participants Clinically stable women with an unruptured tubal pregnancy diagnosed by transvaginal ultrasound and quantitative serum b-hCG measurement. Inclusion criteria included a serum b-hCG concentration , 5000 IU/L, and a tubal pregnancy of , 3.5 cm diameter. Main outcome measures Treatment success, physical and psychological functioning, side effects, and subsequent ipsilateral tubal patency. Results Two hundred and eighteen women with ectopic pregnancies were seen at the three hospitals. 79 women (36% eligibility rate) were eligible for trial entry and 62 women (78% recruitment rate) were recruited. Twenty-six of the 28 women (93%) randomised to laparoscopic surgery required no further treatment, compared with 22 of the 34 women (65%) randomised to methotrexate (95% CI of difference in success rate 10 -47%; P , 0.01). Two women (7%) in the laparoscopic surgery group had persistent trophoblast. Nine women (26%) in the methotrexate group required more than one dose of methotrexate and ®ve women (15%) underwent laparoscopy during follow up. In the laparoscopy group three women (11%) had negative laparoscopies and two women (7%) had were found to have a ruptured fallopian tube at the time of surgery. Women treated with methotrexate had signi®cantly better objective physical functioning scores but there were no differences in any other psychological outcomes. Women treated with methotrexate experienced greater and more prolonged vaginal bleeding. The likelihood of methotrexate treatment failure was greater at higher serum b-hCG concentrations. Ipsilateral tubal patency rates were similar in each group. Conclusion This trial shows that in the treatment of tubal pregnancy single dose systemic methotrexate is a less effective treatment than laparoscopic salpingotomy. It is well tolerated, but should only be offered as an alternative to surgery to women who have mild symptoms and present at low serum b-hCG concentrations. In our population this likely to be no more than a quarter of women presenting with a tubal pregnancy.

The use of GnRHa for three to four months prior to fibroid surgery reduces both uterine volume and fibroid size. They are beneficial in the correction of pre-operative iron deficiency anaemia, if present, and reduce intra-operative blood loss. If uterine size is such that a midline incision is planned, this can be avoided in many women with the use of GnRHa. For women undergoing hysterectomy, a vaginal procedure is more likely following the use of these agents.

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