Fertility and reproductive outcome after tubal ectopic pregnancy: comparison among methotrexate, surgery and expectant management

Abstract

Purpose To compare fertility and reproductive outcome after surgical, medical, and expectant management for tubal ectopic pregnancy (EP). Methods 133 of 228 patients, who were managed between January 2012 and December 2017 for a tubal EP, tried to conceive immediately after treatment: 86 out of 173 (49.7%) underwent surgical treatment; 38 (21.9%) were treated with methotrexate (MTX), and 49 (28.3%) had expectant management. Clinical data were retrieved by medical records, fertility outcomes were obtained by phone follow-up. The cumulative incidence (CI) of intrauterine clinical pregnancy (CP), miscarriage, live birth (LB), and recurrent EP, and the time between treatment and first intrauterine CP were compared between women treated with MTX, surgery and expectant management. Results The CI of intrauterine CP starting from 12 months after the EP was 65.3% for the expectant management, 55.3% for the MTX group, and 39.5% for surgery (p = 0.012). Post-hoc analysis showed expectant management having higher intrauterine CP and LB, and shorter time between treatment and first intrauterine CP compared to surgery (p < 0.05). The CI of recurrent EP was comparable between the 3 groups. The analysis stratified per βhCG cut-off of 1745 mUI/mL and EP mass cut-off of 25 mm reported consistent results. Conclusions Women successfully managed by expectation appear to have better reproductive outcomes compared to women who underwent surgery, with the shortest time to achieve a subsequent intrauterine CP. Therefore, if safely applicable the expectant management should be considered in the case of tubal EP. The fact that the chosen treatment was primarily guided by the βhCG value and EP mass diameter based on the protocol, which is intrinsically related to the characteristics of the EP, represents the main limitation of the present study. Indeed, we cannot completely exclude that the observed differences between treatments are related to the EP itself instead of the treatment.

Ectopic pregnancy in noncommunicating horn of unicornuate uterus: 3D‐ultrasound and primary laparoscopic management

“…For tubal ectopic pregnancies, the cumulative incidence for intrauterine pregnancy was 65.3% for expectant management, 55.3% for methotrexate, and 39.5% for surgery. 19 In cases of tubal surgeries, salpingectomy and salpingostomy have similar post-treatment intrauterine pregnancy rates (56% and 60%, respectively), but salpingostomy has more recurrent ectopic pregnancy rates than salpingectomy ( 18.7% vs 5.3%). 20 Reproductive outcome after laparoscopic excision of unicornuate horn is similar to reproductive outcomes of mullerian anomalies.…”

“…Reproductive outcomes of ectopic pregnancies after treatment have been studied earlier. For tubal ectopic pregnancies, the cumulative incidence for intrauterine pregnancy was 65.3% for expectant management, 55.3% for methotrexate, and 39.5% for surgery 19 . In cases of tubal surgeries, salpingectomy and salpingostomy have similar post‐treatment intrauterine pregnancy rates (56% and 60%, respectively), but salpingostomy has more recurrent ectopic pregnancy rates than salpingectomy ( 18.7% vs 5.3%) 20 .…”

Early diagnosis and surgical management of heterotopic pregnancy allows us to save the intrauterine pregnancy

“…Heterotopic pregnancy refers to the simultaneous presence of intrauterine and ectopic gestational chambers. Epidemiologically it affects about 1 in 15,000/30,000 naturally conceived pregnancies [1], and the risk of heterotopic pregnancy rises from 1 to 3% for pregnancies that occur through assisted reproductive technologies (ART) [2]. Patients with a heterotopic pregnancy are also more likely to have a spontaneous or medically induced abortion and are 30% less likely to have a live-birth delivery compared with women with isolated intrauterine pregnancies [3].…”

“…Patients with a heterotopic pregnancy are also more likely to have a spontaneous or medically induced abortion and are 30% less likely to have a live-birth delivery compared with women with isolated intrauterine pregnancies [3]. Because heterotopic pregnancy is difficult to diagnose, patients affected are at increased risk of tubal rupture, hypovolaemic shock, and maternal or foetal death [1]. Retainment of the dead foetus in abdominal cavity is extremely rare, known as lithopaedion [4].…”

Case Report of an Undisturbed Ectopic Pregnancy with Very High Human Chorionic Gonadotrophin (β-hCG)

“…4 In the past decades, the management of ectopic pregnancy was revolutionized by the development and continuous improvement of transvaginal ultrasonography (TVUS), which, together with the implementation of the Beta human chorionic gonadotropin (β-hCG) assay, allows early diagnosis of ectopic pregnancy with the prevention of complications. 5 As a consequence, the clinical presentation of ectopic pregnancy has changed from a life-threatening disease, necessitating emergency surgery, to a benign condition in almost asymptomatic women for whom non-surgical treatment options are also available. 6 Treatment with methotrexate (MTX) in stable ectopic pregnancies is now a safe alternative instead of surgery.…”