Spontaneous bilateral tubal ectopic pregnancy preoperatively diagnosed by the ultrasound: a case report.

BACKGROUND: Bilateral ectopic pregnancy is extremely rare, with a tremendous maternal mortality and morbidity risk, requiring rapid diagnosis and management. This condition is usually diagnosed during surgery, as radiologists may not pay enough attention to the contralateral side of interest. Therefore, reminding of this rare but emergent situation can be beneficial for both radiologists and gynecologists. Here we report a case of bilateral ectopic pregnancy, which was first diagnosed with ultrasound and was confirmed during laparoscopy. CASE PRESENTATION: A 34 years old woman complaining of light vaginal bleeding at 6 weeks of gestation by her last menstrual period presented to our institute. The serum ß-HCG levels were analyzed and followed during patient's admission. Unfortunately, serum levels weren't decreasing and blood test titration before surgery were as: 851,894,975 IU/l (checked daily and not every 48 h because of patient's status and being bilateral). There was no evidence of intrauterine pregnancy at the transvaginal ultrasound, but heterogeneous adnexal masses were seen at both adnexa, suspected of bilateral ectopic pregnancy. She underwent laparoscopic exploration, which confirmed the diagnosis. Bilateral salpingostomy was done to preserve fertility, and the patient's recovery was uneventful. CONCLUSIONS: Even with a unilateral report of ectopic pregnancy preoperatively in ultrasonography, surgeons should always be aware of the probability of bilateral ectopic pregnancies anytime facing susceptible cases, especially in patients with known risk factors. Also, it is an important reminder for radiologists to check both adnexa when facing a unilateral adnexal mass resembling ectopic pregnancy.

Prognostic value of hysterosalpingography after salpingostomy in patients with hydrosalpinx.

To assess whether post-hysterosalpingography evaluation was associated with pregnancy rate and to identify independent risk factors for pregnancy success after salpingostomy in patients with hydrosalpinx. A retrospective analysis was conducted on the clinical data of 47 patients diagnosed with hydrosalpingography (HSG) in our hospital from 2015 to 2018. These patients received laparoscopic surgery and another salpingography within 2 months after surgery. According to the fallopian tube conditions evaluated by HSG before and after surgery, the patients could be divided into two groups. According to the pregnancy rate and postoperative HSG of patients with hydrosalpinx after laparoscopy, the total pregnancy rate of the tubal improved group was 65.62%, while that of the non-improved group was 20%, with statistical significance (p < 0.05). We found that hysterosalpingography after salpingostomy in patients with hydrosalpinx can provide reference for clinical treatment and improve the prognosis of patients.

Postoperative HSG improvement was an independent risk factor for pregnancy rate in patients with hydrosalpinx after laparoscopic surgery. Impact statementWhat is already known on this subject? Fallopian tube obstruction is an important cause of female infertility. Current studies have shown that most spontaneous pregnancies in patients with hydrosalpinx after salpingostomy occur within 18 months, however, pregnancy rates and outcomes vary from report to report.What do the results of this study add? Many studies have shown that hydrosalpinx reduces the success rate of natural pregnancy and embryo transfer, but the mechanism of hydrosalpinx affecting pregnancy remains unclear. This study explored the mechanism of successful pregnancy through hysterosalpingography after salpingostomy in patients with hydrosalpinx.What are the implications of these findings for clinical practice and/or further research? To evaluate the prognosis of patients with hydrosalpinx after laparoscopic salpingostomy by hysterosalpingography (HSG), and to reflect the improvement according to the postoperative pregnancy rate of the patients. To provide clinical personalized treatment plan.

Reproductive outcomes after expectant and surgical management for tubal pregnancy: a retrospective study.

Background: The management of ectopic pregnancy is widely debated. Salpingectomy, salpingostomy, and expectant management are widely performed, but the best approach in terms of keeping good future spontaneous fertility chances is yet to be determined. Material and methods: We performed a retrospective analysis (Clinical Trial ID: NCT05479786) of the medical records of patients with an ultrasonographic or surgical diagnosis of tubal ectopic pregnancy that were admitted to the University of Debrecen Clinical Centre between 2012 and 2020. Results: A total of 312 patients were included in the analysis. Patients managed expectantly and patients treated with salpingostomy had significantly higher rates of clinical pregnancy than patients treated with salpingectomy. Pregnancy outcomes and recurrence rates were comparable between the study groups. Salpingectomy was found to decrease the likelihood of conceiving spontaneously by 65%. A stratified analysis based on serum ß-HCG levels demonstrated that all treatment modalities carry the same reproductive opportunities for patients presenting with ß-HCG levels ≤ 1745 IU/L. Conclusion: Salpingectomy was found to decrease the patient's chance of achieving a natural conception. Conservative approaches should be considered with caution only when the patient's clinical condition permits, and the patient is appropriately counseled.

Management of Hydrosalpinx in the Era of Assisted Reproductive Technology: A Systematic Review and Meta-analysis.

OBJECTIVE: To conduct a systematic review and meta-analysis evaluating the effect of hydrosalpinx on pregnancy outcomes, to compare different types of management of hydrosalpinx and their impact on pregnancy rates as well as on the ovarian reserve. DATA SOURCES: Electronic search using Pubmed, EMBASE, Ovid MEDLINE, Google Scholar, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials and including all published studies that examined tubal infertility and its management (assisted reproductive technology or surgery) as well as the effects on ovarian reserve. The following medical subject headings (Mesh) terms combinations were used: "fallopian tube disease," hydrosalpinx," "tubal or salpinx occlusion or obstruction," "in vitro fertilization," "fallopian tube surgery," "salpingectomy," "salpingostomy," "infertility," "subfertility," "sterility" and "ovarian reserve." METHODS OF STUDY SELECTION: All randomized trials, cohort, and case controls studies were included. We excluded review articles, meeting abstracts, case series and case reports, and abstracts without access to full texts. The search was limited to trials in humans and published in English. TABULATION, INTEGRATION, AND RESULTS: Our electronic search initially retrieved 6354 articles. Finally, 19 studies were included in the quantitative evaluation of the effects of hydrosalpinx: 23 in the qualitative evaluation and 5 in the quantitative evaluation of different types of hydrosalpinx treatments; and 17 in the quantitative evaluation of ovarian reserve. The presence of a hydrosalpinx was associated with decreased rates of implantation and clinical pregnancy, and increased rates of ectopic pregnancy and miscarriage. Management of hydrosalpinx with salpingectomy, tubal occlusion, or hydrosalpinx aspiration led to better in vitro fertilization pregnancy rates. We found no difference in ovarian response to stimulation after salpingectomy except a decrease in antimüllerian hormone compared to no surgery. CONCLUSIONS: The presence of hydrosalpinx is associated with decreased pregnancy rate and increased rates of ectopic pregnancy and miscarriage. Management of hydrosalpinx, regardless of the type of treatment, leads to an increased chance of pregnancy.

Fertility after Endoscopic Surgery for Ectopic Pregnancy Management in Point "G" Teaching Hospital, Bamako-Mali.

Endoscopic surgery of ectopic pregnancy is actually the gold standard for the management of fallopian tubal diseases. A survey was conducted to evaluate fertility in patients who underwent endoscopic management for ectopic pregnancy. A retrospective study was conducted at the department of general and endoscopic surgery of the Point "G" teaching hospital, in Bamako, Mali, from January 1st 2007 to December 31, 2016. Forty-eight (48) patients who underwent endoscopic management of tubal ectopic pregnancy and who have been followed up for fertility were included in this study. Statistical tests used were X2 or Fisher test and their confident interval, p <1 % has been considered as statistically significant. The therapeutic score of Pouly was less than 4 in 25.0% (n = 12). The return to fertility was observed among 48.0% of patients (n = 23). The chance of conception was less than 80.0% after the fourth postoperative year (p=0.001). The outcome of pregnancies has been seventeen full-term pregnancies, three ectopic pregnancies and three miscarriages. The occurrence of pregnancy after endoscopic management indicated for ectopic pregnancy is possible. However, many factors can influence the future conception.

Analysis of pregnancy outcome after anastomosis of oviduct and its influencing factors.

BACKGROUND: This study aims to investigate the influencing factors of pregnancy after laparoscopic oviduct anastomosis. METHODS: The data of 156 cases of laparoscopic oviduct anastomosis in our hospital were analyzed. RESULTS: The pregnancy rate decreased with age (P < 0.005). The pregnancy rate after six years of anastomosis was higher in those with ligation (P < 0.005). The postoperative pregnancy rate significantly increased in subjects with oviduct lengths of > 7 cm (P < 0.01). The pregnancy rate of isthmus end-to-end anastomosis was higher (P < 0.005). The pregnancy rate after bilateral tubal recanalization was higher than that after unilateral tubal recanalization (P < 0.005). The pregnancy rate after laparoscopic tubal ligation and laparoscopic anastomosis was higher than that of open tubal ligation and laparoscopic anastomosis (P < 0.005). CONCLUSION: The pregnancy rate after laparoscopic oviduct anastomosis is higher in subjects below 35 years old, with a ligation duration of < 6 years, and a length of oviduct of > 7 cm, and those who underwent isthmus anastomosis and laparoscopic oviduct ligation and recanalization.

Factors Predicting Persistent Ectopic Pregnancy After Laparoscopic Salpingostomy or Salpingotomy for Tubal Pregnancy: A Retrospective Cohort Study.

STUDY OBJECTIVE: To identify factors predictive of persistent ectopic pregnancy (PEP) in women who have undergone laparoscopic salpingostomy or salpingotomy for tubal pregnancy. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Tertiary referral center. PATIENTS: Ninety-nine women who underwent laparoscopic tubal preservation surgery for ectopic pregnancy. INTERVENTIONS: Seventy women underwent laparoscopic salpingostomy, and the remaining 29 women underwent laparoscopic salpingotomy. MEASUREMENTS AND MAIN RESULTS: Factors predicting PEP were evaluated. The change in serum beta human chorionic gonadotropin (ß-hCG) levels from baseline observed between postoperative days 5 and 10 (ChCGD5-10) was a predictor of PEP (odds ratio [OR], 0.80; p = .01). Based on receiver operating characteristic (ROC) curve analysis, a cutoff value of 93.1% was determined, with an area under the ROC curve of 0.95 (sensitivity, 85.7%; specificity, 100%). Nonetheless, when considering perioperative variables only, body mass index (BMI) was identified as a predictor of PEP (OR, 0.71; p = .03). Based on the ROC analysis, a BMI cutoff value of ≤22 kg/m2 was determined, with an ROC area of 0.73 (sensitivity, 43.2%; specificity, 100%). In addition, a higher baseline ß-hCG level (hazard ratio [HR], 1.0002; p = .009) and left tubal pregnancy (HR, 6.46; p = .03) were predictive of recurrent ectopic pregnancy. There were no differences in the perioperative outcomes, PEP rates, or subsequent intrauterine pregnancy rates between the salpingostomy and salpingotomy groups. In addition, surgical method was not a predictor of recurrent ectopic pregnancy. CONCLUSIONS: ChCGD5-10 was identified as a predictor for PEP, suggesting that it might be more clinically useful for the follow-up of PEP. When considering perioperative variables only, BMI was a predictor for PEP. In addition, there was no significant difference in clinical outcomes between the salpingostomy and salpingotomy groups.

Optimal use of peri-operative human chorionic gonadotrophin concentrations to identify persistent ectopic pregnancy after laparoscopic salpingostomy: a retrospective cohort study.

The aim of this study was to improve clinical decision-making for the identification of persistent ectopic pregnancy after linear salpingostomy. The study identified 854 laparoscopic salpingostomies performed between 2011 and 2016; 794 had a human chorionic gonadotrophin (HCG) <10 mIU/ml documented in the electronic medical record within 1 month after surgery ('successes'). Sixty (7%) received either methotrexate or repeat surgery for persistent ectopic pregnancy ('failures'). Five hundred and seventeen, including 46 'failures', had two or more immediate post-operative HCG measurements available. The most clinically useful prediction rule was calculated by dividing the difference between the first and second post-operative HCG values by the first post-operative HCG value (i.e. [HCG1 - HCG2]/HCG1). When this ratio exceeded 0.75, it reliably ruled out persistent ectopic with a negative predictive value = 99%. When this ratio was less than 0.2, it identified persistent ectopics with a positive predictive value = 88%. It appears that this simple arithmetic calculation involving two early post-operative HCG values may allow for efficient triage of patients before post-operative day 5. If validated in prospective studies, this could help minimize the risk, inconvenience and expense of requiring several weeks of frequent follow up to rule in/rule out persistent ectopic pregnancy.

Disparities in the management of ectopic pregnancy.

BACKGROUND: Ectopic pregnancy is common among young women. Treatment can consist of either surgery with salpingectomy or salpingostomy or medical management with methotrexate. In addition to acute complications, treatment of ectopic pregnancy can result in long-term sequelae that include decreased fertility. Little is known about the patterns of care and predictors of treatment in women with ectopic pregnancy. Similarly, data on outcomes for various treatments are limited. OBJECTIVE: We examined the patterns of care and outcomes for women with ectopic pregnancy. Specifically, we examined predictors of medical (vs surgical) management of ectopic pregnancy and tubal conservation (salpingostomy vs salpingectomy) among women who underwent surgery. STUDY DESIGN: The Perspective database was used to identify women with a diagnosis of tubal ectopic pregnancy treated from 2006-2015. Perspective is an all-payer database that collects data on patients at hospitals from throughout the United States. Women were classified as having undergone medical treatment, if they received methotrexate, and surgical treatment, if treatment consisted of salpingostomy or salpingectomy. Multivariable models were developed to examine predictors of medical treatment and of tubal conserving salpingostomy among women who were treated surgically. RESULTS: Among the 62,588 women, 49,090 women (78.4%) were treated surgically, and 13,498 women (21.6%) received methotrexate. Use of methotrexate increased from 14.5% in 2006 to 27.3% by 2015 (P<.001). Among women who underwent surgery, salpingostomy decreased over time from 13.0% in 2006 to 6.0% in 2015 (P<.001). Treatment in more recent years, at a teaching hospital and at higher volume centers, were associated with the increased use of methotrexate (P<.05 for all). In contrast, Medicaid recipients (adjusted risk ratio, 0.92; 95% confidence interval, 0.87-0.98) and uninsured women (adjusted risk ratio, 0.87; 95% confidence interval, 0.82-0.93) were less likely to receive methotrexate than commercially insured patients. Among those who underwent surgery, black (adjusted risk ratio, 0.76; 95% confidence interval, 0.69-0.85) and Hispanic (adjusted risk ratio, 0.80; 95% confidence interval, 0.66-0.96) patients were less likely to undergo tubal conserving surgery than white women and Medicaid recipients (adjusted risk ratio, 0.69; 95% confidence interval, 0.64-0.75); uninsured women (adjusted risk ratio, 0.60; 95% confidence interval, 0.55-0.66) less frequently underwent salpingostomy than commercially insured patients. CONCLUSION: There is substantial variation in the management of ectopic pregnancy. There are significant race- and insurance-related disparities associated with treatment.

Repeat acute abdomen and hemoperitoneum during the same pregnancy due to a ruptured ectopic treated by salpingostomy.

A leading cause of maternal mortality in the first trimester is hemorrhage due to a ruptured ectopic pregnancy. With the advent of tube salvage surgery, ectopic pregnancies can be removed while ensuring hemostasis and preserving the integrity of the fallopian tube. A major drawback of tube salvage surgery is the significant risk of persistent trophoblastic tissue being left behind. We report a case of a 30year old female who presented to the ED with acute abdomen and hemoperitoneum due to a ruptured ectopic pregnancy. She was treated with salpingostomy and the pathologic report confirmed removal of the ectopic pregnancy. After an initially uneventful post-operative recovery, she presented to the ED 27days later with signs of acute abdomen and hemoperitoneum. Surgical intervention confirmed a ruptured ectopic pregnancy in the same site as previous, and salpingectomy was performed, after which the patient recovered without complications. The increased risk of persistent trophoblastic tissue associated with tube salvage surgery can lead to subsequent reoperation for tubal rupture. Patients undergoing these procedures should be closely monitored in the following weeks and undergo serial ß-hCG testing in order to confirm successful removal of the ectopic.

Unilateral Salpingectomy and Methotrexate Are Associated With a Similar Recurrence Rate of Ectopic Pregnancy in Patients Undergoing In Vitro Fertilization.

STUDY OBJECTIVE: To determine whether different treatment approaches of ectopic pregnancy (EP), particularly unilateral salpingectomy and methotrexate, affect its recurrence rate in patients undergoing in vitro fertilization (IVF). DESIGN: A retrospective cohort study (Canadian Task Force classification II-2). SETTING: An academic medical center. PATIENTS: Patients with a history of a previous EP who achieved pregnancy after IVF cycles between January 2004 and August 2015 were included. The recurrence rate of EP was compared between patients who underwent different treatment approaches for a previous EP. INTERVENTIONS: IVF. MEASUREMENTS AND MAIN RESULTS: A total of 594 patients were included. Seventeen patients had a recurrence of EP (2.9%). Patients with a history of ≥2 EPs were associated with a significantly higher recurrence rate of EP than those with 1 previous EP (8.5% vs. 1.8%; p = .01; odds ratio [OR] = 2.2; 95% confidence interval [CI], 1.2-4.4). Patients who underwent unilateral salpingectomy (n = 245) had a comparable recurrence rate of EP after IVF with those who received methotrexate (n = 283) (3.6% vs. 2.8%; p = .5; OR = 1.3; 95% CI, 0.4-3.4). This OR remained unchanged after adjusting for patient's age, number of previous EPs, number of transferred embryos, and peak estradiol level during stimulation (adjusted OR = 1.4; 95% CI, 0.5-3.8). None of the patients who underwent bilateral salpingectomy (n = 45) or salpingostomy (n = 21) had a recurrence of EP after IVF. CONCLUSION: The recurrence rate of EP significantly correlates with the number of previous EPs. Treatment of EP with methotrexate has a comparable recurrence rate of EP after IVF with unilateral salpingectomy. Therefore, the risk of recurrence should not be a reason to favor salpingectomy over methotrexate in this population.

Risk factors for recurrent ectopic pregnancy: a case-control study.

OBJECTIVE: To study the risk factors for recurrent ectopic pregnancy (REP). DESIGN: A retrospective case-control study. SETTING: A university medical centre. POPULATION: 554 women with a history of ectopic pregnancy (EP) were included. Among them were 181 women with current EP, 184 women with current intrauterine pregnancy (IUP) and 189 nonpregnant women (NonP). METHODS: The three groups were matched at a ratio of 1:1 with respect to current age, age of initial EP and gestational week of initial EP. Socio-demographic characteristics, reproductive history, gynaecological and surgical history, and experience of contraception were compared among the three groups. A multivariable logistic regression analysis was used to adjust for confounders and calculate adjusted odds ratios (AORs). RESULTS: The risk of REP increased with history of infertility (AOR = 3.84, 95%CI 2.16-6.86) in REP women compared with IUP controls. Compared with NonP controls, salpingotomy (AOR = 3.04, 95%CI 1.21-36.51) for previous EP was a risk factor for REP. Multiparous women were less likely to suffer REP when compared with NonP women (AOR = 0.36, 95%CI 0.18-0.62) or IUP controls (AOR = 0.35, 95%CI 0.20-0.62). Current use of an intrauterine device (IUD) (REP versus NonP, AOR = 0.02, 95%CI 0.00-0.08) or condoms (REP versus NonP, AOR = 0.16, 95%CI 0.07-0.38) significantly reduced the risk of REP compared with those not using any contraception. Similarly, previous use of condoms also prevented REP compared with those with no previous condom use (REP versus NonP, AOR = 0.20, 95%CI 0.08-0.49; REP versus IUP, AOR = 0.40, 95%CI 0.22-0.71). CONCLUSIONS: Women with history of infertility or salpingotomy should be alert for the recurrence of EP. Multiparous women are less likely to suffer REP. We propose the use of condoms for effective prevention of REP. TWEETABLE ABSTRACT: History of infertility and salpingotomy for last EP are risk factors for recurrent EP.

Cost-effectiveness of salpingotomy and salpingectomy in women with tubal pregnancy (a randomized controlled trial).

STUDY QUESTION: Is salpingotomy cost effective compared with salpingectomy in women with tubal pregnancy and a healthy contralateral tube? SUMMARY ANSWER: Salpingotomy is not cost effective over salpingectomy as a surgical procedure for tubal pregnancy, as its costs are higher without a better ongoing pregnancy rate while risks of persistent trophoblast are higher. WHAT IS KNOWN ALREADY: Women with a tubal pregnancy treated by salpingotomy or salpingectomy in the presence of a healthy contralateral tube have comparable ongoing pregnancy rates by natural conception. Salpingotomy bears the risk of persistent trophoblast necessitating additional medical or surgical treatment. Repeat ectopic pregnancy occurs slightly more often after salpingotomy compared with salpingectomy. Both consequences imply potentially higher costs after salpingotomy. STUDY DESIGN, SIZE, DURATION: We performed an economic evaluation of salpingotomy compared with salpingectomy in an international multicentre randomized controlled trial in women with a tubal pregnancy and a healthy contralateral tube. Between 24 September 2004 and 29 November 2011, women were allocated to salpingotomy (n = 215) or salpingectomy (n = 231). Fertility follow-up was done up to 36 months post-operatively. PARTICIPANTS/MATERIALS, SETTINGS, METHODS: We performed a cost-effectiveness analysis from a hospital perspective. We compared the direct medical costs of salpingotomy and salpingectomy until an ongoing pregnancy occurred by natural conception within a time horizon of 36 months. Direct medical costs included the surgical treatment of the initial tubal pregnancy, readmissions including reinterventions, treatment for persistent trophoblast and interventions for repeat ectopic pregnancy. The analysis was performed according to the intention-to-treat principle. MAIN RESULTS AND THE ROLE OF CHANCE: Mean direct medical costs per woman in the salpingotomy group and in the salpingectomy group were €3319 versus €2958, respectively, with a mean difference of €361 (95% confidence interval €217 to €515). Salpingotomy resulted in a marginally higher ongoing pregnancy rate by natural conception compared with salpingectomy leading to an incremental cost-effectiveness ratio €40 982 (95% confidence interval -€130 319 to €145 491) per ongoing pregnancy. Since salpingotomy resulted in more additional treatments for persistent trophoblast and interventions for repeat ectopic pregnancy, the incremental cost-effectiveness ratio was not informative. LIMITATIONS, REASONS FOR CAUTION: Costs of any subsequent IVF cycles were not included in this analysis. The analysis was limited to the perspective of the hospital. WIDER IMPLICATIONS OF THE FINDINGS: However, a small treatment benefit of salpingotomy might be enough to cover the costs of subsequent IVF. This uncertainty should be incorporated in shared decision-making. Whether salpingotomy should be offered depends on society's willingness to pay for an additional child. STUDY FUNDING/COMPETING INTERESTS: Netherlands Organisation for Health Research and Development, Region Västra Götaland Health & Medical Care Committee. TRIAL REGISTRATION NUMBER: ISRCTN37002267.

Safety and feasibility of a single-port laparoscopic adnexal surgery during pregnancy.

STUDY OBJECTIVE: To evaluate the safety and feasibility of single-port laparoscopic adnexal surgery during pregnancy. DESIGN: A retrospective study (Canadian Task Force Classification III). SETTING: A university hospital. PATIENTS: A total of 14 women with intrauterine pregnancy who underwent single-port laparoscopic surgery (SPLS). INTERVENTION: We retrospectively reviewed the medical records of 14 women with intrauterine pregnancy who underwent SPLS between November 2009 and September 2012 for the treatment of an adnexal mass. MEASUREMENTS AND MAIN RESULTS: Factors investigated included the duration of surgery, differences between preoperative and postoperative hemoglobin, the size of the mass as measured by ultrasonography, major intraoperative or postoperative complications, conversion to multiport laparoscopy, and pregnancy outcomes. Single-port laparoscopic adnexal surgery was successfully performed in all 14 pregnant patients with an adnexal mass. The median gestational age at operation was 9 weeks (range, 4 weeks-17 weeks 4 days). Procedures included ovarian cystectomy with or without detorsion (n = 9), cyst aspiration with detorsion (n = 2), salpingectomy (n = 2), and salpingostomy (n = 1). The median duration of surgery was 59 minutes (range, 36-84 minutes). No major intraoperative or postoperative complications were encountered, and there was no need for conversion to multiport laparoscopic surgery. Five women had spontaneous vaginal delivery, and 5 women underwent cesarean delivery at term. One woman had preterm delivery at a gestational age of 24 weeks 5 days. In 1 case, abortion occurred 2 weeks after the operation. CONCLUSION: Based on these initial findings, SPLS appears to be a safe and technically feasible treatment for an adnexal mass during pregnancy.

Changes in the ovarian stromal blood flow in patients treated with laparoscopic salpingostomy for ectopic pregnancy.

This study is aimed to evaluate the impact of laparoscopic salpingostomy on ovarian stromal blood flow indices in patients with ectopic pregnancy, and to compare the ovarian stromal blood flow indices with matched paired healthy women. We included 37 patients who underwent laparoscopic salpingostomy and 37 age- and parity-matched women as controls. The main outcome was the differences in ovarian volume, antral follicle count (AFC), and ovarian stromal blood flow indices between the study group participants after the surgery and the healthy controls. Comparison of the ovarian parameters between the study group after the surgery and the control group revealed no significant differences in terms of ovarian volume (p = 0.783), AFC (p = 0.253), ovarian stromal S/D ratios (p = 0.054), pulsatility index (PI; p = 0.938) and resistance index (RI; p = 0.041). In addition, comparison of the ovarian parameters before and after the surgical treatment revealed no significant differences in the ovarian volume (p = 0.141), AFC (p = 0.084), ovarian stromal S/D ratios (p = 0.187), PI (p = 0.102) and RI (p = 0.108). In conclusion, laparoscopic salpingostomy does not affect ovarian function in terms of ovarian stromal blood flow indices, ovarian volume, and AFC.

Effectiveness of laparoscopic tubal anastomosis in tubal occlusion patients after laparoscopic salpingostomy for tubal pregnancy.

OBJECTIVE: To evaluate the effectiveness of laparoscopic tubal anastomosis for tubal occlusions associated with infertility in patients with previous laparoscopic salpingostomy for ectopic pregnancy. METHODS: This study is a retrospective analysis of the pregnancy outcomes of 173 infertile patients who underwent hysteroscopy and laparoscopic tubal anastomosis treatment between January 2013 and August 2018 in the Department of Reproductive Endocrinology in West China Second University Hospital of Sichuan University. All patients had a history of laparoscopic salpingostomy for tubal pregnancy. The primary outcomes were intrauterine pregnancy, ectopic pregnancy, and delivery rates. We further studied the associated factors that could influence the change in pregnancy status. RESULTS: The 24-month cumulative clinical pregnancy rate of all patients was 107/173 (61.8%). The distribution of outcomes for the entire group of pregnancies was as follows: intrauterine pregnancy rate, 76/173 (43.9%); ectopic pregnancy rate, 31/173 (17.9%); delivery rate, 68/173 (39.3%); and miscarriage rate, 8/173 (4.6%). Age, type of anastomosis, hydrosalpinx, and endometrial polyps were significant prognostic factors in the multivariate model. CONCLUSION: Laparoscopic tubal anastomosis is an effective treatment for tubal-associated infertility due to previous laparoscopic salpingostomy for ectopic pregnancy, especially for women under 35 years of age.

Pregnancy outcomes following in vitro fertilization treatment in women with previous recurrent ectopic pregnancy.

OBJECTIVES: The aim of this study was to investigate the impact of a history of recurrent ectopic pregnancy (EP) on pregnancy outcomes of subsequent in vitro fertilization (IVF) treatment. METHODS: A retrospective cohort study involving 457 women with a history of recurrent EP (REP group), 912 women with a history of single EP (SEP group), and 1169 women with a history of intrauterine pregnancy (IUP group) as the control group, was conducted. IVF outcomes were compared for each cohort. RESULTS: The incidence of EP in the REP group after IVF treatment was significantly lower than those in the SEP group (2.4% vs. 6.8%, P = 0.011), and similar to those in the IUP group (2.4% vs. 2.1%, P = 0.830). No significant differences were observed in the clinical pregnancy rate, miscarriage rate, and live birth rate among the three groups. There was no statistically significant difference in the recurrent EP rate between the salpingectomy and salpingostomy treatments. Adjusting for maternal and treatment factors did not influence live birth rates for women with previous REP compared with women with previous SEP and those with IUP. The odds of EP were 82.2% lower (OR 0.178, 95% CI 0.042-0.762; P = 0.020) in women who had blastocyst transfer compared with cleavage embryo transfer in the SEP group. The odds of EP were over six times (OR 6.260, 95% CI 1.255-31.220; P = 0.025) in women who underwent double embryo transfer as opposed to single embryo transfer in the IUP group. CONCLUSION: Our results indicate that women with previous recurrent EP have a lower risk of EP after IVF in comparison with women with previous single EP. Previous EP has no significant adverse effect on the main IVF outcomes. The salpingostomy and salpingectomy treatments of EP do not significantly affect the incidence of recurrent EP after IVF.

Laparoscopic ureterolysis and dissection of the paravesical space for deeply scarred adnexal masses.

INTRODUCTION: Laparoscopic ureterolysis is a delicate procedure that requires advanced laparoscopic skills. MATERIALS AND METHODS: We are reporting two cases of laparoscopic hysterectomy and salpingo-oophorectomy with severe adhesions to the pelvic sidewall that required ureterolysis and describing a modified technique suitable for the laparoscopic performance of this procedure. RESULTS: In more than 15 years of doing laparoscopic ureterolysis to deal with various gynecological cases, we have never had a ureteral injury related to the ureterolysis procedure. There have been uterine artery lacerations, usually when trying to apply clips for uterine artery ligation in which case the artery can be compressed with a clamp until it is reclipped, bipolar-cauterized or suture-ligated using intracorporeal knot tying. However, we did not have a single patient that required open surgery because of these lacerations. CONCLUSION: Because of the advantage of magnified viewing and laparoscopic dissection techniques which control small vessel bleeding, the laparoscopic route for ureterolysis is far easier to use than its open counterpart once it is learned. Laparoscopy, in addition, offers the added advantages of shorter hospital stay, reduced patient pain, reduced transfusion requirements and far better cosmetic results.

Fatigue and quality of life after risk-reducing salpingo-oophorectomy in women at increased risk for hereditary breast-ovarian cancer.

BACKGROUND: Risk-reducing salpingo-oophorectomy (RRSO) is the safest intervention for prevention of ovarian cancer in women at increased risk for hereditary breast-ovarian cancer. Little is known about other effects of RRSO. The objective of this study was to investigate quality of life (QoL) and fatigue in a sample of women who had RRSO for increased cancer risk and to compare the findings with those of age-matched controls from the general population (NORM). MATERIALS AND METHODS: In a cross-sectional follow-up mailed questionnaire design, 301 (67%) of 450 invited Norwegian women with RRSO attended. The questionnaire contained measures of QoL, fatigue, anxiety/depression, and body image, and questions about demography, lifestyle, and morbidity. The findings were compared with those of the NORM. RESULTS: For RRSO women, mean age at survey was 53.7 years (SD, 9.2), mean age at RRSO was 48.4 years (SD 8.4), and median follow-up time was 5.0 years (range, 1-15 years). No clinically significant differences were observed between RRSO and NORM for any of the QoL or fatigue dimensions. In subgroup analyses of the RRSO group, no clinically significant differences in QoL and fatigue were observed between those who had surgery before or after age 50 years, or between BRCA1/2 carriers and women with unknown mutation statuses. Women who had cancer (32%), however, showed clinically significant lower levels of QoL and more fatigue than women without cancer. CONCLUSIONS: Women who had RRSO showed similar levels of QoL and fatigue as NORM. Women who had cancer before RRSO had lower levels of QoL and more fatigue.

The ESEP study: salpingostomy versus salpingectomy for tubal ectopic pregnancy; the impact on future fertility: a randomised controlled trial.

BACKGROUND: For most tubal ectopic pregnancies (EP) surgery is the treatment of first choice. Whether surgical treatment should be performed conservatively (salpingostomy) or radically (salpingectomy) in women wishing to preserve their reproductive capacity, is subject to debate. Salpingostomy preserves the tube, but bears the risks of both persistent trophoblast and repeat ipsilateral tubal EP. Salpingectomy, avoids these risks, but leaves only one tube for reproductive capacity. This study aims to reveal the trade-off between both surgical options: whether the potential advantage of salpingostomy, i.e. a better fertility prognosis as compared to salpingectomy, outweighs the potential disadvantages, i.e. persistent trophoblast and an increased risk for a repeat EP. METHODS/DESIGN: International multi centre randomised controlled trial comparing salpingostomy versus salpingectomy in women with a tubal EP without contra lateral tubal pathology. Hemodynamically stable women with a presumptive diagnosis of tubal EP, scheduled for surgery, are eligible for inclusion. Patients pregnant after in vitro fertilisation (IVF) and/or known documented tubal pathology are excluded. At surgery, a tubal EP must be confirmed. Only women with a tubal EP amenable to both interventions and a healthy contra lateral tube are included. Salpingostomy and salpingectomy are performed according to standard procedures of participating hospitals. Up to 36 months after surgery, women will be contacted to assess their fertility status at six months intervals starting form the day of the operation. The primary outcome measure is the occurrence of spontaneous viable intra uterine pregnancy. Secondary outcome measures are persistent trophoblast, repeat EP, all pregnancies including those resulting from IVF and financial costs. The analysis will be performed according to the intention to treat principle. A cost-effectiveness analysis will be performed within a decision analysis framework, based on costs per live birth, including IVF treatment whenever a spontaneous pregnancy does not occur. Patients' preferences will be assessed using a discrete choice experiment. DISCUSSION: This trial will provide evidence on the trade off between salpingostomy and salpingectomy for tubal EP in view of the pros and cons of both interventions and will offer guidance to clinicians in making the right treatment choice. TRIAL REGISTRATION: Current Controlled Trials ISRCTN37002267.