Treatment outcomes of tubal pregnancy with tubal preservation: A meta-analysis.

BACKGROUND: Ectopic pregnancy is a common gynecological emergency that poses a significant risk of maternal mortality during the first trimester. It also increases the incidence of infertility and repeated ectopic pregnancy. The aim of this study was to evaluate whether there is a difference in the degree of tubal patency between salpingostomy and systemic treatment with methotrexate (MTX), as well as the odds of intrauterine pregnancy and repeat ectopic pregnancy, and the degree of tubal patency in salpingectomy with or without tubal suturing. METHODS: We searched PubMed, EMBASE, and the Cochrane Library up to April 2023. Four randomized controlled trials were included in the review. We analyzed the combined data using Review Manager 5.3 software and Stata 12.0 software, utilizing a random effects model. RESULTS: When comparing salpingostomy and systemic treatment with MTX, there was no significant difference in the degree of tubal patency (OR = 1.09, 95% CI (0.54-2.38), P = .83). For salpingostomy with or without tubal suturing, there were no significant differences in the rates of intrauterine pregnancy, repeat ectopic pregnancy, and tubal patency degree [(OR = 1.05, 95% CI (0.41-2.68), P = .92), (OR = 0.68, 95% CI (0.19-2.42), P = .92), (OR = 1.68, 95% CI (0.14-20.33), P = .68)]. CONCLUSION: This meta-analysis demonstrates that systemic treatment with MTX is an effective treatment for patients who wish to preserve their fallopian tubes without undergoing surgery. This form of treatment can help avoid surgical procedures that may damage the fallopian tubes and improve fertility prospects. If choosing surgery, we believe that opting for salpingostomy without tubal suturing could reduce the operation time and minimize damage.

Conservative Management of Heterotopic Pregnancy: A Case Report and Review of Literature.

BACKGROUND Tubal heterotopic pregnancy is an extremely rare complication of pregnancy, in which there is a simultaneous presence of a pregnancy in the uterine cavity and in an ectopic location, most commonly in the fallopian tube. The management of such cases is not clearly established. In the case of a desire to maintain an intrauterine pregnancy, the surgical procedure consisting of a salpingectomy or salpingostomy is the most common. Such a procedure is effective, but it involves potential complications typical of surgeries, so, in some cases, it seems reasonable to apply the expectant management. CASE REPORT A 31-year-old woman was admitted to the clinic due to pain in the right lower abdomen. An ultrasound examination revealed a gestational sac in the uterine cavity corresponding to 5 weeks of pregnancy with a yolk sac. A twin sac was found in the right fallopian tube. Due to the patient's mild symptoms, absence of bleeding into the peritoneal cavity, concerns about the safety of the embryo and the pregnant woman in case of surgery, conservative management was decided. On the 20th day, the patient was discharged from the clinic with a viable intrauterine pregnancy and a partially absorbed ectopic pregnancy. CONCLUSIONS In the case of an ectopic tubal pregnancy, if there are no symptoms of bleeding into the peritoneal cavity, it is possible to adopt a safe conservative approach with strict patient observation.

Reproductive outcomes of ectopic pregnancy with conservative and surgical treatment: A systematic review and meta-analysis.

BACKGROUND: Ectopic pregnancy (EP), one of the most common gynecological emergencies, is the major cause of maternal death in the first trimester and increases the incidence of infertility and repeat ectopic pregnancy (REP). The aim of this study was to compare the effects of different treatment methods for tubal EP on natural pregnancy outcomes. METHODS: We systematically searched PubMed, Embase, Cochrane Library, Web of Science, and Clinical Trials for observational studies on EP (published until October 30,2022 in English) comparing methotrexate (MTX) versus surgery, MTX versus salpingostomy, MTX versus salpingectomy, salpingostomy versus salpingectomy, and MTX versus expectant treatment. Our main endpoints included subsequent natural intrauterine pregnancy (IUP) and REP. We assessed the pooled data using Review Manager software (version 5.3) with a random effects model. RESULTS: Of 1274 identified articles, 20 were eligible and 3530 participants were included in our analysis. There was a significant difference in the odds of subsequent IUP in tubal EP patients who underwent MTX compared with those who were treated with surgery [odds ratios (OR) = 1.52, 95% confidence interval (CI):1.20-1.92]. No significant difference was found in the odds of REP between the 2 groups (OR = 1.12, 95% confidence interval [CI]: 0.84-1.51). There was no significant difference in the odds of subsequent IUP and REP in patients after MTX compared to those after salpingostomy (OR = 1.04,95% CI: 0.79-1.38; OR = 1.10, 95% CI: 0.64-1.90). There was a significant difference in the odds of subsequent IUP in patients after MTX compared with those after salpingectomy (OR = 2.11, 95% CI: 1.52-2.93). No significant difference was found in the odds of REP between the 2 groups (OR = 0.98, 95% CI: 0.57-1.71). There was a significant difference in the odds of subsequent IUP between patients who underwent salpingostomy and those who underwent salpingectomy (OR = 1.61, 95% CI: 1.29-2.01). No significant difference was found in the odds of REP between the 2 groups (OR = 1.21, 95% CI: 0.62-2.37). There was no significant difference in the odds of subsequent IUP and REP in patients after MTX compared with those after expectant treatment (OR = 1.25, 95% CI: 0.64-2.45; OR = 0.69, 95% CI: 0.09-5.55). CONCLUSION: For hemodynamically stable tubal EP patients, MTX has advantages over surgery, particularly salpingectomy, in improving natural pregnancy outcomes. However, MTX is not inferior to salpingostomy and expectant treatment.

Análise das gestações ectópicas íntegras tratadas com o protocolo de dose única de metotrexato / Analysis of unruptured ectopic pregnancies treated with single-dose methotrexate protocol

Objetivo: Avaliar o índice de sucesso do tratamento da gravidez ectópica com o protocolo de dose única do metotrexato e verificar sua correlação com variáveis clínicas e dados dos exames complementares. Métodos: É um estudo epidemiológico observacional, analítico, retrospectivo, de delineamento transversal. Foi realizado de janeiro de 2014 a agosto de 2020 em um hospital público, de ensino, em nível terciário, do Sul do Brasil. Em 73 casos com diagnóstico de gestação ectópica íntegra, foi utilizado o protocolo de dose única de metotrexato intramuscular, com a dose de 50 mg/m2 de superfície corporal. As variáveis do estudo foram relacionadas ao sucesso do tratamento e abordaram as características clínicas na admissão, dos exames complementares e do tratamento realizado. As variáveis foram comparadas por análise de regressão de Poisson. O nível de significância estabelecido foi de p < 0,05. Resultados: O índice de sucesso foi de 83,6%, e em nove casos foi necessária uma segunda dose da medicação. Nível de ß-hCG inicial superior a 5.000 mUI/mL foi relacionado a menor chance de sucesso (odds ratio ajustado de 0,20 [0,05-0,95]). Tamanho da imagem anexial, presença de líquido livre na cavidade abdominal e demais variáveis estudadas não afetaram a chance de sucesso do tratamento. Conclusão: O protocolo de dose única de metotrexato mostrou-se uma opção válida para o tratamento da gestação ectópica íntegra, notadamente quando o nível de ß-hCG inicial é inferior 5.000 mUI/mL.

Objective: The purpose of the present study is to evaluate the success rate of treatment of ectopic pregnancy with the single-dose methotrexate protocol and to verify its correlation with clinical variables and complementary exam data. Methods: This is a retrospective epidemiological observational analytical cross-sectional study. It was carried out from January 2014 to August 2020 in a tertiary level teaching hospital in southern Brazil. In 73 cases with a diagnosis of intact ectopic pregnancy, the intramuscular methotrexate single-dose protocol was applied with a dose of 50 mg/m2 of body surface. The study variables were related to the success of the treatment and addressed the clinical characteristics on admission, the complementary exams and the treatment performed. The variables were compared by Poisson regression analysis. The level of significance was set at p < 0.05. Results: The success rate was 83.6%, and in nine cases a second dose of the medication was necessary. An initial ß-hCG level greater than 5,000 mIU/mL was related to a lower chance of success (adjusted odds ratio of 0.20 [0.05- 0.95]). The size of the adnexal image, the presence of free fluid in the abdominal cavity and other variables studied did not affect the chance of a successful treatment. Conclusion: The methotrexate single-dose protocol proved to be a valid option for the treatment of intact ectopic pregnancy, notably when the initial ß-hCG level is below 5,000 mIU/mL.

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.

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.

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.

Evaluation of the recurrence and fertility rate following salpingostomy in patients with tubal ectopic pregnancy.

BACKGROUND: Ectopic pregnancy is one of the leading causes of pregnancy-related mortality; the treatment strategies associated with this condition entail complications, such as recurrence of ectopic pregnancy or infertility. The objective of this study was to evaluate the recurrence and fertility rate after salpingostomy in patients with tubal ectopic pregnancy. METHODS: This cross-sectional retrospective study was conducted at four referral centers of Obstetrics and Gynecology, under the supervision of Shiraz University of Medical Sciences (Iran). The medical records of 125 patients with tubal pregnancy were reviewed. These patients underwent laparoscopic salpingostomy from April 2009 to March 2016.Data on maternal age, BMI, history of previous EP, genital tract infection, IUD insertion, history of previous surgery, and infertility were further obtained. The patients were followed up for approximately 1 to 7 years. The recurrence of EP and subsequent pregnancy rate were assessed during the follow-up period. RESULTS: There was no statistically significant relationship between post-salpingostomy recurrence and maternal age, previous abdominopelvic surgery, and history of infertility(P = .425); however, the post-salpingostomy recurrence of EP was correlated with BMI (P = 0.001), previous history of EP (P = 0.001), genital tract infection (P = 0.001), and IUD insertion (P = 003). Among 95 women who had no contraception, pregnancy occurred in 51 cases (53.6%) and recurrence of EP was observed in 16 patients (12.8%). CONCLUSIONS: Our results suggest that salpingostomy is a safe method with a low risk of recurrence and good fertility outcomes for women who consider future pregnancy.

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.

Ectopic pregnancy: a single-center experience over ten years.

PURPOSE: The aim of this study was to investigate characteristics associated with ectopic pregnancy (EP) that could be utilized for predicting morbidity or mortality. METHODS: This was a retrospective analysis of pregnancy-related records from a tertiary center over a period of ten years. Data on age, gravidity, parity, EP risk, amenorrhea duration, abdominal pain presence and location, ß-human chorionic gonadotropin (ß-HCG) level, ultrasound findings, therapeutic intervention, exact EP implantation site and length of hospital stay (LOS) were obtained from the database. The LOS was used as a proxy for morbidity and was tested for an association with all variables. All statistical analyses were conducted with Stata® (ver. 16.1, Texas, USA). RESULTS: The incidence of EP in a cohort of 30,247 pregnancies over a ten-year period was 1.05%. Patients presented with lower abdominal pain in 87.9% of cases, and the likelihood of experiencing pain was tenfold higher if fluid was detectable in the pouch of Douglas. Only 5.1% of patients had a detectable embryonic heartbeat, and 18.15% had one or more risk factors for EP. While most EPs were tubal, 2% were ovarian. The LOS was 1.9 days, and laparoscopic intervention was the main management procedure. The cohort included one genetically proven dizygotic heterotopic pregnancy (incidence, 3.3 × 10- 5) that was diagnosed in the 7th gestational week. The only association found was between the ß-HCG level and LOS, with a linear regression ß coefficient of 0.01 and a P-value of 0.04. CONCLUSION: EP is a relatively common condition affecting approximately 1% of all pregnancies. ß-HCG correlates with EP-related morbidity, but the overall morbidity rate of EP is low regardless of the implantation site. Laparoscopic surgery is an effective therapeutic procedure that is safe for managing EP, even in cases of heterotopic pregnancy.

Effect of Methotrexate on Salpingostomy Completion Rate for Tubal Ectopic Pregnancy: A Retrospective Cohort Study.

STUDY OBJECTIVE: To determine whether completion rates of salpingostomy for tubal ectopic pregnancy are compromised by initial medical management with methotrexate (MTX). DESIGN: Retrospective cohort study. SETTING: Single academic hospital system. PATIENTS: Patients requiring surgery for ectopic pregnancy between 2006 and 2017. INTERVENTIONS: A subset of patients who went directly to surgery, and all patients who failed MTX before requiring surgery underwent detailed chart review. Salpingostomy plan and success rate and salpingostomy failure reasons were compared between patients pretreated with MTX and those who were MTX-untreated. MEASUREMENTS AND MAIN RESULTS: Among 94 ectopic pregnancies requiring surgery after failed MTX treatment, 55 (59%) underwent planned salpingostomy. From 693 ectopic pregnancies managed without MTX, 166 were analyzed in detail, of which 80 (48%) underwent planned salpingostomy. The patients who underwent planned salpingostomy were thinner (body mass index 27.3 ± 7.2 kg/m2 vs 29.3 ± 8.3 kg/m2; p = .048), less frequently African American (33% vs 47%; p = .017), and more likely to have a visualized adnexal lesion (70% vs 52%; p = .004) than those undergoing planned salpingectomy. Preoperative ultrasound identified fetal cardiac activity and hemoperitoneum at comparable rates. MTX exposure was not associated with age, body mass index, race, ectopic risk factors, human chorionic gonadotropin levels, or gestational age at diagnosis, but the patients treated with MTX underwent surgery later than those who were untreated (gestational age 53.4 ± 11.2 days vs 43.5 ± 11 days; p <.001). The differences between the adnexal lesion size and rates of fetal cardiac activity and hemoperitoneum on ultrasound related to MTX exposure did not meet significance. Planned salpingostomy was completed in 22 (40%) of the patients treated with MTX vs 34 (42%) of those who were untreated. The reasons for failure, surgery time, and rates of hemoperitoneum or ectopic rupture were not associated with MTX exposure. Body mass index, race, tubal anastomosis history, visualization of the adnexal lesion, and MTX exposure were not significantly associated with the salpingostomy rate in a multivariate logistic regression model, but having a subspecialist surgeon (odds ratio 2.70; 95% confidence interval, 1.08-6.76; p = .033) and tubal rupture at surgery (odds ratio 0.23; 95% confidence interval, 0.09-0.54; p = .001) were. CONCLUSION: The initial medical management of an ectopic pregnancy with MTX is not associated with a decreased salpingostomy success rate.

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

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 ßhCG 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 ßhCG 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.

A Systematic Review and Meta-analysis of Surgical Treatment of Ectopic Pregnancy with Salpingectomy versus Salpingostomy.

OBJECTIVE: To evaluate the fertility outcomes of salpingectomy compared with those of salpingostomy among patients treated for tubal ectopic pregnancies, including a separate analysis of women with risk factors along with a review of the surgical technique. DATA SOURCES: Systematic review and meta-analysis from 1990 to the present through PubMed, Embase, CINAHL, and Ovid MEDLINE. The search string included "tubal pregnancy" or "ectopic" as well as "salpingectomy" and various terms describing salpingotomy. METHODS OF STUDY SELECTION: Articles studying women who underwent surgical management of an ectopic pregnancy and the contrasted outcomes of salpingectomy vs salpingostomy were reviewed. The primary outcomes included subsequent intrauterine pregnancy (IUP) and repeat ectopic pregnancy (REP). TABULATION, INTEGRATION, AND RESULTS: Two randomized controlled trials (RCTs), which consisted mostly of patients classified as low risk, and patients from 16 cohort studies were included. In the RCTs, there was no significant difference in the odds of subsequent IUP in patients who underwent a salpingectomy compared with those who were treated with salpingotomy (odds ratio [OR] 0.97; 95% confidence interval [CI], 0.71-1.33). However, a significant and clinically meaningful difference was noted in the cohort studies, with the patients having a lower chance of IUP after salpingectomy (OR 0.45; 95% CI, 0.39-0.52). No significant difference was noted in the OR for a REP in the randomized trials (OR 0.77; 95% CI, 0.41-1.47), but the patients followed in the cohort studies had a cumulatively higher risk of REP after a salpingostomy (OR 0.73; 95% CI, 0.60-0.90). The subgroup analysis examining women within the studies with risk factors for tubal pathology found an even more impressive lowering in the odds of a subsequent IUP in patients classified as at-risk who were treated with salpingectomy (OR 0.30; 95% CI, 0.17-0.54), with a change in the direction of the odds for an REP rate favoring those who were treated with salpingostomy (OR 1.96; 95% CI, 0.88-4.35). CONCLUSION: Salpingectomy has clear advantages over salpingostomy, and RCTs consisting mainly of patients classified as low risk show no difference in outcomes between salpingectomy and salpingostomy. However, in cohort studies inclusive of all patients, the likelihood of a subsequent spontaneous IUP is decreased in patients treated with salpingectomy, and salpingostomies may be especially underused in women with risk factors for tubal disease.

Ectopic Pregnancy: Diagnosis and Management.

Ectopic pregnancy occurs when a fertilized ovum implants outside of the uterine cavity. In the United States, the estimated prevalence of ectopic pregnancy is 1% to 2%, and ruptured ectopic pregnancy accounts for 2.7% of pregnancy-related deaths. Risk factors include a history of pelvic inflammatory disease, cigarette smoking, fallopian tube surgery, previous ectopic pregnancy, and infertility. Ectopic pregnancy should be considered in any patient presenting early in pregnancy with vaginal bleeding or lower abdominal pain in whom intrauterine pregnancy has not yet been established. The definitive diagnosis of ectopic pregnancy can be made with ultrasound visualization of a yolk sac and/or embryo in the adnexa. However, most ectopic pregnancies do not reach this stage. More often, patient symptoms combined with serial ultrasonography and trends in beta human chorionic gonadotropin levels are used to make the diagnosis. Pregnancy of unknown location refers to a transient state in which a pregnancy test is positive but ultrasonography shows neither intrauterine nor ectopic pregnancy. Serial beta human chorionic gonadotropin levels, serial ultrasonography, and, at times, uterine aspiration can be used to arrive at a definitive diagnosis. Treatment of diagnosed ectopic pregnancy includes medical management with intramuscular methotrexate, surgical management via salpingostomy or salpingectomy, and, in rare cases, expectant management. A patient with diagnosed ectopic pregnancy should be immediately transferred for surgery if she has peritoneal signs or hemodynamic instability, if the initial beta human chorionic gonadotropin level is high, if fetal cardiac activity is detected outside of the uterus on ultrasonography, or if there is a contraindication to medical management.

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.

Laparoscopic tuboplasty for mild distal tubal disease.

OBJECTIVE: To review tuboplasty techniques for alleviating fallopian tube blockage. DESIGN: A step-by-step explanation of the techniques that comprise tuboplasty-fimbrioplasty, salpingo-ovariolysis, and salpingostomy-with surgical video footage. SETTING: Academic medical center. PATIENT: A 28-year-old G0 female patient with primary infertility and bilateral fallopian tube occlusion wanting to avoid in vitro fertilization. INTERVENTION(S): Tuboplasty and its component techniques of fimbrioplasty, salpingo-ovariolysis, and salpingostomy are demonstrated in a stepwise fashion for a case of mild tubal disease. Fimbrioplasty includes identifying the agglutinated or phimosed fimbrial end and gently opening it with fine forceps and blunt microdissection. Salpingo-ovariolysis is demonstrated with video and comprises: 1) surveying the anatomy; 2) applying traction to delineate the adhesions; and 3) transecting the adhesions with microsurgical scissors or electrosurgery. Finally, the steps of a salpingostomy are demonstrated, including: 1) identifying the length of the fallopian tube; 2) performing chromotubation to delineate tubal obstruction; 3) creating a salpingostomy at the terminal end; and 4) suturing open the salpingostomy site circumferentially to evert the edges. MAIN OUTCOME MEASURE(S): Successful restoration of normal tubal anatomy and identification of the location of tubal occlusion to guide salpingostomy site placement. RESULT(S): The fallopian tubes were assessed bilaterally and noted to have mild tubal disease and therefore were appropriate for tuboplasty. Normal tubal anatomy was restored bilaterally through salpingo-ovariolysis. Subsequent identification of the area of tubal occlusion bilaterally and salpingostomy were performed to create a patent fallopian tube able to pick up an oocyte from the ovary and facilitate fertilization. CONCLUSION(S): Tubal reconstructive surgery remains an important option to offer patients who want to avoid in vitro fertilization and who have mild tubal disease.

Safety and Assisted Reproductive Technology Outcomes of Hysteroscopic Tubal Microinserts Versus Laparoscopic Proximal Tubal Occlusion or Salpingectomy for Hydrosalpinges Treatment.

OBJECTIVE: This study sought to answer the following question: What are the complications and assisted reproductive technology outcomes among women with hydrosalpinges managed by hysteroscopic microinsert tubal occlusion compared with women with hydrosalpinges managed by laparoscopic proximal tubal occlusion or salpingectomy? METHODS: This was a retrospective cohort study conducted from January 2009 to December 2014 at two academic, tertiary care, in vitro fertilization centres in Toronto, Ontario. All patients (n = 52) who underwent hysteroscopic tubal occlusion for hydrosalpinges were identified. Patients who proceeded with embryo transfer cycles after hysteroscopic microinsert (n = 33) were further age matched to a cohort of patients who underwent embryo transfer after laparoscopic proximal tubal occlusion or salpingectomy (n = 33). Main outcome measures were clinical pregnancy rate per patient and per embryo transfer cycle. RESULTS: Among 33 patients, there were 39 fresh and 37 frozen embryo transfer cycles in the hysteroscopic group (group A); among 33 patients in the laparoscopic group (group B), there were 42 fresh and 29 frozen embryo transfer cycles. The cumulative clinical pregnancy rate in group A and group B was similar (66.7% vs. 69.7%, respectively; P = 0.8). The clinical pregnancy rate per embryo transfer cycle was also similar in both groups (28.9% in group A vs. 32.4% in group B; P = 0.6). There were two incidents of ectopic pregnancy in the laparoscopic group and no ectopic pregnancy in the hysteroscopic group. There were three major complications: tubo-ovarian abscess, distal migration of the coil after microinsert placement, and an acute abdomen following the hysteroscopic procedure. CONCLUSION: Pregnancy outcomes after hysteroscopic placement of a microinsert for hydrosalpinx management before embryo transfer were comparable to those following laparoscopic proximal tubal occlusion or salpingectomy. However, caution is advised regarding microinsert placement for hydrosalpinges before proceeding with assisted reproductive technology.

Interstitial Pregnancy after Ipsilateral Salpingectomy: Analysis of 46 Cases and a Literature Review.

STUDY OBJECTIVE: To investigate the relationship between previous ipsilateral salpingectomy and interstitial pregnancy and report on our experience of laparoscopic cornuostomy for interstitial pregnancy. DESIGN: Single-center, retrospective review. SETTING: University-based hospital. PATIENTS: All patients who had undergone ipsilateral salpingectomy previously, diagnosed with interstitial pregnancy and treated between July 2010 and September 2018. INTERVENTIONS: Laparoscopy or laparotomy as a treatment for interstitial pregnancy after ipsilateral salpingectomy. MEASUREMENTS AND MAIN RESULTS: A total of 414 cases of interstitial pregnancy were identified, of which 46 (11.1%) were after ipsilateral salpingectomy. Of the 46 patients, 20 (43.5%) became pregnant by in vitro fertilization and embryo transfer. Ipsilateral salpingectomy was the result of an ectopic pregnancy in 40 patients, hydrosalpinx in 5 patients, and torsion of an ovarian tumor in 1 patient. The laparoscopic approach was used to treat 78.3% of patients with history of previous salpingectomy. Patients who underwent ipsilateral salpingectomy by laparoscopy previously had a shorter interval from salpingectomy to interstitial pregnancy (24 months vs 60 months; p = .038) compared with patients who underwent ipsilateral salpingectomy by laparotomy. Laparoscopic cornuostomy was performed in 38 patients (82.6%); 12 had fetal cardiac activity, 15 had ruptured masses, and 16 used prophylactic methotrexate (MTX) intraoperatively. The median size of the ectopic mass was 2.5 cm (1.0-5.0 cm). At the time of laparoscopic cornuostomy, more patients with interstitial pregnancies with intact ectopic masses were administered prophylactic MTX (81.3% vs 45.5%; p = .043). Only 1 patient with a ruptured ectopic mass, high preoperative human chorionic gonadotropin levels, and without prophylactic MTX administration experienced a persistent ectopic pregnancy. CONCLUSION: Patients with a history of ipsilateral salpingectomy should be cautioned regarding the possibility of interstitial pregnancy. Laparoscopic cornuostomy appears to be an appropriate treatment for interstitial pregnancy in patients wishing to preserve fertility, and the use of concomitant prophylactic MTX may reduce the risk of persistent ectopic pregnancy, especially in patients with ruptured masses and high human chorionic gonadotropin levels.