eMedicine Specialties > Obstetrics and Gynecology > General Gynecology

Ectopic Pregnancy: Follow-up

Author: Vicken P Sepilian, MD, MSc, Medical Director, Reproductive Endocrinology and Infertility, CHA Fertility Center
Coauthor(s): Ellen Wood, DO, FACOOG, Voluntary Assistant Professor, University of Miami School of Medicine
Contributor Information and Disclosures

Updated: Aug 2, 2009

Outcome and Prognosis

Treatment success rates and future reproductive outcome

The evidence in the literature reporting on the treatment of ectopic pregnancy with subsequent reproductive outcome is limited mostly to observational data and a few randomized trials comparing the various treatment options. Assessment of successful treatment and future reproductive outcome with various treatment options is often skewed by selection bias. For example, comparing a patient who was managed expectantly to a patient who received methotrexate or to a patient who had a laparoscopic salpingectomy is difficult. A patient with spotting, no abdominal pain, and a low initial bhCG level that is falling may be managed expectantly, while a patient who presents with hemodynamic instability, an acute abdomen, and high initial bhCG levels must be managed surgically. These two patients probably represent different degrees of tubal damage, and comparing the future reproductive outcomes of the two would be flawed.

Data in the literature have failed to demonstrate substantial and consistent benefit of either salpingostomy or salpingectomy in improving future reproductive outcome. Despite the risk of persistent ectopic pregnancy, some studies have shown salpingostomy to improve reproductive outcome in patients with contralateral tubal damage.

In 1997, Yao and Tulandi concluded from a literature review that laparoscopic salpingostomy had equal or slightly better reproductive performance than salpingectomy; however, slightly higher recurrent ectopic pregnancy rates were noted in the salpingostomy group.6

Dubuisson et al, reporting on 10 years of surgical experience in Paris, concluded that, for selected patients who desired future fertility, using salpingectomy, which is simpler and avoids the risk of persistent ectopic pregnancy, is possible and can result in a comparable fertility rate to tubal conservation surgery.7 Future fertility rates were no different with either surgical approach when the contralateral tube was either normal or scarred but patent. In 1996, Clausen reported on a review of the past 40 years and concluded that only a small number of investigators have suggested indirectly that conservative tubal surgery increases the rate of subsequent intrauterine pregnancy, and the more recent studies may reflect an improvement in surgical technique. Maymon et al, after reviewing 20 years of ectopic pregnancy treatment, concluded that conservative tubal surgery provided no greater risk of recurrent ectopic pregnancy than the more radical salpingectomy.8

Parker and Bistis concluded that when the contralateral fallopian tube is normal, the subsequent fertility rate is independent of the type of surgery.9 A prospective study of 88 patients by Ory et al indicated that the surgical method had no effect on subsequent fertility in women with an intact contralateral tube.10 Prior history of infertility was the most significant factor affecting postsurgical fertility. Several other studies have reported that the status of the contralateral tube, the presence of adhesions, and the presence of other risk factors such as endometriosis have a more significant impact on future fertility than choice of surgical procedure. According to Rulin, salpingectomy should be the treatment of choice in women with intact contralateral tubes because conservative treatment provides no additional benefit and incurs the additional costs and morbidity associated with persistent ectopic pregnancy and recurrent ectopic pregnancy in the already damaged tube.11

Future fertility rates are similar in patients who were treated surgically by laparoscopy or laparotomy. Salpingectomy by laparotomy carries a subsequent intrauterine pregnancy rate of 25-70%, compared to laparoscopic salpingectomy with rates of 50-60%. Very similar rates exist for laparoscopic salpingostomy versus laparotomy. The rate of persistent ectopic pregnancy between the two groups is similar, ranging from 5-20%. A slightly higher recurrent ectopic pregnancy rate exists in patients treated by laparotomy (7-28%), regardless of conservative or radical approach, when compared to laparoscopy (6-16%). This surprising finding is believed to be secondary to increased adhesion formation in the group treated by laparotomy.

The modern pelvic surgeon has been led to believe that the treatment of choice for unruptured ectopic pregnancy is salpingostomy, sparing the affected fallopian tube and thereby improving future reproductive outcome. However, if the treating surgeon has neither the laparoscopic skill nor the instrumentation necessary to atraumatically remove the trophoblastic tissue via linear salpingostomy, then salpingectomy by laparoscopy or laparotomy is not the wrong choice for operation. Leaving a scarred charred fallopian tube behind after removing the ectopic pregnancy but requiring extensive cautery to control bleeding does not preserve reproductive outcome.

The success rates after methotrexate are comparable with laparoscopic salpingostomy, assuming the selection criteria mentioned above are observed. The average success rates using the multiple-dosage regimen are in the range of 91-95%, demonstrated by multiple investigators. One study of 77 patients desiring subsequent pregnancy showed intrauterine pregnancies in 64%, and recurrent ectopic pregnancy occurred in 11%. Other studies have demonstrated similar results, with intrauterine pregnancy rates ranging from 20-80%.

The average success rates for the single-dosage regimen are reported to be from 88-94%. In a study by Stovall and Ling, 113 patients (94%) were treated successfully, 4 (3.3%) of whom needed a second dose.12 No adverse effects were encountered. Furthermore, 87.2% of these patients achieved a subsequent intrauterine pregnancy, whereas 12.8% experienced a subsequent ectopic pregnancy. Other studies have reported similar results with some mild adverse effects and lower reproductive outcomes. A recent meta-analysis including data from 26 trials demonstrated the success with the single-dose regimen to be 88.1%, while the success with the multiple dose regimen was 92.7%.13 A small randomized clinical trial also demonstrated the single-dose regimen to have a slightly higher failure rate.14 A hybrid protocol, involving 2 equal doses of methotrexate (50 mg/m2) given on days 1 and 4 without the use of leucovorin has been shown to be an effective and convenient alternative to the existingregimens.15

Patient education

For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center. Also, see eMedicine's patient education articles Ectopic Pregnancy; Pregnancy, Bleeding; Vaginal Bleeding, Birth Control Overview; and Birth Control FAQs.

Future and Controversies

As the ability to diagnose ectopic pregnancy improves, physicians will be able to intervene sooner, preventing life-threatening sequelae and extensive tubal damage, which could preserve future fertility. Already, with improving technology, physicians are treating ectopic pregnancies with minimally invasive surgery or no surgery at all. Physicians have been able to reduce the mortality rate secondary to ectopic pregnancy despite its growing incidence. Also, effective vaccination against Chlamydia trachomatis is under investigation. Once clinically available, it should have a dramatic impact on the frequency of ectopic pregnancy, as well as on the overall health of the female reproductive system.

 


More on Ectopic Pregnancy

Overview: Ectopic Pregnancy
Workup: Ectopic Pregnancy
Treatment: Ectopic Pregnancy
Follow-up: Ectopic Pregnancy
Multimedia: Ectopic Pregnancy
References
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References

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Further Reading

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Keywords

tubal pregnancy, extrauterine pregnancy, ectopic gestation, pelvic inflammatory disease, PID, Chlamydia trachomatis, salpingitis, Neisseria gonorrhoeae, salpingostomy, neosalpingostomy, fimbrioplasty, tubal reanastomosis, tubal ligation, clomiphene citrate, injectable gonadotropin therapy, in vitro fertilization, IVF, gamete intrafallopian transfer, GIFT, intrauterine device, IUD, salpingitis isthmica nodosum, pain

amenorrhea, vaginal bleeding, methotrexate, pregnancy-related death, abnormally implanted gestation, pelvic infection, cigarette smoking, diethylstilbestrol exposure, DES exposure, T-shaped uterus, prior abdominal surgery, failure with progestin-only contraception, ruptured appendix, adnexal mass, culdocentesis, hematosalpinx, hemoperitoneum, tubal rupture, uterine rupture, shock, disseminatedintravascular coagulopathy, DIC, laparoscopic salpingectomy

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Contributor Information and Disclosures

Author

Vicken P Sepilian, MD, MSc, Medical Director, Reproductive Endocrinology and Infertility, CHA Fertility Center
Vicken P Sepilian, MD, MSc is a member of the following medical societies: American College of Obstetricians and Gynecologists and American Society for Reproductive Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Ellen Wood, DO, FACOOG, Voluntary Assistant Professor, University of Miami School of Medicine
Ellen Wood, DO, FACOOG is a member of the following medical societies: American Society for Reproductive Medicine
Disclosure: Nothing to disclose.

Medical Editor

Robert K Zurawin, MD, Associate Professor, Director of Baylor College of Medicine Program for Minimally Invasive Gynecology, Director of Fellowship Program, Minimally Invasive Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine
Robert K Zurawin, MD is a member of the following medical societies: American Association of Gynecologic Laparoscopists, American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Harris County Medical Society, North American Society for Pediatric and Adolescent Gynecology, and Texas Medical Association
Disclosure: Johnson and Johnson Honoraria Speaking and teaching; Conceptus Honoraria Speaking and teaching; Biosphere Medical Honoraria Speaking and teaching; Eli Lilly Honoraria Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

A David Barnes, MD, PhD, MPH, FACOG, Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah)
A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners, American College of Obstetricians and Gynecologists, American Medical Association, Association of Military Surgeons of the US, and Utah Medical Association
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

 
 
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