References: Tubal_pregnancy98; Volume 4 Issue 2

TUBAL PREGNANCY

1. AUTHOR	Goldenberg-M, Bider-D, Admon-D, Mashiach-S, Oelsner-G.
INSTITUTION	Department of Obstetrics and Gynaecology, Chaim Sheba Medical Center, Tel Hashomer, Israel.
TITLE	Methotrexate therapy of tubal pregnancy.
SOURCE	Hum-Reprod 1993 May, VOL: 8 (5), P: 660-6, ISSN: 0268-1161 29 Refs.
ABSTRACT	Reports of successful treatment of ectopic pregnancies by administration of methotrexate have recently attracted a great deal of attention. This review summarizes the results of therapy with methotrexate in tubal pregnancy. Different technical approaches and pharmacological doses have been reported. These methods, however, present various problems, including the occurrence of toxicity, long therapeutic periods and treatment failure. With proper selection of patients, a success rate of approximately 90% has been achieved. Preliminary assessment of subsequent fertility provides promising results. However, the majority of the reports do not include controls. Author.

2. AUTHOR	Maymon-R, Shulman-A.
INSTITUTION	Department of Obstetrics, Assaf Harofeh Medical Center, Tel Aviv, Israel.
TITLE	Controversies and problems in the current management of tubal pregnancy.
SOURCE	Hum-Reprod-Update 1996 Nov-Dec, VOL: 2 (6), P: 541-51, ISSN: 1355-4786 82 Refs.
ABSTRACT	The two main conservative treatment alternatives for tubal pregnancy, methotrexate administration and laparoscopic salpingostomy are under constant review. Recently, expectant management of tubal pregnancy has become increasingly popular. In this review, we assess the outcome of conservative management modalities for extrauterine pregnancy and compare the results of treatment with methotrexate and operative laparoscopy. Outcomes of extrauterine pregnancy were obtained from a review compiled from the English literature identified by directed Medline search. Methotrexate and laparoscopic salpingostomies yield good final treatment rates of 85-95% respectively and relatively low rates for further surgical complication (5-10% respectively). Tubal patency, as well as future fertility performance, are quite similar after both techniques. Although they appear to suit the demands of the 21st century, each one has its own benefits and contraindications. With adequate patient selection, expectant management of the tubal pregnancy is a reasonable approach with good results. Although the morbidity rate after tubal pregnancy treatment is decreasing and the main concern is to reduce the decline in fertility potential, the real future challenge remains prevention of the disease, especially among high risk patients, such as those undergoing infertility treatment. Author.

3. AUTHOR	Langebrekke-A, Sornes-T, Urnes-A.
INSTITUTION	Department of Gynecology and Obstetrics, Akershus Central Hospital, Nordbyhagen, Norway.
TITLE	Fertility outcome after treatment of tubal pregnancy by laparoscopic laser surgery (see comments).
SOURCE	Acta-Obstet-Gynecol-Scand 1993 Oct, VOL: 72 (7), P: 547-9, ISSN: 0001-6349. CM Comment in: Acta-Obstet-Gynecol-Scand 1994 May; 73(5):441-2.
ABSTRACT	In 150 women with tubal pregnancy consecutively treated over a two year period by laparoscopic techniques, 74 were treated conservatively by linear salpingotomy with carbon dioxide laser laparoscopy and 76 cases non-conservatively through the laparoscope by salpingectomy. Between 15 and 37 months later all patients were contacted by means of questionnaires to evaluate subsequent fertility outcome. Sixty-six percent (38/58) of those women who desired pregnancy after conservative laparoscopic treatment achieved an intrauterine pregnancy. The corresponding rate for women who desired pregnancy after salpingectomy was 45% (18/40). The recurrent ectopic pregnancy rates in the two groups were 7% (4/58) and 10% (4/40), respectively. This study confirms that tubal pregnancy can be appropriately managed by laparoscopic laser surgery with the advantages of minimal invasive techniques. Author.

4. AUTHOR	Mol-B-W, Hajenius-P-J, Engelsbel-S, Ankum-W-M, Hemrika-D-J, van-der- Veen-F, Bossuyt-P-M.
INSTITUTION	Department of Clinical Epidemiology and Biostatistics, Academic Medical Center, University of Amsterdam, The Netherlands.
TITLE	Is conservative surgery for tubal pregnancy preferable to salpingectomy? An economic analysis.
SOURCE	Br-J-Obstet-Gynaecol 1997 Jul, VOL: 104 (7), P: 834-9, ISSN: 0306-5456.

ABSTRACT	OBJECTIVE: The traditional treatment of ectopic pregnancy is salpingectomy, while conservative surgery aims to save the function of the uterine tube. This study compares the effectiveness and the economic costs of salpingectomy and conservative tubal surgery in women with a tubal pregnancy. METHODS: Salpingectomy and conservative tubal surgery were compared economically, based on a combined retrospective and prospective cohort study and a review of the literature. A model was developed in which conservative surgery and salpingectomy with in vitro fertilisation and embryo-transfer (IVF- ET) were compared with salpingectomy alone. PARTICIPANTS: One hundred and fifteen consecutive women treated laparoscopically for tubal pregnancy. MAIN OUTCOME MEASURES: Complete removal of the tubal pregnancy; subsequent intrauterine pregnancy rate; economic analysis. RESULTS: Tubal pregnancy was always treated successfully by both methods, sometimes with additional treatment for persistent trophoblast. In the short term costs per patient were 1554 pounds (95% confidence interval (CI) 1501 pounds-1656 pounds) for salpingectomy and 1787 pounds (95% CI 1683 pounds-1930 pounds) for conservative surgery. The mean difference between costs of salpingectomy and costs of conservative surgery was 233 pounds (95% CI 80 pounds-371 pounds). Concerning subsequent intrauterine pregnancy, conservative surgery is slightly more effective than salpingectomy but is more expensive. Costs per subsequent intrauterine pregnancy are 4063 pounds. If IVF-ET is performed in all women who are not pregnant within three years after salpingectomy, costs per subsequent intrauterine pregnancy are 15,629 pounds. CONCLUSIONS: Salpingectomy is the treatment of choice in women not desiring future pregnancy. Salpingectomy seems less effective than conservative surgery when future pregnancy is desired, but is less costly. Conservative surgery seems more cost effective than salpingectomy with additional IVF-ET. Author.

5. AUTHOR	Clausen-I.
INSTITUTION	Department of Gynecology and Obstetrics, Kolding Hospital, Denmark.
TITLE	Conservative versus radical surgery for tubal pregnancy. A review (see comments).
SOURCE	Acta-Obstet-Gynecol-Scand 1996 Jan, VOL: 75 (1), P: 8-12, ISSN: 0001-6349 44 Refs. CM Comment in: Acta-Obstet-Gynecol-Scand 1996 Oct; 75(9):866-7.
ABSTRACT	OBJECTIVE. The aim of this work was to analyse the fertility prognosis after conservative or radical surgery for tubal pregnancy. DATA SOURCES. Index Medicus was searched for all attainable literature on the subject. METHODS OF STUDY SELECTION. A total of 40 scientific publications through the latest 40 years were selected. For fulfilling the selection criterias the study design should appear clearly. Furthermore the rate of women obtaining intrauterine pregnancy and the rate of repeat ectopic pregnancy following radical or conservative tubal surgery was to be compared using 95% confidence limits. The results from each report were compared in four groups according to study design i.e. retrospective non-comparing materials, retrospective comparing studies, prospective selected treatment series or prospective randomized comparing investigations. DATA EXTRACTION AND SYNTHESIS. Pooling the results from the retrospective noncomparing materials revealed that there was no significant difference in intrauterine pregnancy rates, i.e. 46% following conservative tubal surgery and 44% after radical surgery. The repeat ectopic pregnancy rate was 10% following conservative surgery and 15% after radical surgery. In the group of restrospective comparing studies only one of 15 materials could document a significant better intrauterine pregnancy rate after conservative tubal surgery than following radical treatment for tubal pregnancy. There were no differences either in this group in repeat ectopic pregnancy rates. Prospective investigations were almost exclusively represented by selected conservative treatment series. In these series the average intrauterine pregnancy rate was 57% and the repeat ectopic pregnancy rate was 13%. CONCLUSIONS. In studies on fertility after radical or conservative surgical treatment for tubal pregnancy no significant difference in intrauterine pregnancy rates or repeat ectopic pregnancy rates were found. Prospective selected treatment series demonstrated higher intrauterine pregnancy rates than retrospective studies. The repeat ectopic pregnancy rate was not raised in prospective series. No prospective randomised trial was found. Author.

6. AUTHOR	Langebrekke-A, Sornes-T, Urnes-A.
INSTITUTION	Department of Gynecology and Obstetrics, Akershus Central Hospital, Nordbyhagen, Norway.
TITLE	Fertility outcome after treatment of tubal pregnancy by laparoscopic laser surgery (see comments).
SOURCE	Acta-Obstet-Gynecol-Scand 1993 Oct, VOL: 72 (7), P: 547-9, ISSN: 0001-6349. CM Comment in: Acta-Obstet-Gynecol-Scand 1994 May; 73(5):441-2.
ABSTRACT	In 150 women with tubal pregnancy consecutively treated over a two year period by laparoscopic techniques, 74 were treated conservatively by linear salpingotomy with carbon dioxide laser laparoscopy and 76 cases non-conservatively through the laparoscope by salpingectomy. Between 15 and 37 months later all patients were contacted by means of questionnaires to evaluate subsequent fertility outcome. Sixty-six percent (38/58) of those women who desired pregnancy after conservative laparoscopic treatment achieved an intrauterine pregnancy. The corresponding rate for women who desired pregnancy after salpingectomy was 45% (18/40). The recurrent ectopic pregnancy rates in the two groups were 7% (4/58) and 10% (4/40), respectively. This study confirms that tubal pregnancy can be appropriately managed by laparoscopic laser surgery with the advantages of minimal invasive techniques. Author.