Of the 49 women allocated to laparoscopic salpingostomy, 72% were successfully treated with laparoscopic salpingostomy alone, 8% required salpingectomy, and 20% needed methotrexate after salpingostomy for persistent trophoblast disease. Overall, the tube was preserved in 90% of the methotrexate group and 92% of the salpingostomy group. Of the 81 patients assessed for ipsilateral tubal patency following treatment, a patent tube was present in 55% of the methotrexate group and 59% of the salpingostomy group. In a later publication using the same database, the authors calculated that systemic methotrexate was less costly than laparoscopic salpingostomy only if it was performed in patients with hCG titers of less than 1,500 mIU/mL.24 Data were calculated based on care rendered in the Dutch health-care system.
Methotrexate is best in patients with ectopic pregnancies less than 4 cm and hCG titers less than 10,000 to 15,000 mIU/mL.
Three randomized studies involving a total of 207 patients compared single-dose methotrexate to laparoscopic salpingostomy.25-27 If failure of medical therapy was defined as a requirement of more than 1 dose of methotrexate, salpingostomy was significantly more successful in treating ectopic pregnancy. However, if success in the medically managed group was defined as avoidance of surgical intervention, the groups were equally successful.
Following treatment, ipsilateral tubal patency could be assessed in 77 patients. No significant differences were found between the 2 groups.13 Subsequent intrauterine pregnancy and repeat ectopic pregnancy rates also were the same in both groups. In an analysis of direct costs, single-dose methotrexate proved to be less expensive than laparoscopy in patients with an initial hCG level of less than 1,500 mIU/mL.27
TABLE 3
Salpingectomy versus salpingostomy
| SALPINGECTOMY | SALPINGOSTOMY | |||
|---|---|---|---|---|
| LBR | REP | LBR | REP | |
| Paavonen15 | 20/39 (51.3%) | 3/39 (7.7%) | 18/34 (52.9%) | 3/34 (8.8%) |
| DeCherney14 | 21/50 (42%) | 6/50 (12%) | 19/48 (39.6%) | 9/48 (18.8%) |
| Swolin16 | 4/44 (9.1%) | 7/44 (15.9%) | 3/24 (12.5%) | 4/24 (16.7%) |
| Timonen17 | ||||
| Nullipara | 46/160 (28.8%) | 14/160 (8.8%) | 9/34 (26.5%) | 6/34 (17.6%) |
| Multipara | 106/398 (26.6%) | 39/398 (9.8%) | 16/49 (32.7%) | 4/49 (8.2%) |
| LBR=live birth rate; REP=repeat ectopic pregnancy | ||||
TABLE 4
Laparoscopy versus laparotomy for treatment of ectopic pregnancy
| LAPAROSCOPY | LAPAROTOMY | |
|---|---|---|
| Blood loss (mL) | 60 to 79 | 115 to 195 |
| Analgesic requirements (mg morphine) | 29 to 69 | 58 to 95 |
| Hospital stay (days) | 1.4 to 2.2 | 3.3 to 5.4 |
Conclusion
While the incidence of ectopic pregnancy has reached epidemic proportions in the United States, the mortality associated with this disease has steadily declined. This decrease is primarily due to diagnosis prior to rupture. In addition, numerous treatment options are now available, including nonsurgical therapy. It is hoped that future research will lead to even earlier diagnosis and provide data on prime candidates for each form of treatment.
In the meantime, it is our belief that single-dose methotrexate offers the best compromise between overall cost, morbidity, patient recovery, and future fertility in patients with ectopic pregnancies less than 4 cm and hCG titers less than 10,000 to 15,000 mIU/mL. Appropriate counseling of the overall risks and benefits, along with personal success rates of the treating practitioner should be considered. This will allow the patient to make an educated treatment decision.
The authors report no financial relationship with any companies whose products are mentioned in this article.