Current evidence on surgery, systemic methotrexate and expectant management in the treatment of tubal ectopic pregnancy: A systematic review and meta-analysis

Background: To evaluate the effectiveness of surgery, medical treatment and expectant management of tubal ectopic pregnancy (EP) in terms of treatment success (i.e. complete elimination of trophoblast tissue), financial costs and future fertility. Methods: We searched for randomized controlled trials which described treatment interventions that have been widely adopted in clinical practice. A systemic literature search identified 15 trials. Results: Laparoscopic salpingostomy was significantly less successful than the open surgical approach (relative risk, RR 0.9, 95%; CI 0.82-0.99) due to a higher persistent trophoblast rate, but was significantly less costly. A prophylactic single shot methotrexate (MTX), given intramuscularly (i.m.) immediately post-operatively, significantly reduced persistent trophoblast after laparoscopic salpingostomy (RR 0.89, 95% CI 0.82-0.98, number needed to treat of 10). With systemic MTX in a fixed multiple dose i.m. regimen the likelihood of treatment success was higher than with laparoscopic salpingostomy (RR 1.15, 95% CI 0.93-1.43), but the difference was not significant. Systemic MTX in a fixed multiple dose i.m. regimen was only cost-effective if serum human chorionic gonadotrophin (hCG) concentrations were <3000 IU/l. If serum hCG concentrations were <1500 IU/l, then the single-dose MTX i.m. regimen-if necessary with additional MTX injections-was also cost-effective. Expectant management could not be evaluated yet. Subsequent fertility did not differ between the interventions studied. Conclusions: This meta-analysis shows that laparoscopic surgery is the most cost-effective treatment for tubal EP. Systemic MTX is a good alternative in selected patients with low serum hCG concentrations.