Fertility outcome after systemic methotrexate and laparoscopic salpingostomy for tubal pregnancy

G. Dias Pereira, P. J. Hajenius, B. W.J. Mol, W. M. Ankum, D. J. Hemrika, P. M.M. Bossuyt, F. Van Der Veen

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40 Citations (Scopus)

Abstract

Conservative laparoscopic surgery is currently the cornerstone in the treatment of tubal pregnancy in women who desire future fertility. Treatment with systemic methotrexate might, however, offer better fertility prospects by avoiding surgical trauma to the tube. We did a randomised clinical trial comparing systemic multi-dose intramuscular methotrexate with laparoscopic salpingostomy in tubal pregnancy.1 This trial was done in six Dutch hospitals between January, 1994, and September, 1996. 100 haemodynamically stable patients with a laparoscopically confirmed unruptured tubal pregnancy, without active bleeding and without fetal cardiac activity on transvaginal sonography, were included. There were no large differences in primary treatment success (relative risk 1·2 [95% CI 0·93–1·4]) or in tubal preservation (0·98 [0·87–1·1]) between the two treatments. Tubal patency, assessed in 81 patients, was slightly, but not significantly lower after systemic methotrexate (0·93[0·64–1·4]).

18 months after the trial ended, we assessed fertility outcome in patients who desired pregnancy. All patients were contacted by telephone and were interviewed about when they had tried to conceive and on the occurrence of spontaneous pregnancies. Follow-up ended with the occurrence of an intrauterine pregnancy, or at the last date of contact. Time to pregnancy through in-vitro fertilisation and embryo transfer was censored at the date of ovum pickup minus 2 weeks.

Data on follow-up was obtained for 90 women. Of these, 74 had tried to conceive-34 after systemic methotrexate and 40 after laparoscopic salpingostomy. In the systemic methotrexate group, 12 women had a spontaneous intrauterine pregnancy, two had an intrauterine pregnancy following in-vitro fertilisation and embryo transfer, whereas three had a spontaneous ectopic pregnancy. In the laparoscopic salpingostomy group, 16 women had a spontaneous intrauterine prenancy, two had an intrauterine pregnancy following in-vitro fertilisation and embryo transfer, and four had a spontaneous ectopic pregnancy.

Cox's proportional hazards estimates of the relative risks were 0·89 (0·42–1·9) for spontaneous intrauterine pregnancy and 0·77 (0·17–3·4) for spontaneous repeat ectopic pregnancy. Kaplan-Meier curves of the cumulative intrauterine pregnancy rates are shown in the figure. These cumulative spontaneous intrauterine pregnancy rates at 18 months were 36% in the systemic methotrexate group and 43% in the laparoscopic salpingostomy group.


Figure. Kaplan-Meier curves of intrauterine pregnancy rates

There is no large positive effect on future fertility with systemic methotrexate, although a more moderate (but worthwhile) benefit remains plausible. Effectiveness and side-effects of treatment, burden to patients, and costs to society should be taken into account when deciding on treatment of tubal pregnancy. Treatment with systemic methotrexate is not superior to laparoscopic surgery on these criteria.2, 3, 4
Original languageEnglish
Pages (from-to)724-725
Number of pages2
JournalLancet
Volume353
Issue number9154
DOIs
Publication statusPublished - 27 Feb 1999

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