The Effect of Therapy for Tubal Ectopic Pregnancy on Subsequent Reproductive Capacity and the Frequency of Recurrence

Ectopic pregnancy (EP), defined as the implantation of an embryo outside the uterine cavity, is a notable complication in the first trimester (especially between the sixth and ninth weeks of gestation) and can cause severe intra-abdominal bleeding and death. In the United States, from 2013‒2017, there were 0.36 EP deaths per 100 000 live births. In addition, from 1998‒2007, excessive haemorrhage, shock or renal failure accompanied 67.4% of the EP deaths of hospitalized women (1). Clinical symptoms of EP are pain in the lower abdomen and vaginal bleeding in combination with a positive pregnancy test. In the case of rupture of a fallopian tube, patients may show signs of haemorrhagic shock, including dyspnoea, hypotonia and tachycardia (2). A prior EP may also negatively affect female fertility due to damage or loss of the fallopian tube. More than 95% of all EPs are tubal pregnancies, 1%‒2% are located in the intramural part of the uterus and a small number are ovarian, cervical or abdominal pregnancies. The very rare case of a combination intrauterine and EP, called a heterotopic pregnancy, occurs in 1 of every 3000 EPs (3). The aetiology of EP is multifactorial, including anatomic obstruction of the fallopian tube, malfunction of the tubal mobility and molecular factors (4). The main risk factors for the occurrence of EP are pelvic inflammatory diseases (chlamydia trachomatis, and gonorrhoea), previous sterilisation, application of an intrauterine device (IUD), previous tubal or intrauterine surgeries, previous EP, endometriosis, smoking and assisted reproductive techniques (ART) such as in vitro fertilisation (IVF) when performed in women with tubal pathologies (5-8). The prevalence of EP has increased worldwide due to improved diagnostic capabilities, increasing use of ART and tubal surgery and increased maternal age (2). The rate of EP following natural conception is approximately 2%, whereas the rates following ART are from 2.1%‒11% (9). In Germany, following IVF, the highest EP rate is 4.5%, which is in smokers under age 30 who have tubal pathology (8). Tubal surgeries also can cause EP, with an incidence rate of up to 40%, depending on the location, type and severity of the tubal pathology and the surgical procedure performed (10). Often, verifying an EP is difficult. The diagnosis is made using a combination of the clinical symptoms, vaginal ultrasound and serum biochemistry, although there is no existing human chorionic gonadotropin (hCG) value Abstract Objectives: Ectopic pregnancy (EP), which is defined as the implantation of an embryo outside the uterine cavity, occurs with notable frequency in the first trimester (especially between the sixth and ninth weeks of gestation) and can cause severe intraabdominal bleeding and death. Treatment options include salpingotomy with tubal preservation, transampullar expression of the EP (“milking” of the tube), wedge excision with the chance for tubal reconstruction in a subsequent surgery and partial or complete salpingectomy. Drug treatment with Methotrexate (MTX) is also an option. Materials and Methods: In this retrospective study, we analysed the data of patients who had been treated for an EP in the gynaecological department of Hanover Medical School, Germany, between 2006 and 2013. Results: We observed a pregnancy rate of 73.1% in those who wanted to have children following EP treatment, and 33 women (28.2%) became pregnant a second time. The birth rate after EP increased from 67.1% in the first subsequent pregnancy to more than 80% in the second. The frequency of recurrent EP was 6.6% in the first pregnancy after surgery and 3% in the second. Conclusions: These data are encouraging for EP patients, who have a good chance to conceive, whether spontaneously, after tubal reconstructive surgery or using in vitro fertilisation (IVF).