... Gynecology-endocrinology

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1 ... Gynecology-endocrinology FERTILITY AND STERILITY Copyright 1990 The American Fertility Society Vol. 5:1, No.2, February 1990 Printed on acid-free paper in U.S.A. Reproductive outcome after conservative surgery for unruptured tubal pregnancy-a 15-year experience Rami Langer, M.D.* Arie Raziel, M.D. Raphael Ron-EI, M.D. Abraham Golan, M.D. Ian Bukovsky, M.D. Eliahu Caspi, M.D. Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Affiliated to Sackler School of Medicine, Tel Aviv University, Israel The fertility outcome is presented in 118 after conservative surgery for unruptured tubal pregnancies. This patient group experienced 142 pregnancies, 127 of which were intrauterine (89.4%). The intrauterine pregnancies (IUPs) occurred in 83 (70.3%) and 63.5% (75/118) had live births. The recurrence rate of tubal pregnancy was 12.7%. Of the 65 with a normal contralateral tube 53 (81.5%) followed surgery with an IUP, 76.1% a live birth, and 7.7% a recurrent tubal Fifty-seven percent of the with a single tube followed with an IUP, and 47.6% had a live birth. The recurrence of tubal pregnancy in this group was 28.5%. Of the who underwent expression of tubal gestation, 60.6% followed with an IUP, and 57.5% with a live birth with no recurrence of tubal Fertil Steril53:227, 1990 In the last two decades a profound change toward the treatment of tubal pregnancy has been made. The traditional concept, introduced by Tait 100 years ago, l of prompt surgical excision of the involved tube as a life saving procedure, has remained for many years with virtually no modification of the surgical method for treating tubal Stromme, in 1953,2 suggested an alternative surgical approach by conserving the affected tube, with prospective view of the patient's future fertility. Encouraged by initial success, conservative surgical techniques have been used with increasing frequency, proving the safety, feasibility, and effectiveness in preserving future fertility.3-4 This approach couples with the increasing rates of ectopic pregnancy in recent years,7 and with improved diagnostic tools tubal pregnancy is now accurately diagnosed and at an earlier stage of gestation. This facilitates early treatment of unruptured Received May 3, 1989; revised and accepted September 26, * Reprint requests: Rami Langer, M.D., Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Zerifin 70300, Israel. tubal pregnancy, the are usually stable preoperatively, and evidence is accumulating that conservative surgery is indicated in the management of tubal The purpose of this study was to present our experience with conservative surgery for tubal pregnancy acquired during 15 years, with regard to selection of, surgical technique, safety, and fertility after surgery. MATERIALS AND METHODS During the 15-year period from 1972 to 1986,496 tubal pregnancies were treated surgically at the Assaf Harofeh Medical Center, accounting for 0.86% of all deliveries during this period. In 347 cases a radical operation was performed-either salpingectomy or salpingoophorectomy. In 149 cases (30%) conservative surgical procedures were performed in 145 (two underwent two operations each, and one patient was operated on three times for repeat tubal pregnancies). The conservative surgical procedure was determined by the presence of an unruptured tubal pregnancy of any size in with poor reproductive perfor- Langer et al. Surgery in unruptured tubal pregnancy 227

2 Table 1 Location of Tubal Pregnancy Associated Pelvic Findings and Treatment in 149 Patients" Laterality Left tube 65 Right tube 84 Location Middle third 61 Outer third 79 Istemic 9 Corpus luteum Homolateral 110 Heterolateral 39 Type of operation 116 Salpingotomy Expression of tubal pregnancy (milking) 33 Additional surgeryb 21 Lysis of pelvic adhesion Finbrioplasty on contralateral tube 11 "Two underwent two operations each and one patient was operated on three times. b Six underwent both lysis of pelvic adhesions and finbrioplasty on the contralateral tube. mance, interested in future pregnancies. Laparoscopy was the most frequent and reliable diagnostic tool used in all cases for unruptured tubal The mean age of this patient group was 26.8 years (15 to 36 years). Forty-nine (32.8%) had never been pregnant before. Seventy-two (48.3%) had had at least one live birth, 35 (23.4%) had had a miscarriage in the past, and 33 (22.1 %) had undergone induced abortion. Twenty-two of the (14.7%) had had a previous ectopic pregnancy, 17 having undergone salpingectomy, whereas in 5 conservative salpingotomy was performed. The majority of tubal pregnancies (140/149) were located in the distal two thirds of the involved tube and only nine istemic pregnancies were found (Table 1). One hundred and sixteen conservative salpingotomies were performed in 112, and expression of the tubal implantation (milking) was performed in 33. Lysis of pelvic adhesions and contralateral finbrinoplasty were indicated in 22 and 11, respectively. The mean follow-up period was 7.2 years (range 3 to 15 years). Surgical Technique In all cases surgery was performed by the abdominal route. Salpingotomy is performed by a 5- to 10- mm longitudinal incision over the pregnancy site on the antemesosalpinx site of the tube. The conceptional products are removed by suction and the remaining trophoblastic tissue is gently removed with forceps. The muscles and serosa are closed with 5/0 interrupted nylon sutures thereby avoiding the endosalpingx. Expression of tubal pregnancy ("milking") where the products of conception were either adherent to the outer part of the ampulla or attached to the finbria was attempted. Manual exertion of direct pressure on the tube was carried out, just beneath implantation site, to express the products of conception. Direct removal of the products of conception were performed in those cases where they were attached to the finbria. After this procedure, hemorhasis was performed by direct manual pressure exerted on the implantation site of the tube or by electrocoagulation of bleeding points on the finbria. This series includes, however, only successful procedures, because finbrial evacuation was attempted in a larger number of distal tubal pregnancies. When technical difficulties arose in accomplishing gentle and complete expression of the gestational products, the conceptus was extended via an antimesosalpingx tubal incision and the cases were included in the linear salpingotomy series. A solution containing hydrocortisone and antibiotics was instilled into the abdominal cavity. Post operative hydrotubations were performed as previously described. 4 RESULTS Table 2 summarizes the postoperative outcome for 118 of 145 operated on conservatively for unruptured tubal Twelve did not wish to conceive and were using contracep- Table 2 Pregnancies and Outcome After Conservative Surgery for Tubal Pregnancies in 118 Patients pregnancies Pregnancies Intrauterine Extrauterine 15 13" Outcome Live birth Spontaneous abortion Induced abortion 7 5 Premature labor (nonviable) 2 2 " Two had a live birth followed by a recurrent tubal 228 Langer et a1. Surgery in unruptured tubal pregnancy Fertility and Sterility

3 Table 3 Contralateral Tube Status During Surgery for Tubal Pregnancy and Fertility Outcome in 118 Patients Status of contralateral tube intrauterine tubal pregnancies live births pregnancies Normal 65 Periadnexal adhesions or sactosalpinx surgically corrected 32 Previous salpingectomy or severely damaged tube b 21 Total 118 a Values in parentheses are percents. b Nineteen had salpingectomy and two had severely damaged oviduct incompatible with normal function. 53 (81.5)a 50 (76.9) 5 (7.7) 18 (56.2) 15 (46.8) 4 (12.5) 12 (57.1) 10 (47.6) 6 (28.5) ', Two had a live birth followed by recurrent tubal tion. Five underwent in vitro fertilization (IVF) procedures within 6 months ofthe operation. Ten (6.9%) were lost to follow up. The results were summarized for the remaining 118 who experienced 142 pregnancies, 127 of which were intrauterine (89.4%). The intrauterine pregnancies (IUPs) occurred in 83 (70.3%,83 of 118). These IUPs resulted in 63.5% live births (75 of 118),7 terminated in induced abortion, and 28 (23.7%) miscarried. Fifteen repeat tubal pregnancies occurred in 13 (11 %), 7 of which were located in the previously operated tube, and 8 tubal pregnancies in the contralateral tube. In 4 cases the underwent repeat conservative salpingotomy and in the remaining recurrent tubal pregnancies, salpingectomy was performed. Table 3 compares fertility outcome and contralateral tubal status as found at surgery for ectopic Tubal status was evaluated both by macroscopic inspection and by gentle probing of the tubal length. With a normal contralateral tube 81.5% of the achieved a normal IUP as compared with 56.2% of those who underwent additional surgical correction of the contralateral tube, because of either adhesions or distal end occlusion. Where the contralateral tube was absent or severely damaged the IUP rate was 57.1 %. Recurrent tubal pregnancy rates were 7.7% with normal contralateral tube, 12.5% when surgical repair was required, and 28.5% in cases with no contralateral tube. Table 4 compares the fertility outcome after the different methods of conservative surgical procedures used. Patients who underwent salpingotomy had 74.1 % (63/85) IUPs, 65.8% (56/85) live births, and a recurrent ectopic rate of 17.6%. Ofthose who underwent a milking procedure, 60.6% had an IUP rate, 57.5% live births, and no recurrence of tubal Complications One patient who underwent a conservative salpingotomy for ampulla pregnancy was reoperated on within 24 hours and a salpingectomy was performed because of perfuse bleeding through the previously operated tube. Trophoblastic tissue was found on histologic examination within the tubal wall. In all the other 148 cases, no postoperative morbidity was encountered, nor did any of the require blood transfusion. DISCUSSION Over the last 15 years we have noticed a rising incidence of ectopic pregnancies in our department. From 1972 through to 1977 we found an ectopic rate of 0.73%, 1.02% during 1978 to 1983, and a 1.3 % ectopic rate in the last 3 years of the study (1984 to 1986). During this period an increasing number of conservative procedures were performed, 38.7% of tubal pregnancies from 1978 to 1986, compared with 17% of conservative surgical procedures performed during the first 6 years (1972 to 1977). This increasing number of conservative procedures can be for several reasons. First, the increasing number of the population receiving an early diagnosis is helped by better diagnostic modalities, such as ultrasound, radioimmunoassay for the {3 subunit of human chorionic gonadotropin, and prompt laparoscopy that greatly enhances the prospect of the early diagnosis of un ruptured tubal Second, after our previous reports 4,6 concerning the feasibility of the procedure, and encouraged by our ongoing results, the procedure has Langer et al. Surgery in unruptured tubal pregnancy 229

4 Table 4 Fertility Outcome Distributed by Type of Surgical Procedure in 118 Patients Operative procedure intrauterine tubal pregnancies live births pregnancies Salpingotomy 85 Expression of tubal gestation (milking) (74.1)a 56 (65.8) 15 (17.6) 20 (60.6) 19 (57.5) a Values in parentheses are percents. developed from its initially limited performance by a few physicians, to a standardized operation that can be performed by all the resident staff. Third, the selection criteria for conservative surgery have been broadened in recent years. Initially (1972 to 1977) these procedures were indicated primarily for younger (mean age 24.2 years) with previously limited fertility performance (74% without children). In the last 9 years (1978 to 1986) we included in an older age group (mean age 26.8 years) with already proven fertility performance (46.3% without children, 33.6% with one child, and 20.1 % with two children). This broadening of the criteria has been encouraged by the subsequent fertility performance of the patient group where the contralateral tube has been found normal on inspection during the operation (Table 4). This group experienced an 81.5% IUP rate with a 76.9% live birth rate and only a 7.7% recurrent ectopic rate. The fertility outcome in this group suggests that the conservative surgical procedure is worth offering to all women hoping to become pregnant in the future. The present study revealed a 70.3% IUP rate (83 of 118 ) after conservative surgery and a 63.5% live birth rate (75 of 118 ). There were 15 ectopic pregnancies after the procedure in this group, a recurrence rate of 12.7%. These figures compare with an 80% IUP rate, a 71 % live birth rate and 12% recurrent ectopic pregnancies found in a smaller patient group previously reported. 6 These figures, for a larger series, demonstrate the reproducibility of our previous results. Extended follow up for the smaller series has shown further improvement in the number of live births and IUP rates, and we believe that a 10-year follow-up would more adequately cover the patient's reproductive career. Two surgical methods have been used for the conservative management of tubal Salpingotomy is widely accepted in most reports 3,8 while expression of tubal gestation (milking) has been the subject of both controversial and inadequate literature reports. Some authors,9,lo mentioned the use of milking as a part of their surgical methods, but their data were supported by a very small number of. Timonen and Niemenen ll reported the use of the milking procedure in 29 cases. After this operation, ectopic gestation recurred in 21 % of those who subsequently conceived, 24.1% resulted in term deliveries and 20.7% miscarried. Their conclusion was that expression of the ovum seems to be the method leading to the most untoward effects, because abortion and recurrent ectopic pregnancies occurred more often after this operation than after any other. Our experience, as previously reported 12,13 contradicts such pessimistic evaluations. A 60.6% IUP rate, a 57.5% live birth rate and especially no ectopic recurrence, although in a small series, suggest a more optimistic outcome with this procedure that may represent a valuable addition to the conservative treatments available for ectopic gestation. A special interest is found in those cases with either absence or occlusion of the contralateral tube. The IUP rate in this group (Table 4) was 57.1 % and a 47.6% live birth rate was found. This clearly indicates that the conservatively treated tube is capable of normal function. While the 28.5% recurrent tubal pregnancy rate seems high in this group, our patient selection already presupposes an increased incidence of pathology in the residual tube. Similar results from residual tubal surgery have been obtained by others. 8,14 A single complication occurred in 1 of 149 conservative surgical procedures performed during the years. A laparotomy was needed because of the surgeon's mishandling during the primary operation. Sporadic similar case reports were found in the literature/ 5 and it was recommended to place a prophylactic suture in the mesosalpinx to interrupt the circulation to the implantation site. It is our feeling that such measures are unnecessary because compromise of blood supply to the fallopian tube is a distinct possibility. In conclusion, the increasing frequency of ectopic gestation and the increasing population with early diagnosis of unruptured tubal pregnancy, 230 Langer et al. Surgery in unruptured tubal pregnancy Fertility and Sterility

5 which is facilitated by better diagnostic modalities, offers the physician an opportunity to evaluate less radical operative procedures than previously performed. Our experience, despite the growing trend toward nonsurgical methods, suggests that the conservative surgical methods should be offered to all with unruptured tubal pregnancy hoping to become pregnant, regardless of their past fertility performance or the current state of the contralateral tube. REFERENCES 1. Tait RL: Pathology and treatment of extrauterine Br Med J 2:317, Stromme WB: Salpingotomy for tubal pregnancy: Report of a successful case. Obstet Gynecol1:472, Stromme WB: Conservative surgery for ectopic pregnancy: A twenty year review. Obstet Gynecol41:215, Bukovsky I, Langer R, Herman A, Caspi E: Conservative surgery for tubal Obstet Gynecol 53:709, DeCherney AH, Romero R, Naftolin F: Surgical management of unruptured ectopic Fertil Steril 35:21, Langer R, Bukovsky I, Herman A, Sherman D, Sadovsky G, Caspi E: Conservative surgery for tubal Fertil Steril38:427, Kitchin JD, Wein RM, Nunley WC Jr, Thiagarajah S, Thorton WN Jr: Ectopic pregnancy: current clinical trends. Am J Obstet Gynecol 134:870, Hallet JG: Repeat ectopic pregnancy: a study of 123 consecutive cases. Am J Obstet Gynecol122:520, Sarvinence P A, Kinnuen 0: The treatment of extrauterine pregnancy and subsequent fertility. Int J Fertil11:2, Plowman L, Wicksell F: Fertility after conservative surgery in tubal Acta Obstet Gynecol Scand 39:143, Timonen S, Niemenen U: Tubal pregnancy, choice of operative method of treatment. Acta Obstet Gynecol Scand 46: 327, Langer R, Bukovsky I, Herman A, Lipshitz Y, Caspi E: "Milking"-A conservative surgical technique for a tubal testation. Int J Fertil28:49, Sherman D, Langer R, Herman A, Bukovsky I, Caspi E: Reproductive outcome after fimbrial evacuation of tubal Fertil Steril47:420, DeCherney AH, Maheaux R, Naftolin F: Salpingostomy for ectopic pregnancy in the sole patent oviduct: reproductive outcome. Fertil Steril37:619, Kelly MT, Santos-Ramos R, Duenhoelter JH: The value of sonography in suspected ectopic Obstet Gynecol 53:703, 1979 Langer et al. Surgery in unruptured tubal pregnancy 231