Ectopic pregnancy: its relationship to tubal reconstructive surgery

Transcription

1 FERTILITY AND STERILITY Copyright D 1987 The American Fertility Society Vol. 47, No.4, April 1987 Printed in U.s.A. Ectopic pregnancy: its relationship to tubal reconstructive surgery Gad Lavy, M.D. Michael p, Diamond, M.D. Alan H. DeCherney, M.D. Department of Obstetrics andvynecology, Division of Reproductive Endocrinology, Yale University, School of Medicine, New Haven, Connecticut The passage of the fertilized ovum through the fallopian tube has been compared to a perilous journey.1 Indeed, only too frequently, this journey terminates in disaster. Failure of the fertilized egg to gain access into the uterine cavity may lead to a catastrophic event in which the fertilized egg implants outside of the uterine cavity proper. Ectopic pregnancy is, indeed, a reproductive disaster, compromising the woman's life and frequently leading to a permanent loss of reproductive function. Most ectopic pregnancies occur in the fallopian tube, usually in its distal portion. Both mechanical and hormonal factors, by interfering with the successful transport of the ovum through the fallopian tube, can lead to an ectopic implantation. The association of tubal surgery and ectopic pregnancy is well recognized. This "iatrogenic" etiology of ectopic pregnancy is of particular concern to the reproductive surgeon. The risk of ectopic pregnancy after tubal surgery varies greatly and depends on the prior condition of the tube, the nature of the surgical procedure performed, the technique employed, and the surgeon's skill. This section reviews the various aspects of the association between tubal surgery and ectopic pregnancy. The impact of the improvement in surgical technique and the availability of in vitro fertilization and embryo transfer (lvf-et) as an alternative to tubal surgery is also evaluated. INCIDENCE The incidence of ectopic pregnancy in the United States is approximately 1 in 120 pregnancies. The incidence varies greatly in different populations and can be as high as 1 in 80 pregnancies in some large urban centers. A steep rise in the incidence of ectopic pregnancy in this country has been observed over the past several decades. From 1965 to 1977 the number of ectopic pregnancies in the United States almost tripled. 2 The increase in incidence is linked to the rise in the incidence of sexually transmitted diseases, and, paradoxically, to the improvement in early antibiotic therapy for these diseases. Aggressive antibiotic therapy results in damaged but partially functional tubes, which, in turn, can give rise to an ectopic pregnancy. Ectopic pregnancy is one of the leading causes of maternal mortality and a major etiologic factor in infertility. In the United States, the mortality associated with ectopic pregnancy is approximately 1 in 1000 cases, contributing to 10% to 12% of maternal deaths. 3, 4 An improvement in the early diagnosis and therapy of this disease has resulted in a decrease in mortality rates and has offset the rise in incidence of this disease. After an ectopic gestation, approximately 50% of women will be unable to conceive, and in a substantial number of patients, the condition will Vol. 47, No.4, April 1987 Lavy et al. Tubal surgery and ectopic pregnancy 543

2 recur in a future pregnancy, representing a constant threat to the woman's health and wellbeing. 5 THE TUBAL ETIOLOGY OF ECTOPIC PREGNANCY The most common etiologic factors for ectopic pregnancy are related to abnormalities of the fallopian tube resulting from prior pelvic inflammatory disease (PID), tubal and abdominal surgery, or a combination of these factors. In more than 50% of patients with ectopic pregnancy one or more of these factors is present. Less common, ectopic pregnancy occurs in morphologically normal tubes. An abnormal endocrine milieu leading to abnormal tubal transfer may be the underlying factor in these cases. The two major "tubal" etiologies of ectopic pregnancy, tubal surgery and PID cannot be readily separated, because a substantial number of patients undergoing tubal surgery have underlying tubal disease resulting from prior PID. The association between ectopic pregnancy and PID is well established. A six- to seven-fold increase in the incidence of ectopic pregnancy after acute salpingitis was demonstrated by Westrom and colleagues. 6 The exact nature of the association between the two conditions is, however, difficult to determine, because only poor correlation exists between a clinical history of PID and histopathologic evidence for its existence. In various reports, a history of PID can be elicited in 10% to 50% of patients presenting with an ectopic pregnancy. Morphologic evidence for prior PID was found in up to 50% of patients at the time of surgery for ectopic pregnancy. 5 An association between ectopic pregnancy and tubal surgery is also evident. Among 195 patients with ectopic pregnancy, DeCherney et a1. 7 have reported 27% to have had prior abdominal surgery and 9% prior tubal surgery. Other authors 8,9 have reported a history of prior abdominal surgery in 15% to 30% of patients presenting with an ectopic pregnancy. The association between appendectomy and right-sided tubal pregnancy has also been proposed. It appears, therefore, that only a relatively small proportion of patients with ectopic pregnancy have prior tubal surgery as the likely etiologic factor. The presence of such historical data, however, should place these patients at a higherrisk category for encountering an ectopic preg- 544 Lavy et al. Tubal surgery and ectopic pregnancy nancy because its occurrence is more common in these patients than in the general population. PATHOPHYSIOLOGY NORMAL TUBAL ULTRASTRUCTURE AND FUNCTION A delicate balance of structure and function governs tubal transport. The oviduct actively participates in the transport of sperm and the egg to the site offertilization, and of the pre embryo from the tube into the uterine cavity. Tubal function is affected by the contraction of the smooth muscle in the tubal wall, and by the constant beat of the cilia that line some of the tubal mucosal cells. Tubal contractile activity in the periovulatory phase of the cycle, and under the influence of estrogen, is regular and well coordinated. Under the influence of progesterone (P), in the early luteal phase, this pattern is replaced by one of irregular and "random" contractions. These contraction patterns facilitate sperm transport in the peri ovulatory phase and preembryo transport in the early luteal phase. lo, 11 Tubal ultrastructure is also under direct influence of ovarian estrogen and P. The mucosa of the fallopian tube is lined by ciliated and mucus-secreting cells. Both cell types demonstrate structural changes related to circulating levels of these hormones. The growth of the cilia and their beat frequency are enhanced by estrogen and inhibited by py-14 Similarly, the nonciliated mucus-secreting cells of the tubal mucosa secrete thick tenacious mucus under the influence of estrogen. This mucus is responsible, in part, for retaining the fertilized egg in the ampulla after fertilization. 15 Tubal surgery or infection can disrupt this balance of structure and function and thus predispose the patient to an ectopic pregnancy. TUBAL SURGERY, TUBAL DISEASE, AND ECTOPIC PREGNANCY Ectopic pregnancy results from a delay in the passage of the preembryo through the fallopian tube. This delay can be caused by anatomic defects (e.g., constriction, false passage formation) or by tubal dysfunction (altered contractility or abnormal ciliary activity). Tubal anatomy and function can both be altered by either tubal surgery or prior PID. The relative importance of these two factors is difficult to determine because Fertility and Sterility

3 they are often both present in the same individual. The study of ectopic pregnancy is limited by the absence of an animal model. Our understanding of the pathophysiology of this condition is, therefore, derived mostly from observations made in patients presenting with this disease. The association between ectopic pregnancy and other gynecologic conditions, such as PID, and tubal surgery, also helps in understanding its pathophysiology. Animal models can be used, however, to assess the degree of tubal dysfunction that is caused by surgery. Tubal dysfunction can be determined by the "nidation index" (the ratio of embryos implanted in the uterine horn to the number of corpora lutea in the homolateral ovary); this measure of tubal dysfunction can serve indirectly to study the effect of tubal surgery on tubal function and thus can help in the understanding of the pathophysiology of ectopic pregnancy. TUBAL ANATOMY AND FUNCTION AFTER SURGERY The tubal dysfunction that follows tubal surgery is exemplified by the discrepancy that exists between the rates of tubal patency after surgery and the rates of pregnancy,16 and by the increased incidence of both ectopic pregnancy and spontaneous abortions after tubal surgery.17 Tubal anatomy can be readily disrupted as a result of surgery. Even with the use of magnification in relatively "healthy" tubes, it is often difficult to restore normal anatomy. Animal studies have demonstrated the difficulty in achieving proper alignment of the mucosal folds at surgery for tubal anastomosis.18 Women who have undergone tubal anastomosis after a simple tuballigation may be the human counterpart ofthis condition. Imperfect surgical repairs may also lead to the formation of blind mucosal pouches, which in turn could entrap the ovum and thus predispose the patient to an ectopic pregnancy. Tubal function can also be disrupted after surgery; peritubal adhesions, which are a common sequel of surgery, may restrict tubal motility and thus interfere with ovum pickup and transport. It appears that the partial denervation of the tube, which accompanies some surgical procedures, does not have a significant impact on tubal function. Disruption of the rich adrenergic nerve supply of the tubal isthmus does not cause a significant impairment in tubal function.19 The operator's skill determines, to a large extent, the anatomic and functional integrity of the tube after surgery. Gomel20 and Paterson and WOOd21 have demonstrated that simple transection and anastomosis of the fallopian tube in the rabbit, with microsurgical technique, do not result in a reduction in fertility. Oelsner et al.,22 however, have clearly demonstrated the effect of training on the outcome of microsurgical procedures in the rabbit. In human beings, under normal circumstances, one can expect some degree of tubal dysfunction to follow tubal surgery, because in most cases tubal surgery involves more than the repair of a simple tubal transection. In addition, the surgery is not uncommonly performed by surgeons lacking in experience. The surgical technique used in performing the surgery also has an effect on the incidence of ectopic pregnancy, as will be demonstrated in the next section. The introduction of microsurgical technique has resulted in a reduction in the rate of ectopic pregnancy. This may be due to better restoration of normal tubal function that can be achieved with microsurgery. TUBAL FUNCTION AFTER TUBAL DISEASE Pelvic infections can lead to disruption of the normal tubal anatomy and function. The peritubal and intratubal adhesions that are a common sequel of PID can also interfere with tubal motility and ovum transport and thus predispose the patient to an ectopic pregnancy. Even more important, the destruction of the endosalpinx by the infectious process can be a source of major tubal dysfunction. The effect of tubal disease on the structure and function of the cilia has been demonstrated. In the human being, a significant reduction in the concentration of the ciliated cells was observed after infections. The ciliary beat frequency in these diseased tubes is also abnormally low. Ultrastructural studies of fallopian tubes obtained from patients at the time of surgery for ectopic pregnancy demonstrate a decrease in cell height and an early onset of deciliation.23, 24 This reduction in the number and function of the cilia may explain the persistence of infertility after tuboplasty even in the face of tubal patency, and the occurrence of tubal pregnancy. In animals, by use of microsurgical techniques, structural changes simulating tubal disease have been created and correlated with tubal function. Vol. 47, No.4, April 1987 Lavy et a1. Tubal surgery and ectopic pregnancy 545

4 Vasquez et a1. 25 have demonstrated the process of deciliation that accompanies the development of hydrosalpinx. In addition to the loss of cilia, these structurally altered tubes may lose their steroid receptors, thus impairing their ability to respond to hormones. The deciliation process may not be reversible even after surgical restoration of patency, thus leading to a permanent loss of tubal function. 26 SPECIFIC TUBAL SURGERY Various types of tubal surgery are associated with different rates of ectopic pregnancy. It is often difficult to separate the contribution to the creation of the ectopic pregnancy by the surgical procedure itself from that of the underlying tubal disease process, because each procedure is performed to correct a specific tubal lesion. The success of surgery is measured by a high rate of intrauterine pregnancy, a low rate of ectopic pregnancy, and a short delay from the procedure to conception. These reflect the extent to which normal tubal function has been restored. Restoration of anatomic and functional integrity depends on the severity of the mucosal damage present before surgery, and on the surgical technique used for the repair. SURGICAL TECHNIQUE AND ECTOPIC PREGNANCY The use of magnification and of microsurgical technique for surgery of the female reproductive tract has introduced new hopes for higher reproductive success after surgery (i.e., an increase in the rate of intrauterine pregnancy and a reduction in the incidence of tubal pregnancy). As will be demonstrated later in this section, such an improvement in outcome has, indeed, occurred. Some drawbacks to the improved surgical technique do exist, however. The reproductive surgeon is now able to achieve patency of severely damaged tubes. These patent but functionally abnormal tubes may predispose the patient in some cases to an increased risk of ectopic pregnancy. The impact of the newer operative techniques such as the operative laparoscopy and the use of the CO 2 laser will also be discussed with reference to the incidence of ectopic pregnancy associated with their use in performing the various surgical procedures. 546 Lavy et al. Tubal surgery and ectopic pregnancy MUCOSAL DAMAGE AND ECTOPIC PREGNANCY A good correlation exists between the degree of tubal mucosal damage and the occurrence of ectopic pregnancy. Surgery often cannot reverse the mucosal damage and the abnormal function that resulted from prior tubal disease. The surgically repaired tube is therefore functionally abnormal and predisposes the patient to an ectopic pregnancy. For this reason, even a skilled surgeon using the most meticulous of techniques will not be able to eliminate completely the occurrence of ectopic pregnancy. An exception to this rule can be found in patients with severe tubal disease. In some patients with severe hydrosalpinx the incidence of both intrauterine and ectopic pregnancy is low, reflecting the complete loss of the functional capacity of the tube, and precluding the' occurrence of intrauterine or extrauterine pregnancy. SALPINGOLYSIS AND OVARIOLYSIS These procedures involve the removal of peritubal and/or periovarian adhesions. The adhesions are usually caused by extragenital disease such as appendicitis, and the endosalpinx is, therefore, usually spared. The disruption of normal tubal anatomy and function in these patients is only minimal, and as a result, one can expect a high rate of intrauterine pregnancy, and a low rate of ectopic pregnancy. Patients with thicker, more vascular, and more extensive adhesions fare worse after surgery. In these patients, the pregnancy rates are reduced, and the ectopic pregnancy rates are increased The outcome of these procedures is represented in Table 1. As can be seen in the table, the use of microsurgical technique has led to a substantial reduction in the rate of ectopic pregnancy and to a modest increase in the overall pregnancy rates associated with this procedure. The use ofmagnification for simple lysis of peri adnexal adhesions does not seem necessary. Meticulous microsurgical technique is, however, recommended to prevent adhesion reformation and to improve the outcome. The role of operative laparoscopy in the lysis of periadnexal adhesions is still to be determined. Fayez35 has reported a pregnancy rate of 50% to 72% in 24 patients. The incidence of pregnancy was dependent on the extent of the adhesions found at laparoscopy. The ectopic pregnancy rate in this group was 8% for patients who underwent Fertility and Sterility

5 Table 1. Salpingolysis and Ovariolysis - Macrosurgery Versus Microsurgery Author Surgery Year Patients Siegler and Kontopoulos27 Macra Wallach et al.3o Macr Bronson and Wallach31 Macr Diamond32 Macr Caspi and Halperin28 Macr Diamond32 Micrb Hulka29 Micr Siegler and Kontopoulos27 Micr Frantzen and Schlosser33 Micr Betz et al. 34 Micr Pregnancies % Ectopic Ectopic % patients % pregnancies Total 736 Macr 465 Micr amacr, macrosurgery. bmicr, microsurgery. lysis of both periovarian and peri tubal adhesions. None of the 26 patients undergoing either ovariolysis or salpingolysis alone had an ectopic pregnancy. Similar results have been reported by Gome1. 36 These reports suggest that operative laparoscopy may have a role in the treatment of this condition (Table 2). The functional integrity of the tube in these patients with peritubal and periovarian adhesions seems to be relatively intact resulting in high pregnancy rates, and in low rates of ectopic pregnancy. The occurrence of ectopic pregnancy seems to be related to the nature and extent of the adhesive disease and to the surgical technique used for its repair. FIMBRIOPLASTY Fimbrial agglutination interferes with ovum pickup and conception in these patients. Tubal occlusion if present is only partial. PID is the underlying process in the majority of cases, and involvement of the endosalpinx is, therefore, common. The pregnancy rates after fimbrioplasty (50% to 60%) are similar to those observed after salpingolysis or ovariolysis. The rate of ectopic pregnancy, however, is slightly higher and may reflect a higher degree of tubal dysfunction in these patients. Table 3 demonstrates the pregnancy rates in patients undergoing fimbrioplasty by either microsurgical or macrosurgical techniques. The use of microsurgical technique in this group results in both an increase in intrauterine pregnancy (from 42% to 59%) and a decrease in the rate of ectopic pregnancy (from 14% to 6%). The use of operative laparoscopy in these patients was reported by Fayez 35 in his series. A pregnancy rate of 35% and an ectopic pregnancy rate of 14% were obtained in a group of 14 patients. Despite the small number of patients, the results seem inferior to those achieved by laparotomy and microsurgical repair. The role of operative laparoscopy in these instances should therefore be carefully reevaluated. NEOSALPINGOSTOMY Distal tubal occlusion and varying degrees of dilatation of the distal tubal segment are characteristic of this situation and are usually a result of PID. The endosalpinx is often severely affected as a result of the underlying disease process, and the long-standing dilatation of the tube that follows obstruction. Tubal function in these patients Table 2. Operative Laparoscopy Fayez35 Gomel36 Author Surgery Year Patients Pregnancies % Ectopic alap, operative laparoscopy. Lapa 1983 Lap 1983 Ectopic % patients % pregnancies Vol. 47, No.4, April 1987 Lavy et al. Tubal surgery and ectopic pregnancy 547

6 Table 3. Fimbrioplasty Author Surgery Year Patients Pregnancies % Ectopic Ectopic % patients" % pregnancies b Palmer 37 Macrc Siegler and Kontopoulos 27 Macr Siegler and Kontopoulos 27 Micrd Audebert et a1. 38 Micr Patton 39 Micr Frantzen and Schlosser 33 Micr Fayez 35 Lape Total (Macr and micr) Macr Micr apercent of all patients with ectopic pregnancy. bpercent of pregnant patients with ectopic pregnancy. emacr, macrosurgery. dmicr, microsurgery. elap, laparoscopy is usually severely affected. The outcome ofsurgical repair is determined by the size of the hydrosalpinx and its thickness, the extent of disruption to the tubal mucosa, and the presence or absence of peri tubal adhesions. Table 4 describes the overall pregnancy rates and the ectopic pregnancy rates in patients undergoing salpingostomy. The variability in pregnancy rates after surgical repair (17% to 44%) represents, at least in part, the varying degrees of tubal destruction associated with this condition and the varying length of follow-up. 50 In addition to an overall low pregnancy rate, the risk of ectopic pregnancy in these patients is higher than that seen with most other procedures. Paradoxically, patients with either mild or severe disease have lower ectopic pregnancy rates than those with moderate disease. The degree of tubal dysfunction determines the rate of both intrauterine and ectopic pregnancy. Severe dysfunction interferes with both intrauterine and ectopic pregnancy, whereas moderate dysfunction allows for higher rates of ectopic pregnancy. Paradoxically, the use of microsurgical technique for salpingostomy has resulted in a surprisingly high rate of ectopic pregnancy (Table 4). The total pregnancy rate in the two groups appears not to be different. The reason for this difference is not entirely clear. Possibly, the partial restoration of tubal function, made possible by the new surgical technique, allows for ovum pickup. The abnormal tube, however, is unable to transport the embryo into the uterus properly, and an ectopic pregnancy results. 548 Lavy et a1. Tubal surgery and ectopic pregnancy The use of the CO 2 laser for salpingostomy, as can be seen in Table 5, does not offer any clear advantages over electrocautery in either increasing the incidence of pregnancy or reducing the incidence of ectopic pregnancy.51,53 Similarly, the use of operative laparoscopy in 20 patients resulted in a pregnancy rate of 10% and in an ectopic pregnancy rate of 10%,30 offering no clear advantage over conventional techniques. In some patients distal tubal occlusion results from previous fimbriectomy, usually performed for the purpose of sterilization. Neosalpingostomy in these patients is associated with a pregnancy rate of 44% to 57% and an ectopic pregnancy rate of 0% to 14%. Two such reports are represented in Table 6. TUBAL ANASTOMOSIS Tubal anastomosis is performed to overcome an area of blockage. The block can be a result of prior tubal sterilization, previous PID, or even a segmental resection, which is occasionally used in the treatment of an ectopic pregnancy. Tubal dysfunction often follows an anastomosis. Causes for dysfunction may include the sterilization procedure itself, the damage caused by prolonged tubal occlusion that follows obstruction, the effect of prior tubal infection, and the anastomosis procedure itself. Abnormal tubal function is manifested by a prolongation of the interval from reversal to conception, and by the occurrence of ectopic pregnancies in these operated tubes. Fertility and Sterility

7 Table 4. N eosalpingostomy Author Surgery Year Patients O'Brien et al. 4O Mac!"" Horne et al. 41 Macr Marik42 Macr Cognat and Rochet43 Macr Siegler and Kontopoulos27 Macr DeCherney and Kase44 Ma~rb Wallach et al. 30 Macr Swolin45 Micr" Rock et al. 46 Micr Gomel47 Micr Siegler and Kontopoulos27 Micr Gomel and Swolin48 Micr Audebert et al. 38 Micr Winston26 Micr DeCherney and Kase44 Micr Larsson49 Micr Frantzen and Schlosser33 Micr Russell et al. 50 Micr Total (macr and micr) 1193 Macr 327 Micr 866 amacr, macrosurgery. brock-mulligan Hood prosthesis. cmicr, microsurgery. Pregnancies % Ectopic % patients % pregnancies The effect of prolonged occlusion on tubal ultrastructure was demonstrated by Vasquez and coworkers55 in patients after surgical sterilization. A variety of lesions could be demonstrated at the time of the anastomosis. Those lesions included deciliation, flattening of the mucosal folds, and mucosal polyps and were found to progress with time after the original sterilization procedure. The anastomosis procedure itself can lead to tubal malfunction because constriction at the site of anastomosis and malalignment of the mucosal folds can result in a delay in ovum transport and can predispose the patient to an ectopic pregnancy. The outcome of tubal anastomosis is determined by a variety of factors, including the location of anastomosis along the tube, a residual tubal length of greater than 3 to 4 cm,56, 57 the presence of coexisting tubal disease, the method used for sterilization, and whether or not microsurgical technique was used for the repair. Some sterilization procedures carry a higher rate of ectopic pregnancy than others when reversal is attempted. The reversal of tubes treated with unipolar cautery carries a notoriously high incidence of ectopic pregnancy. 58 Table 7 summarizes the outcome of tubal anastomosis after sterilization by a variety of methods. As is clearly evident from this table, the use of simple ligation and of the Falope ring (Cooper Medical, Langhorne, PA) is associated with a higher overall pregnancy rate, and a low rate of ectopic pregnancy, whereas the use of cautery is associated with lower overall pregnancy rates and higher ectopic pregnancy rates. Anastomosis of one versus two tubes can also alter the rate of ectopic pregnancy. Repair of one tube is associated with lower overall pregnancy rates and ectopic pregnancy rates than the Table 5. Neosalpingostomy-Laparoscopy and Laser Fayez 35 Tulandi et al. 51 Daniell et al. 52 Author Surgery Year Patients Pregnancies % Ectopic ULap, operative laparoscopy. blaser, CO 2 laser. LapU Laserb Laser Ectopic % patients % pregnancies Vol. 47, No.4, Apri11987 Lavy et al. Tubal surgery and ectopic pregnancy 549

8 Table 6. Neosalpingostomy Postfimbriectomy Author Surgery Year Patients Pregnancies % Ectopic Ectopic % patients % pregnancies Novy54 Betz et au4 Fimba 1980 Fimb afimb, postfimbriectomy. anastomosis of both tubes 60 (pregnancy rate of 55% versus 64% and ectopic pregnancy rate of 10% versus 15%). The effect of surgical technique on the outcome of midsegment tubal anastomosis is presented in Table 8. The figures demonstrate the superiority of the microsurgical technique in improving the outcome of surgery and reducing the rate of ectopic pregnancy. Tubocornual anastomosis is performed in cases of cornual occlusion. The outcome of this procedure was shown to be dependent on the etiology of the cornual block. Lavy et al. 59 have reported on the outcome of tubocornual anastomosis. In 8 patients with cornual occlusion secondary to PID and in 17 patients with obstruction secondary to sterilization, the ectopic pregnancy rate was 40% and 11%, respectively. Of the 17 patients with cornual occlusion secondary to surgical sterilization who conceived, ectopic pregnancy occurred in 16%. In the group of six patients sterilized by tubal ligation and requiring tubocornual anastomosis, no ectopic pregnancies were reported. Table 9 represents some of the available data on pregnancy outcome after tubocornual anastomosis for reversal of sterilization and correction of the sequel of tubal disease. RECURRENT ECTOPIC PREGNANCY Patients with a history of prior ectopic pregnancy are at significant risk for recurrence. This risk is related to the underlying tubal disease that led to the initial ectopic pregnancy and to the surgical procedure performed for its removal. The procedures aimed at removing the ectopic pregnancy can be classified as either radical (salpingectomy) or conservative (e.g., salpingostomy, segmental resection). The choice of procedure usually depends on the condition of the patient, the location of the ectopic pregnancy within the tube, its size, and whether or not tubal rupture has already occurred. In general it is desirable to attempt to preserve the involved tube at the time of surgery, because recurrence of an ectopic pregnancy in the contralateral tube may necessitate salpingectomy, rendering the patient without tubes. Radical Surgery Salpingectomy is indicated in the case of tubal pregnancy, uncontrollable bleeding, or multiple recurrences in the same tube. In a literature review that included 1083 women, Oelsner et al. 73 have calculated the risk of Table 7. Tubal Anastomosis for Reversal of Sterilization-Outcome by Procedure Author Year Rock et a Seiler Method Caut unia Pomeroyb Falop ring C Irvingd Caut uni Pomeroy Falop ring Irving Patients Pregnant % Ectopic % Total Pomeroy Caut uni Falop ring Irving acaut uni, unipolar cautery. bpomeroy, Pomeroy's tubal ligation. cirving, Irving's tubal ligation. dfalop ring, Falope ring sterilization. 550 Lavy et al. Tubal surgery and ectopic pregnancy Fertility and Sterility

9 r Table 8. Midsegment Tubal Anastomosis Author Surgery Year Patients Siegler and Perez61 Macr" Diamond62 Macr Jones and Rock63 Macr Siegler and Kontopoulos27 Macr WaUach et a1. 30 Macr Siegler and Kontopoulos27 Micr b Gomel64 Micr Wilson65 Micr Silber and Cohen56 Micr Winston66 Micr Grunert et a1. 67 Micr Meldrum68 Micr Gomel1 Micr DeCherney et a1. 69 Micr Total 607 Macr 108 Micr 509 amacr, macro surgery. bmicr, microsurgery. Pregnancies % Ectopic % patients % pregnancies ectopic pregnancy after salpingectomy in women desiring pregnancy. Ectopic pregnancy occurred in 15.4% of the women and intrauterine pregnancy in 36.5%. Similar results have been reported by other authors and are represented in Table 10. Conservative Surgery Conservative procedures are performed to remove the ectopic pregnancy and preserve the tube. The choice of technique is determined by the location of the pregnancy within the tube and by the presence or absence of active bleeding. These surgical procedures include linear salpingostomy, expression of the pregnancy through the distal tubal ostium, and segmental resection followed by an end-to-end anastomosis. Linear salpingostomy has become the procedure of choice for the treatment of ectopic pregnancy. The pregnancy is removed through a linear incision on the anti mesenteric surface of the tube, bleeding is controlled, and the incision is left open to prevent scarring. Indications for this procedure include a hemodynamically stable patient with an unruptured tubal pregnancy who desires to preserve her reproductive potential. The recurrent ectopic pregnancy rates following this procedure are listed in Table 10. The rates of recurrence in these patients are not different from those achieved after salpingectomy. A group of special interest consists of patients with one remaining patent oviduct after salpingostomy for ectopic pregnancy. The recurrence rate of ectopic pregnancy in these patients is unusually high. In 15 patients with a sole patent oviduct, DeCherney Table 9. Tubocornual Anastomosis-The Effect of Etiology of Obstruction Author Winston70 Winston66 Henderson 71 Lavy et a1. 57 McComb and GomeF2 Gomel20 Meldrum68 Lavy et a1. 57 Year Lesion Patients Tsa 16 TS 43 TS 8 TS 17 TDc 38 TD 14 TD 7 TD 8 Pregnancies % Ectopic % patients % pregnancies NAb NA 2 25 NA ats, tubal sterilization. bna, not available. <TD, tubal disease. Vol. 47, No.4, April 1987 Lavy et ai. Tubal surgery and ectopic pregnancy 551

10 Table 10. Surgical Management of Ectopic Pregnancy Salpingectomy Salpingostomy "Milking" Procedure Operative laparoscopy asingle remaining tube. bmicrosurgical technique. Author Vehaskari74 Polman and Wickse1l75 Timonen and Nieminen76 Kucera et al. 77 DeCherney and Kase 78 V ehaskari 7 4 Tomonen and Nieminen76 Jarvinen et al. 79 Bukovsky et al. 80 DeCherney and Kase 78 DeCherney et al.81a Patton82a DeCherney et al. 83b Timonen and Nieminen76 Swollin84 DeCherney et al. 85 Bruhat et al.86 Year Patients % pregnancies % ectopic et al.81 have reported a 53% intrauterine pregnancy rate and a 20% recurrent ectopic pregnancy rate. Segmental resection is recommended for patients with isthmic ectopic pregnancies and for those with ruptured ectopic pregnancies who are hemodynamically stable. An anastomosis at the resection site can be performed either at the time of the original operation or later. Swolin and Fa1l84 have reported a series of 42 patients who underwent a segmental resection and anastomosis. Intrauterine pregnancy was achieved in 10 (23.8%) and an ectopic pregnancy in 6 patients (14.3%). In another report, elective tubal reconstruction in 6 patients after segmental resection resulted in an intrauterine pregnancy in 4 (66%), with one of the pregnancies ectopic (16%).87 Expressing the ectopic pregnancy through the distal tubal ostium (milking) results in an extremely high rate of ectopic pregnancy and in a low rate of intrauterine pregnancy,76, 84 suggesting possible damage to the tube at the time of the procedure. The use of microsurgical technique for removal of an ectopic pregnancy can reduce the incidence of recurrence. With microsurgical technique, intrauterine pregnancy was achieved in five of nine patients. No ectopic pregnancies occurred in this group.84 Similar results have been reported by other authors. 80, 88 These reports clearly demonstrate the advantage of microsurgical technique over conventional surgery in these patients. Operative laparoscopy can be used for removal of an ectopic pregnancy. A linear salpingostomy with unipolar cautery is usually performed. For best results and fewer complications, preselection of patients is advisable. The patient must be hemodynamically stable, and the tubal gestation should be unruptured and < 3 cm in size. Encouraging results have been reported with this technique in preselected patients (Table 10). Special consideration should be given to patients who have had multiple ectopic pregnancies. The recurrence in this group is high and the rate of intrauterine pregnancy is low. DeCherney et al.89 have followed 13 patients actively attempting to conceive after two previous ectopic pregnancies. Only 4 of 13 patients were able to conceive (39%), and one had a recurrent ectopic pregnancy (20% of conceptions). Halat90 has reported repeat ectopic pregnancy in 4 of 7 patients conceiving after two ectopic pregnancies (57% of conceptions). The high rate of repeat ectopic pregnancy and the low rates of intrauterine pregnancy should suggest the use of other methods, such as salpingectomy or in vitro fertilization and embryo transfer in order to avoid recurrence in these patients. 552 Lavy et al. Tubal surgery and ectopic pregnancy Fertility and Sterility

11 r THE ALTERNATIVE IVF-ET is rapidly becoming an alternative mode of therapy for patients with a variety of infertility disorders. Tubal factor infertility remains the major indication for IVF-ET, accounting for up to 80% of the patients.91 In this procedure, ova are aspirated from the ovaries and fertilized in vitro, and the resulting preembryo(s) are then placed in the uterine cavity approximately 48 hours later. The fallopian tube is thus bypassed. The success achieved with IVF-ET as reported by multiple centers is modest at best. Factors associated with success include the method of ovarian stimulation, the etiology of infertility, the woman's age, the quality of the semen, and many others. The pregnancy rate per treatment cycle ranges from 7% to 17%.91 Ectopic pregnancy, although uncommon, was reported in the World Collaborative report in 1.7% of pregnancies (19/1084), and in 0.23% of embryo transfers ( ).91 In fact, the first pregnancy achieved through IVF-ET was ectopic.92 A higher incidence, up to 11% of the pregnancies' was reported by others.93 Ectopic pregnancy occurring in IVF-ET cycles is the result of reflux of the embryo from the uterine cavity into the tube after embryo transfer. Yovich and coworkers94 have reported an increased incidence of ectopic pregnancy, which appeared to be associated with high fundal transfers of the embryos. The embryos refluxed into the tubes are not able to return into the uterine cavity because of me chanical interference caused by tubal disease. Mar- tinez et a1. 95 have reported 10 ectopic pregnancies after IVF -ET. Nine of the patients had tubal factor infertility. No other association could be demonstrated between the occurrence of ectopic pregnancy and the ovarian stimulation protocol, the method of ova recovery, or the number of embryos transferred. Although in most cases the pregnancy rates achieved with tubal surgery are superior to those of IVF-ET, several exceptions exist. Some surgical procedures, such as repeat tubal surgery after an unsuccessful attempt, carry a low rate of pregnancy even when compared with IVF-ET. IVF-ET is an attractive alternative to tubal surgery in these patients. In conditions that predispose the patient to an unacceptably high rate of ectopic pregnancy, such as multiple previous ectopics or a significant hydrosalpinx, IVF-ET should also be considered as an alternative to surgery as the risk of ectopic pregnancy can be significantly reduced. SUMMARY Ectopic pregnancy is the shady companion of tubal surgery. Among patients with ectopic pregnancy, relatively few have a history of tubal surgery as their underlying etiologic factor when compared with other etiologies such as PID. Nevertheless, a history of tubal surgery should place the patient at a higher-risk group for ectopic pregnancy; 3% to 20% of these patients will encounter an ectopic pregnancy after the corrective surgery. Table 11. Summary: Ectopic Pregnancy After Tubal Surgery Procedure Technique % Total pregnancy Pregnancy range % Ectopic Ectopic range Salpingostomy Mac!"" Micrb Fimbrioplasty Macr Micr Neosalpingostomy Macr Micr Tubal anastomosis Removal of ectopic pregnancy Macr Micr Salpingectomy Salpingostomy ~ amacr, macrosurgery. bmicr, microsurgery. Vol. 47, No.4, April 1987 Lavy et al. Tubal surgery and ectopic pregnancy 553

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