Conservative laparoscopic treatment of 321 ectopic pregnancies

Transcription

1 FERTILITY AND STERILITY Copyright c 1986 The American Fertility Society Vol. 46, 6, December 1986 Printed in U.SA. Conservative laparoscopic treatment of 321 ectopic pregnancies Jean Luc Pouly, M.D.* Hubert Mahnes, M.D.t Gerard Mage, M.D.* Michel Canis, M.D.* Maurice Antoine Bruhat, M.D.*:j: Polyclinique du Centre Hospitalier et Universitaire de Clermont, Ferrand, Cedex, and Clinique la Pergola Allee des Ailes, Vichy, France From 1974 to 1984, 321 tubal pregnancies were treated conservatively with laparoscopic techniques. Fifteen cases (4.8%) required a subsequent laparotomy or second laparoscopic procedure because of retained trophoblastic tissue. Of 118 patients desiring subsequent pregnancy, 76 had an intrauterine pregnancy (64.4%) and 26 had a second ectopic pregnancy (22%). Eleven of24 (45.8%) women attempting conception following conservative laparoscopic removal of an ectopic gestation from the sole remaining fallopian tube established an intrauterine pregnancy. In this same group, seven patients (29.2%) had a second ectopic pregnancy. The fertility results were also analyzed according to the previous history. The postoperative intrauterine pregnancy rate was 85.5% among 62 patients without q history of infertility (group I), compared with 41.1 % among 56 patients with a history of infertility or a previous ectopic pregnancy (group II). The subsequent ectopic pregnancy rate in group I was 16.1% versus 28.6% in group II. This large series clearly demonstrates the relative safety and efficacy of conservative laparoscopic treatment of tubal pregnancies. Fertil Steril46:1093, 1986 The combination of sensitive human chorionic gonadotropin (hcg) assays and ultrasonography provides the possibility of the early diagnosis of unruptured ectopic pregnancies (). Evidence supports a conservative approach to the unruptured in women wishing to preserve their fertility.1-12 Intrauterine pregnancy () rates and the incidence of recurrent in these studies Received March 3, 1986; revised and accepted August 13, *Service de Gynecologie-Obstetrique, Polyclinique du Centre Hospitalier et Universitaire de Clermont. tclinique la Pergola Allee des Ailes. :j:reprint requests: Professeur Maurice Antoine Bruhat, Service de Gynecologie-Obstetrique, Polyclinique, 5, Boulevard Charles de Gaulle, Clermont Ferrand, Cedex, France. appear as good as or better than the results following salpingectomy. This conservative approach initially involved laparotomy, linear salpingotomy, and removal of intraluminal blood clots and products of conception. Recent modifications in operative laparoscopic instrumentation and technique have permitted the endoscopic approach to, with a potential reduction in morbidity and duration of hospitalization This report details the operative techniques and results of conservative laparoscopic salpingotomy for in 321 cases (295 women). MATERIALS AND METHODS From July 1974 to December 1984, 321 cases of in 295 patients were treated conservatively by Vol. 46, 6, December 1986 Pouly et al. Laparoscopic treatment of ectopic pregnancy 1093

2 means of laparoscopy in the Gynecology Department of the Clermont Ferrand University Hospital or in the Pergola Clinic in Vichy. The mean age of the patients was 25.4 ± 4.9 years (range, 18 to 42 years). One hundred seventy-seven patients had at least one living child before their. In 118 patients (40%), was associated with a failure of contraception: 107 had an intrauterine contraceptive device, 6 had a previous ectopic ligation, 3 conceived despite progestin-only oral contraception, and 2 conceived despite postovulatory estrogens. The operative technique was modified from that previously described Multiple punctures were employed with the use of an 11-mm laparoscope (Storz-France S.A., Paris, France), 5-mm atraumatic forceps (Microfrance, Bourbon l'archambault, France), and the 7-mm Triton (Microfrance). The Triton is an instrument with three functions: potential aspiration through a 6-mm diameter channel, injection of saline under pressure, and electrocoagulation with a retractable monopolar needle electrode. Mter diagnosis of, two suprapubic operative trocars are inserted, a 5-mm trocar at the end of an imaginary Pfannenstiel incision on the side of the and a 7-mm trocar in the midline. The first stage is aspiration of the hemoperitoneum. The is evaluated for location and operability. Vasopressin (POR 8, Sandoz Laboratories, Basel, Switzerland), 5 IU, was diluted in 20 ml of sterile saline and injected into the mesosalpinx through a 19-9auge needle for 168 patients in the latter phase of the series. Blanching of the tube and transient ischemia provide a virtually bloodless operating field. A 10- to 15-mm incision is made in the antimesenteric portion of the hematosalpinx with the needle electrode, and the clots and trophoblast are gently aspirated. The tube is irrigated and the residual products of conception aspirated or removed with the grasping forceps. The salpingotomy is left open. In the early cases in the series, an intraperitoneal drain was inserted through the pouch of Douglas for 24 to 72 hours. The postoperative follow-up evaluation included weekly hcg assays, until the level was undetectable «5 miulmi), and serial hematocrits. Statistical analysis of data was performed using the chi-square test, with a level of significance of P < Second-look laparoscopy was performed in 18 women early in the series to assess 1094 Pouly et ai. Laparoscopic treatment of ectopic pregnancy tubal healing and postoperative adhesion formation. Currently laparoscopy is performed in postoperative infertile patients. RESULTS Three hundred twenty-one s in 295 patients were treated using laparoscopic techniques. Failure of treatment occurred in 15 cases (4.8%) secondary to incomplete removal of the trophoblast. In seven instances, a second laparoscopic procedure completed the initial conservative treatment. In eight other patients, a laparotomy was performed (6 salpingectomies and 2 conservative treatments). In one patient, a salpingectomy was performed 4 days later, after histologic diagnosis of a choriocarcinoma had been made. Retained trophoblastic tissue occurred in four women in whom a tubal abortion was attempted without a salpingostomy. Prior to use of vasopressin, bleeding at the site of the salpingotomy required a laparotomy for hemostasis or salpingectomy in 15% of the cases. Subsequent to the use of vasopressin, only one patient required a laparotomy, 1 hour later: this woman was under anticoagulation treatment with an antivitamin K agent. At second-look laparoscopy in 5 of 18 patients demonstrated generalized pelvic adhesions, but 4 of them had had significant adhesions at the time of the conservative operation. Fourteen tubes were patent (77.8%) and all salpingotomy sites were covered by serosa. Postectopic fertility was evaluated in 118 patients who wished to become pregnant, with a I-year follow-up period. Of the 177 patients excluded, 22 have had a follow-up period ofless than 1 year or a delated desire for pregnancy, 133 use contraception, and 22 were lost to follow-up study earlier than 1 year after operation. Patients who were lost to follow-up study after this period and were infertile at that time are considered sterile for this analysis. The fertility results are summarized in the Table 1. Of the 118 women who desired fertility, 76 (64.4%) had a subsequent. Five s occurred after a second, which was also done using a conservative laparoscopic procedure. The rate was 22%, and 36 patients (30.5%) had subsequent infertility (recurrent s plus failure to conceive). There was recurrence in 18 patients with two patent tubes: in the same tube in 7 cases and in the contralateral tube in 11. Fertility and Sterility

3 Table 1. Fertility Results Relative to Patient History Group % Total I a II a III Solitary tube ap < bp> 0.2. cp < Infertility % % b 5 c b 31c These 118 patients were divided into two groups: Group I, 62 patients without any history of infertility or ; and group II, the other 56 patients. An occurred in 53 patients in group I (85.5%) and 23 patients (41.1%) in group II (P < ). An occurred in 16.1% (10 cases) in group I and 28.6% (16 cases) in group II (P > 0.2). The postectopic infertility rate was 8.1% (5 cases) in group I and 55.3% (31 cases) in group II (P < ). Group III included 17 patients who had an after microsurgical tuboplasty; 4 subsequently had an (23.5%),13 remained sterile (76.5%), and 7 (41.2%) had recurrence. The "solitary tube" group included patients with a previous salpingectomy (nine women), patients with a previous contralateral obstructed tube (eight women), and patients who presented serially with an in each tube, both treated by means of laparoscopy (seven women). Patients with previous tubal microsurgical plasty were excluded. These women presented 11 s (45.8%): 3 in the first subgroup, 5 in the second, and 3 in the third (P > 0.2). Seven patients (29.1%) had recurrence: two in the first subgroup, two in the second, and three in the third (in this case it was the third ) (P > 0.2). The postoperative fertility and the recurrence of were studied relative to the rupture of the tubal wall, to the use of vasopressin, and to the location of the (Table 2). The tube ruptured in 47 patients. These women had 27 s (57.4%), and 9 had a recurrence of (19.1%). Of the 71 with an unruptured, 49 developed an (69%) and 17 a recurrence of (23.9%) (P > 0.05). Vasopressin was used for 64 patients. These women had 43 s (67.2%), and 14 a recurrence of (21.9%). Of the 54 who had been treated without vasopressin, 33 had an (61.1%) and 12 had a recurrence of (22.2%) (P > 0.05). The first was located in the ampulla in 81 in- stances (68.6%), in the fimbria in 15 (12.7%) and in the isthmus in 22 (18.6%). The rate in these groups were 64.2%, 80%, and 54.5%, respectively (P > 0.05). The recurrence rates in these groups were 18.5%, 20%, and 36.4%, respectively (P> 0.05). DISCUSSION Conservative laparoscopic treatment of s is safe, technically feasible, and effective. No severe intraoperative complications were encountered, with the exception of the patient receiving anticoagulant therapy. There was no delayed postoperative hemorrhage, but residual trophoblastic tissue remained in 15 women, as manifested by failure of the hcg levels to return to normal. The high incidence of this complication in women treated without salpingotomy led us to perform tubal abortion only for fimbrial s. Similar, but less frequent, experience at laparotomy has been described. 16, 17 Tubal abortion at laparotomy compared with ampullar salpingotomy, seems to decrease fertility rates. 1, 18 Vasopressin and the needle electrode rendered laparoscopic salpingotomy technically practical, Table 2. Postoperative Fertility and s Relative to the Status of the Tubal Wall, the Location of the, and the Use of Vasopressin G % G % Tubal wall Ruptured Unruptured Location of the Ampulla Fimbria Isthmus Use of vasopressin No Yes ap > 0.1. Vol. 46, 6, December 1986 Pouly et at. Laparoscopic treatment of ectopic pregnancy 1095

4 because hemostasis was invariably obtained with this combination. The pharmacologic effect of vasopressin persisted for 2 hours and is probably sufficient to allow physiologic hemostasis to occur. This transient ischemia did not affect tubal patency, as was verified by a second-look laparoscopy (15 cases) and proved by a similar rate in groups with or without the use of vasopressin. Possibly, the ischemia induced a better cleavage between the trophoblast and the tubal wall; this requires further histologic studies. The use of this drug must be carefully controlled, because intravascular injection induced a dramatic arterial hypertension. Extravascular injection induced a moderate increase of the arterial pressure and a moderate bradycardia, in some cases. The only significant complication occurred in an anemic woman who developed pulmonary edema 4 hours after laparoscopy, perhaps secondary to this drug (through a coronarian vasoconstriction?). Absolute contraindications to this laparoscopic approach include tubal pregnancies > 6 cm in diameter, shock, hemoperitoneum> 2000 ml, interstitial pregnancies, and an hcg level> 15,000 IU/ml. Relative contraindications are s > 4 cm in diameter, hemoperitoneum> 500 ml, obesity, extensive pelvic adhesions, and a well-implanted. In the latter group, the hcg levels increase as in. Previous reports of conservative procedures for at laparotomy have shown subsequent s between 20% and 83% (mean, 40.3%)1-11 and recurrent ectopics between 1.1% and 19% (mean, 12.7%).1-11 Our result of 65.8% postoperative s and 22% subsequent s compare favorably. DeCherney confirmed the efficacy of the laparoscopic procedure, with 50% in 18 operations.11 The incidence of repeated was high, but it was overestimated because this series began before IVF programs were widespread. At that time, the conservative procedure was the only one possible, even in dramatic cases, such as occurrence or recurrence of in a solitary tube or after tuboplasty (14 repeated in 41 patients, 34.1 %). Today, most of these cases are treated with laparoscopic salpingectomy and the patients are then referred to an IVF program. The advantage of either salpingectomy or conservative treatment is unclear. In some series, it seems that salpingectomy resulted in better postoperative fertility than salpingotomy: 27.2% ver Pouly et al. Laparoscopic treatment of ectopic pregnancy sus 24.8% for Timonen1 and 34.1 % versus 25% for Swollin.18 In these two series, the treatment was about 50% conservative. On the other hand, Ploman2 reported 52% s in the conservative group, compared with 34.7% in a salpingectomy series, but only 16.1% of the cases were treated conservatively. In another report,9 no difference was observed, except in patients with either a history or operative findings suggestive of coexistent sterility. In these cases, postoperative occurred in 76% after a conservative procedure and in 44% after salpingectomy. Many authors advocate a conservative procedure, mainly among women complaining of infertility.8-10, 12, 19 Postoperative adhesions were found in only 5 of 18 patients on second-look laparoscopy. Ryan et al. 20 showed that fresh, unclotted blood does not induce adhesion formation if it is not associated with serosa drying. Laparoscopic treatment and microsurgical procedures avoid the drying of the serosa, and vasopressin decreases postoperative bleeding. Salpingotomy without closure may decrease the risk of obstruction and allow better healing of the mucosal folds. 21,22 McComb and Gomel22 noted that mucosal folds were oriented transversally after tubal suture but longitudinally in cases without primary closure. In women, two types of abnormal scarring occur. Sometimes the spontaneous healing of the salpingotomy leads to a tubal diverticulum without a muscular layer. In one patient, we observed a tubal fistula after two laparoscopic salpingotomies were performed at the same site. The patient's previous history was the main factor bearing on postoperative fertility. In our series the rate among patients complaining of infertility was 43.4%, compared with 86.2% of the other patients. Sherman et al.9 found a similar difference: 53.1% versus 81.2%. This difference was increased further when infertility was caused by tubal blockage requiring a microsurgical repair. In 17 patients, only 4 s (23.5%) and 7 s (41.2%) occurred. Comparisons of post- fertility results must be regarded critically, for several reasons. First, there is a recent general improvement of the post rate due to earlier diagnosis. Second, our technique should be compared with other conservative treatments, but most series include a small percentage of conservative treatment versus a large rate of salpingectomy. In our program, > 90% of the s are treated with laparoscopy. Third, there can be a large difference in the Fertility and Sterility

5 Table 3. Comparison of the Post- Fertility Among Patients with a Solitary Tube Author % % Ploman and Wickse1l Jarvinen Stromme Henri-Suchet S Mintz Vehaskari DeCherney et al Present series treated population, which can significantly influence postoperative fertility. For instance, in our series 47.5% of the patients were sterile before the, compared with 20.9% in the report by Sherman et al. 9 This difference can explain, at least in part, the discrepancy in the percentage of s between the two series (74.5% in Sherman's study versus 64.4% in our study). s occurred in 45.8% of women after removal of an from a single functioning tube. These results are consistent with previous reports of conservative treatment, which demonstrated 32% to 100% s 2, 5, 6, 8, (Table 3). The risk of a subsequent in patients with a solitary tube in our study was 29.1 %, compared with 0% to 40% in the literature.2, 5, 6, 8, But selection of the cases, the definition of "solitary tubes," the small number of patients in most reports, and the unspecified incidence of other infertility factors and peritoneal disease make comparison difficult. For surgeons experienced in operative laparoscopy, the techniques described above offer the opportunity for conservative treatment of unruptured,12 Careful follow-up study, particularly the monitoring of hcg levels and the hematocrits, is necessary after all conservative procedures. The associated reduction in morbidity and hospitalization warrant further consideration of this technique for properly selected patients. REFERENCES 1. Timonen S, Nieminen U: Tubal pregnancy, choice of operative method of treatment. Acta Obstet Gynecol Scand 46:327, Ploman L, Wicksell F: Fertility after conservative surgery in tubal pregnancy. Acta Obstet Gynecol Scand 39:143, Skulj V, Palvic Z, Stoiljkovic C, Bacic G, Drazancic A: Conservative operative treatment of tubal pregnancy. Fertil Steril 15:634, Palmer R: Resultats et indications de la chirurgie conservatrice au cours de la grossesse extra-uterine. C R Soc Fr GynecoI42:317, Jarvinen PA: Conservative operative treatment of tubal pregnancy with post-operative daily hydrotubation. Acta Obstet Gynecol Scand 51:169, Stromme WB: Conservative surgery for ectopic pregnancy. Obstet Gynecol 41:251, DeCherney A, Kase N: The conservative surgical management of unruptured ectopic pregnancy. Obstet Gynecol 54:451, Henri-Suchet J: Chirurgie conservatrice de la grossesse extra uterine. In Oviducte et Fertilite, Edited by Societe Nationale pour I'Etude de la Sterilite et de la Fecondite. Paris, Masson Publishers, 1979, p Sherman D, Langer R, Sadovsky G, Bukowsky I, Caspi E: Improved fertility following ectopic pregnancy. Fertil Steril 37:497, DeCherney AH, Polan ML, Kort H, Kase N: Microsurgical technique in the management of tubal ectopic pregnancy. Fertil Steril 34:324, DeCherney AH, Romero R, Naftolin F: Surgical management ofunruptured ectopic pregnancy. Fertil Steril35:21, SchenkerJG, Evron S: New concepts in the surgical management of tubal pregnancy and the consequent postoperative results. Fertil Steril 40:709, Bruhat MA, Manhes H, Mage G, Pouly JL: Treatment of ectopic pregnancy by means of laparoscopy. Fertil Steril 33:411, Mage G, Manhes H, Pouly JL, Ropert JF, Bruhat MA: Etude de la fertilite apres traitement coelioscopique de la grossesse tubaire non rompue. J Gynecol Obstet BioI Reprod (Paris) 12:775, Manhes H, Mage G, Pouly JL, Ropert JF, Bruhat MA: Traitement coelioscopique de la grossesse extrauterine non rompue: ameliorations techniques. Nelle Presse Med 12:1431, Johnson TRB, Sanborn JR, Wagner KS, Compton AA: Gonadotropin surveillance following conservative surgery for ectopic pregnancy. Fertil Steril 33:207, Kelly RW, Martin SA, Strickler RC: Delayed hemorrhage in conservative surgery for ectopic pregnancy. Am J Obstet Gynecol 133:225, Swollin K, Fall M: Ectopic pregnancy. Acta Eur Fertil. 3:147, Stangel JJ, Reyniak V, Stone ML: Conservative surgical management of tubal pregnancy. Obstet Gyneco148:241, Ryan GB, Grobety J, Majno G: Postoperative peritoneal adhesions. Am J PathoI65:117, Gordji M, Henri-Suchet J, Pigeaud F, Tesquier L, Debache C, Achard B, Chahine N, Loffredo V: Etude comparee des salpingotomies avec et sans suture. Recherche microchirurgicale experimentale sur la trompe de lapine. J Gynecol Obstet BioI Reprod (Paris) 10:765, MacComb P, Gomel V: Linear ampullary salpingotomy heals better by secondary versus primary closure (Abstr). Fertil Steril 41:45S, Mintz M: La chirurgie conservatrice de la trompe gravide: 17 interventions et revue de la litterature. Obstet Gynecol (Paris) 61:385, Vehaskari A: The question of choice for ectopic pregnancy. Acta Obstet Gynecol Scand (Suppl3) 39:14, DeCherney AH, Maheaux R, Naftolin F: Salpingotomy for ectopic pregnancy in the sole patent oviduct: reproductive outcome. Fertil Steril 37:619, 1982 Vol. 46, 6, December 1986 Pouly et al. Laparoscopic treatment of ectopic pregnancy 1097