Multifactorial analysis of fertility after conservative laparoscopic treatment of ectopic pregnancy in a series of 223 patients

FERTILITY AND STERILITY Copyright 99 The American Fertility Society Vol. 56, No.3, September 99 Printed on acid-free paper in U.S.A. Multifactorial analysis of fertility after conservative laparoscopic treatment of ectopic pregnancy in a series of 223 patients Jean Luc Pouly, M.D.* Charles Chapron, M.D. Hubert Manhes, M.D. Michel Canis, M.D. Arnaud Wattiez, M.D. Maurice-Antoine Bruhat, M.D. Departement de Gynecologie Obstetrique et Reproduction Humaine, Polyclinique Philippe Marcombe, Centre Hospitalier Universitaire, Clermont-Ferrand, France Objectives: To lay down the criteria to clearly define whether conservative or radicallaparoscopic treatment should be adopted in cases of ectopic pregnancies (EP).. Design: Retrospective, noncomparative. Setting: At the University Hospital of Clermont Ferrand and the La Pergola Clinic at Vichy from July 974 to December 987. Patients: This study was carried out in 223 patients who had been treated laparoscopically for EP and who desired future childbearing and who were not lost to follow-up. Main Outcome Measures: The measures chosen to achieve the objective included age, parity, size of hematosalpinx, volume of hemoperitoneum, tubal rupture, location, intrauterine device, ipsilateral and contralateral adhesions, and patient's previous history of salpingitis, EP, solitary tube, and tubal infertility. Results: The general intrauterine pregnancy rate was 67% (49 patients) and the recurrence rate 2% (27 patients). The results according to the studied factors demonstrated that age, parity, and the type of the EP have no influence on the postectopic fertility. The history of the patient, ipsilateral adhesions, or contralateral tubal status significantly reduce the future fertility prognosis and risk of recurrence. Conclusions: From a multivariable analysis, the authors propose a scoring system to choose the most suitable treatment to preserve fertility and to reduce the risk of recurrence ranging from laparoscopic conservative treatment to laparoscopic salpingectomy with contralateral sterilization. Fertil Steril 56:453, 99 Received March, 990; revised and accepted May 3, 99. *Reprint requests: Jean Luc Pouly, M.D., Departement de Gynecologie Obstetrique et Reproduction Humaine, Centre Hospitalier Universitaire de Clermont-Ferrand, 3, bd Charles de Gaulle-63033 Clermont-Ferrand Cedex, France. Our previous publications on the laparoscopic treatment of ectopic pregnancy (EP) have been corroborated by several investigators - 6 and support the concept that the conservative surgical treatment of EP by laparoscopy protects the subsequent fertility and is associated with results that compare favorably with those reported from the large series using traditional or microsurgical techniques. DeCherney and Diamond's early investigations 4 have established the safety of the conservative surgical approach of a salpingotomy instead of salpingectomy for some types of tubal pregnancies. Subsequent studies by our group and others have reported that after laparoscopic salpingotomies for EP intrauterine pregnancy rates (PRs) range between 50% and 70%. - 6 We share the concern that not all the patients with EP may benefit from the conservative surgical approach because it may predispose them to an unacceptably high risk of subsequent infertility and recurrent EP. These patients may have a better prognosis from in vitro fertilization (IVF) than conservative surgery. Therefore, we carried out this study to elucidate the factors that are likely to influence the future fertility of our patients with EP and to select those patients with the worst prognosis in which removal of the tube would Vol. 56, No.3, September 99 Pouly et al. Fertility after endoscopic removal of EP 453

Table Demographic Data of the Population General criteria Age (y) Nulliparous Parous (range to 4) Data obtained during laparoscopy Ruptured tubal wall Unruptured tubal wall Fimbriallocation Ampullar location Isthmic location Abdominal pregnancy Ipsilateral adhesions Contralateral blockage b Contralateral adhesions< The patient's previous history None Previous abdominopelvic surgery IUD Previous history of EP Salpingitis Solitary tube Infertility Primary Secondary Tubal Microsurgery Adhesiolysis Nontubal a Values in parentheses are percents. b Obstructed or absent tube with or without adhesions. c Adhesions with a patent tube. No. 26.3 ± 5.2 23 (55.2)a 00 (44.8) 6 (72.2) 62 (27.8) 9 (8.5) 5 (67.7) 48 (2.5) 5 (2.3) 35 (5.7) 47 (2.) 3 (3.9) 53 (23.8) 25 (.2) 23 (0.3) 3 (3.9) 29 (3.0) 36 (6.) 02 (45.7) 67 (65.8) 35 (34.2) 62 (27.8) 36 (58.) 26 (4.9) 40 (7.9) be preferable to removal of only the EP with preservation of the tube. MATERIALS AND METHODS Between July 974 and December 987, a total of 503 EP (465 patients) were treated by conservative laparoscopic surgery - 3 at the Obstetrics and Gynecology Department of the University Hospital of Clermont-Ferrand and at the La Pergola Clinic in Vichy. One hundred sixty-seven patients (35.9%) expressed no desire for pregnancy, and 75 were lost to follow-up (6.%). Two hundred twenty-three patients (48%) desired pregnancy, and it was possible to study their subsequent fertility for a minimum of year. These 223 patients were studied individually to establish which factors were associated with future fertility. The following information was collected: age, parity, size of the hematosalpinx, volume of hemoperitoneum, condition of the tube (whether ruptured or not), location of the EP, presence of ipsilateral adhesions, contralateral tubal status, previous abdominopelvic surgery (except for sterility), intrauterine device (IUD) in situ when the EP was diagnosed, previous history of EP, salpingitis, solitary tube according to our previous definition, 2 infertility specifying the type (primary or secondary, tubal or not, whether previously treated by microsurgery or adhesiolysis). All these data concerning the population are reported in Table. These results were analyzed statistically using the X 2 test, with the threshold of significance P < 0.05 (X 2 > 3.84). Infertility was defined as the inability to conceive at the end of the follow-up that is from to 5 years after the initial surgery for ectopic. The mean duration of the follow-up is 6.4 ± 2.9 years. Patients referred for IVF and embryo transfer (ET) were systematically classed as infertile, whatever their actual subsequent fertility. Overall Results RESULTS The overall pregnancy results are summarized in Table 2. One hundred forty-nine patients (67%) successfully conceived with normal intrauterine pregnancy (IUP). Five of these pregnancies occured after two prior EP (laparoscopically treated) and Table 2 General Fertility Results per Cases and per Patients st EP 2nd Total Total 3rd per case per patient No. EP IUP Infertility 223 27 (2)a 43 (64) 53 (24) 24 (46) 5 (2) 8 (33) 258 223 (9) 39 (5) (9) 49 (58) 49 (67) 9 (82) 70 (27) 74 (33)b a Values in parentheses are percents. b All the patients that presented a recurrence that was not treated by laparoscopy remained infertile and are included in the total per patient. 454 Pouly et al. Fertility after endoscopic removal of EP Fertility and Sterility

one IUP pregnancy occurred after three EP. Twenty-seven patients (2%) suffered recurrent EP. Of the 39 recurrent EP, 33 occurred in the ipsilateral tube (84.6%). Most of the recurrent EP were also treated laparoscopically. Finally, 74 patients (33%) failed to conceive. Age and Parity In this series, age had no effect on future fertility. Of the 69 patients (75.8%) 30 years of age or less, (65.7%) became pregnant, 20 (.8%) had arecurrent EP, and 38 (22.5%) remained infertile. Among the group of 54 women over 30 years of age, the rates of IUP, recurrence, and infertility were 59.2% (32 patients), 3% (7 patients), and 27.8% (5 patients) (P =not significant [NS]), respectively. This lack of difference probably comes from the limited number of patients. The 23 nulliparous patients (55.2%) had significantly poorer rates of IUP and significantly higher rates of infertility than parous patients: 52.8% (65 cases) versus 78% (78 cases) for IUP, and for infertility 35.8% (44 patients) versus 9% (9 patients), respectively (P < 0.00). The recurrence risk ofep, however, was not affected by the parity: there was recurrence for.4% (4 patients) among the nulliparous women and 3% (3 patients) for parous women (P = NS). Forty of the nulliparous patients (32.5%) had no history of infertility. Their subsequent fertility was not statistically different from that of women already having children (00 patients). For these two groups the rates of IUP, recurrent EP, and infertility were, respectively: 85% (34 patients), 7.5% (3 patients), and 7.5% (3 patients among the nulliparous patients versus 78% (78 patients), 3% (3 patients), and 9% (9 patients) among the parous patients (P = NS). Therefore, parity appeared to be an issue only when the past history of infertility is taken into account. Characteristics of the Tubal Pregnancy Future fertility appeared to be unrelated to the characteristics of the EP. The size of the hematosalpinx, the volume of hemoperitoneum, and tubal rupture also had no significant influence on the rates of IUP, EP recurrence, or infertility. When the hematosalpinx was >3 em, the IUP rate and the recurrence rate were 64.3% and 8.3%, respectively. They do not differ from the cases with smaller hematosalpinx ( <3 em) in which they were 64.0% and 4.4%, respectively. When there was a large hemoperitoneum at the time of the laparoscopy, the IUP rate and the recurrence rate were 63.6% and 4.6%, respectively. They did not differ from the cases with small hematoperitoneum ( <500 cc) in which they were 64.2% and 2.9%, respectively. When the tube was ruptured, the IUP was 62.9%, and the recurrence rate 4.2%. These results were similar to those obtained when the tube was not ruptured, being 64.6% and.2%, respectively. Similarly, the location of the EP in the tube appeared to be of no predictive value; whether at the fimbria (9 cases, 8.5%), ampulla (5 cases, 67.7%), or isthmus (48 cases, 2.5%), the subsequent difference in rates was not statistically significant in terms of IUP, EP recurrence, or infertility. According to the fimbria!, ampullar, isthmic, or abdominal location the IUP rates were 84.2%, 6.6%, 60.4%, and 00%, respectively (P = NS), and the recurrence rates 5.3%,.2%, 8.8%, 0%, respectively (P = NS). In contrast, the prognosis for future fertility is dramatically affected by the incidence of ipsilateral periadnexal adhesions. One hundred twenty-seven patients (67.5%) of the group of 88 patients in whom no ipsilateral adhesions were found during laparoscopy (group I) subsequently conceived with an IUP, whereas normal pregnancy occurred in only 6 patients ( 45.7%) of the group of 35 patients presenting with ipsilateral adhesions (group II). This was statistically significant (P < 0.02). The presence of adnexal adhesions was also significant in terms of subsequent infertility: group I, 2.3% ( 40 patients) versus group II, 37.2% (3 patients) (P < 0.05). However, there was no statistical difference regarding the risk of recurrence: group I,.2% (2 patients) versus group II, 7.% (6 patients) (P = NS). The condition of the contralateral tube also played an important part in fertility prognosis. In 2.% of the cases (47 patients), the contralateral tube was nonfunctional (missing or blocked). For these patients the rates found for IUP, recurrence, and infertility were 2.3% (0 patients), 2.3% (0 patients), and 57.4% (27 patients), respectively. Those patients who had a patent contralateral tube had a significantly better subsequent pregnancy outcome: 75.5% achieved an IUP (33 patients) (P < 0.00), 9.7% had EP recurrence (7 patients) (P < 0.05), and 4.8% were infertile (26 patients) (P < 0.00). Moreover, when the contralateral tube was patent (78.9%; 76 patients), the existence of periadnexal adhesions was of prime importance. Adhesions were found in 7.6% (3 patients) with patent contralateral tubes, and this finding significantly affected the results. The rate of IUP was 4.9% (3 patients), and the rate of infertility was 38.7% (2 patients). Vol. 56, No. 3, September 99 Pouly et al. Fertility after endoscopic removal of EP 455

These results were statistically lower than those obtained for patients with patent contralateral tubes without adhesions with 82.8% IUP (20 patients) and 9.6% infertility (4 patients), respectively, (P < 0.00). Again, adhesions had no influence on the rates of EP recurrence: 9.4% (6 patients) versus 7.6% ( patients) (P = NS). Previous History From a total of 223 patients, group A is made up of the 53 patients (23.8%) without prior abdominopelvic surgery, IUD use, or prior history of EP, infertility, or salpingitis. Subsequent fertility for these patients was significantly better than that for the 70 patients presenting with one or more of the aforementioned past histories. In these two groups, the rates for IUP and infertility were 88.7% (47 patients) and 3.8% (2 patients) versus 56% (96 patients) and 30% (5 patients) (P < 0.00), respectively. However, there was no significant difference in rates of recurrence: 7.5% (4 patients) versus 3.5% (23 patients) (P = NS). Of the 233 patients, 23 (0.3%) in group B had an IUD in situ at the time of the EP. Future fertility for these patients (IUP rate: 00% [23 patients]; EP rate: 0%; infertility rate: 0%) was not significantly different from that for group A patients (P = NS). Similarly, 25 patients (.2%) of the 233 belonged to group C with only a prior history of abdominopelvic surgery (not including surgery for infertility). The subsequent fertility for these patients (IUP rate: 84% [2 patients]; EP rate: 4% [ patient]; infertility rate: 2% [3 patients]) did not differ statistically from that for patients in group A (P = NS). These data demonstrated that women with a history of IUD use or with prior abdomino-pelvic surgery experience were not compromised in their fertility prognosis nor had they an increased risk for recurrence of an EP. Therefore, groups A, B, and C were combined to form group D (0 patients), which was considered as the control group of women with no risk factors. When the fertility of women with no risk factors was compared with women with one or more risk factors consisting of history of salpingitis, EP, solitary tube, or infertility, there was a highly significant statistical difference as far as the rates of IUP, recurrence of EP, and subsequent fertility were concerned. In the group of 29 patients with a history of salpingitis, the rates for IUP, EP recurrence, and infertility were 38% ( patients), 24% (7 patients), and 38% ( patients), respectively. These results were statistically lower than those obtained for pa- tients in group D, 90% (9 patients) (P < 0.00), 5% (5 patients) (P < 0.02), and 5% (5 patients) (P < 0.0), respectively. In the group of patients presenting with a previous EP (3 patients), the results were 8 IUP (25.8%), 9 EP (29%), and infertilities (45.2%). These results were all significantly different from those in group D (P < 0.00). The "solitary tube" group 2 included patients with a previous salpingectomy, patients with a contralateral obstructed tube, and patients who presented serially with an EP in each tube, both treated by means of laparoscopy. Patients with previous microsurgical tuboplasty were excluded. Of these 36 patients, 4 had an IUP (38.9% ), patients (30.5%) had a recurrence of EP, and patients (30.5%) remained infertile. These results were statistically worse than those for the patients in group D (P < 0.00). Subsequent fertility for the 02 patients presenting with a history of infertility also proved to be significantly lower than that for the patients in group D with IUP: 38 patients (37.2%) versus 9 patients (90%) (P < 0.00), respectively; EP: 8 patients (7.7%) versus 5 patients (5%) (P < 0.0), respectively; and infertility: 46 patients (45%) versus 5 patients (5%) (P < 0.00), respectively. Whether the infertility was primary (67 patients, 65.7%) or secondary (35 patients, 34.3%), the fertility prognosis remained unaltered. For the cases of primary infertility the rates of IUP, EP, and infertility were 38.8% (26 patients), 3.4% (9 patients), and 47.8% (32 patients), respectively, versus 34.3% (2 patients), 25.7% (9 patients), and 40% (4 patients), respectively, for the cases of secondary infertility (P = NS). In 60.8% of cases (62 patients) the infertility was because of a tubal pathology or peritubal adhesion. In this case, the rates for IUP (25.8% [6 patients]) and infertility (56.4% [35 patients]) were significantly worse than those observed for nontubal infertility, being 55% (22 patients) and 27.5% ( patients) (P < 0.0), respectively. Moreover, the recurrence risk for EP seems to be higher in those cases in which the tubal factor is the cause of infertility. Probably, the small number of cases does not indicate a statistical significance (7.8% [ patients] versus 7.5% [7 patients]) (P = NS). Out of the 62 patients presenting with tubal infertility, 36 had been treated by microsurgery and 26 by laparoscopy adhesiolysis alone. The postectopic fertility results in these two groups for IUP were 9.5% (7 patients) versus 34.6% (9 patients), 456 Pouly et al. Fertility after endoscopic removal of EP Fertility and Sterility

respectively; for EP 9.5% (7 patients) versus 5.4% (4 patients), respectively; and for infertility 6% (22 patients) versus 50% (3 patients) (P = NS), respectively. Nevertheless, the small number of cases in each group meant the difference was not statistically significant for the IUP rate (X2 =.8; p < 0.2). DISCUSSION The results of this series are similar to those we published previously 2 and suggest that laparoscopic treatment of EP may protect subsequent fertility. The above results are comparable, if not better, than those reported in major series using traditional or microsurgical techniques.7 Other recent studies on laparoscopic treatment of EP substantiate this claim by presenting very encouraging results. DeCherney and Diamond 4 in a series of 79 laparoscopic salpingotomies for EP obtained an IUP rate of 52%. Reich et al. 5 recently reported on 09 consecutive laparoscopic treatments of EP with an IUP rate of 50%. But there is some concern that not all the patients should be treated conservatively because this could put some of them at an unacceptably high risk for a recurrent EP. Therefore, the main aim of the present study was to elucidate the factors likely to modify future fertility prognosis. General Criteria In agreement with Thorburn et al., 8 the results in our series do not show any significant correlation between future fertility and the patient's age. This factor, therefore, will not be considered as relevant for the prognosis from an individual point of view. Similarly, like Nagamani et al.6 and Thorburn et al. 8 we feel that parity is not a relevant factor either. We do not agree with Tuomivaara et al.9 who found that subsequent fertility was lower in nulliparous women. Our results indeed do show statistically different rates for IUP among nulliparous and parous women (58% for 65 cases compared with 78% for 78 cases, respectively), but this difference is solely because of the prior history of infertility among the nulliparous patients. When we studied the nulliparous women with no history of infertility, we found that their future fertility was not significantly different from that of parous women. Characteristics of the EP The EP characteristics have no effect on fertility. The size of hematosalpinx, the volume of he moper- itoneum, and tubal rupture have no effect on the prognosis, whether considering IUP, EP recurrence, or sterility. Regarding the volume of the hemoperitoneum, our conclusions are identical to those of Thorburn et al., 8 but when considering the influence of tubal rupture, there is a difference in opinion. Some, like Sandvei et al. 0 and Thorburn et al. 8 agree with us, whereas others feel that tubal rupture has a negative impact on future fertility.7 Our results also indicate that the location of the EP has no effect on fertility. Moreover, the prognosis seems slightly more favorable when the EP is located at the fimbria. Comparison of patients having had a fimbrial EP with others reveals a difference in the rate of IUP that approaches significance (84.2%, 6 of 9 patients compared with 62.3%, 27 of 204 patients, respectively (P < 0.06). However, as far as the rate of recurrence and infertility are concerned, the differences between the two groups are not significant. Also, the results for EP at the isthmus are very encouraging, with a 60.4% rate ofiup (29/48). These results are similar to the results of DeCherney and Boyers who, in a series of six patients treated via laparotomy using the technique combining partial resection and anastomosis later on, obtained a 50% IUP. So not only can EP be treated without resection because salpingotomy gives the same results, but what is more important, it can be carried out via laparoscopy. The only two EP characteristics that show any significant correlation with future fertility are the existence of ipsilateral adhesions and the condition of the contralateral tube. Other authors7 8 0 have also emphasized the negative role played by adhesions. The part played in the prognosis by the contralateral tubal condition has also been previously described.7 9 2-6 For Tuomivaara et al.,9 the best indicator regarding future fertility was the state of the contralateral tube. Based on a series of 323 patients, he reported that patients with a normal contralateral tube have a significantly higher rate (P < 0.0) of IUP compared with a group of patients with an impaired contralateral tube. Similarly, the risk of recurrence was significantly lower if the contralateral tube was intact. These results are in concurrence with those of Langer et al.6 in a series of 49 patients in which he reported a 90% rate ofiup (27 patients) in the group with a normal contralateral tube. This rate dropped to 62.5% (5 patients) when the contralateral tube was severely damaged or missing. These findings are in agreement with our observations. Thus, laparoscopy allows not only treatment Vol. 56, No.3, September 99 Pouly et al. Fertility after endoscopic removal of EP 457

of the EP but also an assessment of other risk factors such as the presence of adhesions and the status of the contralateral tube. Not surprisingly, these findings are more common in women with history of salpingitis and infertility. The Past History In contrast to the findings of Thorburn et al., 8 our study demonstrates that a history of abdominopelvic surgery (not including surgery for infertility) has no effect on fertility. The prognosis for patients with the sole antecedent of pelvic surgery is identical to that for patients with no antecedent at all. Similarly, we believe, like the others 8 0 7 that the fertility of patients experiencing EP with an IUD in situ is not impaired. The 23 patients in our series who had only the past history of EP with an IUD in situ later conceived with an IUP, and like Thorburn et al., 8 we had no recurrent EP. This particularly favorable prognosis is directly related to the absence of high risk factors, particularly infection and infertility, in these patients with an IUD. The results of our study enable us to retain four past historical factors as directly responsible for a decrease in future fertility: a history of salpingitis, prior EP, infertility, or a "solitary tube." The fertility of patients presenting with each of these factors separately, compared with those of patients with no antecedent, shows a significant difference in the rates for IUP, for recurrence of EP, and for infertility. The part played by infertility had already been reported by some authors, 7 8 and others 6 9 0 had previously mentioned the negative effects of prior salpingitis. Cumulative IUP Rate The computer-generated curve for cumulative IUP rates (Fig. ) demonstrates that nearly 52% of the expected IUP occurred within the st year of the operation and 70% within 2 years of conservative management of EP. Other authors 8 9 3 have strongly stressed this aspect even more but on the basis of laparotomic treatments. Tuomivaara et al. 9 and Thorburn et al. 8 found nearly 70% of IUP occurring within 24 months of the operation. Only Oelsner et al. 3 reports a rate of 70% of IUP within year from the operation. But the patient's history can modify this expected cumulative IUP rate (Fig. ). In addition to decreasing fertility, past history also delays the onset of IUP. This can be clearly seen from the curves for cumulative PRs that show that nearly 83% of those patients who have no antecedent Probability of IUP.000,---------------------, 6 2 8 24 36 48 60 72 84 96 months Figure Cumulative PR according to the patients' history. 0, Total group; 0, group D (no significant history); +, history of ectopic; e, history of salpingitis; X, history of tubal infertility. (group D) and who will conceive a pregnancy have done so within 2 years after the surgery, compared with a maximum of 40% when at least one of the four antecedents in past history is present. Therapeutic Score In practice, the problem that the gynecologist is faced with when dealing with a patient presenting an EP is to choose the best course of therapy according to the prognosis viewed in terms of subsequent fertility and the risk of recurrence. This decision should be made based on two considerations. First, the same patient may present more than one factor, and this would impair fertility even more. Table 3 gives the risk of recurrence of EP compared with the chance of achieving an IUP according to the combination of past history. It can be seen that in most cases the probability of an IUP is lower than that of a recurrent EP, which means that conservative surgical treatment may be contraindicated because of the high risk of recurrent EP. Second, the last few years have been marked by improved availability and conception rates after IVF-ET. In certain circumstances, IVF-ET offers a better chance of an IUP than would be expected from conservative surgical treatment. In our experience, the cumulative delivery rate in women with tubal factor infertility is 49% after four IVF-ET attempts. With the aim of selecting the best course of therapy, we evaluated the relative responsibility of each of the factors that was found to adversely affect the fertility prognosis. This evaluation was performed using Orthotran-Varimax multivariable analysis. The relative weight given to each set of data is shown in Table 4. We thus set down a therapeutic scoring system for EP that takes into account these factors and their approximate coefficients (Table 4). 458 Pouly et al. Fertility after endoscopic removal of EP Fertility and Sterility

Table 3 Fertility Results Relative to the History of Associated Factors Ectopic Infertility Solitary tube Salpingitis Microsurgery Adhesiolysis EP 3.6 4.3 9. 9. 4.4 2.0.7 2.0 2.0 3.0 Infertility 3.6 9.5 23.7 9.4 25.5 2.0. 0.9.0 0.8 Solitary tube 4.3 9.5 9.4 9. 9.2.7..0 2.5.4 Salpingitis 9. 23.7 9.4 9.5 29.0 2.0 0.9.0 2.5 0.8 Microsurgery 9. 9.4 9. 9.5 6.0 2.0.0 2.5 2.5.7 Laparoscopic 5.4 25.5 9.2 29.0 6.0 adhesiolysis 3.0 0.8.4 0.8.7 For each association, the upper number is the IUP percentage and the lower the ratio EP recurrence/iup rate. Each patient then was scored by adding up the weights given to each risk factor. We then confronted this score with all our cases, studying the rates of IUP, recurrence, and infertility. Figure 2 clearly shows that the IUP rate varies inversely with the score, whereas the rates for recurrence and infertility vary directly. There comes a point, at a score of 4, at which the risk of EP equals that of IUP. For higher scores, the risk of recurrence is dramatically higher than the probability of an IUP. Therefore, based on this analysis the following treatment recommendations are made according to the total risk score: score 0 to 3: conservative laparoscopic treatment; score 4: radicallaparoscopic treatment consisting of salpingectomy; score 5 and above: radical laparoscopic treatment with contralateral sterilization and IVF procedures. Table 4 Statistical Weight of the Risk Factors and Therapeutic Score of the EP Score data Statistical weight Two comments are called for. Obviously, this treatment proposition should take into account the possibility of referring the patients easily to an IVF ET setup. This may be limited in some countries either because of the lack of sufficient IVF-ET programs or because of pecuniary reasons. In France, IVF-ET is widespread (76 official IVF centers for 55 million people), less expensive than in most other countries ($2,000 including drugs, medical care, and biological procedures), and completely covered by the National Social Security for the first four attempts. Therefore, this proposition is logical in our country. However, if the price of IVF -ET is prohibitively expensive, it may well be in the best interest of the patient to attempt a more conservative management only for financial reasons. Probability of IUP or EP.000 One previous EP For each additional EP Previous laparoscopic adhesiolysisd Previous tubal microsurgeryd Solitary tube Previous salpingitis Homolateral adhesions Contralateral adhesions 2 2 2 0.434 0.26 0.258 0.35 0.472 0.242 0.207 0.98 From Bruhat et al. 3 Reproduced with permission of the publisher, Mediscience/McGraw-Hill, New York, New York. b Score 0 to 3: laparoscopic conservative treatment, score 4: laparoscopic salpingectomy, score 5 or more: laparoscopic salpingectomy and contralateral sterilization. If the ectopic occurred in both tubes just count "Solitary tube." d Only one is taken in count. If the tube is blocked or absent, count "Solitary tube." Vol. 56, No.3, September 99 Figure 2 0 2 3 Therapeutic Score Probability of IUP and risk of EP according to the score. (calculated and observed data). Regression lines for the IUP: y = -2.97x + 83.433 (R 2 = 0.93). Regression lines for the EP: y = 3.367x + 8.992 (R 2 = 0.687). Pouly et al. Fertility after endoscopic removal of EP 459

On the other hand, for score 4 we propose alaparoscopic salpingectomy. Because in patients who had both the tubes, 80% of the recurrence occurred in the same tube, we strongly believe that when the risk of recurrence is elevated, a salpingectomy could go a long way in reducing it. Of course, for the score 5 or more, if IVF-ET cannot be proposed, we think that laparoscopic salpingectomy must be the elective treatment. Further prospectives studies are necessary to evaluate this attitude on fertility prognosis and on the risk of recurrence. Acknowledgments. We thank Salil Khandwala, M.D., for his help in reviewing the translation of this text in English and Gerard Mage, for scientific advice. REFERENCES. Bruhat MA, Manhes H, Mage G, Pouly JL: Treatment of ectopic pregnancy by means of laparoscopy. Fertil Steril 33: 4,980 2. Pouly JL, Manhes H, Mage G, Canis M, Bruhat MA: Conservative laparoscopic treatment of 32 ectopic pregnancies. Fertil Steril 46:093, 986 3. Bruhat MA, Mage G, Pouly JL, Manhes H, Canis M, Wattiez A: Operative Laparoscopy, Edited by MA Bruhat, G Mage, JL Pouly, H Manhes, M Canis, A Wattiez. New York, Medscience/McGraw-Hill Publishers, 99. In press 4. DeCherney AH, Diamond MP: Laparoscopic salpingostomy for ectopic pregnancy. Obstet Gynecol 70:948, 987 5. Reich H, Johns DA, DeCaprio J, McGlynn F, ReichE: Laparoscopic treatment of 09 conservative ectopic pregnancies. J Reprod Med 33:885, 988 6. Nagamani M, London S, St-Amand P: Factors influencing fertility after ectopic pregnancy. Am J Obstet Gynecol 49: 533, 984 7. Vermesh M: Conservative management of ectopic gestation. Fertil Steril 5:559, 989 8. Thorburn J, Philipson M, Lindblom B: Fertility after ectopic pregnancy in relation to background factors and surgical treatment. Fertil Steril 49:595, 988 9. Tuomivaara L, Kauppila A: Radical or conservative surgery for ectopic pregnancy? A follow-up study of fertility of 323 patients. Fertil Steril 50:580, 988 0. Sandvei R, Ulstein M, Wollen AL: Fertility following ectopic pregnancy with special reference to previous use of an intrauterine contraceptive device (IUCD). Acta Obstet Gynecol Scand 66:3, 987. DeChemey AH, Boyers SP: Isthmic ectopic pregnancy: segmental resection as the treatment of choice. Fertil Steril 44: 307, 985 2. Langer R, Bukovsky I, Sherman A, Ron-El R, Lifshitz Y, Caspi E: Fertility following conservative surgery for tubal pregnancy. Acta Obstet Gynecol Scand 66:649, 987 3. Oelsner G, Morad J, Carp H, Mashiach S, Serr DM: Reproductive performance following conservative microsurgical management of tubal pregnancy. Br J Obstet Gynaecol 94: 078, 987 4. Thorburn J: Ectopic pregnancy. Clinical features, risk factors and fertility prognosis. Thesis, University of Goteborg, Sweden, 987 5. Hallat JG: Tubal conservative in ectopic pregnancy: a study of 200 cases. Am J Obstet Gynecol 54:26, 986 6. Langer R, Bukovsky I, Herman A, Sherman D, Sadovsky G, Caspi E: Conservative surgery for tubal pregnancy. Fertil Steril38:427, 982 7. Meirik 0, Nygren KG: Ectopic pregnancy and IUDs: incidence risk rate and predisposing factors. Acta Obstet Gynecol Scand 59:425, 980 460 Pouly et al. Fertility after endoscopic removal of EP Fertility and Sterility