Reproductive outcome after fimbrial evacuation of tubal pregnancy

FERTILITY AND STERILITY Copyright 198 The American Fertility Society Vol. 4, No.3, March 198 Printed in U.8A. Reproductive outcome after fimbrial evacuation of tubal pregnancy Dan Sherman, M.D. Rami Langer, M.D. Arie Herman, M.D. Ian Bukovsky, M.D. Eliahu Caspi, M.D. * Department of Obstetrics and Gynecology, Assaf Harafe Medical Center, Sackler School of Medicine, Tel-Aviv University, Zerifi,n, Israel Thirty-one ectopic pregnancies were manually expressed (i.e., "'milked out") by the tubal fimbria during a 13-year period. Reproductive histories and operative findings were unremarkable when compared with the general population with ectopic gestation. The subsequent reproductive performance was evaluated in 2 patients who attempted conception. Twenty-five (92%) of the 2 patients subsequently conceived, 23 (85%) had at least one successful term pregnancy, and the remaining 2 (%) had abortions only. There was no repeat ectopic pregnancy. Average follow-up time was 38.5 months. Previous experience with this technique has been disappointing with low postoperative rates of successful term pregnancies. Favorable outcomes after fimbrial expression have been reported only in small numbers of patients. It is suggested that the procedure is appropriate for distal tubal gestations that are loosely adherent within the tubal lumen; these are usually expressed with minimal efforts. However, if the gestational mass does not yield to gentle milking of the tube or evacuation has been incomplete, the surgeon can always use a linear salpingotomy. More experience is obviously needed to verify these preliminary results, suggesting that fimbrial evacuation is simple, safe, and advantageous in properly selected cases. Fertil Steril 4:420, 198 Received June 24, 1986; revised and accepted November 24, 1986. *Reprint requests: Professor Eliahu Caspi, M.D., Assaf Harofe Medical Center, Department of Obstetrics and Gynecology, Zerifin 0300, Israel. In the past, radical surgery (salpingectomy or salpingo-oophorectomy) was the treatment of choice for both ruptured and unruptured tubal gestations. Today, with more sensitive and refined diagnostic methods, more tubal pregnancies are diagnosed before rupture and extensive tubal damage. 1-4 Surgical treatment at this early stage not only reduces morbidity and mortality but also enables a conservative approach aimed at preservation of the involved tube. The feasibility, safety, and improved postoperative fertility of conservative surgery have been repeatedly demonstrated, and is currently justified in any patient of reproductive age who desires further pregnancies. A variety of conservative surgical techniques is available for maximal preservation of fertility. The choice of surgical procedure depends on the patient, the location of the pregnancy, the surgical experience of the operator, and the subsequent reproductive performance. 3, 5, 6 Linear salpingotomy is appropriate for most unruptured tubal gestations, the majority of which are located in the ampulla. Fimbrial evacuation or "milking out" of a distal ampullar or infundibular preg- 420 Sherman et al. Fertility after "milking" of tubal pregnancy Fertility and Sterility

'i i : I I ' nancy has been suggested as a possible alternative to salpingotomy. It is usually accomplished by manual expression of the gestational products through the fimbriated ostium of the tube. Although this procedure is technically the simplest, it is not used routinely, and the conditions under which it may be applied are ill defined. Furthermore, the theoretic advantages of the technique are disputed, the clinical experience with it is sparse, and the effect on postoperative fertility is controversial. The experience gained in our department with this technique has been favorable, with postoperative pregnancy rates similar to those associated with our salpingotomy series. Encouraged by these preliminary results, we have extended our evaluation of this technique in the current study. PATIENTS MATERIALS AND METHODS Between 192 and 1984, 31 unruptured tubal gestations were manually expressed through the fimbriated end of the tube. These represent 22.5% of the 138 conservative surgical procedures for tubal pregnancy performed in our department during the 13-year period. This series includes, however, only successful procedures, because fimbrial evacuation was attempted in a larger number of distal tubal pregnancies. When technical difficulties arose in accomplishing gentle and complete expression of the gestational products, the conceptus was extruded through an antimesenteric tubal incision, and the cases were included in the linear salpingotomy series. Average age of the 31 patients who underwent fimbrial expression was 26.6 ± 4.5 years (± standard deviation [SD]). Their previous reproductive performance (Table 1) is not significantly different from that of the general population with ectopic gestation in our department. 8 Age of the tubal pregnancy could be estimated in 30 of the 31 patients and averaged 46.5 ± 9.1 days (± SD). A radioimmunoassay for the serum beta subunit of human chorionic gonadotropin (l3-hcg) was performed just before or on admission in 13 patients. Levels of l3-hcg ranged from nearly undetectable concentrations to 400 miu/ml, with the majority of patients (9 of 13) having concentrations ~ 200 miu/mi. At laparotomy 19 pregnancies were noted on the right side and 12 on the left. Seventeen pregnancies were classified as distal ampullar, 6 as infundibular, and 8 as fimbrial gestations. After fimbrial expression, tubal hemostasis was required in 11 cases (35%). This was accomplished by direct external pressure in seven cases and in the remaining four by electrocoagulation of bleeding points in the infundibulum or fimbria. In only 20 patients (65%) both tubes appeared otherwise normal at the time of operation. The contralateral tube was absent in four patients (previous ectopic gestation) and was abnormal in four (three with distal and one with proximal tubal occlusion). Periadnexal and/or pelvic adhesions were present in seven patients; in four abnormal contralateral tube coexisted. Additional lysis of adhesions and/ or tuboplasty was carried out in eight of these patients. Measures directed toward prevention of postoperative scar formation included gentle tissue handling, saline irrigations, blood-clot removal, and intraabdominal instillation of a solution containing steroids, antibiotics, and antihistamines. Three hydrotubations were carried out on alternate days, beginning on the second postoperative day, with hydrocortisone acetate (25 mg) and streptomycin (1.0 gm) in 15 ml normal saline. Neither were there postoperative complications nor were blood transfusions required. Table 1. Previous Reproductive Performance of 31 Patients Who had Fimbrial Evacuation of Tubal Pregnancy No previous pregnancies No previous live births 1 child ~ 2 children Previous ectopic pregnancya Previous sterilityb Intrauterine device use No. of patients % 8 13 8 10 4 6 26 42 26 32 13 19 23 a All underwent unilateral salpingectomy. bfive patients had secondary sterility with known mechanical factor; four patients had previous tuboplasty. RESULTS Of the 31 patients under study, 1 was lost to follow-up, and 3 patients were excluded because they were practicing contraception postoperatively. Subsequent reproductive performance was evaluated in the remaining 2 potentially fertile patients (Table 2). They were followed up for a mean time of 38.5 ± 18.6 months (± SD), with a range of 12 to 81 months. Only two patients failed to conceive postoperatively. Both had operative findings of a severe mechanical sterility factor. In Vol. 4, No.3, March 198 Sherman et al. Fertility after "milking" of tubal pregnancy 421

Table 2. Reproductive Performance After Fimbrial Evacuation in 2 Patients Unable to conceive Conceived ;;. 1 live birth Abortions only Repeat ectopic No. of patients % 2 25 23 2 o 93 85 o addition both underwent reconstructive tubal surgery before the ectopic gestation. Twentythree patients subsequently had at least one live birth (85%); 2 patients had either spontaneous or induced abortions only. None of the patients experienced a repeat ectopic gestation. The overall yield of viable infants, from a total of 39 conceptions experienced by 25 women, was 33 infants (84.6%), and the rate of known abortions 12.8%. All patients with otherwise apparently normal reproductive organs at the time of operation, who were willing to conceive, subsequently experienced at least one live birth. DISCUSSION Fimbrial evacuation or "milking out" of a tubal pregnancy represents the least invasive conservative surgical procedure and perhaps the simplest and easiest to perform. Several authors have suggested that as such, it bears the most favorable prognosis for subsequent successful pregnancies.9-11 These claims, however, have not been supported by clinical data. Others have pointed out that "squeezing of the tube" is likely to cause tubal damage with subsequent adhesion formation, as a result of either overzealous attempts to evacuate the tube or incomplete removal of the gestational products.2, 3, 12, 13 Continued bleeding from the implantation site is another (reportedly) frequent complication of the procedure.14 The validity of fimbrial expression has been seriously questioned by recent histopathologic observations,15 which suggests that the vast majority of ampullar gestations rapidly invade the tubal wall and rupture extratubally into the loose connective tissue between the tubal wall and its serosa. Although exact figures were not submitted, this implies that the gestational sac is usually extraluminal and that attempts at forcibly milking the ectopic pregnancy out of the fimbria will cause further tubal destruction. In contrast, more recent observations, by use of special histopathologic techniques, indicate that trophoblastic spread was predominantly intraluminal in 6% of 25 consecutive ectopic pregnancies, the majority of which were ampullar.16 In addition, nearly all (13 of 14) unruptured tubal gestations were associated with intraluminal trophoblast growth, while extraluminal extension was associated mostly with ruptured tubes.16 Hence, manual expression of an unruptured ampullar pregnancy may be ultimately justified. However, it is suggested that fimbrial evacuation cannot be successfully accomplished when the pregnancy has penetrated deep into the tubal wall. In contrast, when the gestational sac is loosely attached within the lumen of the distal portion of the tube (i.e., incomplete tubal abortion), the pregnancy may be converted to a complete tubal abortion by gentle manual expression with no further tubal damage, obviating the need for tubal incision and suture. Low serum j3-hcg levels at the time of surgery, consistent with incomplete abortion, lend credit to this hypothesis. Unfortunately, because of the retrospective nature of the study, the number of cases in which fimbrial evacuation was attempted but unsuccessful cannot be accurately determined. However, because fimbrial evacuation is attempted only in distal tubal pregnancies and these constitute 46 of our 138 conservatively treated cases, a conservative estimate of the operative success rate would be 6% (31 of 46). Regretfully, other seriesl2, 1 do not submit success rates for this technique. Clinical reports on fimbrial evacuation are relatively few and mostly outdated. The postoperative results are seldom reported separate from those following other types of conservative surgery. Some specific information was gained, however, in several small series; some containing six or fewer potentially fertile patients4, 18, 19 and a few with a larger number of patients (Table 3). Timonen and Nieminen12 in an analysis relating to the choice of operative method in tubal pregnancy reported on the postoperative outcome of 29 tubal gestations that were "milked out" during the years 1954 to 1965 (Table 3). They12 noted that this technique leads to the greatest number of untoward effects, because abortions and recurrent ectopic pregnancies occur more often after this operation than after any other conservative procedure. These frequently cited results, along with other arguments,15 have since supported the case against fimbrial evacuation. Even updated reviews of the subject condemn its use in the 422 Sherman et al. Fertility after "milking" of tubal pregnancy Fertility and Sterility

Table 3. Reproductive Performance After Fimbrial Evacuation and Salpingotomy in Various Series Reference Procedure No. of patients no. Conception 12 Milking 29 66 Salpingotomy 83 61 1 Milking 16 50 Salpingotomy 24 38 Milking 12 5 Salpingotomy 3 95 aone or more live births. Subsequent rates (% of total no. of patients) Live birth a Abortions only Ectopic only Recurrent ectopic 24 21 21 24 36 13 12 18 25 6 19 25 1 4 1 21 6 8 3 8 14 16 management of tubal pregnancy and recommend that fimbrial expression be abandoned. 2, 13, 14, 20, 21 Analysis of the data from the Timonen and Nieminen series12 shows that the differences in postoperative reproductive performance between patients in whom the "milking" method was used and those who underwent salpingotomy are not statistically significant (chi-square test, P = 0.5). Moreover, reviewing the literature w'e could not find other series to corroborate the verdict against fimbrial evacuation. In contrast, the postoperative results of fimbrial expression compare favorably with those following salpingotomy, evaluated in the same series (Table 3).4,18 The results of the current study fare better than those of several salpingotomy seriesl4: the live birth rate is among the highest reported after conservative surgery, and there is no recurrent ectopic gestation. Several explanations may be offered for the exceptionally good reproductive outcome after fimbrial expression in the current series. First, a general trend of improved fertility after all types of surgically treated ectopic pregnancies is notable in recent years.8, 14 This is undoubtedly a result of improvements in diagnosis as well as in intra- and postoperative management. The introduction of newer diagnostic methods (i.e., l3-hcg testing, ultrasound, and laparoscopy) enabled earlier diagnosis and treatment of the ectopic gestation. In the last decade more than 60% of tubal gestations in our department have been diagnosed intact before extensive tubal and/or pelvic damage. The evolution of modern operative techniques (e.g., atraumatic tissue handling, saline irrigations, pinpoint electrocautery, fine nonabsorbable sutures) has contributed to an improved fertility outcome compared with the initial studies of the 1950s and 1960s. Second, it seems that the feasibility as well as the postoperative outcome of the "milking" procedure depend largely on proper selection of cases. We have selected our patients by the anatomic location of the pregnancy and by the ease with which it could be expressed (i.e., only distally located tubal gestations that yielded to gentle manual expression). Apparently, similar selection criteria were not used in earlier series.12, 1 Conservative treatment (including fimbrial evacuation), however, was recommended "only in cases of sterility in which the contralateral tube is destroyed.,,12 This may explain an improved outcome of later series, which provide such treatment to all patients who desire further pregnancies. Finally, although our results after fimbrial evacuation seem to suggest superiority over other conservative surgical procedures, the current series is too small and other factors may be contributing to a better outcome. In conclusion, the technical ease and simplicity of fimbrial evacuation cannot be overlooked. If complete evacuation of the tubal content cannot be accomplished or bleeding is not controlled, the surgeon may always use an alternative procedure (i.e., linear salpingotomy). If rules of gentle tissue handling are kept and vigorous "milking" efforts are avoided, this procedure may prove to be the most beneficial in terms of subsequent fertility. More definite recommendations should be forthcoming if and when additional experience and data become available. REFERENCES 1. Makinen J, Nikkanen V, Kivikoski A: Problems and benefits in early diagnosis of ectopic pregnancy. Eur J Obstet Gynecol Reprod BioI 16:381, 1984 2. DeCherney AH, Maheux R: Modern management oftubal pregnancy. CUIT Probl Obstet Gynecol 6:9, 1983 3. Brosens I, Gordts S, Vasquez G, Boeckx W: Function-retaining surgical management of ectopic pregnancy. Eur J Obstet Gynecol Reprod BioI 18:395, 1984 4. Paavonen J, VaIjonen-Toivonen M, Komulainen M, Heinonen PK: Diagnosis and management of tubal pregnancy: effect on fertility outcome. Int J Gynecol Obstet 23: 129, 1985 Vol. 4, No.3, March 198 Sherman et ai. Fertility after "milking" of tubal pregnancy 423

5. Stangel JJ, Gomel V: Techniques in conservative surgery for tubal gestation. Clin Obstet Gynecol 23:1221, 1980 6. Valle JA, Lifchez AS: Reproductive outcome following conservative surgery for tubal pregnancy in women with a single fallopian tube. Fertil Steril 39:316, 1983. Langer R, Bukovsky I, Herman A, Lifshits Y, Caspi E: "Milking"-a conservative surgical technique for a tubal gestation. Int J Fertil 28:49, 1983 8. Sherman D, Langer R, Sadovsky G, Bukovsky I, Caspi E: Improved fertility following ectopic pregnancy. Fertil Steril 3:49, 1982 9. Abrams J, Farell DM: Salpingectomy and salpingoplasty for tubal pregnancy: survey of the literature. Obstet Gynecol 24:281, 1964 10. Grant A: The effect of ectopic pregnancy on fertility: report of a study of 353 cases. Clin Obstet Gynecol 5:861, 1962 11. Bronson RA: Tubal pregnancy and infertility. Fertil Steril 28:221, 19 12. Timonen S, Nieminen U: Tubal pregnancy, choice of operative method of treatment. Acta Obstet Gynecol Scand 46:32, 196 13. Taylor PJ, Leader A, Pattinson HA: Conservative management of the unruptured tubal pregnancy. Int J Fertil 29:149, 1984 14. Weckstein LN: Current perspective on ectopic pregnancy. Obstet Gynecol Surv 40:259, 1985 15. Budowick M, Johnson TRB, Genadry R, Parmley TH, Woodruff JD: The histopathology of the developing tubal ectopic pregnancy. Fertil Steril 34:169, 1980 16. Pauerstein CJ, Croxatto HB, Eddy CA, Rarnzy I, Walters MD: Anatomy and pathology of tubal pregnancy. Obstet Gynecol 6:301, 1986 1. Swolin K, Fall M: Ectopic pregnancy. Acta Eur Fertil 3: 14, 192 18. Vehaskari A: The operation of choice for ectopic pregnancy with reference to subsequent fertility. Acta Obstet Gynecol Scand (Suppl 3) 39:1, 1960 19. Jarvinen PA, Kinnuen 0: The treatment of extrauterine pregnancy and subsequent fertility. Int J Fertil 2:131, 195 20. McElin TW, Iffy L: Ectopic gestation: a consideration of new and controversial issues relating to pathogenesis and management. Obstet 'Gynecol Annu 5:241, 196 21. Stangel JJ: Conservative surgical procedures for tubal pregnancy. J Reprod Med 31:103, 1986 424 Sherman et al. Fertility after "milking" of tubal pregnancy Fertility and Sterility