Archives of.
Arch Gynecol Obstet (1992) 252:45-48
Gynecology and Obstetrics
© Springer-Verlag1992
Reproductive performance after local and systemic prostaglandin for ectopic pregnancy Ch. Egarter, H. Kiss, N. Vavra, and P. Husslein I. Department of Obstetrics and Gynecology, University of Vienna, Spitalgasse 23, A-1090 Vienna, Austria Received April 21, 1992/Accepted July 16, 1992
Summary. The injection of different substances into early, unruptured tubal pregnancies is increasingly advocated. In this study, fertility was evaluated after treatment of tubal pregnancy by means of prostaglandins. The overall tubal patency rate was 86.4% and 14 of 20 patients (70%) could subsequently achieve pregnancy. Key words: Tubal pregnancy - Prostaglandin treatment - Reproductive performance Introduction The justification for the conservative management of tubal pregnancy is improved subsequent fertility. Recent studies increasingly advocate local injection of different substances for the treatment of unruptured tubal pregnancy (Stovall 1990, Egarter 1989b, Lang 1990). Subsequent fertility is difficult to assess because many factors such as previous pelvic sepsis, sterility treatment, etc have to be considered. But this essential question has been addressed in several studies (Thornburn 1988, Langer 1987, Oelsner 1987, Egarter 1989a). The pregnancy rates after treatment with methotrexate have recently be shown to be better than those achieved by traditional conservative surgical methods and postoperative fertility is comparable to that after laparoscopic salpingostomy (Stovall t990). We treat patients with tubal pregnancies by local and systemic prostaglandin (Egarter 1989b, Egarter 1988) and we have examined their subsequent fertility.
Correspondence to: Prim. Univ. Doz. Dr. Ch. Egarter, Abteilung ffir Geburtshilfe und Gyn~kologie, LKH V6cklabruck, A-4840 V6cklabruck, Austria
46
Ch. Egarter et al.
Patients and m e t h o d s Since Nov. 1987, 75 patients presenting with unruptured tubal pregnancy have been treated with a local PG F2alpha injection and a systemic PG E2 derivative according to a protocol which has been described elsewhere (Egarter 1989b). Briefly, 5-10 mg PG F2atpha (Minprostin F2alpha, Upjohn, sussex) are injected laparoscopically at various sites into the tubal mass and the patients receive 50 mcg of a synthetic PG E2 derivative (Nalador, Schering, Berlin) intramuscularly twice daily on the first three postoperative days. Successfully treated patients were usually discharged from hospital on the 2nd or 3rd postoperative day and B-human chorionic gonadotropin ([3-hCO) levels were monitored until levels became undetectable. A second-look laparoscopy or hysterosalpingographywas offered in a following cycle. One year after the treatment the patients were asked about their desire to conceive and pregnancy rates were recorded.
Results O f the 75 patients enrolled in this study, eight had had a previous tubal pregnancy. The m e a n age was 29.8 years (range 18 to 41 years). T h e tubal pregnancy occurred on the right in 48 patients and on the left side in 27 patients. T h e trophoblast invaded the ampullary part of the tube in 33 cases (44%), the isthmic part in 24 cases (32%), and in 18 cases (24%) invasion occurred between the ampulla and the isthmus. Forty-three patients (84%) with a preoperative ~-hCG level less than 2500 m l U / m l serum were m a n a g e d successfully with intratubal injection of the prostaglandin; 8 patients (16%) had to undergo l a p a r o t o m y for surgical r e m o v a l of the trophoblast later on either on the basis of clinical symptoms or because of rising [3-hCG levels. In the group with an initial [3-hCG higher than 2500 m I U / m l the success rate dropped to 25%; in only 6 patients was no further intervention necessary, whereas 18 patients (75%) needed further surgery. In the 49 patients treated successfully with prostaglandins the interval between t r e a t m e n t and a [3-hCG level of less than 5 m I U / m l serum ranged from 5 to 45 days. Forty-four of these 49 patients later had a tubal patency test (Table 1). Hysterosalpingography and laparoscopy demonstrated an overall patency rate of the f o r m e r involved tube in 86,4%. A f t e r one year 40 out of 49 successfully treated patients responded to a questionnaire a b o u t their desire for future pregnancy. Eight patients were either using oral contraceptives or were not sexually active. Twenty-four of the 49
Table 1. Tubal patency after treatment of ectopic pregnancy with prostaglandins Tube involved with tubal pregnancy showed
Hystersalpingogram Laparoscopy
n = 41 n= 3
Occlusion
Patency
5 (12.2%) 1 (33.3%)
36 (87.8%) 2 (66.6%)
6 (13.6%)
38 (86.4%)
Tubal pregnancyand prostaglandins
47
patients had actively attempted to become pregnant. Seventeen (70%) patients subsequently achieved pregnancy, all within the year following the tubal gestation. Two of these pregnancies ended in spontaneous abortions and three patients had a repeat ectopic prgnancy, two of them in the contralateral tube. The other eleven pregnancies ended in delivery of a healthy child or are still ongoing. One of the delivered patients had only one tube and in another two cases the corpus luteum could be demonstrated on the same side as the previous tubal pregnancy.
Discussion According to many reports fertility after ectopic pregnancy is poor. Some authors claim a subsequent livebirth in only about one-third of cases (Kitchin 1979), whereas others report 75 per cent rates (Thornburn 1988, Dadak 1985). However, it is difficult to compare and draw conclusions from investigations of differing design and follow-up. In our study where prostaglandins were used to treat tubal pregnancy, 17 patients (70%) out of 24 who actively tried to become pregnant had a subsequent conception. Three of them, however, had a further ectopic gestation. Our overall tubal patency rate was 86.4%. Recently, Stovall et al. 1990 obtained comparable figures in a small study of reproductive performance after methotrexate injection. The tubal patency rate was 81.4% and 11 of 14 (78.6%) achieved pregnancy. One patient experienced a repeat ectopic pregnancy in the contralateral tube. Although numbers are still small with these methods, the results seem to be at least equal to those achieved by traditional surgery. On the basis of our experience with prostaglandins, these substances can be advocated for the treatment of unruptured ectopic pregnancy. In fact, they appear to be more harmless especially in view of the possible teratogenic or mutagenic effects of methotrexate (Egarter 1991). However, as recently demonstrated by Lang et al. (Lang 1990), hyperosmolar glucose solutions might be even safer because accidental intravenous injection has obviously no serious sequelae. But we still need more information about the results of the glucose solution in terms of success rates, tubal patency, and subsequent fertility.
Acknowledgement. This studywas partly supported by "WissenschaftlicherFond des Btirgerrneisters der BundeshauptstadtWien" 1989 and "Fond zur F6rderung der WissenschaftlichenForschung" 1990.
References Dadak Ch, FeiksA, DeutingerJ, ReinthallerA, JanischH (1985) Fertilitfitnachfunktionserhaltenden Operationenbei TubargraviditM. GeburtshilfeFrauenheilkd45:559-562 Egarter Ch (1991) Methotrexatetreatment of ectopic gestation and reproductive outcome. Am J Obstet Gynecot164:698-699 Egarter Ch, HussleinP (1988) Treatmentof tubal pregnancyby prostaglandins.LancetI:1104-1105
48
Ch. Egarter et al.
Egarter Ch, Husslein P (1989a) First successful intrauterine pregnancy after treatment of tubal pregnancy by prostaglandin F2alpha. Am J Obstet Gyneeol 161:904 Egarter Ch, Fitz R, Spona J, Grfinberger W, Wagenbichler P, Haidbauer R, Baumgarten K, Beck A, Leodolter S, Kiss H, Husslein P (1989b) Behandlung der Eileiterschwangerschaft mit Prostaglandinen: Eine Multizenterstudie. Geburtshilfe Frauenheilkd 49:808-812 Kitchin JD, Wein RM~ Nunley WC, Thiagarajah S, Thornton WN (1979) Ectopic pregnancy: current clinical trends. Am J Obstet Gynecol 134:870 Lang PF, Weiss PAM, Mayer HO, Haas JG, H6nigl W (1990) Conservative treatment of ectopic pregnancy with local injection of hyperosmolar glucose solution or prostaglandin F2alpha: a prospective randomised study. Lancet 336:78-81 Langer R, Bukovsky I, Herman A, Ron-E1 R, Lifshitz Y, Caspi E (1987) Fertility following conservative surgery for tubal pregnancy. Acta Obstet Gynecol Scand 66:649-652 Oelsner G, Morad J, Carp H, Mashiach S, Serr DM (1987) Reproductive performance following conservative microsurgical management of tubal pregnancy. Br J Obstet GynaecoI 94:10781083 Stovall TG, Ling FW, Buster JE (1990) Reproductive performance after methotrexate treatment of ectopic pregnancy. Am J Obstet Gynecol 162:1620-1624 Thornburn J, Philipson M, Lindblom B (1988) Fertility after ectopic pregnancy in relation to background factors and surgical treatment. Fertil Steril 49:595-601