Ectopic Pregnancies: Treatment Does Not Alter Fertility

Joe Barber Jr, PhD

March 12, 2013

The fertility of women after an ectopic pregnancy appears to be similar between those who received medical treatment and those who received conservative or radical surgery, according to the findings of a randomized controlled trial.

Hervé Fernandez, MD, from Inserm, Hôpital Bicêtre, and Université Paris-Sud, Le Kremlin Bicêtre, and Hôpital Béclère, Clamart, France, and colleagues published their findings online March 12 in Human Reproduction.

The authors note there has been a lack of trial data available on fertility after an ectopic pregnancy. "Published data on fertility after [ectopic pregnancy] are mainly observational," the authors write. "No randomized trial has thus far compared radical and conservative surgery."

In the study, the authors initially divided women into 2 groups on the basis of the activity of their ectopic pregnancies (low-activity and high-activity ectopic pregnancies). In group 1, the researchers randomly assigned women with low-activity ectopic pregnancies to receive methotrexate injections or undergo conservative surgery with postoperative methotrexate injections. In group 2, the authors randomly assigned women with high-activity ectopic pregnancies to undergo radical (salpingectomy) or conservative (salpingostomy plus postoperative methotrexate injections) surgery.

The primary endpoint of the study was the rate of fertility in each group, as assessed by spontaneous intrauterine pregnancy in the 24 months after treatment. Women in the study received treatment at 1 of 17 participating centers in France.

In group 1 (n = 210), no difference in the rate of ectopic pregnancy recurrence was noted between the medical treatment and conservative surgery groups (12% vs 9%; χ2, 0.31; P = .58), and the groups also had similar 24-month cumulative rates of intrauterine pregnancy (71% vs 67%; hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.59 - 1.22). A per treatment analysis comparing medical treatment and conservative surgery also revealed no significant difference between the groups (HR, 0.95; 95% CI, 0.66 - 1.39).

In group 2 (n = 230), the rates of ectopic pregnancy recurrence were 12% in the radical surgery group and 8% in the conservative surgery group (χ2, 0.003; P = .96), and the 24-month cumulative rates of intrauterine pregnancy were 70% after conservative surgery and 64% after radical surgery (HR, 1.06; 95% CI, 0.65 - 1.56). In a per treatment analysis, no difference between the radical and conservative surgery groups was noted (HR, 1.07; 95% CI, 0.69 - 1.67).

The authors suggest several clinical recommendations based on their findings. "Medical treatment should be preferred in less-active ectopic pregnancies when possible, to take into account women's preferences and also because it entails fewer anaesthesia- and surgery-related risks," the authors write.

"Once surgery is necessary, in more active ectopic pregnancies, the non-significant (and quantitatively small) difference in subsequent fertility should lead to a reconsideration of the balance between considerations of initial recovery and those of fertility preservation," they conclude.

Study funding was provided by the Paris Public Hospital System from PRHC 2004. The authors have disclosed no relevant financial relationships.

Hum Reprod. Published online March 12, 2013.