- The document discusses fertility outcomes after ectopic pregnancy and various treatment options. - Fertility rates after ectopic pregnancy are around 60% for subsequent intrauterine pregnancy and 28% risk of recurrent ectopic pregnancy, regardless of treatment. - Expectant management, methotrexate treatment, and surgery all have comparable fertility outcomes, with subsequent intrauterine pregnancy rates around 60-70% within 2 years. The risk of recurrent ectopic pregnancy is also similar between treatments.

1. Poonam Loomba,M.D.

2. SITES OF ECTOPIC PREGNANCY
1)Fimbrial 2)Ampullary 3)Isthmic 4)Interstitial
5)Ovarian 6)Cervical 7)Cornual-Rudimentary horn
8)Secondary abdominal 9)Broad ligament 10)Primary
abdominal
Ampulla (>85%)
Isthmus (8%)
Cornual (< 2%)
Ovary (< 2%)
Abdomen (< 2%)
Cervix (< 2%)

3. Fertility after ectopic pregnancy
There is no simple answer to the problem of
fertility after one ectopic pregnancy. Results
reported in the literature have been
satisfactory with rate of subsequent
pregnancy about 60% and the risk of new
ectopic pregnancy (EP) around 28%.

4.  After two ectopic pregnancies 25% achieved delivery,
40% had a third ectopic pregnancy, and 35% did not
conceive.
 After three tubal pregnancies 16% delivered, 26% had a
repeat tubal pregnancy, and 58% did not conceive.
 There was no significant difference between fertility
results after salpingectomy and those after conservative
surgery.
Intl J Fertil 1989


5. Pregnancy rates after ectopic pregnancy are
satisfactory whatever treatment is used.
Laparoscopy being the gold standard.
Medical treatment is at least as effective as surgical
treatment.
Associated infertility factors appear to be the most
important for fertility outcome.
•.J Gynecol Obstet Biol Reprod
Paris 2003 Nov;32(7 Suppl):S83-92.

6.  Age : < 35
 No h/o Infertility in the past
 No Associated factors for infertility
 Healthy contralateral tube
 Early diagnosis and treatment of ectopic improves
prognosis
 No AnteriorTubal damage

7. Hum Reprod
. 2013 May;28(5):1247-53. 10.1093/
.
Fertility after ectopic pregnancy: the
DEMETER randomized trial
Hervé Fernandez 1, Perrine Capmas, Jean
Philippe Lucot, Benoit Resch, Pierre
Panel, Jean Bouyer, GROG

8. This randomized controlled trial included all women with an
ultrasound-confirmed EP. Women were divided into two arms
according to the activity of the EP (defined by Fernandez's score). In
arm 1 (less active ectopic pregnancies, i.e. Fernandez's score <13 and
no haemodynamic failure), medical treatment was considered
practicable, and women were randomly allocated to conservative
surgery with a systematic post-operative i.m. methotrexate
injection within 24 h or to an i.m. methotrexate injection alone. In
arm 2 (active ectopic pregnancies), medical treatment was
considered impracticable, and, thus, all women had to undergo
surgery; they were randomly allocated to either a radical or
conservative procedure, the latter including a post-operative
methotrexate injection. Sample sizes (n = 210 in arm 1 and n = 230 in
arm 2) were computed to provide a statistical power of 80% to
detect a 20% difference in subsequent cumulative fertility rates
between treatments in each arm.The total duration of the trial was
5 years.

9. Main results: Arm 1: cumulative fertility curves were not
significantly different between medical treatment and
conservative surgery. HR was 0.85 (0.59-1.22) P = 0.37.The
2-year rates of IUP were 67% after medical treatment and
71% after conservative surgery.
Arm 2: cumulative fertility curves were not significantly
different between conservative and radical surgery. HR
was 1.06 (0.69-1.63) P = 0.78.The 2-year rates of IUP were
70% after conservative surgery and 64% after radical
surgery.

10.  Survival analysis of fertility after ectopic
pregnancy
A Ego1, D Subtil, M Cosson, F Legoueff,V Houfflin-
Debarge, D Querleu
Affiliations expand
PMID: 11239542
DOI: 10.1016/s0015-0282(00)01761-1

11. Three hundred and twenty-eight women treated between
April 1994 and March 1997 .
(65.5%) women became pregnant after a mean of 5 months.
(84.7%) pregnancies were intrauterine
(10.2%) were recurrent ectopic pregnancies
The cumulative intrauterine pregnancy rate was 56% at 1 year
and 67% at 2 years.

12. EXPECTANT
METHOTREXATE/KCL : LOCAL OR SYSTEMIC
SALPIGOTOMY/ SALPINGECTOMY
CORNUAL RESECTION
FERTILITY PRESERVING SURGERY FOR
CORNUAL
PREGNANCY and CSP

13. Fertility outcomes following expectant
management of tubal ectopic pregnancy
S Helmy1, E Sawyer, D Ofili-Yebovi, JYazbek, J Ben Nagi, D
Jurkovic
Ultrasound ObstetricGynecol: 2007
Dec;30(7):988-93.
doi: 10.1002/uog.5186.

14. Spontaneous intrauterine pregnancy occurred in
41/49 (83.7%; 95% CI, 73.3-94.2%) women
managed expectantly and in 62/97 (63.9%; 95%
CI, 54.4-73.5%) women managed surgically
(odds ratio 2.89; 95% CI, 1.22-6.86%).The risk of
recurrent ectopic pregnancy was not
significantly different between the two
management groups.
Conclusions: Fertility outcomes following the
expectant management of tubal ectopic
pregnancy are comparable to those following
salpingectomy.

15. •. 2004 Aug;82(2):304-8.
10.1016/j.fertnstert.2004.04.023.
Reproductive outcome after methotrexate
treatment of tubal pregnancies
Amélie Gervaise 1, Laurent Masson, Renaud
de Tayrac, René Frydman, Hervé Fernandez

16. Patient(s): A cohort of 158 patients treated with MTX for tubal pregnancies
between April 1991 and March 1999.
The cumulative intrauterine pregnancy rate was 57.5% after 1
year and 66.9% after 2 years.
The cumulative ectopic pregnancy rate was 15.4% after 1 year
and 23.7% after 2 years
After adjusting for factors associated with fertility with a Cox
regression, only one factor was associated with poor
reproductive performance: previous history of infertility.
The analysis indicates that fertility depends more on
the patients' previous medical history than on her
treatment for EP.

17. EFFECT ON OVARIAN RESERVE
2008 Nov;90(5):1579-82.
doi: 10.1016/j.fertnstert.2007.08.032. Epub
2007 Dec 11.
Systemic methotrexate to treat ectopic
pregnancy does not affect ovarian reserve
Bárbara Oriol1, Ana Barrio, Alberto
Pacheco, José Serna, José Luis
Zuzuarregui, Juan A Garcia-Velasco

18. Patient(s): Twenty-five women undergoing IVF-ICSI who were treated with
MTX (1 mg/kg IM) for an EP after ART.
Result(s): Serum AMH levels before MTX were not statistically
significantly different from those after treatment (3.7 +/- 0.3
ng/mL vs. 3.9 +/- 0.3 ng/mL).
Patients undergoing a subsequent cycle after systemic
treatment for EP had similar cycle durations (10.3 vs. 10.8 d),
gonadotropin requirements (2,775 vs. 2,630.3 IU
Peak E(2) levels (1,884.3 vs. 1,523.6 pg/mL)
number of oocytes retrieved (12.1 vs. 10.5)
and total number of embryos obtained (7.1 vs. 6.5).

19. Fertility and reproductive outcome after tubal ectopic
pregnancy: comparison among methotrexate,
surgery and expectant management
Silvia Baggio1 2, Simone Garzon3, Anna Russo4, Cesare
Quintino Ianniciello4, Lorenza Santi5
•. Arch Gynecol Obstetrics:2021 Jan;303(1):259-268. doi: 10.1007/s00404-020-05749-2. Epub 2020 Aug 27.

20. The CI of intrauterine CP starting from 12 months after
the EP was
65.3% for the expectant management
55.3% for the MTX group
39.5% for surgery (p = 0. 012).
Post-hoc analysis showed expectant management
having higher intrauterine CP and LB, and shorter time
between treatment and first intrauterine CP compared
to surgery (p < 0.05).The CI of recurrent EP was
comparable between the 3 groups.The analysis
stratified per βhCG cut-off of 1745 mUI/mL and EP
mass cut-off of 25 mm reported consistent results.

21. The impact of expectant management,
systemic methotrexate and surgery on
subsequent pregnancy outcomes in tubal
ectopic pregnancy
E Demirdag1, I Guler2, S Abay1,Y Oguz1, M
Erdem1, A Erdem1
Ir J Med Sci 2017 May;186(2):387-392.
doi: 10.1007/s11845-016-1419-5. Epub 2016 Feb 19.

22. Results: One hundred twelve of 151 women desired to
conceive following tubal ectopic pregnancy.Twenty-seven
of 112 (24.1 %) patients were managed expectantly. Fifty-
three (47.3 %) and 32 (28.5 %) patients were managed with
systemic MTX or surgery, respectively. All patients in
expectant and surgery groups were managed successfully.
Two (3.7 %) patients had surgery after failed treatment with
systemic MTX. Spontaneous intrauterine pregnancy rates
were 62.9 % in expectantly managed women, 58.4 % in
women with systemic MTX and 68.7 % in women with
surgery (p > 0.05).
Conclusions: Treatment of ectopic pregnancy with either
expectant management or systemic MTX is equally
effective as compared to surgery. Spontaneous intrauterine
pregnancy rates were comparable in expectant
management, systemic methotrexate and surgery.

23. Surgical Management

24. Surgical Treatments:
The ESEP study:
Salpingostomy versus Salpingectomy for
tubal ectopic pregnancy
The impact on future fertility: a
randomised controlled trial
•.BMC WOMENS HEALTH 2008 Jun 26;8:11.

25. International multi centre randomised controlled trial comparing salpingostomy versus
salpingectomy in women with a tubal EP without contra lateral tubal pathology.
Patients pregnant after in vitro fertilisation (IVF) and/or known documented
tubal pathology are excluded. At surgery, a tubal EP must be confirmed.
446 women were randomly assigned between Sept 24, 2004, and Nov 29, 2011, with
215 allocated to salpingotomy and 231 to salpingectomy.
The cumulative ongoing pregnancy rate was 60·7% after salpingotomy and
56·2% after salpingectomy .
Persistent trophoblast occurred more frequently in the salpingotomy group
than in the salpingectomy group (14 [7%] vs 1 [<1%]; RR 15·0, 2·0-113·4).
Repeat ectopic pregnancy occurred in 18 women (8%) in the salpingotomy
group and 12 (5%) women in the salpingectomy group (RR 1·6, 0·8-3·3).
Interpretation: In women with a tubal pregnancy and a healthy
contralateral tube, salpingotomy does not significantly improve
fertility prospects compared with salpingectomy.

26. 2016 Mar 25;11(3):e0152343.
doi: 10.1371/journal.pone.0152343. eCollection 2016.PLoS ONE
Comparison of the Fertility Outcome of
Salpingotomy and Salpingectomy in Women
withTubal Pregnancy: A Systematic Review
and Meta-Analysis
Xiaolin Cheng1, XiaoyuTian1, Zhen
Yan1, Mengmeng Jia1, Jie Deng1,Ying
Wang1, Dongmei Fan1

27. Two randomized controlled trials (RCTs) and eight cohort studies, including a total of
1,229 patients, were znalyzed
The meta-analysis of the RCT subgroup indicated that there was no statistically
significant difference in IUP rates (RR = 1.04, 95% CI = 0.89-1.21, P = 0.61) nor the
repeat ectopic pregnancy (REP) rate (RR = 1.30, 95% CI = 0.72-2.38, P = 0.39) between
the salpingotomy and salpingectomy group.
Cohort study subgroup analysis revealed that the IUP rate was higher in the
salpingotomy group compared with the salpingectomy group (RR = 1.24, 95% CI
= 1.08-1.42, P = 0.002);
Salpingotomy also increased the risk of REP rate (RR = 2.27, 95% CI = 1.12-4.58, P
= 0.02).
The persistent ectopic pregnancy (PEP) occurred more frequently in the
salpingotomy group than the salpingectomy group (RR = 11.61, 95% CI = 3.17-
42.46, P = 0.0002).
An IUP would be more likely to occur after salpingotomy than salpingectomy
when the follow-up time was more than 36 months (RR = 1.16, 95% CI = 1.02-1.32,
P = 0.03).

28. Fertility outcomes after laparoscopic
salpingectomy or salpingotomy for tubal
ectopic pregnancy: A retrospective cohort
study of 95 patients
Lifeng Chen1, Danpeng Zhu1, QingWu1,Yan
Yu2
INT J SURG :2017 Dec;48:59-63.
doi: 10.1016/j.ijsu.2017.09.058. Epub 2017 Sep 22.

29. No significant difference in fertility
outcomes between the two groups.
Conclusions: Surgical management
options for EP should be comprehensively
evaluated in the clinical setting as
numerous factors influence the decision
making process.

30. Hum Reprod : 1996 Jan;11(1):99-104.
doi: 10.1093/oxfordjournals.humrep.a019048.
Fertility after ectopic pregnancy: first results of a population-
based cohort study in france
N Job-Spira1, J Bouyer, J L Pouly, E Germain, J Coste, B Aublet-
Cuvelier, H Fernandez
The 1 year cumulative intrauterine pregnancy rate (i.e. the
probability of obtaining an intrauterine pregnancy within 1
year of seeking pregnancy) was 70%. After multivariate
analysis by a Cox regression, the factors associated with higher
fertility were age < 30 years, high educational level and no
prior tubal damage.

31. Minim Invasive Gynecol : Jul-Aug 2019;26(5):865-870.
doi: 10.1016/j.jmig.2018.08.017. Epub 2018 Aug 31.
Fertility Outcome after Cornual Resection for
Interstitial Pregnancies
Rune Svenningsen1, Anne Cathrine Staff2,Anton Langebrekke3, Erik
Qvigstad2
Interstitial pregnancy : 2%-4% of all
ectopic pregnancies

32. Forty consecutive women with interstitial ectopic
pregnancies were treated in the study period from 2005
to 2016, 33 of whom were treated with laparoscopic
cornual resection (3 converted to laparotomy).
Subsequent pregnancy rates beyond gestational week 24 were
equal in both groups (46% [cases] and 54% [controls]).
Cesarean delivery in subsequent pregnancies was more common
among women having undergone cornual resections (60% vs
18%, p = .006).
Only 2 subsequent uterine ruptures were encountered.

33. Retrospective case series of fertility outcomes following laparoscopic resection of
interstitial ectopic pregnancy
Master M*, HardyTSE, Wagaarachchi PTDepartment of Obstetrics and
Gynaecology,Women’s and Children’s Hospital,Austral
Although most papers conclude that laparoscopic
resection of cornual ectopic pregnancy is an
appropriate option for fertility preservation . few
series have reported data regarding pregnancy
outcomes following the procedure. Ng, et al.
published a retrospective review of 53 cases of
laparoscopically treated cornual ectopic
pregnancy.The pregnancy rate was 35% (18
patients).There were no cases of uterine rupture
or dehiscence reported.

34. A Fertility Sparing SurgicalTreatment of Cornual Ectopic
Pregnancy[22K]
Sadek, Seifeldin MD; Ravins, Claudia MD;Vallejo,Victoria MD; Dad, Nimra MD
Two pregnant women diagnosed with cornual ectopic pregnancy were
identified by ultrasound (US). Both were initially treated using methotrexate
(MTX).After the failure of medical treatment, both underwent fertility-
preserving surgery.The pelvis was accessed laparoscopically, 100 ml of
vasopressin (dilution of 1:20) was injected into the myometrium at the base
of the cornual ectopic pregnancy.After blanching of the cornual pregnancy
was observed, using the operative hysteroscope, the cornual pregnancy was
dislodged with alligator grasping forceps. A suction curettage was then
performed, removing products of conception.A Beta-hCG was measured at
postoperative day (POD) 1 and 28.

35. CAESERIAN SCAR PREGNANCY
Eur J ObstetGynecol Reprod Biol 2016 MAY
Reproductive outcomes following cesarean
scar pregnancy - a case series and review of
the literature
Lufen Gao1, Zhongwei Huang2, Xian Zhang3, Na Zhou3, Xinke
Huang3, XiaoyuWang4

36. Most women were able to conceive following CSPs.
Reproductive outcomes included normal intrauterine term
pregnancy, miscarriage, recurrentCSP, and infertility.
Placenta accreta, which could be misdiagnosed antenatally,
was a serious complication in subsequent pregnancies.
Diverticulum or defect in the lower uterine segment could
happen after CSP. Repair of the uterine defect, following a
CSP neither guaranteed the healing of the scar, nor the
ability to ensure a safe pregnancy outcome.Appropriate
counseling to women desiring fertility with a history of CSP
is essential and once they conceive early referral to tertiary
centers for follow up is pertinent.

37. •.
Acta Obstet Gynecol Scand 2020 Oct;99(10):1278-1289.
doi: 10.1111/aogs.13918. Epub 2020 Jun 19.
Reproductive outcome after
cesarean scar pregnancy: A
systematic review and meta-
analysis
Maddalena Morlando1, Danilo Buca2, IlanTimor-
Tritsch3, Giuseppe Cali4 5, Jose Palacios-
Jaraquemada6, Ana Monteagudo7, Asma
Khalil8, Carmen Cennamo1,Viviana La Manna1, Marco
Liberati2, Alice D'Amico2, Luigi Nappi9, Nicola
Colacurci1, Francesco D'Antonio2

38. Forty-four studies (3598 women with CSP) were
included.
CSP recurred in 17.6% of women.
Miscarriage, preterm birth and placenta accreta spectrum disorders
complicated 19.1% (65/341), 10.3% (25/243) and 4.0% of pregnancies,
and 67.0% were uncomplicated.
When stratifying the analysis according to the type of management,
CSP recurred in 21% of women undergoing surgical and in 15.2% of
those undergoing non-surgical management.
Placenta accreta spectrum disorders complicated 4.0% and 12.0% of
cases, respectively.

39. Analysis of the Reproductive Outcome of Patients with Cesarean Scar Pregnancy
Treated by High-Intensity Focused Ultrasound and Uterine Artery Embolization: A
Retrospective Cohort Study
Lixing Chen1, Songshu Xiao1, Xiaogang Zhu1, Sili He1, Min Xue2
Affiliations
Minim Invasive Gynecol Jul-Aug 2019;26(5):883-890.
doi: 10.1016/j.jmig.2018.09.001. Epub 2018 Sep 8.
Between January 2007 andApril 2016, a total
of 650 patients were included, all diagnosed
with CSP and treated by high-intensity
focused ultrasound (HIFU) and uterine artery
embolization (UAE), followed by suction
curettage under hysteroscopic guidance.

40. More attention should be given to subsequent
reproductive outcomes after CSP, not only for
intrauterine pregnancy, but also for infertility
and recurrent CSP. Early diagnosis and
treatment of CSP could reduce the risk of
infertility and recurrent CSP. HIFU seemed to
be superior to UAE in reducing the risk of
recurrent CSP. Patients with CSP should
adhere to strict contraception if they do not
desire more children.

41. Conclusion(s):
Single-dose MTX is a safe first-treatment
choice that does not compromise future
reproductive outcomes in women who are
diagnosed with EP after ART.

42. CONCLUSION
Ectopic pregnancy is prevalent in our
environment affecting mainly young women of
low parity who desire future pregnancies.The
subsequent impact on future fertility of these
women could be improved if efforts are focused
on early diagnosis to prevent tubal rupture.
Early diagnosis prior to rupture offers
opportunity for medical management and
conservative surgical procedures that are proven
to improve future fertility prognosis.

43. CONCLUSION
More than half of the women treated for
ectopic pregnancy spontaneously
conceive and have a normally progressive
pregnancy at 1 year. Fertility depends
more on established patient
characteristics than characteristics of
ectopic pregnancy itself or treatment
thereof.