Correspondence

Treatment of Ectopic Pregnancy

N Engl J Med 2001; 344:384-385February 1, 2001

Article

To the Editor:

Lipscomb et al. (Nov. 2 issue)1 describe medical treatment for ectopic pregnancy almost as a stand-alone approach, which may leave nongynecologists with the wrong impression. For balanced decision making, several factors should be considered.

If the serum human chorionic gonadotropin level exceeds 4000 mIU per milliliter, the ectopic pregnancy should be treated laparoscopically, as should an ectopic pregnancy with a mass larger than 3.5 to 4.0 cm in diameter.2 At the other extreme, if the human chorionic gonadotropin level is below 2000 mIU per milliliter, the ectopic pregnancy may regress spontaneously.3 Medical treatment may thus erroneously be deemed very effective, which explains in part the difference in efficacy between parenteral and direct intratubal injection.4 Although ultrasonography is highly accurate in diagnosing ectopic pregnancy,2 there remains the possibility of a regressing intrauterine pregnancy.

Hajenius et al. concluded on the basis of the Cochrane Database5 that systemic treatment with methotrexate administered as a single intramuscular injection is less effective than laparoscopic salpingostomy, whereas multiple intramuscular doses have a similar efficacy but are associated with a greater impairment of the health-related quality of life. Systemic methotrexate therapy is also more expensive because of surgical interventions for tubal rupture, prolonged hospitalization, and loss of productivity. Only with a low initial level of human chorionic gonadotropin does systemic methotrexate therapy lead to cost savings, as compared with laparoscopic salpingostomy. There is also evidence that salpingectomy does not impair future fertility, as compared with salpingostomy, and eliminates the possibility of residual products of conception after surgery. We suggest that the choice between surgery and medical treatment should be left to the patient and should be based on her preferences and her perception of the risks associated with each of the options.

Eliezer Shalev, M.D.
Izhar Ben-Shlomo, M.D.
Haemek Medical Center, Afula 18101, Israel

5 References

1. 1

   Lipscomb GH, Stovall TG, Ling FW. Nonsurgical treatment of ectopic pregnancy. N Engl J Med 2000;343:1325-1329
   Full Text | Web of Science | Medline

2. 2

   Shalev E, Yarom I, Bustan M, Weiner E, Ben-Shlomo I. Transvaginal sonography as the ultimate diagnostic tool for the management of ectopic pregnancy: experience with 840 cases. Fertil Steril 1998;69:62-65
   CrossRef | Web of Science | Medline

3. 3

   Shalev E, Peleg D, Tsabari A, Romano S, Bustan M. Spontaneous resolution of ectopic tubal pregnancy: natural history. Fertil Steril 1995;63:15-19
   Web of Science | Medline

4. 4

   Shalev E, Peleg D, Bustan M, Romano S, Tsabari A. Limited role for intratubal methotrexate treatment of ectopic pregnancy. Fertil Steril 1995;63:20-24
   Web of Science | Medline

5. 5

   Hajenius PJ, Mol BW, Bossuyt PM, Ankum WM, Van Der Veen F. Interventions for tubal ectopic pregnancy. Cochrane Database Syst Rev 2000;2:CD000324 (software)-CD000324 (software)
   

Author/Editor Response

Dr. Lipscomb replies:

To the Editor: Since the focus of our review was the nonsurgical management of ectopic pregnancy, we did not attempt to discuss all other appropriate treatment methods. The available data do not conclusively favor any particular approach, either surgical or medical, and we certainly concur with Shalev and Ben-Shlomo that surgical options should be considered and discussed with the patient. The choice of treatment for a particular patient must reflect not only the patient's desires and the characteristics of the disorder but also the physician's level of comfort, surgical ability, and experience with each of these approaches.

Gary H. Lipscomb, M.D.
University of Tennessee, Memphis, TN 38163