What are the Treatments?
Once an ectopic is diagnosed, there are several different treatments. It is not possible to take the pregnancy from the tube and put it into the womb. The options are as follows:
- Expectant management – a proportion of all ectopics will not progress to tubal rupture, but will regress spontaneously and be slowly absorbed. This may be appropriate if the level of hCG is falling and a woman is clincally well.
- Medical treatment – with a drug called methotrexate, which is given by injection. This makes the ectopic pregnancy shrink away by stopping the cells dividing. Only a few ectopics can be treated this way, which is the least invasive. Certain criteria must be fulfilled, such as small diameter of the ectopic and low level of hCG. Close follow-up with further scans and blood tests is also necessary.
- Laparoscopic surgery – via ‘keyhole’ surgery, it may be possible to either open the tube and remove the pregnancy (salpingotomy), or remove the tube altogether (salpingectomy). The decision on which of these options is taken is very specific to each patient. Follow-up with blood tests for hCG will more than likely be needed as persistant ectopic tissue can occur in 5% to 10% of patients.
- Open surgery (laparotomy) – this involves a 5cm incision at the top of the pubic hairline. The affected tube is brought out and either salpingotomy or salpingectomy performed.
- Repeat Methotrexete–further treatment for ectopic pregnancy.
What About Further Pregnancies?
Of course in the future one may wish to try again for a pregnancy. As mentioned above, after having an ectopic pregnancy, a woman is at risk of it happening again (though it is more likely that the next pregnancy will be in the right place).
All the above treatments have been evaluated in clincal studies to see what the subsequent pregnancy rate is like. It is very difficult to compare these exactly as every case is different, not all women try for a further pregnancy again and surgeons use different techniques.
What does come out of this is that methotrexate, open surgery and laparoscopic surgery all have pretty similar rates of subsequent normal (intrauterine) pregnancy.
The risk of another ectopic depends on several factors, in particular the type of surgery that has taken place, the presence of any damage to the other tube and whether there were any difficulties conceiving first time around.
Studies that compare removing the tube (salpingectomy) with opening it at the time of surgery and removing the pregnancy (salpingostomy) have found that when the other factors above have been controlled for, the risk of repeat ectopic is about 9% if the tube is removed and 12% if the tube is left behind.
There is no difference in outcome whether the operation was an open one or key-hole surgery was used (laparoscopy), but recovery is certainly quicker with the key-hole option.