About 2% of pregnancies are ectopic, representing 15,000 women annually in France. They represent the development of the egg outside the uterus which can endanger the woman’s life in the absence of medical intervention. In developed countries, mortality linked to an ectopic pregnancy remains the exception; doctors are therefore interested in preserving subsequent fertility and thus the possibility for the women in question to become pregnant again. For the first time, researchers in the Inserm “Epidemiology of reproduction and infant development” team (Unit 1018 at the “Centre for Research in Epidemiology and Population Health”) compared all of the existing treatments for ectopic pregnancy with respect to their impact on natural fertility during the subsequent two years.
The conclusions of the study reproduced in the journal Human Reproduction indicate that the ability to have a normal pregnancy after an ectopic pregnancy (subsequent fertility) is not linked to the type of treatment, especially the conservation of the Fallopian tube in which the pregnancy was implanted
In 95% of cases, an ectopic pregnancy is implanted in a Fallopian tube. This is a medical emergency. The treatment consists in interrupting the growth of the egg and removing it. Three types of treatment may be used:
– Medical treatment by injection (intramuscular or directly into the tube) of methotrexate which destroys the egg and eliminates the ectopic pregnancy without damaging the tube.
– A so-called “conservational” surgical treatment in which the tube is incised to remove the egg, preserving the tube.
– A so called “radical” surgical treatment in which the tube is removed with the egg.
Each of these treatments successfully eliminates the ectopic pregnancy, and, thanks to the improvements in diagnosis, the woman’s life is hardly ever in danger in developed countries. The objective of doctors is thus the preservation of the woman’s subsequent fertility.
Depending on the gravity and urgency of the case, two types of situations could occur:
– on the one hand, so-called inactive ectopic pregnancies for which medical or surgical treatment may be decided
– on the other hand, so-called active ectopic pregnancies for which surgical treatment is necessary which may be conservational or radical.
For the first time in a single therapeutic trial, the Inserm researchers compared the fertility of women two years after the various treatments.
For this purpose, the researchers included women presenting with an ectopic pregnancy that was treated in the 17 French centres that took part in the study between 2005 and 2009. Just over 400 women were divided into two groups depending on the activeness (and seriousness) of the ectopic pregnancy. In each group, one of two possible treatments were selected through drawing lots and the women were then monitored for two years.
In the second group, two years after treatment, 70% of the women who wanted to become pregnant again were able to achieve an intra-uterine pregnancy after conservation surgery and 64% after radical surgical treatment.
For the researchers, the results of this trial are an invitation to gynæcologists to reconsider the treatment they offer for ectopic pregnancies, taking account of the various factors governing subsequent fertility, the length of follow-up after treatment and patient preference as well as the risks inherent in each of the treatments.
As far as Perrine Capmas is concerned, “medical treatment should be prioritised in the case of an inactive ectopic pregnancy due on the one hand to patient preference but also to the lesser risk especially thanks to the absence of anæsthesia and surgery. In view, however of the absence of difference regarding subsequent fertility, surgical treatment should be offered initially to women who, it is feared, might not to stick to the treatment (supervision after medical treatment can be extended for several weeks)”.
“In the case of ectopic pregnancies that require surgical treatment, doctors can reassure women that even radical surgery will not alter their chances of subsequently having a natural pregnancy”.
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