#PAGE_PARAMS# #ADS_HEAD_SCRIPTS# #MICRODATA#

Hysterosalpingographic evaluation following management of ectopic pregnancy


Hysterosalpingografické vyšetření po léčbě mimoděložního těhotenství

Cíl: Posoudit ipsilaterální a kontralaterální průchodnost vejcovodů pomocí hysterosalpingografie po salpingostomii a léčbě metotrexátem u tubárního těhotenství. Pacientky a metody: Studie byla provedena v období od září 2021 do října 2023. Probíhala na radiologickém a gynekologicko-porodnickém oddělení univerzitních nemocnic Al-Hussin a Al-Azher. Do studie byly zařazeny pacientky, které podstoupily salpingostomii nebo léčbu metotrexátem. Za 3 měsíce po propuštění z nemocnice byly pacientky, které se snažily otěhotnět, znovu vyšetřeny pomocí hysterosalpingografie. Studie se zúčastnily dvě skupiny žen: skupina I (n = 50) podstoupila léčbu metotrexátem, zatímco skupina II (n = 50) podstoupila salpingostomii. Výsledky: Mezi oběma skupinami (léčba medikamenty a chirurgický zákrok) nebyl statisticky významný rozdíl v zachování průchodnosti vejcovodů. Po léčbě metotrexátem byla ipsilaterální průchodnost vejcovodů 72 % a po chirurgickém zákroku 74 %. Kromě toho byla po léčbě metotrexátem průchodnost kontralaterálního vejcovodu 92 % a po salpingostomii 90 %. Závěr: Výsledky ukazují srovnatelnou úspěšnost salpingostomie a metotrexátu v zachování průchodnosti vejcovodů.

Klíčová slova:

neplodnost – metotrexát – mimoděložní těhotenství – salpingostomie – hysterosalpingografie


Authors: Adel Aly Elboghdady 1 ;  Mohamed Ibrahim Mohamed 1 ;  Mohammed Farouk Abd El Azeem Farahat 1 ;  Mohamed Ali Mohamed Mohamed 1 ;  Emad Mohamed Atalla 1 ;  Ahmed Abd Elkader Eltabakh 1 ;  Abdall Khalel Ahmad 1 ;  Yasser Momamed Said Diab 1 ;  Gehad Fawzy Ali Ali Khalil 1 ;  Mai Mohammed Metwally 1 ;  Alshaimaa Rabie El Makawy 1 ;  Adel Mohamed Ghit 1 ;  Ibrahim Mohamed Ibrahim Mohamed Abo Eldahab 1 ;  Fadila Mamdouh Elsayed 2
Authors‘ workplace: Departments of obstetrics and gynecology, Al-Azher University, Cairo, Egypt 1;  Department of radiodia gnosis, Faculty of medicine for girls, Al-Azher University, Cairo, Egypt 2
Published in: Ceska Gynekol 2025; 90(3): 222-225
Category: Original Article
doi: https://doi.org/10.48095/cccg2025222

Overview

Objective: It is to assess the ipsilateral and contralateral tubal patency by hysterosalpingography following salpingostomy and methotrexate therapy for tubal pregnancy. Patients and methods: The study was conducted between September 2021 and October 2023. It was conducted in the radiodiagnosis and obstetrics and gynecology departments of the Al-Hussin and Al-Azher university hospitals. Patients who had undergone salpingostomy or received methotrexate treatment were included in this research. Three months after being discharged, the individuals who were seeking for fertility were assessed again for Fallopian tube patency using hysterosalpingographs. Two groups of women participated in the study: group I (N = 50) received methotrexate treatment, while group II (N = 50) had undergone salpingostomy management. Results: The two groups (medical and surgery) did not vary statistically significantly in preserving tubal patency. Following methotrexate therapy, the ipsilateral tubal patency was 72%, and following surgical management, it was 74%. Furthermore, following methotrexate therapy, contralateral tubal patency was 92%, and 90% following salpingostomy. Conclusion: The results point to comparable success rates with salpingostomy and methotrexate in preserving fallopian tube patency.

Keywords:

infertility – Methotrexate – ectopic pregnancy – salpingostomy – hysterosalpingography

Introduction

The term “ectopic pregnancy“ (EP) refers to implantation of the conceptus outside the normal uterine cavity. Fallopian tube accounts for 95.5% of all implantation sites, with ovarian (3.2%) and abdominal (1.3%) sites following closely behind. Early pregnancy deaths in the world are primarily caused by EP. Studies have shown that case fatality rates (1–3%) from EP were 10-times greater in underdeveloped African nations than they were in wealthy nations [1].

Methotrexate is a folic acid antagonist used in chemotherapy that combines with the enzyme tetrahydrofolate reductase to produce an antimetabolite effect. It prevents the synthesis of pyrimidine and purine bases, which are necessary for the synthesis of DNA and RNA. It works on cells that replicate quickly, such as pregnancy’s trophoblastic cells. For EP, systemic methotrexate is a secure and efficient therapy. Methotrexate is less intrusive, less expensive, and avoids anaesthesia as compared to surgery. In cases of ectopic pregnancy, methotrexate has helped to reduce the disease burden by providing a nonsurgical, fertility-preserving treatment option for about 25% of women [2].

We conducted this study to fill the data gap and provide an overview of tubal patency after using medical treatment for ectopic pregnancy instead of surgical methods. Variable results are present regarding tubal patency after methotrexate treatment of unruptured ectopic pregnancy, with lacking published studies held in Egypt.

Patients and methods

Over the course of two years, women receiving either salpingostomy or methotrexate treatment were included in the research. The study was conducted between September 2021 and October 2023. It was conducted in the radiodiag- nosis and obstetrics and gynecology departments of the Al-Hussin and Al-Azher university hospitals. Three months after being discharged, hysterosalpingography (HSG) reevaluated the fallopian tube patency of the individuals seeking fertility. Two groups of women participated in the study: group I (N = 50) received methotrexate treatment, while group II (N = 50) received salpingostomy treatment.

Patients with a diagnosis of tubal pregnancy who are treated with salpingostomy or methotrexate alone, without a history of pelvic infections within three months of therapy, or who have had no laparotomy, are eligible for inclusion. HSG was performed using balloon-tipped catheters while being seen fluoroscopically. If the dye did not appear to leak out the tubal end, an anomaly was noted.

 

Statistical analysis

SPSS for Windows 20.0 must be used for analysis. For numerical parametric variables, data should be displayed as range, mean, and standard deviation; for numerical non-parametric variables, range, median, and interquartile range; and for categorical variables, number and percentage. The mean difference and its 95% CI can be used to evaluate the difference between two independent groups. The two groups were compared using the T-test and the Chi-squared test. Significant results were defined as P < 0.05 and very significant results as P < 0.001.

 

Results

Fifty cases were treated by methotrexate (group I) while 50 were managed surgically by salpingostomy (group II) (Tab. 1–3).

1. Comparison between the two studied groups as regards demographic data and the tubal patency (ipsilateral and contralateral tubes) after treatment (outcome).
Comparison between the two studied groups as regards demographic data and the tubal patency (ipsilateral and contralateral tubes) after treatment (outcome).

2. Comparison between rates of ipsilateral tubal occlusion among cases in group I as regards the number of doses of methotrexate.
Comparison between rates of ipsilateral tubal occlusion among cases in group I as regards the number of doses of methotrexate.

3. Comparison between rate of patency in the ipsilateral and contralteral tubes in group II as regards the method of salpingiostomy.
Comparison between rate of patency in the ipsilateral and contralteral tubes in group II as regards the method of salpingiostomy.

Discussion

In our study, group I treated with methotrexate, had a mean age of 32.7 years (± 2.8 standard deviation – SD) and a mean parity of 1.8 (± 0.8 SD). In contrast, group II, treated with surgery, had a mean age of 32.6 years (± 2.1 SD) and a mean parity of 1.6 (± 0.7 SD). In terms of mean age and mean parity, smoking, occupation, previous pelvic inflammatory disease (PID), previous septic miscarriage, previous pelvic operations and history of infertility, there was no statistically significant difference between the two groups under investigation (Tab. 1).

According to the current study, 28% of patients had ipsilateral obstructed tubes and 72% of patients had patent tubes in group I and 26% and 74% resp. in group II. Additionally, 8% of patients had a contralateral tubal block in group I and 10% in group II. This may be because methotrexate (MTX) treatment kills cells that proliferate quickly, such as trophoblastic cells, leaving behind lesion or tissue remains in the Fallopian tube that have the potential to obstruct the tube. Additionally, the inflammatory response at the implantation site may cause intratubal adhesions that impair tubal patency, which would account for the frequency of ipsilateral tubal block. On the other hand, a contralateral tubal block may result from a tubal illness that developed before to the present pregnancy, such as PID, salpingitis, or prior surgery.

The results of this trial were in line with those of a previously published one, in which methotrexate therapy increased ipsilateral tube patency to 84% and contralateral tubal patency to 97% [3]. According to earlier studies, women using methotrexate had a general ipsilateral tubal patency percentage of 66.7% (26/39) [4].

Higher rates of tubal patency (97.5%) following combination systemic and local methotrexate treatment were found in a previous research. Different treatment approaches account for this variation in outcome [5].

9/100 of participants in the current research experienced hydrosalpinx. These results were in line with the previously cited study, which showed that 9 (6.3%) of the patients had tubal patency but with a non-obstructive hydrosalpinx defect [6]. Moreover, 5% of participants had septic miscarriages. 17% of patients reported having had prior pelvic surgery. No patient reported having had an ectopic pregnancy in the past.

The two groups’ ectopic pregnancy risk variables were contrasted. In terms of prior PID or laparotomy, the two groups were contrasted. Although group II has a larger proportion of PID than group I, the statistical difference is not statistically significant. Although group II had more laparotomies than group I, the statistical difference is not statistically significant. The prior history of infertility for the two groups was compared. Group I has a higher percentage of infertility than Group I, however the statistical difference is not statistically significant (Tab. 1).

Between the two groups, the ipsilateral tube’s patency was evaluated. Between the two groups under investigation, there is no statistically significant variation in the frequencies of tubal patency and occlusion following therapy. Up to 72% of tubal patency patients treated with parenteral MTX were found in systematic evaluations covering. Methotrexate treatment administered once at a dosage of 50 mg/M2 of surface area is used to treat. Additionally, Stoval reported that 82.6% of patients receiving methotrexate had ipsilateral tubal patency. Human chorionic gonadotropin (hCG) levels dropped quickly following surgery in a small randomised trial comparing linear salpingostomy with ultrasound-guided intratubal methotrexate injection, showing comparable success rates and tubal patency [7].

Comparable tubal patency of 90% and 92%, resp., were found by Hajenius et al. in patients treated with linear salpingostomy and those undergoing a single dose of methotrexate [8]. Additionally, comparable trials like Guven et al. [9] and Elito et al. [10] reported tubal patency rates of 84% and 83.9%, resp. As to the findings of the 2004 study by Fujishita et al., 90% of salpingostomies without tubal suturing and 94% of salpingostomies with tubal suturing had tubal patency [11].

According to Colacurci et al., bilateral tubal patency was found in 60% of cases and 90% of cases if hCG was greater than 10,000 U/L [12]. The percentages of ipsilateral tubal patency following salpingostomy were 68%, 64%, and 80%, resp., in many researches [13–15]. In a related research, Olofsson et al. found comparable patency rates following surgery and methotrexate [16].

The contralateral tube was evaluated in the two groups, and although the rate of blockage is lesser among those receiving medical therapy, the statistical difference is not statistically significant. The contralateral tube had a 56.7% patency rate in the Guven et al. study [9]. A similar 81.5% of findings were obtained by Langer et al. in 1990 [17].

It was determined how often instances in group I had blockage in relation to the quantity of methotrexate dosages. More patent tubes were found in cases involving a single dose, and the statistical difference was not significant. This is inconsistent with the findings of Guven et al., who reported that tubal patency following a single dose of methotrexate was 83.9%, while tubal patency following multiple doses of methotrexate was 56.7%. Additionally, he stated that multiple doses of methotrexate had a detrimental effect on tubal patency [9].

In group II, the rate of occlusion in the afflicted and contralateral tubes is evaluated in relation to the salpingostomy route. Greater risk of occlusion in instances involving laparotomies, however statistically there is no difference. This is consistent with Vermesh et al., who found no discernible difference between the two groups’ tubal patency rates of 89% following laparoscopy and 80% following laparotomy [15]. On the other hand, compared to traditional conservative surgery, laparoscopic treatment of ectopic pregnancy leads in less deterioration of the pelvic state [18].

Conclusion

As a result, there was no discernible variation in the groups’ ipsilateral and contralateral tube patency. These findings demonstrate that the effects of surgery (salpingectomy) and therapeutic therapy (MTX or expectant management) on tubal patency are identical.


Sources
1. Aboelroose AA, Eldein AM, Ahmed WA et al. Hysterosalpingography for tubal patency after methotrexate therapy for ectopic pregnancy. Int J Pregn Chi Birth 2020; 6 (3): 76–79. doi: 10.15406/ipcb.2020.06.00201.
2. Bedoui Y, Guillot X, Sélambarom J et al. Methotrexate an old drug with new tricks. Int J Mol Sci 2019; 20 (20): 5023. doi: 10.3390/ijms202 05023.
3. Elito J, Han KK, Camano L. Tubal patency after clinical treatment of unruptured ectopic pregnancy. Int J Gynaecol Obstet 2005; 88 (3): 309–313. doi: 10.1016/j.ijgo.2004.12.018.
4. Soliman AT, Salem HA. Unruptured tubal ectopic pregnancy: conservative laparoscopy or methotrexate? EBWJ 2014; 4 (4): 179–183. doi: 10.1097/01.EBX.0000456495.64710.98.
5. Debby A, Golan A, Sadan O et al. Fertility outcome following combined methotrexate treatment of unruptured extrauterine pregnancy. BJOG 2000; 107 (5): 626–630. doi: 10.1111/j.1471-0528.2000.tb13304.x.
6. Garcia Grau E, ChecaVizcaíno MÁ, Oliveira M et al. The value of hysterosalpingography following medical treatment with methotrexate for ectopic pregnancy. Obstet Gynecol Int 2011; 2011: 547946.
7. Stovall TG, Ling FW. Single-dose methotrexate: an expanded clinical trial. Am J Obstet Gynecol 1993; 168 (6 Pt 1): 1759–1765. doi: 10.1016/0002-9378 (93) 90687-e.
8. Hajenius A, Engelsbel D, Mol C et al. Randomised trial of systemic methotrexate versus laparoscopic salpingostomy in tubal pregnancy. Lancet 199; 350 (9080): 774–779. doi: 10.1016/s0140-6736 (97) 05487-1.
9. Guven ES, Dilbaz S, Dilbaz B et al. Comparison of the effect of single-dose and multiple-dose methotrexate therapy on tubal patency. Fertil Steril 2007; 88 (5): 1288–1292. doi: 10.1016/j.fertnstert.2006.12.059.
10. Elito Junior J, Han KK, Camano L. Tubal patency following surgical and clinical treatment of ectopic pregnancy. Sao Paulo Med J 2006; 124 (5): 264–266. doi: 10.1590/s1516-318020 06000500005.
11. Fujishita A, Masuzaki H, Khan KN et al. Laparoscopic salpingotomy for tubal pregnancy: comparison of linear salpingotomy with and without suturing. Hum Reprod 2004; 19 (5): 1195–1200. doi: 10.1093/humrep/deh196.
12. Colacurci N, Zarcone R, de Franciscis P et al. Tubal patency after laparoscopic treatment of ectopic pregnancy. Panminerva Med 1998; 40 (1): 45–47.
13. Spalding H, Tekay A, Martikainen H et al. Assessment of tubal patency with transvaginal salpingosonography after treatment for tubal pregnancy. Hum Reprod 1997; 12 (2): 306–309. doi: 10.1093/humrep/12.2.306.
14. Keckstein G, Wolf AS, Hepp S et al. Tube-preserving endoscopic surgical procedures in unruptured tubal pregnancy. What significance does laser use have? Geburtshilfe Frauenheilkd 1990; 50 (3): 207–211. doi: 10.1055/ s-2007-1026464.
15. Vermesh M, Silva PD, Rosen GF et al. Management of unruptured ectopic gestation by linear salpingostomy: a prospective, randomized clinical trial of laparoscopy versus laparotomy. Obstet Gynecol 1989; 73 (3 Pt 1): 400–404.
16. Olofsson JI, Poromaa IS, Ottander U et al. Clinical and pregnancy outcome following ectopic pregnancy; a prospective study comparing expectancy, surgery and systemic methotrexate treatment. Acta Obstet Gynecol Scand 2001; 80 (8): 744–749. doi: 10.1034/j.1600-0412. 2001.080008744.x.
17. Langer R, Raziel A, Ron-El R et al. Reproductive outcome after conservative surgery for unruptured tubal pregnancy – a 15-year experience. Fertil Steril 1990; 53 (2): 227–231. doi: 10.1016/s0015-0282 (16) 53271-3.
18. Lundorff P, Hahlin M, Källfelt B et al. Adhesion formation after laparoscopic surgery in tubal pregnancy: a randomized trial versus laparotomy. Fertil Steril 1991; 55 (5): 911–915. doi: 10.1016/s0015-0282 (16) 54298-8.
ORCID of authors
A. A. Elboghdady 0009-0005-7574-4877
M. I. Mohamed 0009-0003-0588-2321
M. F. Abd El Azeem 0009-0003-6655-9122
M. A. M. Mohamed 0009-0007-0705-895X
E. M. Atalla 0009-0003-7933-2381
A. A. E. Eltabakh 0009-0009-6886-6349
A. K. Ahmad 0009-0002-5504-6084
Y. M. S. Diab 0009-0008-6905-1689
G. F. Khalil 0009-0001-8604-4551
M. M. Metwally 0009-0007-6803-2470
A. S. R. El Makawy 0009-0002-3457-6641
I. M. I. M. Abo Eldahab 0009-0003-0396-8914
A. M. Ghit 0009-0005-2626-5431
F. M. Elsayed 0009-0007-3393-9742
Submitted/Doručeno: 18. 12. 2024
Accepted/Přijato: 24. 1. 2025
Adel Aly Elboghdady, MD
Department of obstetrics and gynecology
Al-Azher university
377J+VHW
43910050 Cairo
Egypt
Labels
Paediatric gynaecology Gynaecology and obstetrics Reproduction medicine
Login
Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.

Login

Don‘t have an account?  Create new account

#ADS_BOTTOM_SCRIPTS#