What is the most appropriate surgical procedure for a 32-year-old patient with a 4-cm unruptured right-sided ectopic pregnancy who desires to preserve fertility?

Management of Ectopic Pregnancy: Right-Sided Salpingectomy is the Most Appropriate Procedure

Right-sided salpingectomy alone (option B) is the most appropriate procedure for this 32-year-old patient with a 4-cm right-sided ectopic pregnancy who became pregnant through IVF.

Rationale for Salpingectomy

The decision for surgical management of ectopic pregnancy depends on several key factors:

1. Size of the ectopic pregnancy: At 4 cm, this is a relatively large ectopic pregnancy, which increases the risk of rupture and hemorrhage.

2. Fertility considerations:

   • This patient conceived through IVF, indicating pre-existing fertility issues
   • Future pregnancies will likely also require IVF assistance
   • Preserving the fallopian tube through salpingotomy offers no fertility advantage when IVF is the planned method of conception

3. Risk of persistent trophoblastic tissue:

   • Salpingotomy carries a significantly higher risk of persistent trophoblastic tissue (7% vs <1% with salpingectomy) 1
   • This would require additional treatment and monitoring

Why Not Other Options?

• Salpingotomy alone (option A): Not recommended because:

  • Higher risk of persistent trophoblastic tissue (7% vs <1%) 1
  • No proven fertility benefit over salpingectomy when the contralateral tube is healthy 1
  • The 4-cm size increases technical difficulty and bleeding risk during salpingotomy

• Excision of both tubes (option C): Unnecessarily aggressive when only the right tube contains the ectopic pregnancy. Removing the healthy left tube would eliminate any possibility of spontaneous conception.

• Intraoperative methotrexate injection (option D): Not standard practice for surgical management of ectopic pregnancy. When surgery is performed, complete removal of ectopic tissue is preferred to avoid persistent trophoblastic tissue.

Surgical Approach

• Laparoscopic approach is appropriate as mentioned in the case
• Complete removal of the right fallopian tube including the proximal isthmus (but not the interstitial portion) 2
• Care should be taken not to damage the vascular supply to the right ovary 2

Post-Surgical Considerations

• Monitor β-hCG levels until undetectable to ensure complete resolution
• Be vigilant for signs of persistent trophoblastic tissue, which can occur rarely even after salpingectomy 3
• Future fertility will likely require continued IVF treatment
• The patient should be counseled that the risk of recurrent ectopic pregnancy is approximately 5-8% in subsequent pregnancies 1

Conclusion

For this 32-year-old patient with a 4-cm right-sided ectopic pregnancy who conceived through IVF, right-sided salpingectomy alone provides the optimal balance of safety and effectiveness. This approach minimizes the risk of persistent trophoblastic tissue while not compromising future fertility options through IVF.