What is the most appropriate procedure for a 7-week pregnant patient with a 4-cm right-sided ectopic pregnancy and a left tubal hydrosalpinx, who conceived through in-vitro fertilization (IVF)?

Surgical Management of Ectopic Pregnancy with Concurrent Hydrosalpinx in IVF Patient

The most appropriate procedure is excision of both tubes (bilateral salpingectomy). This patient requires removal of the right tube containing the 4-cm ectopic pregnancy AND removal of the left hydrosalpinx to optimize future IVF success rates.

Rationale for Bilateral Salpingectomy

Management of the Right-Sided Ectopic Pregnancy

• Salpingectomy is preferred over salpingostomy for this 4-cm ectopic pregnancy because the size increases risk of persistent trophoblast (7% with salpingostomy vs <1% with salpingectomy) and repeat ectopic pregnancy (8% vs 5%) 1

• Salpingostomy offers no fertility advantage when the contralateral tube is present, as demonstrated by the ESEP trial showing identical ongoing pregnancy rates (60.7% vs 56.2%, p=0.678) between salpingostomy and salpingectomy 1

• The patient conceived via IVF, indicating she will require ART for future pregnancies, making tubal preservation functionally irrelevant since IVF bypasses tubal function entirely 2

• 20% of attempted salpingostomies require conversion to salpingectomy due to persistent bleeding, adding unnecessary surgical risk 1

Critical Importance of Removing the Left Hydrosalpinx

• Hydrosalpinx significantly impairs IVF outcomes through mechanical and chemical disruption of the endometrial environment, reducing implantation and pregnancy rates 3

• Current guidance mandates salpingectomy of hydrosalpinx before IVF treatment to optimize success rates 3

• This patient will require IVF for future pregnancies (she already conceived through IVF), making the diseased left tube not only non-functional but actively detrimental to her reproductive outcomes 3

• Leaving the hydrosalpinx would necessitate a second surgery before future IVF attempts, exposing the patient to additional anesthetic and surgical risks 3

Why Other Options Are Inappropriate

Option A (Right Salpingostomy Alone) - Incorrect

• Fails to address the hydrosalpinx, which will impair future IVF success and require subsequent surgery 3

• Salpingostomy provides no fertility benefit when future conception will occur via IVF rather than natural conception 1

• Carries 7% risk of persistent trophoblast requiring methotrexate treatment, potentially delaying future fertility treatments 1

Option C (Intraoperative Methotrexate Injection) - Incorrect

• No established role for intraoperative methotrexate in surgical management of ectopic pregnancy 4

• Methotrexate is a medical (non-surgical) treatment option that would have been considered before proceeding to laparoscopy 4

• Does not address the hydrosalpinx, leaving the patient with impaired future IVF outcomes 3

Surgical Approach Considerations

• Laparoscopy is the preferred surgical approach over laparotomy for ectopic pregnancy management 4, 5

• Surgery during pregnancy requires specific precautions: left lateral tilt positioning, low intra-abdominal pressure (10-13 mmHg), procedures limited to 90-120 minutes when possible, and experienced surgical team 6

• The concurrent intrauterine pregnancy at 7 weeks requires careful surgical technique to minimize risk to the viable pregnancy, though the laparoscopic approach has been associated with fewer fetal adverse effects than laparotomy 6

Common Pitfalls to Avoid

• Do not preserve tubes "for fertility" in IVF patients - this represents outdated thinking that fails to recognize ART bypasses tubal function 3, 1

• Do not defer hydrosalpinx removal - addressing it at the time of ectopic surgery prevents need for subsequent operation 3

• Do not attempt salpingostomy for large (4-cm) ectopic pregnancies - higher failure rates and conversion to salpingectomy 1