What is the most appropriate procedure for a 7-week pregnant patient with a right-sided 4-cm ectopic pregnancy achieved through in-vitro fertilization (IVF)?

Surgical Management of 4-cm Ectopic Pregnancy in IVF Patient

The most appropriate procedure is right-sided salpingectomy alone (Option B). 1

Rationale for Salpingectomy Over Salpingotomy

In this IVF patient, bilateral tubal function is irrelevant for future fertility since she will require assisted reproductive technology for any subsequent pregnancies, making tubal preservation functionally unnecessary. 1 The patient conceived through IVF, which bypasses fallopian tube function entirely, eliminating any reproductive benefit from conservative tubal surgery. 1

Size and Surgical Considerations

• The 4-cm ectopic pregnancy is relatively large, making salpingotomy technically more challenging and associated with higher failure rates. 2
• Salpingectomy provides definitive treatment with lower risk of persistent ectopic pregnancy compared to salpingotomy. 3
• While salpingotomy can result in persistent ectopic pregnancy requiring additional treatment (methotrexate or repeat surgery), salpingectomy removes this risk entirely. 3

Why Other Options Are Inappropriate

Option A (Salpingotomy Alone) - Incorrect

• Salpingotomy is reserved for patients desiring natural conception who have normal contralateral tubes. 4, 5
• This patient requires IVF for conception, making tubal preservation unnecessary. 1
• The 4-cm size increases risk of incomplete removal and persistent ectopic pregnancy after salpingotomy. 2, 3

Option C (Bilateral Salpingectomy) - Incorrect

• There is no indication to remove the contralateral healthy left tube. 1
• While some fertility specialists advocate prophylactic bilateral salpingectomy before IVF in patients with hydrosalpinx (which can reduce IVF success rates), this scenario involves an acute ectopic pregnancy requiring urgent surgical management, not elective fertility optimization. 1
• The question provides no evidence of left tubal pathology requiring removal. 1

Option D (Intraoperative Methotrexate) - Incorrect

• Intraoperative methotrexate injection into the ectopic mass is not standard practice and lacks strong evidence support. 6
• Systemic methotrexate is contraindicated once surgical intervention has begun. 6, 5
• At 4 cm with surgical intervention already planned, complete surgical excision (salpingectomy) is more definitive. 5, 2

Surgical Technique Considerations

The laparoscopic approach should be used with specific precautions given the concurrent 7-week intrauterine pregnancy (if this is a heterotopic pregnancy scenario). 1 Key technical points include:

• Maintain low intra-abdominal insufflation pressure to minimize fetal risk. 1
• Limit procedure duration to 90-120 minutes when possible. 1
• Use left lateral tilt positioning to optimize uteroplacental perfusion. 1
• Ensure experienced surgical team familiar with pregnancy-related physiologic changes. 1

Post-Operative Monitoring

• Serial β-hCG levels should be monitored to confirm resolution (should decline to undetectable). 5, 3
• If β-hCG plateaus or rises postoperatively, consider persistent ectopic tissue (rare after salpingectomy but reported) requiring methotrexate. 3
• Monitor the intrauterine pregnancy (if heterotopic) with ultrasound to confirm ongoing viability. 7

The definitive answer is right-sided salpingectomy alone, which provides complete removal of the ectopic pregnancy while preserving the contralateral tube and avoiding unnecessary intervention on healthy tissue. 1, 5