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

Surgical Management of Ectopic Pregnancy in IVF Patient

For this 7-week pregnant patient with a 4-cm right-sided ectopic pregnancy who conceived through IVF, right-sided salpingectomy alone (Option B) is the most appropriate procedure. 1

Rationale for Salpingectomy in IVF Patients

The key principle is that bilateral tubal function is irrelevant for future fertility in patients who conceived through IVF, as they will require assisted reproductive technology for any subsequent pregnancies, making tubal preservation functionally unnecessary. 1

• IVF bypasses tubal function entirely, so preserving the affected fallopian tube offers no reproductive advantage 1, 2
• Salpingectomy eliminates the risks associated with salpingotomy without compromising future fertility prospects in this population 1

Why Other Options Are Inappropriate

Option A: Right-sided Salpingotomy Alone - NOT Recommended

• Salpingotomy is designed to preserve tubal function for patients who desire spontaneous conception 3, 4
• In IVF patients, tubal preservation is functionally unnecessary since future pregnancies will require ART 1
• Salpingotomy carries a 7% risk of persistent trophoblast requiring additional methotrexate treatment, compared to <1% with salpingectomy 3
• The repeat ectopic pregnancy rate is 8% after salpingotomy versus 5% after salpingectomy 3
• Even in patients desiring spontaneous conception with a healthy contralateral tube, salpingotomy does not significantly improve fertility outcomes compared to salpingectomy (60.7% vs 56.2% cumulative ongoing pregnancy rate, p=0.678) 3

Option C: Excision of Both Right and Left Tubes - NOT Indicated

• Bilateral salpingectomy is not indicated as there is no evidence of contralateral tubal pathology requiring removal 1
• The left tube shows no abnormality on ultrasound and should be preserved 1

Option D: Intraoperative Methotrexate Injection - NOT Standard Practice

• Intraoperative methotrexate injection into the ectopic mass is not standard practice and lacks strong evidence support 1
• Methotrexate is typically reserved for medical management of unruptured ectopic pregnancies or for persistent trophoblast after salpingotomy 5

Important Surgical Considerations for Pregnant Patients

Because this patient has a concurrent 7-week intrauterine pregnancy (heterotopic pregnancy), specific laparoscopic precautions are essential:

• Use low intra-abdominal insufflation pressure to minimize effects on uteroplacental perfusion 1
• Limit procedure duration to 90-120 minutes when possible 2
• Position patient in left lateral tilt to optimize uteroplacental perfusion 1
• Ensure experienced surgical team familiar with managing pregnant patients 2
• Laparoscopic approach has been associated with fewer fetal adverse effects than laparotomy 2

Post-Operative Management

• Monitor the intrauterine pregnancy with ultrasound to confirm ongoing viability 1
• No additional methotrexate therapy is needed after salpingectomy, unlike salpingotomy where 7% of patients require it for persistent trophoblast 3

Common Pitfall to Avoid

Do not default to salpingotomy based on the outdated assumption that preserving both tubes improves fertility. The landmark ESEP trial definitively demonstrated that in women with a healthy contralateral tube, salpingotomy does not improve fertility outcomes compared to salpingectomy, while exposing patients to higher risks of persistent trophoblast (7% vs <1%) and potentially higher repeat ectopic pregnancy rates 3. In IVF patients specifically, this consideration becomes entirely moot since tubal function is bypassed by assisted reproduction 1.