What is the most appropriate procedure for a 7-week pregnant patient with a right-sided 4-cm 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 right and left tubes (bilateral salpingectomy), Option C. 1

Primary Rationale

Since this patient conceived through IVF, she will require assisted reproductive technology for all future pregnancies, making tubal preservation functionally irrelevant as IVF bypasses tubal function entirely. 1 This fundamentally changes the surgical decision-making compared to patients desiring natural conception.

Management of the Right-Sided Ectopic Pregnancy

• The 4-cm right tubal ectopic pregnancy requires complete removal of the affected tube 2
• Salpingectomy (not salpingotomy) is the definitive treatment that eliminates risk of persistent ectopic pregnancy 3
• Partial salpingectomy should be avoided as tubal remnants pose risk for recurrent ectopic pregnancy 4
• Salpingotomy (Option A) would be inappropriate as it leaves diseased tubal tissue and increases risk of persistent ectopic pregnancy, particularly problematic given the concurrent intrauterine pregnancy 3

Management of the Left-Sided Hydrosalpinx

The left hydrosalpinx should be removed concurrently because hydrosalpinx significantly reduces IVF success rates through mechanical and chemical disruption of the endometrial environment. 5

• Women with hydrosalpinges have lower implantation and pregnancy rates in ART 5
• Current guidance recommends removal of hydrosalpinx by salpingectomy (preferably laparoscopically) before IVF treatment 5
• Since the patient is already undergoing laparoscopy for the ectopic pregnancy, concurrent removal avoids a second surgery 1
• Leaving the hydrosalpinx (Option B) would necessitate another surgery before future IVF attempts and compromise her current intrauterine pregnancy outcomes 5

Why Other Options Are Inappropriate

Option A (Right Salpingotomy Alone)

• Salpingotomy leaves tubal tissue in place, risking persistent ectopic pregnancy 3
• Does not address the hydrosalpinx, which will impair future IVF success 5
• Only appropriate when tubal preservation is desired for natural conception, which is irrelevant in IVF patients 2

Option B (Right Salpingectomy Alone)

• Fails to address the left hydrosalpinx, which will reduce future IVF success rates 5
• Requires a second surgery before future IVF attempts 5

Option D (Intraoperative Methotrexate)

• Methotrexate is contraindicated with a concurrent viable intrauterine pregnancy at 7 weeks 3
• Methotrexate is teratogenic and would harm the desired intrauterine pregnancy
• Only used for persistent trophoblastic tissue after surgical management, not as primary treatment 3

Surgical Technique Considerations

The concurrent intrauterine pregnancy at 7 weeks requires specific laparoscopic precautions: 1

• Left lateral tilt positioning to avoid vena cava compression 1
• Low intra-abdominal pressure to minimize uterine perfusion compromise 1
• Procedures limited to 90-120 minutes when possible 1
• Experienced surgical team essential 1
• Laparoscopic approach has fewer fetal adverse effects than laparotomy 1

Critical Pitfall to Avoid

Do not perform partial salpingectomy—ensure complete removal of both tubes including the proximal isthmus to prevent recurrent ectopic pregnancy in tubal remnants. 2, 4 The interstitial portion should not be removed to preserve ovarian blood supply 2.