Tubal ectopic pregnancy: Surgical treatment

INTRODUCTION — An ectopic pregnancy is an extrauterine pregnancy. The majority of ectopic pregnancies occur in the fallopian tube, but other possible sites include the cervix, interstitial portion of the fallopian tube (a pregnancy located in the proximal segment of the fallopian tube that is embedded within the muscular wall of the uterus), myometrium, ovary, or abdomen. Other abnormally implanted pregnancies, including hysterotomy (ie, cesarean, myomectomy) scar pregnancies can also occur. In addition, in rare cases, a multiple gestation may be heterotopic (include both a uterine and extrauterine pregnancy).

Historically, ectopic pregnancy was managed surgically, but in current practice, treatment with methotrexate (MTX) is preferred for appropriately selected patients [1]. Some patients undergo surgical therapy by choice or by necessity and others are candidates for expectant management.

The surgical treatment of tubal ectopic pregnancy will be reviewed here. Related topics regarding ectopic pregnancy are discussed in detail separately:

●Epidemiology, risk factors, and pathology (see "Ectopic pregnancy: Epidemiology, risk factors, and anatomic sites")

●Clinical manifestations and diagnosis (see "Ectopic pregnancy: Clinical manifestations and diagnosis")

●Choosing a treatment approach (see "Ectopic pregnancy: Choosing a treatment")

●Management with MTX (see "Ectopic pregnancy: Methotrexate therapy")

●Expectant management (see "Ectopic pregnancy: Expectant management of tubal pregnancy")

●Diagnosis and management of nontubal sites of ectopic or abnormal implanted intrauterine pregnancies (see "Abdominal pregnancy" and "Ectopic pregnancy: Clinical manifestations and diagnosis", section on 'Heterotopic pregnancy' and "Ectopic pregnancy: Choosing a treatment", section on 'Heterotopic pregnancy' and "Cesarean scar pregnancy")

●Patients with pregnancy of unknown location (see "Approach to the patient with pregnancy of unknown location")

INDICATIONS — Pharmacologic therapy (methotrexate [MTX]) is the preferred treatment for ectopic pregnancy. Indications for surgical therapy include hemodynamic instability, suspicion of or risk factors for rupture, contraindications to MTX, or failed medical therapy, as follows:

●Emergency surgery is required:

•Hemodynamically unstable

•Signs or symptoms of impending or ongoing rupture of ectopic mass (eg, pelvic or abdominal pain or evidence of intraperitoneal bleeding suggestive of rupture)

●Indications for a concurrent surgical procedure, which may include:

•Desire for sterilization

•Planned in vitro fertilization for future pregnancy with known hydrosalpinx (removal of hydrosalpinges increase the likelihood of successful in vitro fertilization). (See "Female infertility: Reproductive surgery", section on 'Salpingectomy before in vitro fertilization'.)

Alternatively, the ectopic pregnancy may be treated with MTX, and surgery for concurrent conditions may be performed electively at a later date.

●Heterotopic pregnancy with coexisting viable intrauterine pregnancy. (See "Ectopic pregnancy: Choosing a treatment", section on 'Choosing between methotrexate and surgery'.)

●Contraindications to MTX therapy. (See "Ectopic pregnancy: Choosing a treatment", section on 'Choosing between methotrexate and surgery'.)

●Failed MTX therapy

CONTRAINDICATIONS — Ectopic pregnancy is treated surgically if the patient is not a candidate for other treatment options, if current or impending tubal rupture is suspected, or if other options fail. Thus, it is often the treatment of last resort and there are few contraindications. For those who are candidates for either surgical or medical therapy, patient characteristics that increase the risk of perioperative complications are relative contraindications to surgery.

In hemodynamically stable patients, surgical intervention should be performed only if a transvaginal ultrasound examination clearly shows a tubal ectopic pregnancy or an adnexal mass suggestive of ectopic pregnancy. If no mass is visualized sonographically, there is a high likelihood that a tubal pregnancy will not be visualized or palpated at surgery, and the surgery may be unnecessary or unsuccessful. This may occur in early gestations in which the ectopic pregnancy is small or if the abnormal pregnancy is actually intrauterine or at another ectopic site. These patients should be managed conservatively with either medical therapy or expectant management. A repeat ultrasound examination after a few days may visualize an abnormality, thus enabling a surgical procedure, if this option is desired. If there is diagnostic uncertainty about whether a pregnancy is intrauterine or ectopic and it is certain that the pregnancy is not viable, a dilation and curettage may be performed. (See "Ectopic pregnancy: Clinical manifestations and diagnosis", section on 'Ancillary diagnostic tests'.)

SURGICAL PLANNING

Salpingostomy versus salpingectomy — There are two choices of surgical approach for tubal pregnancy. Salpingectomy (removal of the fallopian tube) and salpingostomy (incising the tube to remove the tubal gestation but leaving the remainder of the tube intact) appear to result in similar fertility outcomes in subsequent pregnancies. Traditionally, salpingectomy has been the standard procedure, but salpingostomy provides a conservative option [2].

Two randomized trials have compared salpingostomy with salpingectomy and found similar fertility outcomes; however, both trials lacked sufficient statistical power to detect infrequent outcomes [3,4]. Neither trial found a statistically significant difference in the risk of recurrent ectopic pregnancy, but one trial favored salpingostomy while the other favored salpingectomy [4]. Operative morbidity was similar for both procedures. The results of the trials were:

●One trial (n = 199) found that salpingostomy and salpingectomy resulted in similar rates of spontaneous conception of an intrauterine pregnancy at two years (70 versus 64 percent) [3]. In the salpingostomy group, 21 patients (21 percent) ultimately had salpingectomy for persistent tubal bleeding. The rate of persistent trophoblast was not reported. The rates of recurrent ectopic pregnancy did not differ significantly (8 versus 12 percent).

●In another trial (n = 446), patients with a tubal pregnancy who had conceived without in vitro fertilization were assigned to salpingostomy or salpingectomy [4]. Randomization was done at surgery after confirmation of the diagnosis of tubal ectopic pregnancy and the presence of a healthy-looking contralateral tube. Salpingostomy compared with salpingectomy had no significant difference in rate of spontaneous conception at 36 months (61 versus 56 percent). As expected, the salpingostomy group had a higher rate of persistent trophoblast (7 versus <1 percent). Surgical complication rates were low for both groups. The rate of repeat ectopic pregnancy in the ipsilateral tube was similar (3 versus 1 percent).

Data from these two trials were combined in a meta-analysis with data from eight comparative observational studies that included an additional 654 patients [5]. Pooled statistics from the observational studies showed that, for salpingostomy compared with salpingectomy, there was a significantly higher spontaneous intrauterine pregnancy rate (72 versus 54 percent, risk ratio [RR] 1.24, 95% CI 1.08-1.42), but the rate of recurrent ectopic pregnancy was significantly higher (10 versus 4 percent, RR 2.27, 95% CI 1.12-4.58).

The choice of salpingostomy or salpingectomy relies upon many factors and includes shared decision-making between the surgeon and patient.

Salpingectomy is the standard procedure if the condition of the tube with the ectopic gestation is damaged (ruptured or otherwise disrupted), bleeding is uncontrolled, or the gestation appears too large to remove with salpingostomy.

Another advantage of salpingectomy is that it avoids the need for further treatment for persistent trophoblast, which is required in some patients following salpingostomy. This typically involves treatment with methotrexate (MTX) and, while this is generally safe and effective, it does require further follow-up and some potential morbidity. Based on the risk of retained gestational tissue following salpingostomy, salpingectomy is required in patients who have contraindications to MTX therapy.

For patients who have completed childbearing, bilateral salpingectomy may be performed as permanent sterilization. An additional potential benefit of salpingectomy rather than another method of sterilization is a decrease in the risk of tubal neoplasia with spread to the ovary. Salpingectomy appears to be associated with a reduced risk of ovarian cancer, and some data suggest that the tube is the site of origin for some high-grade serous carcinomas that were presumed to be ovarian. However, further study of this is needed, and unilateral salpingectomy has not been investigated. (See "Opportunistic salpingectomy for ovarian, fallopian tube, and peritoneal carcinoma risk reduction".)

On the other hand, the advantage of salpingostomy is preservation of the tube for potential future fertility. Even with unilateral salpingectomy, patients may have anxiety regarding future fertility. In particular, salpingostomy is preferred for patients who desire future childbearing and in whom the contralateral tube is absent or damaged. The availability and high intrauterine pregnancy rate of in vitro fertilization (IVF) have decreased the need to preserve diseased fallopian tubes, including tubes with an ectopic pregnancy. However, many patients do not have access to IVF for financial, geographic, or religious reasons.

Salpingectomy is required for patients with:

●Ruptured tube or moderately or severely damage tube.

●Uncontrolled tubal bleeding.

●A large tubal pregnancy. In our practice, we use 3 cm as the threshold.

Patients may also choose salpingectomy if they:

●Are planning IVF for subsequent conceptions (only the affected tube is removed; the unaffected tube is left in-situ if it appears normal).

●Desire permanent sterilization (both tubes are removed).

Laparoscopy versus laparotomy — Laparoscopic surgery is the standard surgical approach for ectopic pregnancy. Most ectopic pregnancies, even in the presence of hemoperitoneum, may be treated using a laparoscopic procedure. However, for patients with acute bleeding, some surgeons prefer laparotomy. The choice of surgical approach should be made by the surgeon with consultation from the anesthesiologist and by taking into consideration the clinical status of the patient.

In addition, some surgeons prefer laparotomy for interstitial pregnancy. This is a rare type of ectopic pregnancy, and surgeons may have less experience with the procedure. The procedure may also result in more blood loss and require suturing because a myometrial incision is involved. (See 'Interstitial pregnancy' below.)

The benefits of laparoscopy were illustrated in a systematic review of randomized trials that compared laparoscopic salpingostomy with the open surgical approach [2]. Laparoscopic salpingostomy resulted in significantly shorter operation time (73 versus 88 minutes), less perioperative blood loss (79 versus 195 mL), shorter duration of hospital stay (1 to 2 versus 3 to 5 days), shorter convalescence time (11 versus 24 days), and, therefore, lower costs.

Laparoscopic salpingostomy resulted in a higher rate of persistent trophoblast than salpingostomy via laparotomy (odds ratio 3.5, 95% CI 1.1-11; actual risk 9/78 [11.5 percent] versus 3/87 [3.4 percent]) [2]. However, there were no significant differences in the rate of subsequent intrauterine pregnancy or repeat ectopic pregnancy. The higher rate of persistent ectopic pregnancy following laparoscopic salpingostomy may reflect the experience of the laparoscopic surgeon.

Use of single-port laparoscopy (also referred to as laparoendoscopic single-site surgery [LESS]) for ectopic pregnancy has been described [6-11]. As an example, a prospective study reported that patients with a tubal pregnancy who underwent salpingectomy with LESS compared with conventional laparoscopy had similar outcomes for operative duration, blood loss, and hospital stay [12]. (See "Abdominal access techniques used in laparoscopic surgery", section on 'Single-incision laparoscopic surgery'.)

PREOPERATIVE EVALUATION AND PREPARATION — Prior to surgery, patients undergo evaluation for ectopic pregnancy and routine preoperative evaluation and preparation. These are discussed in detail separately. (See "Ectopic pregnancy: Clinical manifestations and diagnosis" and "Overview of preoperative evaluation and preparation for gynecologic surgery".)

PROCEDURE — The aspects of the procedure that are specific to treatment of ectopic pregnancy are reviewed here. Abdominal access techniques for laparoscopy are discussed separately. (See "Abdominal access techniques used in laparoscopic surgery".)

Salpingostomy — Salpingostomy consists of making an incision in the fallopian tube and removing the ectopic gestation.

The steps of the procedure are the following:

●The ectopic pregnancy is identified and the tube is immobilized with laparoscopic forceps.

●A 22-gauge needle is inserted through a 5 mm portal and used to inject a solution of vasopressin into the wall of the tube at the area of maximal distention; this helps to minimize bleeding at the salpingostomy site (figure 1). In our practice, we use vasopressin diluted with normal saline to a concentration of 0.2 units/mL and inject a volume of up to 5 mL.

●Using electrosurgery or scissors, a 10 mm longitudinal incision is made along the tube overlying the ectopic gestation (figure 2). The incision is made along the border of the tube that is not on the side to which the mesosalpinx attaches.

●The products of conception are released from the tube using a combination of hydrodissection with irrigating solution under high pressure and gentle blunt dissection with a suction irrigator. The specimen can then be placed into a laparoscopic pouch and removed from the abdominal cavity; it is also useful for removal of large fragments of placental tissue. Using fluid to remove the gestation is preferable to removing it bluntly. Extracting the products of conception in pieces with forceps may lead to retained trophoblastic tissue, particularly in the area of the tube proximal to the ectopic gestation.

●The tube is carefully irrigated and inspected for hemostasis. Bleeding points can be controlled by applying pressure or coagulated with light application of bipolar coagulation. In order to avoid excessive coagulation to the tube, we use a microbipolar forceps. If bleeding persists, vessels in the mesosalpinx can be ligated with 6-0 polyglactin suture (figure 3). The placental bed inside the tube should not be coagulated because this will seriously damage the tube.

●The incision is left open to heal by secondary intention; the subsequent rates of fertility and adhesion formation are similar after secondary intention or primary closure [13].

Salpingectomy — Salpingectomy is the removal of a portion or all of the fallopian tube.

Total or partial salpingectomy may be performed for the tube with the ectopic gestation. The decision for partial versus total salpingectomy depends on the patient's age, whether the patient has one or two tubes, the condition of the tube, and the patient's plans for future fertility.

If the tubal damage is confined to a midportion tubal segment containing the ectopic gestation, either a partial or total salpingectomy may be performed. If the length of the remaining portions of tube is minimal or the fimbria must be removed to remove the ectopic gestation, total salpingectomy is performed.

If the patient has two tubes, removal of one tube will not necessarily result in tubal sterilization. If the patient has a solitary tube, salpingectomy results in tubal sterilization, limiting the patient's pregnancy option to in vitro fertilization (IVF). Total bilateral salpingectomy is performed if the patient desires sterilization and/or desires opportunistic salpingectomy for potential ovarian cancer risk reduction. (See "Opportunistic salpingectomy for ovarian, fallopian tube, and peritoneal carcinoma risk reduction".)

In general, we perform partial salpingectomy to allow the option for tubal reanastomosis at a future date. However, in patients who will undergo IVF, we prefer total salpingectomy to decrease the possibility of tubal stump pregnancy and the development of hydrosalpinx of the proximal portion of the tube. The presence of a hydrosalpinx decreases the IVF pregnancy rate. (See "In vitro fertilization: Overview of clinical issues and questions", section on 'Negative effect'.)

There are several methods for laparoscopic salpingectomy. One approach is to bring the fallopian tube through a pre-tied surgical loop using a grasping forceps. The knot is tightened; the tube is then resected and removed. A second loop can be placed on the excised stump (figure 4).

Alternatively, electrosurgery or preferably a device with minimal thermal effects can be used to seal the vessels in the mesosalpinx, followed by resection of the specimen with scissors (figure 5). The cornual portion of the tube is excised close to the uterus. It is important to elevate the tube and cut the mesosalpinx close to the tube to avoid inadvertently damaging the ovarian vessels.

If laparotomy is performed, total salpingectomy via laparotomy is accomplished by placing a clamp across the mesosalpinx and then placing a second clamp across the proximal portion of the fallopian tube as close as possible to the cornua (figure 6). The tips of the clamps should touch to completely occlude the vessels in the mesosalpinx. The tube is then excised and the pedicles ligated using a 2-0 or 3-0 synthetic absorbable suture. For partial salpingectomy, the clamps are placed proximal and distal to the ectopic gestation.

OUTCOME AND FOLLOW-UP — Outcomes and complications particular to surgical treatment of ectopic pregnancy are reviewed here.

Surgical complications — Surgical complications for laparoscopy or laparotomy are discussed separately. Following surgical treatment of ectopic pregnancy, patients should have routine postoperative care. (See "Complications of laparoscopic surgery" and "Complications of gynecologic surgery".)

Persistent ectopic pregnancy — The incidence of persistent ectopic pregnancy reported in case series ranges from 4 to 15 percent [14]. The risk of persistent ectopic pregnancy varies by the surgical treatment technique and is less likely with salpingectomy than salpingostomy and with laparotomy than laparoscopy. Risk factors for persistent trophoblast after salpingostomy include surgeon's inexperience, removal of the gestational tissue in fragments, and trophoblasts infiltrating deeply into the tubal wall. (See 'Salpingostomy versus salpingectomy' above and 'Laparoscopy versus laparotomy' above.)

Monitoring hCG postoperatively

●For patients who undergo salpingostomy, serum human chorionic gonadotropin (hCG) is measured weekly until the level is undetectable. One study (n = 147) of patients who underwent salpingostomy found that the serum hCG concentration on the first postoperative day generally declined by more than 50 percent of the preoperative value [15]. There were no cases of persistent ectopic pregnancy when the postoperative hCG on day 1 fell by more than 76 percent.

For cases in which the surgeon is not certain whether the entire products of conception have been removed, a single prophylactic dose of methotrexate (MTX) may be given immediately postoperatively [16].

●For patients who undergo salpingectomy, if the pathology evaluation confirms a tubal gestation, many surgeons do not check a postoperative hCG, and others check a single postoperative hCG to confirm a large decline in the level.

Treatment — If the hCG level does not decline with each measurement or does not reach an undetectable level within a reasonable time period, we treat with MTX. The regimen of MTX is the same as for primary medical treatment of ectopic pregnancy. (See "Ectopic pregnancy: Methotrexate therapy", section on 'Preferred approach for most patients: Single-dose'.)

Future pregnancy — Ectopic implantation usually occurs because clinical or subclinical salpingitis has caused anatomic and functional changes in the fallopian tubes. These changes are typically bilateral and permanent; thus, it is not surprising that ectopic pregnancy is often followed by recurrent ectopic pregnancy and infertility. Other factors that also influence a patient's fertility after a tubal pregnancy include increasing age, history of infertility, and prior tubal damage as a result of pelvic inflammatory disease [17,18].

Studies regarding reproductive outcomes after ectopic include:

●Intrauterine pregnancy – In patients with a history of ectopic pregnancy, review of observational data from a variety of patient populations and with varying durations of follow-up shows that 38 to 89 percent will achieve a subsequent intrauterine gestation [14].

●Recurrent ectopic pregnancy – The incidence of recurrent ectopic pregnancy is approximately 15 percent (range 4 to 28 percent) [14]. Two randomized trials found that the rates of recurrent ectopic pregnancy after salpingostomy or salpingectomy are similar [3,4]. After MTX treatment, the recurrent ectopic rates range between 10.2 and 18.7 percent [19,20]. The differences could be related to the varied condition of the fallopian tubes. The recurrence risk rises to 30 percent following two ectopic pregnancies [21]. (See 'Salpingostomy versus salpingectomy' above.)

A prospective study followed 328 patients who were not using intrauterine contraception at the time of their ectopic pregnancy and who subsequently tried to become pregnant [19]. Cumulative outcomes after 12 months were pregnancy rate (66 percent), intrauterine pregnancy rate (56 percent), ectopic pregnancy rate (13 percent), and live birth rate (31 percent). Maternal age greater than 35 years, history of infertility, and tubal damage were associated with decreased reproductive performance.

In our practice, if the patient does not conceive 12 months after an episode of ectopic pregnancy, we refer the patient for in vitro fertilization. (See "In vitro fertilization: Overview of clinical issues and questions".)

Interval to conception — There are no data to establish the optimal interval to conception following surgical treatment of an ectopic pregnancy. In our practice, we advise patients that they may try to conceive again following their next menstrual period.

INTERSTITIAL PREGNANCY — In our practice, when surgery is required, we prefer laparoscopic removal of the interstitial pregnancy via cornuostomy, with resection of the interstitial portion of the tube (cornual resection) if necessary (figure 7 and figure 8) [22]. Historically, cornual resection and hysterectomy were the most common procedures for treatment of interstitial pregnancy, probably as a result of late diagnosis [23-25]. However, given interstitial pregnancy is now typically diagnosed at an early gestational age and prior to rupture, conservative medical or surgical treatment is now possible [26]. (See "Ectopic pregnancy: Choosing a treatment", section on 'Medical versus surgical treatment'.)

In a series of 75 patients with interstitial pregnancy who underwent cornual resection (53 patients) or cornuostomy (22 patients), the success rates were comparable. However, cornuostomy was associated with reduced operating time (59.36±19.32 minutes) compared with that of cornual resection (77.11±23.97 minutes). The rates of persistent ectopic pregnancy were similar [27].

The procedure for laparoscopic cornuostomy is as follows: Dilute intramyometrial vasopressin is injected into the cornual myometrium at the commencement of the operation to minimize blood loss and improve visibility. Alternatively, hemostasis can be achieved by ligating the ascending branches of the uterine vessels. If a cornuostomy is planned, the products of conception can be removed with hydrodissection, grasping forceps, aspiration, or gentle curettage. We prefer hydrodissection to flush out the gestational products, as it helps to ascertain complete removal of trophoblast. A modification of this approach, using a purse-string stitch placed in the myometrium circumferential to the pregnancy prior to excision, has also been described [28].

Successful hysteroscopic removal of interstitial ectopic pregnancy has also been described [29,30]. The efficacy and long-term results of this technique are unknown.

The possibility of uterine rupture during a subsequent pregnancy should be discussed with patients undergoing treatment for interstitial pregnancy. In a series of 10 patients after cornual resection, three cases had uterine rupture in a subsequent pregnancy [31]. In addition, compared with patients with a previous tubal ectopic pregnancy, those who had previous cornual resection for interstitial pregnancy tended to have higher elective cesarean deliveries [32]. The risk of uterine rupture after medical treatment of an interstitial pregnancy is unknown, and the integrity of the uterus following conservative surgical treatment is unclear, although cases of uterine rupture have been reported. Multilayered suturing of the myometrium and serosa of the uterine cornua following conservative surgical treatment may prevent this complication.

Close antenatal monitoring of patients with a history of interstitial pregnancy is mandatory. The patient should be counseled regarding whether a cesarean delivery at term is advised to avoid the risk of uterine rupture during labor. (See "Uterine fibroids (leiomyomas): Issues in pregnancy", section on 'Patients with prior myomectomy'.)

Medical treatment of interstitial pregnancy is discussed in detail separately. (See "Ectopic pregnancy: Methotrexate therapy", section on 'Patients with an interstitial pregnancy: Multiple-dose'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Ectopic pregnancy".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Ectopic pregnancy (The Basics)")

●Beyond the Basics topics (see "Patient education: Ectopic (tubal) pregnancy (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Patient selection

•Most patients with tubal ectopic pregnancy are treated with methotrexate (MTX). Indications for surgical therapy include hemodynamic instability, suspicion of or risk factors for rupture, contraindications to MTX, or failed medical therapy. (See 'Indications' above.)

•For hemodynamically stable patients, surgical intervention should only be considered if a transvaginal ultrasound examination clearly shows a tubal ectopic pregnancy or an adnexal mass suggestive of ectopic pregnancy. If no abnormality is imaged sonographically, there is a high probability that an ectopic pregnancy will not be visualized or palpated at surgery. (See 'Indications' above.)

●Surgical planning

•For most patients with an unruptured tubal pregnancy and a reasonably undamaged tube who are planning surgical treatment, we suggest salpingostomy (figure 2) rather than salpingectomy (Grade 2C). Salpingectomy (figure 5 and figure 4 and figure 6) is typically required for patients with a ruptured tube, uncontrolled tubal bleeding, moderately or severely damaged tube, or large tubal pregnancy (3 to 5 cm). Patients may also reasonably choose salpingectomy if they are planning in vitro fertilization for subsequent conceptions or if they desire permanent sterilization. (See 'Salpingostomy versus salpingectomy' above.)

•Laparoscopic surgery is the most common surgical approach, even in the presence of hemoperitoneum. However, for patients with acute heavy bleeding, some surgeons prefer laparotomy. (See 'Laparoscopy versus laparotomy' above.)

•When surgery is required for an interstitial pregnancy, a laparoscopic cornuostomy with hydrodissection is preferred, with resection of the interstitial portion of the tube (cornual resection) only if necessary (figure 8). (See 'Interstitial pregnancy' above.)

●Persistent ectopic pregnancy – Persistent ectopic pregnancy after salpingostomy occurs in 4 to 15 percent of cases. We perform a single serum human chorionic gonadotropin measurement one week after surgery. A level that is less than 5 percent of the preoperative value is consistent with complete resolution of the ectopic pregnancy; a higher value calls for repeat measurement. (See 'Persistent ectopic pregnancy' above.)

●Future pregnancy

•After an ectopic pregnancy, 38 to 89 percent of patients will achieve a subsequent intrauterine gestation. Recurrent ectopic pregnancy occurs in 15 percent (range 4 to 28 percent); the recurrence risk rises to 30 percent following two ectopic pregnancies. (See 'Outcome and follow-up' above.)

•If the patient does not conceive in the first 12 to 18 months after surgical therapy of ectopic pregnancy or the contralateral tube is damaged or absent, referral for in vitro fertilization is appropriate. (See 'Outcome and follow-up' above.)