FERTILITY AND STERILITY
Vol. 58, No.3, September 1992
Copyright © 1992 The American Fertility Society
Printed on acid-free paper in U.S.A.
Intrauterine pregnancy in a patient with a sole remaining tube after local treatment of tubal pregnancy with hyperosmolar glucose
Werner Honigl, M.D.* Peter F. Lang, M.D. Department of Obstetrics and Gynecology, University of Graz, Graz, Austria
Local instillation of hyperosmolar glucose solution is an effective treatment for selected unruptured tubal pregnancies (1, 2). However, intact tubal function after glucose instillation has not been proved unequivocally. We report a spontaneous intrauterine pregnancy (IUP) 8 months after instillation of hyperosmolar glucose for treatment of ectopic gestation in a patient with a sole remaining oviduct. This is the first reported demonstration of normal reproductive function by a tube previously treated with this regimen. CASE REPORT
The patient was a 28-year-old gravida-2, para-O with a history of two ectopic pregnancies (EP). In June 1990, a right-sided unruptured ampullary tubal pregnancy measuring 3 X 2 cm had been treated by laparoscopic instillation of 50% glucose solution. The preoperative serum beta-human chorionic gonadotropin ({1-hCG) level was 3,710 mIUjmL. The pregnancy persisted clinically and biochemically, and a right laparoscopic salpingectomy was performed 11 days later. This patient was included in an earlier series (2). After three regular menstrual cycles, the patient had irregular vaginal bleeding from cycle day 42 onward. The patient was admitted to the hospital on day 51 with a serum {1-hCG of 880 mIUjmL and sonographic findings consistent with ectopic gestation. Laparoscopy on day 52, when serum {1-hCG
Received April 3, 1992; revised and accepted April 29, 1992. M.D., Department of Obstetrics and Gynecology, University of Graz, Auenbruggerplatz 14, A-8036 Graz, Austria.
* Reprint requests: Werner Honigl,
Vol. 58, No.3, September 1992
was 1,100 mIUjmL, showed a left-sided unruptured ampullary tubal pregnancy measuring 3.0 X 1.5 cm. There were no adhesions in the left adnexal region, and the right tube was absent. Ten milliliters of 50% glucose solution was injected into the tubal gestation as described elsewhere (1, 2). The postoperative course was uneventful. Serum {1-hCG was 748 mIU jmL on day 1, 125 mIU jmL on day 8, 27 mIU jmL on day 17, and undetectable «5 mIU jmL) on day 24 after laparoscopy. Five months later hysterosalpingography (HSG) showed patency of the left tube and absence of an uteroabdominal fistula on the right side. At 8 months, the patient conceived again. A viable IUP was confirmed by sonography. The pregnancy is currently in the third trimester and uneventful. DISCUSSION
Local medical treatment of tubal pregnancies with low trophoblastic activity is an attractive alternative to conservative laparoscopic surgery with a linear incision of the tube in patients desiring preservation of fertility. Hyperosmolar glucose solution is both safe and effective for local treatment of un ruptured tubal pregnancies with a serum hCG level < 2,500 mIUjmL (1, 2). Forty nine (98%) of 50 patients were treated successfully with this regimen, and no side effects were seen (2). The success rate of glucose instillation dropped to 60% in 10 patients with a serum hCG > 2,500 mIU jmL, including the first ectopic gestation in the patient reported here (2). Intact tubal function after glucose instillation has not been proved unequivocally. There has been concern that hyperosmolar glucose solution might be cytotoxic to the tubal epithelium as well as to the trophoblast. Evaluation of tubal function is difficult; Honigl and Lang
Communications-in-brief
625
the ovum pick-up mechanism and tubal transport may be disturbed even in the presence of mechanical patency. Intrauterine pregnancies have been reported after medical treatment of tubal pregnancy with hyperosmolar glucose (1, 2), but none of these patients had only one oviduct, and conception may have occurred via the contralateral tube. Because the prognostic information of HSG is limited, this mechanism cannot be ruled out in the two patients that we have reported earlier with prior radiologic evidence of occlusion of the contralateral tube (2). Proximal obstruction may be because oftubal spasm, and conception has been reported in four of eight patients with radiologic findings suggestive of distal occlusion (3). A spontaneous IUP has been reported 14 months after laparoscopic diagnosis of a tubal gestation presenting as a hematosalpinx in a patient with a single oviduct who refused surgical intervention (4). Some EP resolve spontaneously, but those that will cannot be identified at laparoscopy. The preoperative increase of hCG levels in the patient reported here indicates that the tubal pregnancy was viable and required treatment.
626
Honigl and Lang
Communications-in-brief
SUMMARY
A spontaneous IUP occurred 8 months after laparoscopic instillation of hyperosmolar glucose solution into a tubal pregnancy in a patient with a sole remaining tube. This is the first unequivocal proof of intact tubal function after treatment of a tubal pregnancy with local hyperosmolar glucose. Key Words: Tubal pregnancy, medical treatment, glucose, intrauterine pregnancy, reproductive function. REFERENCES 1. Lang PF, Weiss PAM, Mayer HO, Haas JG, Honigl W. Conservative treatment of ectopic pregnancy with local injection of hyperosmolar glucose solution or prostaglandin-F2alpha: a prospective randomized study. Lancet 1990;336:78-81. 2. Lang PF, Tamussino K, Honigl W, Ralph G. Treatment of un ruptured tubal pregnancy by laparoscopic instillation of hyperosmolar glucose solution. Am J Obstet Gynecol 1992. In press. 3. Mitchell DE, McSwain HF, Peterson HB. Fertility after ectopic pregnancy. Am J Obstet GynecoI1989;161:576-80. 4. Pent D, Loffer FD. The natural history of an hematosalpinx. Obstet GynecoI1976;47:2S-4S.
Fertility and Sterility
Vol. 58, No.3, September 1992
Copyright © 1992 The American Fertility Society
Printed on acid-free paper in U.S.A.
Intrauterine pregnancy in a patient with a sole remaining tube after local treatment of tubal pregnancy with hyperosmolar glucose
Werner Honigl, M.D.* Peter F. Lang, M.D. Department of Obstetrics and Gynecology, University of Graz, Graz, Austria
Local instillation of hyperosmolar glucose solution is an effective treatment for selected unruptured tubal pregnancies (1, 2). However, intact tubal function after glucose instillation has not been proved unequivocally. We report a spontaneous intrauterine pregnancy (IUP) 8 months after instillation of hyperosmolar glucose for treatment of ectopic gestation in a patient with a sole remaining oviduct. This is the first reported demonstration of normal reproductive function by a tube previously treated with this regimen. CASE REPORT
The patient was a 28-year-old gravida-2, para-O with a history of two ectopic pregnancies (EP). In June 1990, a right-sided unruptured ampullary tubal pregnancy measuring 3 X 2 cm had been treated by laparoscopic instillation of 50% glucose solution. The preoperative serum beta-human chorionic gonadotropin ({1-hCG) level was 3,710 mIUjmL. The pregnancy persisted clinically and biochemically, and a right laparoscopic salpingectomy was performed 11 days later. This patient was included in an earlier series (2). After three regular menstrual cycles, the patient had irregular vaginal bleeding from cycle day 42 onward. The patient was admitted to the hospital on day 51 with a serum {1-hCG of 880 mIUjmL and sonographic findings consistent with ectopic gestation. Laparoscopy on day 52, when serum {1-hCG
Received April 3, 1992; revised and accepted April 29, 1992. M.D., Department of Obstetrics and Gynecology, University of Graz, Auenbruggerplatz 14, A-8036 Graz, Austria.
* Reprint requests: Werner Honigl,
Vol. 58, No.3, September 1992
was 1,100 mIUjmL, showed a left-sided unruptured ampullary tubal pregnancy measuring 3.0 X 1.5 cm. There were no adhesions in the left adnexal region, and the right tube was absent. Ten milliliters of 50% glucose solution was injected into the tubal gestation as described elsewhere (1, 2). The postoperative course was uneventful. Serum {1-hCG was 748 mIU jmL on day 1, 125 mIU jmL on day 8, 27 mIU jmL on day 17, and undetectable «5 mIU jmL) on day 24 after laparoscopy. Five months later hysterosalpingography (HSG) showed patency of the left tube and absence of an uteroabdominal fistula on the right side. At 8 months, the patient conceived again. A viable IUP was confirmed by sonography. The pregnancy is currently in the third trimester and uneventful. DISCUSSION
Local medical treatment of tubal pregnancies with low trophoblastic activity is an attractive alternative to conservative laparoscopic surgery with a linear incision of the tube in patients desiring preservation of fertility. Hyperosmolar glucose solution is both safe and effective for local treatment of un ruptured tubal pregnancies with a serum hCG level < 2,500 mIUjmL (1, 2). Forty nine (98%) of 50 patients were treated successfully with this regimen, and no side effects were seen (2). The success rate of glucose instillation dropped to 60% in 10 patients with a serum hCG > 2,500 mIU jmL, including the first ectopic gestation in the patient reported here (2). Intact tubal function after glucose instillation has not been proved unequivocally. There has been concern that hyperosmolar glucose solution might be cytotoxic to the tubal epithelium as well as to the trophoblast. Evaluation of tubal function is difficult; Honigl and Lang
Communications-in-brief
625
the ovum pick-up mechanism and tubal transport may be disturbed even in the presence of mechanical patency. Intrauterine pregnancies have been reported after medical treatment of tubal pregnancy with hyperosmolar glucose (1, 2), but none of these patients had only one oviduct, and conception may have occurred via the contralateral tube. Because the prognostic information of HSG is limited, this mechanism cannot be ruled out in the two patients that we have reported earlier with prior radiologic evidence of occlusion of the contralateral tube (2). Proximal obstruction may be because oftubal spasm, and conception has been reported in four of eight patients with radiologic findings suggestive of distal occlusion (3). A spontaneous IUP has been reported 14 months after laparoscopic diagnosis of a tubal gestation presenting as a hematosalpinx in a patient with a single oviduct who refused surgical intervention (4). Some EP resolve spontaneously, but those that will cannot be identified at laparoscopy. The preoperative increase of hCG levels in the patient reported here indicates that the tubal pregnancy was viable and required treatment.
626
Honigl and Lang
Communications-in-brief
SUMMARY
A spontaneous IUP occurred 8 months after laparoscopic instillation of hyperosmolar glucose solution into a tubal pregnancy in a patient with a sole remaining tube. This is the first unequivocal proof of intact tubal function after treatment of a tubal pregnancy with local hyperosmolar glucose. Key Words: Tubal pregnancy, medical treatment, glucose, intrauterine pregnancy, reproductive function. REFERENCES 1. Lang PF, Weiss PAM, Mayer HO, Haas JG, Honigl W. Conservative treatment of ectopic pregnancy with local injection of hyperosmolar glucose solution or prostaglandin-F2alpha: a prospective randomized study. Lancet 1990;336:78-81. 2. Lang PF, Tamussino K, Honigl W, Ralph G. Treatment of un ruptured tubal pregnancy by laparoscopic instillation of hyperosmolar glucose solution. Am J Obstet Gynecol 1992. In press. 3. Mitchell DE, McSwain HF, Peterson HB. Fertility after ectopic pregnancy. Am J Obstet GynecoI1989;161:576-80. 4. Pent D, Loffer FD. The natural history of an hematosalpinx. Obstet GynecoI1976;47:2S-4S.
Fertility and Sterility
