LETTER TO THE EDITOR REPLY OF THE AUTHORS: Thanks to Infante et al. for their comments on the recent American Society for Reproductive Medicine (ASRM) Practice Committee document titled ‘‘Medical treatment of ectopic pregnancy: a committee opinion’’ (1). The ASRM Practice Committee does not intend to promote techniques that risk interrupting a normal pregnancy. The Committee Opinion presents alternative approaches to diagnosing ectopic pregnancy and determining when to suspect a pregnancy is not normal and states that a definitive diagnosis should be made prior to treatment. In the diagnosis of ectopic pregnancy discussed in the Committee Opinion, the approaches that are advocated include serial hCG determinations, ultrasonographic examinations, and sometimes uterine curettage. The Committee Opinion does not indicate that a single serum hCG concentration above the discriminatory level with absence of an intrauterine gestation on transvaginal ultrasound is diagnostic of an ectopic pregnancy. Rather, the Committee Opinion states that ‘‘with hCG levels above the discriminatory zone of 1,500–2,500 IU/L a normal intrauterine pregnancy, defined as a gestational sac, should be visible by transvaginal ultrasound.’’ Furthermore, ‘‘the absence of an intrauterine gestational sac when the hCG concentration is above the discriminatory zone implies an abnormal gestation.’’ As stated in the document, in the case of multiple pregnancy, hCG levels are higher at an early stage of development than in singleton intrauterine gestations. It further discusses the rate of rise of serum hCG levels and their use in determining normal from abnormal values. The ASRM Committee Opinion states that every effort should be made to diagnose ectopic pregnancy definitively before medical treatment with methotrexate. The specific discriminatory zone may vary for

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different institutions, depending on clinical expertise and specific characteristics of the serum hCG assay used, and serial serum hCG measurements are valuable to document either a growing, potentially viable, or a nonviable pregnancy. The use of uterine curettage is suggested as a tool to differentiate an abnormal intrauterine gestation from an ectopic pregnancy once the determination has been made that the pregnancy is not normal and thereby avoids exposure to methotrexate unnecessarily. The diagnosis of ectopic pregnancy can be challenging, and many factors need to be considered to achieve the correct diagnosis and avoid unnecessary treatments or avoid interruption of a normal pregnancy. Serial serum hCG measurements and transvaginal ultrasound assessments by an experienced examiner to avoid interruption of a normal pregnancy is a valid approach supported by the Committee Opinion. On behalf of the Practice Committee: Samantha Pfeifer, M.D. Chair, ASRM Practice Committee American Society for Reproductive Medicine, Birmingham, Alabama December 5, 2013 http://dx.doi.org/10.1016/j.fertnstert.2013.12.014

REFERENCE 1.

Practice Committee of the American Society for Reproductive Medicine. Medical treatment of ectopic pregnancy: a committee opinion. Fertil Steril 2013; 100:638–44.

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