Laparoscopic surgery for ectopic pregnancy: A comparative study on the clinical benefits and impact on tubal patency and reproductive outcomes

2.1.1 Inclusion criteria for medical conservative treatment

Methotrexate (MTX) is widely used for the treatment of tubal pregnancy [8]. The criteria include: (1) Pre-treatment evaluations suggest an unruptured ectopic pregnancy, and the patient wishes to retain fertility. (2) The patient’s vital signs are relatively stable, with no severe abdominal pain or significant intra-abdominal bleeding. (3) The tubal pregnancy mass measures less than 35–40 mm, with no cardiac activity observed. (4) Serum beta-human chorionic gonadotropin ( β -HCG) level is below 2,000 U/L. (5) The patient consents to medical treatment and has no contraindications to drug therapy.

2.1.2 Inclusion criteria for laparoscopic surgery

(1) Unstable vital signs and symptoms of ruptured tubal pregnancy (pelvic pain, intra-abdominal bleeding). (2) Absolute contraindications to medical treatment or treatment failure requiring surgical intervention. Surgical treatment may be considered for patients with relative contraindications. The laparoscopic procedures include salpingostomy (removal of the ectopic pregnancy while preserving the fallopian tube) and salpingectomy on the affected side.

Salpingectomy is indicated for the following:

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Patients who require removal of the affected fallopian tube.

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Emergency cases with significant intra-abdominal bleeding and shock.

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Patients with severe tubal adhesions or large lesions that compromise the mesosalpinx or blood vessels.

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Patients with a history of disease or surgery on the affected side, such as previous tubal pregnancy or tubal anastomosis for infertility.

2.2 Treatment methods

2.3 Outcomes measures

The primary outcomes were the comparison of observation indicators in 3 groups of patients after 3 years of treatment for normal intrauterine pregnancy and ectopic pregnancy, and comparison of tubal patency and ectopic pregnancy sites between the group undergoing laparoscopic salpingostomy for the removal of ectopic pregnancy and the group receiving medical conservative treatment. Tubal patency refers to the unobstructed or un-narrowed condition of the fallopian tubes, allowing sperm and egg to meet without difficulty. To evaluate this, we used hysterosalpingography (HSG) or laparoscopy, which are standard methods in clinical practice.

2.4 Statistical analysis

Statistical analysis was performed using SPSS 19.0 software. Count data were presented as number of cases (%) and compared using the chi-square test. A p -value of less than 0.05 was considered statistically significant.

2.5 Ethics approval

The study was approved by the Institutional Review Board of our hospital, and all methods were carried out following the relevant guidelines and regulations. As this was a retrospective study using de-identified data, the requirement for informed consent was waived.

3.1 Patient demographics

This study incorporated clinical data from 206 patients who were treated for ectopic pregnancy at our hospital from January 2018 to June 2020. Among these patients, 46 underwent laparoscopic ipsilateral salpingectomy, 54 underwent laparoscopic ipsilateral salpingostomy with lesion removal, and 106 were treated conservatively with medication. The age range for the salpingectomy group was between 21 and 42 years, with an average age of 33.5 ± 4.8 years. The salpingostomy group’s age range was 24 to 39 years, with an average age of 29.2 ± 3.5 years. The medication group had an age range of 22 to 40 years, with an average age of 29.7 ± 6.7 years. There were no significant differences between the groups in terms of these general demographic characteristics ( $p>$ 0.05) (Table 1).

Both the group that underwent laparoscopic unilateral salpingostomy for ectopic pregnancy removal and the group receiving conservative medical treatment exhibited higher rates of ectopic pregnancy compared to the group that underwent laparoscopic unilateral salpingectomy. These differences were statistically significant ( 0.05) (salpingectomy group vs. conservative surgical treatment group, X 2 = 4.7236; p = 0.030; salpingectomy group vs. medical conservative treatment group, X 2 = 4.4806; p = 0.034). The comparison of ectopic pregnancy rates between the laparoscopic unilateral salpingostomy group and the conservative medical treatment group revealed no statistically significant difference ( X 2 = 0.0586; p = 0.809). Additionally, there was no statistically significant difference in the rates of normal intrauterine pregnancy amongst the three groups ( $p>$ 0.05), as displayed in Table 2. Within a span of 3 years, the laparoscopic unilateral salpingostomy group experienced 10 instances of recurrent ectopic pregnancy, with 2 cases occurring on the same side, while the conservative medical treatment group reported 18 cases of recurrent ectopic pregnancy, with 8 cases occurring on the same side.

When comparing tubal patency between the group that underwent unilateral salpingostomy for ectopic pregnancy and the group that received conservative medical treatment, the results were as follows: Three months post-normalization of blood β -HCG levels, the unilateral salpingostomy group reported 43 cases of tubal patency (patency rate: 79.63%), while the conservative medical treatment group reported 57 cases (patency rate: 53.77%). A statistically significant difference was observed between the two groups ( X 2 = 10.2045; p = 0.01) (Table 3). During this period, it is important to note that we did not administer additional MTX treatment to these patients. We opted for a more conservative approach, closely monitoring the patients with regular HCG level checks and ultrasound examinations. The rationale behind this approach was to allow more time for the HCG levels to naturally normalize, considering that the persistence of HCG does not necessarily signify treatment failure but can occur due to the normal slow decline of HCG after salpingostomy. Additional treatments were only considered if there were signs of re-escalation of HCG levels or other concerning symptoms. This approach in our study might have contributed to the significant difference observed in tubal patency rates between the two treatment groups. Image data captured during the laparoscopic surgery is presented in Fig. 1. This study substantiates that laparoscopic surgery for ectopic pregnancy offers significant clinical advantages over conservative medical treatment, including enhanced tubal patency and improved reproductive outcomes post-treatment. These findings advocate for laparoscopic surgery as an effective strategy in the management of ectopic pregnancy.

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4.1 Comparison with previous studies

Our findings are consistent with existing literature, which indicates that laparoscopic surgery, whether salpingectomy or salpingostomy, provides better outcomes compared to the medical management of ectopic pregnancy [11]. Moreover, the higher rates of recurrent ectopic pregnancy observed in our salpingostomy and medication groups are in line with previous studies that suggest an increased recurrence risk following conservative treatments [12]. However, the higher tubal patency rate observed in our salpingostomy group three months post-treatment represents a significant finding that contradicts some prior studies, which have reported similar patency rates between surgical and medical management groups [13]. This finding implies a potential advantage of laparoscopic salpingostomy in preserving tubal patency, which merits further investigation.

4.2 Explanation of findings

The reduced recurrence rate of ectopic pregnancy in the salpingectomy group is likely attributable to the complete removal of the affected fallopian tube. By eradicating the site of the ectopic pregnancy, the risk of reimplantation in the same location is theoretically eliminated [14]. However, it is important to mention that this doesn’t entirely rule out the possibility of an ectopic pregnancy in the opposite tube.

The superior tubal patency observed in the salpingostomy group can be credited to the conservative nature of the procedure. Salpingostomy involves the extraction of the ectopic pregnancy while preserving the fallopian tube, thereby retaining its potential functionality and contributing to improved rates of subsequent intrauterine pregnancy [15]. It should be considered, however, that while tubal patency is enhanced, the risk of recurrent ectopic pregnancy persists.

4.3 Clinical implications

The study’s findings could influence the management of ectopic pregnancy. It presents a clear rationale for considering the preservation of the fallopian tube in patients who desire future fertility. However, it is important to balance this desire against the risk of recurrent ectopic pregnancy. These factors should be discussed with patients when making a decision about the best treatment approach.

The standard medical suggestions for future fertility for patients who have had previous ectopic pregnancies are individualized based on the patient’s specific conditions, such as their age, overall health status, and the details of their previous ectopic pregnancy. Generally, we emphasize close monitoring in subsequent pregnancies, as the risk for another ectopic pregnancy increases after one has occurred. We also recommend waiting for at least three months after treatment for an ectopic pregnancy before trying to conceive again, to allow for physical recovery and emotional readiness. We understand the importance of explicitly stating these suggestions in our manuscript.

4.4 Strengths and limitations

The strengths of this study involve a sizable sample and the comparison of three distinct treatment methods, which bolsters the validity of our findings. In addition, our study was executed at a single center, thereby minimizing variability due to differing institutional practices or patient demographics [16].

Nonetheless, it is imperative to acknowledge some limitations. Firstly, the absence of long-term follow-up may have influenced our comprehension of fertility outcomes post-ectopic pregnancy treatment, especially considering that fertility impacts might not be evident until years later. Secondly, the study’s retrospective design is prone to potential biases, including selection bias and information bias. Although the manuscript has a retrospective design, it is still necessary to point out the risk of elevated type I errors. Lastly, although we accounted for known confounding variables, the potential for residual confounding from unmeasured variables persists [17].

4.5 Future research directions

Our study underscores the importance of continuing research in this area. Future prospective studies with longer follow-up periods could provide valuable information about long-term fertility outcomes. Research could also be aimed at identifying patient-specific factors that could help predict which patients might benefit most from each treatment approach, allowing for more personalized care.

Artificial intelligence (AI) technologies, such as machine learning and deep learning, are rapidly evolving and are being integrated into various aspects of healthcare, including predicting outcomes, diagnosing conditions, and personalizing treatments [18]. In maternal-fetal medicine and obstetrics, AI can be beneficial in several ways. For instance, it can improve the accuracy of prenatal screening and diagnosis, optimize the management of high-risk pregnancies, and enhance fetal monitoring during labor. Previously, a study demonstrated the potential of a machine learning model in predicting preterm birth based on electronic health record data [19]. Another study investigated the reliability of using deep learning in quantifying the synchronization between the mother and fetus cardiac rhythms throughout gestation.

AI has been making significant strides in the realm of medical imaging, particularly in the diagnosis of infant neurological impairment disorders. Ultrasound remains a crucial tool in detecting such conditions. However, the interpretation of results often depends on the skill and experience of the sonographer, which can lead to inconsistencies. This is where AI can play a transformative role. AI-based ultrasound image classification systems leverage sophisticated algorithms to analyze the ultrasound images, identify patterns, and make predictions about potential neurological impairments. These systems can be trained on large datasets to increase their accuracy and efficiency. For example, a study by Xie et al. [20] utilized deep learning mode to classify pediatric brain ultrasound images and achieved promising results. Not only can AI help increase the accuracy and consistency of diagnoses, but it can also support radiologists by alleviating their workload and reducing the risk of human error.

AI continues to show substantial potential in the field of diagnostic medical imaging [21]. Recent advancements in machine learning and deep learning techniques have led to the development of models that can aid in image acquisition, interpretation, and diagnosis. A study comprehensively examined the use of AI in medical imaging [22]. They found that AI has been used across various imaging modalities, including MRI, CT, and Ultrasound, and for various diseases, such as cancer, cardiovascular diseases, and neurological disorders. AI-based models have demonstrated performance on par with or even exceeding that of human experts in some tasks, such as detecting certain types of cancer in imaging studies [23]. The application of AI in diagnostic medical imaging brings several benefits, such as improving diagnostic accuracy, enabling quantitative imaging, and potentially reducing the workload of radiologists. However, despite these promising results, the transition of AI into clinical practice presents challenges. These include the need for robust validation of AI models, regulatory concerns, issues related to data privacy and security, and the need for proper integration with existing healthcare IT systems. In conclusion, while the application of AI in diagnostic medical imaging presents considerable promise, careful consideration must be given to the aforementioned challenges to ensure its safe and effective use.