Symposium: Tubal disease and fertility outcome. Controversies in the management of ectopic pregnancy

Ectopic pregnancy is a common clinical problem, but there appears to be much controversy surrounding the surgical management of its occurence. This paper reviews the available evidence on the management of ectopic pregnancy. The discussion focuses initially around the choice of medical versus surgical treatment. Next, the question is addressed that if surgical management is deemed necessary, whether the approach should be laparoscopic or via open laparotomy. Lastly, if surgery is undertaken, should salpingectomy or salpingotomy be performed? Laparoscopy will remain the main method of treatment for women with ectopic pregnancy, as it provides obvious advantages over open surgery. On balance, salpingotomy should be the surgical treatment of choice for the majority of women with ectopic pregnancy, as it results in a higher subsequent pregnancy rate, although there is a slightly higher recurrent ectopic pregnancy rate and persistent trophoblastic disease rate when compared with women treated with salpingectomy. There is also a place for medical treatment of women with low concentrations of human chorionic gonadotrophin. A variable dosing methotrexate regimen is more effective compared with single dose regimen, and the fixed multiple regimen is associated with a high rate of side effects