- Email: [email protected]
Reproductive performance following a second ectopic gestation
Int J Gynecol
International
Obstet, 1993, 43: 191-194 Federation of Gynecology
191 and Obstetrics
Reproductive performance following a second ectopic gestation J.L. Glock”, R.A. Loyb and J.R. Brumsted” ‘Division Medicine,
of Reproductive Burlington,
Endocrinology
Vermont
and Infertility,
05405 and hCenter for
Department Infertility
Abstract OBJECTIVES: Our purpose was to determine the obstetric outcome following a second ectopic gestation in women actively trying to conceive, with a review of the literature. METHODS: Charts of 37 patients coded for having at least two ectopic pregnancies between 1986 and 1989 were reviewed. Duration of follow-up rangedfrom 7 months to 7 years with r .. -a mean follow-up time of* 25 months, KIYSULTS: We report a 45.4% intrauterine pregnancy rate, 27.3% live birth rate, and 36.4% recurrent ectopic pregnancy rate. Review of the literature shows an intrauterine pregnancy rate of 26-500A, live birth rate of 25-31.2’%, and recurrent ectopic pregnancy rate of 7.7-40’%, CONCLUSIONS: Four of five studies report the risk of a third ectopic gestation is less than an intrauterine gestation. This may prove helnfirl in ---I-J -__ -._
rnunmlinu ___ _._____._ b ~nntipntr _.-_.. “_ with .r .“.I
n hirtnrv I “‘ “‘“‘J
nf ..J
recurrent ectopic gestation in choosing IVF or attempting conception naturally.
Keywords: Second
Ectopic;
Recurrent;
Repeat;
Introduction It is stated that an epidemic of ectopic pregnancies has occurred in the United States since 1970. Interestingly, the increased incidence of tubal pregnancies has not been accounted for, by the dramatic increase in 0020-7293/93/%06.00 0 1993 International Federation Printed and Published in Ireland
of Obstetrics
and Reproductive
and Gynecology, Medicine,
University
Orlando,
Florida
qf Vermont
College of
(USA)
sexually transmitted disease [I]. In fact, ectopic pregnancy has occurred in the presence of histologically normal tubes in 70% of recent ectopic pregnancies [2]. Enhanced diagnostic technology resulting in earlier diagnosis and a trend toward more conservative tubal surgery is believed to account in part for the epidemic. Although conservative tubal surgery has improved future fertility, it has also increased the risk of recurrent ectopic pregnancies. Given this, a deciine in recurrent ectopic pregnancies in the near future is unlikely. Although several investigators [3-61 have reported the reproductive performance in women following recurrent ectopic pregnancies, the data are difficult to interpret because those patients actively trying to conceive were not always identified. This report will hopefully contribute to a more accurate assessment of the reproductive potential of WQm_eTl fQiiQWin!Z ~ -2 second nrPun2nrv I___ --- ertnnir ‘-‘-r” r’.,~“u..-J by evaluating these women who were actively trying to conceive. Materials and methods Charts of 37 patients coded for having at least two ectopic pregnancies at the Orlando Regional Medical Center between 1986 and 1991 were reviewed. Careful review of the operative notes confirmed the presence of at least two ectopic pregnancies in each patient. This information included the type of surgical procedure, a description of both adnexa, and the location of the ectopic gestation. Follow Case Report
of Gynecology
and Obstetrics
192
Clock et al.
up was based on studying the hospital records for evidence of subsequent pregnancy, private physicians were contacted, and patients were contacted by telephone. Specifically, patients were asked whether they used contraception, the length of time they were actively trying to PA~P.GVP 2nd u2 uv”“lAyu”u JPrrrintinn “n nf their nhctetrir “““V’ l.W, USIU %&1”11 “““C”CIA” outcome if pregnancy did occur. Duration of follow-up ranged from 7 months to 7 years with a mean follow-up time of 25 months from their second ectopic gestation.
Table 1. Profile of 11patients actively trying to conceive after two ectopic pregnancies. Patient
Age
Time from 2nd Ectopic to 1st Conception
Outcome of pregnancy no. (years)
9 IO
33 29 24 26 28 21 26 25 31 30
12 24 28 I 18 28 60 72 36 15
II
30
23
NSVD”, NSVD Ectopic Ectopic Fxtopic NSVD NSVD SABb, Ectopic Ectopic SAB Unable to conceive Unable to conceive
8
Results Of the 37 patients evaluated, three were lost to follow up and 21 were sterilized. Nineteen patients were sterilized during surgery for the second ectopic pregnancy and two had elective sterilizations performed subsequent to the second ectopic pregnancy. Of the 13 patients who were not sterilized, 2 were using contraception and 11 were actively trying to conceive. Of these 11, 4 patients had a third ectopic pregnancy, 5 patients had a total of 6 intrauterine pregnancies (4 term deliveries and 2 first trimester spontaneous abortions), and 2 patients were unable to conceive (Table 1). Of those patients having a live birth, 1 patient had 2 term vaginal deliveries after a left salpingostomy followed by a left salpingooophorectomy; 1 patient had a term vaginal delivery following a right salpingostomy for both her first and second ectopic pregnancy; and one patient delivered a term infant after a right salpingostomy followed by a right salpingectomy. All patients having a live birth had an intact contralateral tube. In the 2 pa.:,...r, l..,..:,, LIC‘IL> llavlllg a spontaneous abortion, t-cl. UULll pregnancies occurred following a left salpingostomy as the first surgical procedure and a left partial salpingectomy as the second surgical procedure. Of the 5 patients with a third ectopic pregnancy, 3 occurred following a salpingostomy procedure on the one remaining tube and 2 occurred in the remaining intact contralateral tube. In those 2 patients unable to conceive, 1 had a left partial salpingectomy Int J Gyneeol
Obstet 43
“NSVD, normal spontaneous vaginal delivery. bSAB, spontaneous abortion.
followed by a right salpingostomy; the other patient had a left salpingostomy followed by a left partial salpingectomy. Discussion This study reports an overall live birth rate of 27.3% in those patients actively trying to conceive after a second ectopic pregnancy. Only the first intrauterine and extrauterine pregnancies are reported in these calculations. This is comparable to studies by Uotila et al. [7], DeCherney et al. 181,and Tulandi [9] who report 31.2%, 30.7%, and 25%, respectively (Table 2). Oelsner et al. [lo] reported a total of 16 intrauterine pregnancies (11 live births and 5 spontaneous abortions) in 12 patients. XTI~-L..--,-L!_._._.r_ .._.-__A_>on -- __.L:-.L -.IYO inIorrndtx_m wds repvrux wriicm pdtients had more than one pregnancy, so the percentage of live birth and spontaneous abortion were not calculated. In the present study, a third ectopic pregnancy occurred in 36.4% of patients. This is comparable to reports by Oelsner [lo] of 26.9% and Uotila et al. [7] of 40%, but is considerably greater than reports of 7.7% and 18.7% by DeCherney et al. [8] and Tulandi [9], respectively.
Repeat ecropic pregnancy
Table 2.
193
Current study with review of literature. Oelsner (1978-1983)
Uotila et al. (1972-1985)
Tulandi
No. patients
28
23
67
24
34
followed up Sterilized Actively trying
0 (0%) 26 (92.8%)
6 (26%) 13 (56.5%)
12 (17.9”/0) 53 (79.1%)
4 (16.7%) 16 (66.7%)
21 (61.7%) II (32.3%)
to conceive Intrauterine
12 (46.2%)
4 (30.7%)
14 (26%)
pregnancy Live birth Abortion Ectopic
NS NS 7 (26.9%)
4 (30.7%) NS I (7.7%)
13 (25%) 1 (1.9%) 21 (40%)
’
(NS)a
Current study (1986-1991)
DeCherney et al. (1976-1981)
8 (50%)
5 (45.5%)
5 (31.2%) 3 (18.7%) 3 (18.7%)
3 (27.3%) 2 (18.1%) 4 (36.4%)
aNS, not specified.
In the present series, there were 3 patients with a solitary tube treated by salpingostomy. All 3 subsequently had a third ectopic pregnancy. The previous report by Tulandi [9] was more encouraging. He reports a 18.7% third ectopic pregnancy rate and a 50% intrauterine pregnancy rate in 20 patients with a solitary tube treated by saipingostomy at the second ectopic pregnancy. Oelsner et al. [lo] reports a 46% intrauterine pregnancy rate and a 38% ectopic pregnancy rate in 26 women with a solitary tube treated by conservative surgery for the second ectopic gestation. In 7 patients, the second ectopic pregnancy occurred in the ipsilateral tube, leaving an intact contralateral tube. Of these, 5 of 7 (7 1.4%) had intrauterine pregnancies and 2 of
pregnancy was greater than the risk of a third ectopic gestation in women actively trying to conceive following a second ectopic pregnancy. Although the medical treatment of ectopic pregnancy with methotrexate has shown great promise [l l-141, follow up studies on the reproductive performance of these women are limited. Furthermore, no study to date has prospectively compared methotrexate therapy with surgical therapy.
7I 13Q f&‘ s thirrl \A”.“,“ , /L\h-A llLIU u LllllU
tllhcTn thprp na&=ntr U”.‘ artiv.-lv U”“. 111 ~~I”“I ~U”Y”W” .“‘J
prtnnir ~~c”yIv
nrpnnonrxr y‘r~nu.L”YJ.
Tn_ 111-
terestingly, all intrauterine pregnancies in this study occurred in the presence of an intact contralateral tube. These findings reinforce the fact that there remains a significant risk of recurrent ectopic gestation following conservative tubal surgery. It also suggests that although in vitro fertilization remains a viable alternative in any patient with a history of recurrent ectopic pregnancy, the chance of a spontaneous intrauterine pregnancy seems highest for those patients with an intact contralateral tube. Regardless, in 4 of the 5 studies reported, the risk of an intrauterine
Conclusion In this study, the best obstetric outcome following a second ectopic pregnancy occurred in patients with an intact contralateral ??
t&no mm_ C’J”‘b tn SV ““aa
ceive, there was a 45.5% intrauterine pregnancy rate and a 27.3% live birth rate. This may be helpful in counseling patients with a history of recurrent ectopic gestation in choosing IVF or attempting conception naturally. It also suggests that tubal pathology may in fact be unilateral in many cases. References 1
Ectopic pregnancy 1970-1987. MMWR.
surveillance: United 39(SS-4): 9. 1988.
States,
Case Report
194
Glock et al.
2
Patterstein CJ, Croxatto HB, Eddy CA, Ramzy I, Walters MD: Anatomy and pathology of tubal pregnancy. Obstet Gynecol 67: 301, 1986. 3 Hallatt JG: Repeat ectopic pregnancy: a study of 123 consecutive cases. Am J Obstet Gynecol 122: 520, 1975. 4 Schoen JA, Nowak RJ: Repeat ectopic pregnancy: a 16 year clinical survey. Obstet Gynecol 45: 542, 1975. 5 Kitchin JD, Wein RM, Nunley WC, Thiagarajah S, Thorton WN: Ectopic pregnancy: current trends. Am J Obstet Gynecol 134: 870, 1979. 6 Sandvei R, Bergsjo P, Ulstein M, Steier JA: Repeat ectopic pregnancy: a twenty-year hospital survey. Acta Obstet Gynecol Stand 66: 35, 1987. 7 Uotila J, Heinonen PK, Punnonen R: Reproductive outcome after multiple ectopic pregnancies. Int J Fertil 34: 102, 1989. 8 DeChemey AH, Silidker JS, Mezer HC, Tarlatzis RC: Reproductive outcome following two ectopic pregnancies. Fertil Steril 43: 82, 1985. 9 Tulandi T: Reproductive performance of women after two tubai ectopic pregnancies. Fertii Sterii 50: i64, i988. 10 Oelsner G: Ectopic pregnancy in the sole remaining tube and the management of the patient with multiple ectopic pregnancies. Clin Obstet Gynecol 30: 225, 1987.
Inr J Gynecol Obster 43
II
I2
I3
I4
Ory SJ, Villanueva AL, Sand P et al.: Conservative treatment of ectopic pregnancy with methotrexate. Am J Obstet Gynecol 154: 1299, 1986. Sauer MV, Gorrill MJ, Rudi IA et al.: Nonsurgical management of unruptured ectopic pregnancy: an extended clinical trial. Fertil Steril 48: 752, 1987. Stovall TG, Ling FW, Gray LA, Carson SA, Buster JE: Methotrexate treatment of unruptured ectopic pregnancy: a report of 100 cases. Obstet Gynecol 77: 749, 1991. Stovall TG, Ling FW, Buster JE: Reproductive performance with methotrexate treatment of ectopic pregnancy. Am J Obstet Gynecol 162: 1620, 1990.
Address for reprints:
J.L. Glock Division of Reproductive Endocrinology and Infertility Department of Obstetrics and Gynecology University of Vermont College of Medicine Rurlington Vermont 05405 USA
International
Obstet, 1993, 43: 191-194 Federation of Gynecology
191 and Obstetrics
Reproductive performance following a second ectopic gestation J.L. Glock”, R.A. Loyb and J.R. Brumsted” ‘Division Medicine,
of Reproductive Burlington,
Endocrinology
Vermont
and Infertility,
05405 and hCenter for
Department Infertility
Abstract OBJECTIVES: Our purpose was to determine the obstetric outcome following a second ectopic gestation in women actively trying to conceive, with a review of the literature. METHODS: Charts of 37 patients coded for having at least two ectopic pregnancies between 1986 and 1989 were reviewed. Duration of follow-up rangedfrom 7 months to 7 years with r .. -a mean follow-up time of* 25 months, KIYSULTS: We report a 45.4% intrauterine pregnancy rate, 27.3% live birth rate, and 36.4% recurrent ectopic pregnancy rate. Review of the literature shows an intrauterine pregnancy rate of 26-500A, live birth rate of 25-31.2’%, and recurrent ectopic pregnancy rate of 7.7-40’%, CONCLUSIONS: Four of five studies report the risk of a third ectopic gestation is less than an intrauterine gestation. This may prove helnfirl in ---I-J -__ -._
rnunmlinu ___ _._____._ b ~nntipntr _.-_.. “_ with .r .“.I
n hirtnrv I “‘ “‘“‘J
nf ..J
recurrent ectopic gestation in choosing IVF or attempting conception naturally.
Keywords: Second
Ectopic;
Recurrent;
Repeat;
Introduction It is stated that an epidemic of ectopic pregnancies has occurred in the United States since 1970. Interestingly, the increased incidence of tubal pregnancies has not been accounted for, by the dramatic increase in 0020-7293/93/%06.00 0 1993 International Federation Printed and Published in Ireland
of Obstetrics
and Reproductive
and Gynecology, Medicine,
University
Orlando,
Florida
qf Vermont
College of
(USA)
sexually transmitted disease [I]. In fact, ectopic pregnancy has occurred in the presence of histologically normal tubes in 70% of recent ectopic pregnancies [2]. Enhanced diagnostic technology resulting in earlier diagnosis and a trend toward more conservative tubal surgery is believed to account in part for the epidemic. Although conservative tubal surgery has improved future fertility, it has also increased the risk of recurrent ectopic pregnancies. Given this, a deciine in recurrent ectopic pregnancies in the near future is unlikely. Although several investigators [3-61 have reported the reproductive performance in women following recurrent ectopic pregnancies, the data are difficult to interpret because those patients actively trying to conceive were not always identified. This report will hopefully contribute to a more accurate assessment of the reproductive potential of WQm_eTl fQiiQWin!Z ~ -2 second nrPun2nrv I___ --- ertnnir ‘-‘-r” r’.,~“u..-J by evaluating these women who were actively trying to conceive. Materials and methods Charts of 37 patients coded for having at least two ectopic pregnancies at the Orlando Regional Medical Center between 1986 and 1991 were reviewed. Careful review of the operative notes confirmed the presence of at least two ectopic pregnancies in each patient. This information included the type of surgical procedure, a description of both adnexa, and the location of the ectopic gestation. Follow Case Report
of Gynecology
and Obstetrics
192
Clock et al.
up was based on studying the hospital records for evidence of subsequent pregnancy, private physicians were contacted, and patients were contacted by telephone. Specifically, patients were asked whether they used contraception, the length of time they were actively trying to PA~P.GVP 2nd u2 uv”“lAyu”u JPrrrintinn “n nf their nhctetrir “““V’ l.W, USIU %&1”11 “““C”CIA” outcome if pregnancy did occur. Duration of follow-up ranged from 7 months to 7 years with a mean follow-up time of 25 months from their second ectopic gestation.
Table 1. Profile of 11patients actively trying to conceive after two ectopic pregnancies. Patient
Age
Time from 2nd Ectopic to 1st Conception
Outcome of pregnancy no. (years)
9 IO
33 29 24 26 28 21 26 25 31 30
12 24 28 I 18 28 60 72 36 15
II
30
23
NSVD”, NSVD Ectopic Ectopic Fxtopic NSVD NSVD SABb, Ectopic Ectopic SAB Unable to conceive Unable to conceive
8
Results Of the 37 patients evaluated, three were lost to follow up and 21 were sterilized. Nineteen patients were sterilized during surgery for the second ectopic pregnancy and two had elective sterilizations performed subsequent to the second ectopic pregnancy. Of the 13 patients who were not sterilized, 2 were using contraception and 11 were actively trying to conceive. Of these 11, 4 patients had a third ectopic pregnancy, 5 patients had a total of 6 intrauterine pregnancies (4 term deliveries and 2 first trimester spontaneous abortions), and 2 patients were unable to conceive (Table 1). Of those patients having a live birth, 1 patient had 2 term vaginal deliveries after a left salpingostomy followed by a left salpingooophorectomy; 1 patient had a term vaginal delivery following a right salpingostomy for both her first and second ectopic pregnancy; and one patient delivered a term infant after a right salpingostomy followed by a right salpingectomy. All patients having a live birth had an intact contralateral tube. In the 2 pa.:,...r, l..,..:,, LIC‘IL> llavlllg a spontaneous abortion, t-cl. UULll pregnancies occurred following a left salpingostomy as the first surgical procedure and a left partial salpingectomy as the second surgical procedure. Of the 5 patients with a third ectopic pregnancy, 3 occurred following a salpingostomy procedure on the one remaining tube and 2 occurred in the remaining intact contralateral tube. In those 2 patients unable to conceive, 1 had a left partial salpingectomy Int J Gyneeol
Obstet 43
“NSVD, normal spontaneous vaginal delivery. bSAB, spontaneous abortion.
followed by a right salpingostomy; the other patient had a left salpingostomy followed by a left partial salpingectomy. Discussion This study reports an overall live birth rate of 27.3% in those patients actively trying to conceive after a second ectopic pregnancy. Only the first intrauterine and extrauterine pregnancies are reported in these calculations. This is comparable to studies by Uotila et al. [7], DeCherney et al. 181,and Tulandi [9] who report 31.2%, 30.7%, and 25%, respectively (Table 2). Oelsner et al. [lo] reported a total of 16 intrauterine pregnancies (11 live births and 5 spontaneous abortions) in 12 patients. XTI~-L..--,-L!_._._.r_ .._.-__A_>on -- __.L:-.L -.IYO inIorrndtx_m wds repvrux wriicm pdtients had more than one pregnancy, so the percentage of live birth and spontaneous abortion were not calculated. In the present study, a third ectopic pregnancy occurred in 36.4% of patients. This is comparable to reports by Oelsner [lo] of 26.9% and Uotila et al. [7] of 40%, but is considerably greater than reports of 7.7% and 18.7% by DeCherney et al. [8] and Tulandi [9], respectively.
Repeat ecropic pregnancy
Table 2.
193
Current study with review of literature. Oelsner (1978-1983)
Uotila et al. (1972-1985)
Tulandi
No. patients
28
23
67
24
34
followed up Sterilized Actively trying
0 (0%) 26 (92.8%)
6 (26%) 13 (56.5%)
12 (17.9”/0) 53 (79.1%)
4 (16.7%) 16 (66.7%)
21 (61.7%) II (32.3%)
to conceive Intrauterine
12 (46.2%)
4 (30.7%)
14 (26%)
pregnancy Live birth Abortion Ectopic
NS NS 7 (26.9%)
4 (30.7%) NS I (7.7%)
13 (25%) 1 (1.9%) 21 (40%)
’
(NS)a
Current study (1986-1991)
DeCherney et al. (1976-1981)
8 (50%)
5 (45.5%)
5 (31.2%) 3 (18.7%) 3 (18.7%)
3 (27.3%) 2 (18.1%) 4 (36.4%)
aNS, not specified.
In the present series, there were 3 patients with a solitary tube treated by salpingostomy. All 3 subsequently had a third ectopic pregnancy. The previous report by Tulandi [9] was more encouraging. He reports a 18.7% third ectopic pregnancy rate and a 50% intrauterine pregnancy rate in 20 patients with a solitary tube treated by saipingostomy at the second ectopic pregnancy. Oelsner et al. [lo] reports a 46% intrauterine pregnancy rate and a 38% ectopic pregnancy rate in 26 women with a solitary tube treated by conservative surgery for the second ectopic gestation. In 7 patients, the second ectopic pregnancy occurred in the ipsilateral tube, leaving an intact contralateral tube. Of these, 5 of 7 (7 1.4%) had intrauterine pregnancies and 2 of
pregnancy was greater than the risk of a third ectopic gestation in women actively trying to conceive following a second ectopic pregnancy. Although the medical treatment of ectopic pregnancy with methotrexate has shown great promise [l l-141, follow up studies on the reproductive performance of these women are limited. Furthermore, no study to date has prospectively compared methotrexate therapy with surgical therapy.
7I 13Q f&‘ s thirrl \A”.“,“ , /L\h-A llLIU u LllllU
tllhcTn thprp na&=ntr U”.‘ artiv.-lv U”“. 111 ~~I”“I ~U”Y”W” .“‘J
prtnnir ~~c”yIv
nrpnnonrxr y‘r~nu.L”YJ.
Tn_ 111-
terestingly, all intrauterine pregnancies in this study occurred in the presence of an intact contralateral tube. These findings reinforce the fact that there remains a significant risk of recurrent ectopic gestation following conservative tubal surgery. It also suggests that although in vitro fertilization remains a viable alternative in any patient with a history of recurrent ectopic pregnancy, the chance of a spontaneous intrauterine pregnancy seems highest for those patients with an intact contralateral tube. Regardless, in 4 of the 5 studies reported, the risk of an intrauterine
Conclusion In this study, the best obstetric outcome following a second ectopic pregnancy occurred in patients with an intact contralateral ??
t&no mm_ C’J”‘b tn SV ““aa
ceive, there was a 45.5% intrauterine pregnancy rate and a 27.3% live birth rate. This may be helpful in counseling patients with a history of recurrent ectopic gestation in choosing IVF or attempting conception naturally. It also suggests that tubal pathology may in fact be unilateral in many cases. References 1
Ectopic pregnancy 1970-1987. MMWR.
surveillance: United 39(SS-4): 9. 1988.
States,
Case Report
194
Glock et al.
2
Patterstein CJ, Croxatto HB, Eddy CA, Ramzy I, Walters MD: Anatomy and pathology of tubal pregnancy. Obstet Gynecol 67: 301, 1986. 3 Hallatt JG: Repeat ectopic pregnancy: a study of 123 consecutive cases. Am J Obstet Gynecol 122: 520, 1975. 4 Schoen JA, Nowak RJ: Repeat ectopic pregnancy: a 16 year clinical survey. Obstet Gynecol 45: 542, 1975. 5 Kitchin JD, Wein RM, Nunley WC, Thiagarajah S, Thorton WN: Ectopic pregnancy: current trends. Am J Obstet Gynecol 134: 870, 1979. 6 Sandvei R, Bergsjo P, Ulstein M, Steier JA: Repeat ectopic pregnancy: a twenty-year hospital survey. Acta Obstet Gynecol Stand 66: 35, 1987. 7 Uotila J, Heinonen PK, Punnonen R: Reproductive outcome after multiple ectopic pregnancies. Int J Fertil 34: 102, 1989. 8 DeChemey AH, Silidker JS, Mezer HC, Tarlatzis RC: Reproductive outcome following two ectopic pregnancies. Fertil Steril 43: 82, 1985. 9 Tulandi T: Reproductive performance of women after two tubai ectopic pregnancies. Fertii Sterii 50: i64, i988. 10 Oelsner G: Ectopic pregnancy in the sole remaining tube and the management of the patient with multiple ectopic pregnancies. Clin Obstet Gynecol 30: 225, 1987.
Inr J Gynecol Obster 43
II
I2
I3
I4
Ory SJ, Villanueva AL, Sand P et al.: Conservative treatment of ectopic pregnancy with methotrexate. Am J Obstet Gynecol 154: 1299, 1986. Sauer MV, Gorrill MJ, Rudi IA et al.: Nonsurgical management of unruptured ectopic pregnancy: an extended clinical trial. Fertil Steril 48: 752, 1987. Stovall TG, Ling FW, Gray LA, Carson SA, Buster JE: Methotrexate treatment of unruptured ectopic pregnancy: a report of 100 cases. Obstet Gynecol 77: 749, 1991. Stovall TG, Ling FW, Buster JE: Reproductive performance with methotrexate treatment of ectopic pregnancy. Am J Obstet Gynecol 162: 1620, 1990.
Address for reprints:
J.L. Glock Division of Reproductive Endocrinology and Infertility Department of Obstetrics and Gynecology University of Vermont College of Medicine Rurlington Vermont 05405 USA