To the Editor:
I have read the recent article in press by Eun et al (1) with great interest. The authors described their clinical experiences in laparoscopic cornuotomy in interstitial pregnancy using a temporary tourniquet suture and diluted vasopressin injection.
I compliment their attempt at introducing a new surgical technique for interstitial pregnancy which could effectively preserve reproductive capacity. However, I would like to point out two things in this paper which must be clarified to the readers.
First of all, their results (Table 1; Summary of the clinical characteristics of the patients who underwent laparoscopic cornuotomy) include data of days to resolution of beta-hCG, which can only be obtained through daily follow up of serum beta-hCG. However, not only is daily serum beta-hCG assay clinically impossible, but the authors have also clearly stated that sequential beta-hCG assays were obtained in each patient at 1-week intervals. Therefore, the authors should either clarify their method of serum beta-hCG follow-up or change the word ‘days’ to a more appropriate word.
Secondly, in the discussion, while mentioning the shortcomings of other surgical methods which are sacrificing the salpinx and cornua both anatomically and functionally, the authors referred to studies conducted by Tulandi et al (2), Huang et al (3), Moon et al (4), and Yoo et al (5), immediately followed by two cases of uterine rupture following surgeries for interstitial pregnancy (6,7), both of which were reported more than 15 years ago. It was then followed by a conclusion that their surgical method has an advantage of preserving reproductive capacity but lacking data on actual outcome of postsurgical pregnancy. What I am concerned about is that many readers might draw a wrong conclusion that the above-mentioned surgical techniques (2-5) are less effective in preserving reproductive capability and even have a potential risk of serious complications such as uterine rupture. However, in our study (4), 15 of 17 patients with interstitial pregnancy who had wanted a future pregnancy became pregnant and among them 11 women gave birth to healthy babies by cesarean section at term and there wasn’t a single case of uterine rupture. Moreover, unlike what the authors have mentioned, the gross findings in the cornual area at the time of cesarean section confirmed no significant adhesions or defects, which demonstrate there was no sacrifice of salpinx and cornua.
In conclusion, we think that the authors suggested a safe and effective laparoscopic technique for interstitial pregnancy but it lacks data on pregnancy outcome, which is necessary if they wish to discuss reproductive capacity. Furthermore, the above-mentioned studies (2-5) were inappropriately cited to exemplify shortcomings related to future reproductive function and post-operative complications without objective comparison of each study’s result.
Hwasook Moon, MD, PhD
Center for Minimally Invasive Surgery
Good Moonhwa Hospital
Busan, South Korea
1. Eun DS, Choi YS, Choi J, Shin KS, Choi JG, Park HD. Laparoscopic cornuotomy using a temporary tourniquet suture and diluted vasopressin injection in interstitial pregnancy. Fertil Steril 2008.
2. Tulandi T, Al-Jaroudi D. Interstitial pregnancy: results generated from the Society of Reproductive Surgeons Registry. Obstet Gynecol 2004; 103: 47-50.
3. Huang MC, Su TH, Lee MY. Laparoscopic management of interstitial pregnancy. Int J Gynecol Obstet 2005; 88: 51-2.
4. Moon HS, Choi YJ, Park YH, Kim SG. New simple endoscopic operations for interstitial pregnancies. Am J Obstet Gynecol 2000; 182: 114-21.
5. Yoo EH, Chun YJ, Park YH, Kim SG. Endoscopic treatment of interstitial pregnancy. Acta Obstet Gynecol Scand 2003; 82: 189-91.
6. Weissman A, Fishman A. Uterine rupture following conservative surgery for interstitial pregnancy. Eur J Obstet Gynecol Reprod Biol 1992; 44: 237-9.
7. Downey GP, Tuck SM. Spontaneous uterine rupture during subsequent pregnancy following non-excision of an interstitial ectopic gestation. Br J Obstet Gynecol 1994; 101: 162-3.
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2009.04.006
The Authors Respond
We have read the letter from Dr. Moon with great pleasure. I want to clarify two points.
1. Regarding serum beta hCG resolution day:
Sequential serum beta-hCG assays were obtained from each patient every week . If serum beta hCG level was below 5mIU, then that was determined as resolution and the day of blood sampling was determined beta hCG resolution day.
2. Regarding reproductive capacity:
We evaluated the uterine integrity and uterotubal patency through MRI and HSG respectively and we obtained acceptable results. Of course, MRI and HSG were not sufficient to evaluate the uterotubal patency and uterine integrity, but the studies were noninvasive and allowed the presumption of anatomical reproductive capacity indirectly.
Moreover, we experienced 4 pregnancies after laparoscopic cornuotomy. To my surprise, 2 multiparous women had conceived 12 and 17 months after the surgery and were safely delivered by vaginal route at full term, and 1 nulliparous woman had conceived 30 months after surgery and she was safely delivered by cesarean section at full term. One multiparous woman is in the 20th week of pregnancy now. Results will be reported at a later date in a separate article.
Young-Sam Choi, M.D.
Department of Obstetrics and Gynecology
Kwang-ju, South Korea
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2009.04.005