The effect of methotrexate injection for treatment of an ectopic pregnancy on ovarian reserve

7 01 2014

To the Editor:

We read with great interest the paper “Does methotrexate administration for ectopic pregnancy after in vitro fertilization (IVF) impact ovarian reserve or ovarian responsiveness?” by Boots et al. (1). In the article, the authors evaluated the effects of methotrexate (MTX) on the future fertility of women undergoing IVF by comparing markers of ovarian reserve (day 3 FSH, antral follicle count), measures of ovarian responsiveness (duration of stimulation, peak E2 level, total dose of gonadotropins, number of oocytes retrieved, fertilization rate), and time from MTX administration to subsequent IVF cycle, in the IVF cycle before and after an ectopic pregnancy (EP) treated with MTX. They concluded that MTX treatment of an EP does not compromise ovarian reserve or ovarian responsiveness in subsequent cycles. However, other studies have demonstrated that when gonadotropin stimulation dose remains unchanged, fewer oocytes may be collected after MTX is taken as management of an ectopic pregnancy, suggesting a decrease in ovarian reserve (2). Read the rest of this entry »

Regarding “Medical treatment of ectopic pregnancy: a committee opinion”

6 12 2013

To the Editor:

We welcome the recently published article by the Practice Committee of the American Society for Reproductive Medicine on the medical treatment of ectopic pregnancy (EP) (1). In selected patients, Methotrexate (MTX) is an effective treatment for unruptured EP and helps to avoid surgical intervention.

We are however concerned about some aspects of the committee’s opinion. The document advocates the use of single measurements of serum human chorionic gonadotropin (hCG) as a discriminatory zone to separate abnormal from normal gestations at the first presentation, if a transvaginal ultrasound scan (TVS) fails to identify the location of a pregnancy. This approach is not without risk. For example, it does not take into account the possibility of a multiple pregnancy where for a given gestational age serum hCG levels are higher than in a singleton. Consequently, hCG levels in multiple pregnancies are usually much higher before the pregnancy reaches a size that may be visualized on TVS (2). This could result in the administration of MTX to a woman with a pregnancy of unknown location (PUL) who has a developing twin pregnancy rather than an underlying EP. Such an outcome would in all likelihood lead to major congenital abnormalities in the developing fetuses. We recommend that the diagnosis of EP be based on the positive identification of an EP mass if inappropriate use of MTX is to be avoided. In the event of a PUL, waiting 48 hours to determine the hCG ratio has been shown to be a safe management approach, which offers further reassurance if the ratio is incompatible with a viable IUP (3). Read the rest of this entry »

Comment on “Effect of cigarette smoking on human oviductal ciliation and ciliogenesis”

5 11 2012

To the Editor:

Defects in motile cilia are associated with several human diseases (1), so understanding the regulatory mechanisms of cilia function in the disease stage is of great importance. The results of a retrospective cohort study on the effect of cigarette smoke exposure on ciliation and ciliogenesis in human oviductal epithelium in vivo are currently in press in Fertility and Sterility ( Pier et al., 2012). From a methodological standpoint, the quality of the evidence presented appears to be the best that is currently available on this topic in oviduct-related scientific research. However, some considerations in this study require attention.

In the experiments of Pier et al., no significant differences in cilia-specific protein expression or ciliogenesis-related transcription factor regulation were observed between the two groups of patients with or without smoking. Thus, the authors conclude that “cigarette smoking does not seem to result in quantitative differences in the density of ciliation nor expression of ciliogenesis factors.” The pathogenic mechanisms underlying cigarette smoking in human oviductal cells, however, is still not well understood. To my understanding, the paper only provides a snapshot of cilia-specific gene and protein expression profiles in the oviducts of women following chronic exposure to cigarette smoke. The effects of biomedical interventions on a biological system, however, are normally measured by steady-state or time-course experiments. Thus this study cannot exploit and describe the dynamic mechanisms of tubal gene and/or protein regulation affected by cigarette smoke exposure. The failure to detect differences in the expression of cilia-specific molecules in women with or without chronic cigarette smoke exposure may be due to (a) a length of time after cigarette smoke exposure that is not favorable to the processes of ciliation and ciliogenesis or (b) indirect effects of cigarette smoking, or both. I suggest that an in vitro experiment could address this issue for establishment of a cause-and-effect relationship between cigarette smoke exposure and ciliation and ciliogenesis factor expression in human tubal ciliated cells. Read the rest of this entry »

Gestational Sac Aspiration and Instillation for Treatment of Early Ectopic Pregnancy

14 09 2011

To the Editor:

We thank Cepni et al. for sharing their recent case series, “An alternative treatment option in tubal ectopic pregnancies with fetal heartbeat: aspiration of the embryo followed by single-dose methotrexate administration” (1). This was of great interest to us, as we have used a similar aspiration and instillation technique using hyperosmolar glucose to treat a heterotopic pregnancy created after in vitro fertilization (IVF). Read the rest of this entry »

Disintegrin and metalloprotease and ectopic pregnancy

11 02 2011

To the Editor:

I read the recent publication on disintegrin and metalloprotease protein – 12 (ADAM 12) and ectopic pregnancy (EP) with great interest (1). Rausch et al. concluded that “ADAM-12 is a promising marker for the diagnosis of EP in women with symptoms in the first trimester, validating the proteomics findings.” (1) Read the rest of this entry »