There is debate about which surgical procedure is best. Salpingo-oophorectomy was once considered appropriate because it was theorized that this technique would eliminate transperitoneal migration of the ovum or zygote, which was thought to predispose to recurrent ectopic pregnancy (179). Ovarian removal results in all ovulations occurring on the side with the remaining normal fallopian tube. Subsequent studies have not confirmed that ipsilateral oophorectomy increases the likelihood of conceiving an intrauterine pregnancy; therefore, this practice is not recommended (180). Whether to treat the ectopic pregnancy with a salpingostomy or salpingectomy is strongly debated and multiple studies investigated this issue. If one surgical technique resulted in higher treatment efficacy, lower rates of recurrent ectopic pregnancies, and higher rates of future intrauterine pregnancies, the decision would be clear. Studies have not demonstrated a clear advantage of either salpingectomy or salpingostomy. The decision to chose one technique over the other depends on the condition of the affected and contralateral fallopian tubes, history of a previous ectopic pregnancy in the affected tube, and the patient’s desire for future fertility.
Linear salpingostomy can be considered when the patient has an unruptured ectopic pregnancy, wishes to retain her potential for future fertility, and the affected fallopian tube appears otherwise normal. If the contralateral tube appears damaged, a salpingostomy should be considered.
In a salpingostomy, the products of conception are removed through an incision made into the tube on its antimesenteric border. The procedure can be accomplished with needle-tip cautery, laser, scalpel, or scissors. It can be done with operative laparoscopic techniques or via a laparotomy. Contraindications to a salpingostomy include ruptured fallopian tube, use of extensive cautery to obtain hemostasis, severely damaged tube, and a recurrent ectopic pregnancy in the same tube. The main risk factor of salpingostomy is a persistent ectopic pregnancy resulting from failure to remove the entire pregnancy from the fallopian tube. This was reported in 5% to 20% of cases, and the rate appears to be higher in laparoscopic cases as compared to salpingostomies at the time of a laparotomy (181–184). Patients with high starting β-hCG levels, early gestations, and small ectopic pregnancies (<2 cm) are at greater risk of having a persistent pregnancy after a salpingostomy (185). Because of this risk, it is recommended to follow weekly β-hCG levels to ensure complete resolution of the ectopic pregnancy. β-hCG levels that persist or plateau can usually be treated successfully with a single dose of methotrexate, as described below (26).
Milking the tube to effect a tubal abortion was advocated; if the pregnancy is fimbrial, this technique may be effective. When milking was compared with linear salpingostomy for ampullary ectopic pregnancies, milking was associated with a twofold increase in the recurrent ectopic pregnancy rate (186).
Reproductive outcome after ectopic pregnancy is evaluated by determining tubal patency by hysterosalpingography, the subsequent intrauterine pregnancy rate, and the recurrent ectopic pregnancy rate. Pregnancy rates are similar in patients treated by either laparoscopy or laparotomy. Tubal patency on the ipsilateral side after conservative laparoscopic management is about 84% (187).