A new fertility-preserving surgery for interstitial pregnancy involving hysteroscopic removal under laparoscopic guidance

Abstract

Interstitial pregnancy is a rare form of tubal ectopic pregnancy, accounting for 2%–4% of all such pregnancies [1]. Although medical treatment can successfully resolve the pregnancy when detected early enough, the standard treatment is cornual resection [2]. However, surgical treatmentmay result in aweakened uterinewall, leading to reduced fertility and a risk of uterine rupture in subsequent pregnancies. Successful transcervical evacuation of interstitial pregnancy under laparoscopic guidance has been reported [2]. However, owing to the characteristics of interstitial pregnancy and potential difficulties encountered during surgery, the placenta may be left behind—necessitating further treatment [3]. Hysteroscopic removal, when possible, reduces the incidence rate of this complication. In 2013, a 26-year-old nulliparous woman presented with an interstitial pregnancy. She wanted to preserve an intact uterus, so hysteroscopic removal was carried out using a technique similar to that performed for intrauterine evacuation. Hegar dilators were used for dilation of the cervical canal and the ostium of the fallopian tube; the dilators were used to reach the uterine cornu and to carefully establish a passage to the gestational site under laparoscopic guidance. A 6-mm suction catheter was then inserted into the uterus and introduced into the gestational site. The products of conception were evacuated at a negative pressure of 180 mm Hg. The hysteroscope was then introduced into the interstitial cavity because a more dilated pathologic tubal ostium was observed. Graspers were used to remove residual tissue from the interstitial cavity, leaving it empty (Fig. 1). Had uterine perforation occurred, cornual resection and salpingectomy would have been performed via laparoscopy. Thewomanwas discharged 2 days later; her serum β-human chorionic gonadotropin levels were undetectable by the second postoperative week. Ultrasound examination 4 weeks postoperatively showed that the cornual region had a normal appearance. When there is a possibility of interstitial pregnancy that is a relatively short distance from the cornual end and is associated with an unruptured mass and hemodynamic stability, hysteroscopic removal under laparoscopic guidance—rather than cornual resection—is a feasible treatment option. Furthermore, this new treatment can prevent a large amount of blood loss; however, when there is a high risk of tubal scarring, recurrent interstitial pregnancy may occur.