Treatment of Tubal Pregnancy in The Netherlands: An Economic Comparison of Systemic Methotrexate Administration and Laparoscopic Salpingostomy

Abstract

Analyses of recent literature and theoretical cost evaluations have suggested that administration of systemic methotrexate to treat patients with tubal pregnancy is more cost-effective than surgical treatment with laparoscopic salpingostomy. This study was conducted to evaluate the two methods of treatment in actual clinical settings with an emphasis on economic comparison. One hundred patients with a diagnosis of nonruptured ectopic pregnancy confirmed by ultrasound and measurement of serum human chorionic gonadotropin (hCG) concentration met the study criteria and were randomly assigned to receive either systemic methotrexate (N = 51) or laparoscopic salpingostomy (N = 49). The two groups were similar in patient characteristics. Of the 51 patients receiving methotrexate, 3 (6 percent) had persistent trophoblast that required a second course of treatment, and surgical intervention was necessary in 7 (14 percent). Of the 49 patients undergoing laparoscopic salpingostomy, 4 were converted to salpingectomy, and 10 (20 percent) underwent a course of systemic methotrexate for persistent trophoblast. Patients in the methotrexate group had an average initial hospital stay of 3.2 days, but seven women were readmitted with severe abdominal pain or for surgical intervention. The overall length of hospital stay for this group was 4.5 days. Patients in the salpingostomy group stayed in the hospital an average of 2.5 days, and none were readmitted. An average of 2.3 transvaginal sonograms and 6.1 hCG concentration measurements were required for the methotrexate group, compared with 1.3 and 5.4, respectively, for the salpingostomy group. Slightly more women in the methotrexate group reported needing help from family and friends at home, and help for a longer period of time, than in the salpingostomy group. The average time away from work was 38 and 28 days, respectively. The mean cost of treatment was $5721 for patients receiving systematic methotrexate, compared with $4066 for patients undergoing laparoscopic salpingostomy. Cost-minimization analyses found that serum hCG concentrations had the greatest influence on total costs. Both treatment arms had similar mean costs when the serum hCG concentration was <1500 IU/liter. If diagnostic procedures were limited to ultrasound and repeated hCG measurement (no confirmatory laparoscopy), systemic methotrexate treatment would reduce the cost by an additional $1500 with hCG concentrations <1500 IU/liter. At serum hCG levels >3000 IU/liter, the cost of systemic methotrexate was higher even without confirmatory laparoscopy. Am J Obstet Gynecol 1999;181:945–951