Ectopic pregnancy (EP) occurs when a fertilized
egg implants somewhere other than the main cavity of
the uterus. EP cannot continue as a normal pregnancy.
EP comprises about 1.6% of all pregnancies and it is a
potential leading cause of pregnancy-related mortality in
the first trimester of pregnancy (
Laparoscopy is the gold standard for managing EP (
Anti-Mullerian hormone (AMH) is an endocrine marker
considered for assessing the ovarian reserve and it is not
affected by gonadotropins (
This prospective cohort study was conducted from 2015 to 2017 in Tehran General Women Hospital, an educational hospital affiliated with Tehran University of Medical Sciences (TUMS), Tehran, Iran. The study was approved by the Ethical Board Committee of Tehran University of Medical Sciences by number 90-0339-14127. Patients were thoroughly informed of the experiment and fully consented to taking part in the study
Patients who referred to our hospital with suspicious EP, were assessed for eligibility. AFC, AMH, (FSH and LH on the 3rd day of the cycle) and 17 beta estradiol (E2) in mid cycle were assessed before recruiting in the ART cycle. For baseline assessment, beta-human chorionic gonadotropin (β-hCG) concentration was measured and trans-vaginal ultrasound was performed to evaluate the pregnancy sac in spontaneous course and at baseline before any intervention. The diagnosis of EP was made based on an increasing serum β-hCG concentration (>2000 mlU/ml) and no intrauterine sac visualized by trans-vaginal ultrasound after 6 weeks of gestational age. The unnecessary tests are not mentioned. All tests were done in a single lab in the reference hospital.
Eligible subjects were adult women with at least 18
years of age with history of infertility that had previously
Eligibility for MTX administration included: stable
homodynamic status, the size of ectopic mass below 4
cm on ultrasound examination, unruptured EP and no
contraindication either relative or absolute for MTX use.
Serum concentration of β-hCG >5000 mlU/ml and fetal
heart activity were relative contraindications for nonsurgical management of EP. Absolute contraindications
were chronic liver disease, pre-existing blood
dyscrasias, pulmonary disease, peptic ulcer disease and
immunodeficiency. In addition, the participants who
had sensitivity to MTX, or were breastfeeding, were not
included for MTX therapy (
Plasma levels of 17 beta-estradiol (in mid cycle), LH and FSH (on the 3rd day of the cycle) as well as AMH were measured at baseline (definitely before MTX administration) and 8 weeks after treatment with MTX. Selection of the time point (i.e. after eight weeks) was according to our pilot study that showed the highest alteration at this time. Antral follicle count (AFC) was estimated by trans-vaginal ultrasound before and after the study. These markers had been checked in the same laboratory before pregnancy.
Statistical analysis was done by SPSS version 19.0 software (IBM SPSS Statistics, USA). Mean ± SD and numbers (%) were calculated for continuous and categorical variables, respectively. T test for paired observation was used (after running KolmogorovSmirnov test reassurance for parametric distribution) to evaluate any differences in AMH, LH, FSH, AFC and E2 values between the pre-pregnancy values and those obtained 8 weeks after MTX administration. A P≤0.05 was considered statistically significant.
Sample size was calculated by Cochran’s formula. Given the probability of 1.6% of EP (in normal population) of which 35% are eligible for receiving medical treatment, the estimated sample size was 20. The sample size was determined by a pilot study done on ten subjects before initiation of the main study.
Twenty patients were recruited and all of them were followed until the end of the study. None of our cases needed extra dose of MTX nor needed an emergent surgery due to ruptured EP. No serious adverse effect was reported during the study. None of our cases had persistent EP. In other word, all patients were cured both clinically and according to laboratory tests.
The mean (± SD) age of patients was 30.9 ± 5.37 years (range: 21 to 43 years old). Table 1 illustrates the age and obstetrics background of the participants. Two patients had a history of EP. None of the participants had heterotopic pregnancy.
Age and obstetrics background of the participants
|Age (Y)||30.9 ± 5.37|
|BMI (Kg/m2)||27.1 ± 4.7|
Data are presented as mean ± SD or n (%). BMI; Body mass index.
The mean (± SD) of AMH levels at baseline and after 8 weeks were 9.5 ng/ml (± 4.23) and 9.15 ng/ml (± 4.24), respectively which were not statistically significantly different (P=0.36). For FSH, E2 and AFC, there was a nonstatistically significant difference between baseline value and the value obtained 8 weeks after MTX administration. However, the mean (± SD) LH values were 6.63 IU/l (± 3.03) and 8.1 IU/l (± 2.63) at baseline and 8 weeks after MTX administration, respectively (P=0.02). Table 2 compares lab data and AFC, before and after EP treating by MTX.
Comparison lab data and AFC, before and after EP treated by MTX
|FSH (mIU/ml)||6.6 ± 3.1||8.2 ± 4.9||0.1|
|LH (IU/L)||6.6 ± 3.0||8.1 ± 2.6||0.02|
|AMH (ng/ml)||9.5 ± 4.2||9.1 ± 4.2||0.36|
|AFC||9.1 ± 2.0||8.6 ± 2||0.49|
|E2 (pg/ml)||21.9 ± 20.1||16.3 ± 13.5||0.15|
Data are presented as mean ± SD.
AFC; Antral follicle count, EP; Ectopic pregnancy, MTX; Methotrexate, FSH; Folliclestimulating hormone, LH; Luteinizing hormone, AMH; Anti-Mullerian Hormone, and E2; 17-beta estradiol.
Our study demonstrated that medical management of
EP using MTX does not have adverse effects on ovarian
reserve in infertile women undergoing various types of
ART. EP management by using MTX is safe and effective
in carefully selected patients. It is beneficial in cases with
no tendency for surgery (
Another important issue in management of patients is the
maintenance of women’s fertility. Infertile women under
infertility treatment, may already have compromised
ovarian reserve (
Evaluation of ovarian reserve is important in assessment
and treatment of infertility. Ovarian reserve will decline
by age. The most commonly used approach to assess
ovarian reserve, is the measurement of FSH and LH.
However, AMH and inhibin-B are other biomarkers of
ovarian reserve that are most popular since they provide
direct determination of ovarian status (
Ovarian reserve, ovarian responsiveness, or subsequent
IVF outcomes was discussed in other studies and most
of such reports did not reveal a significant difference in
IVF cycle parameters or outcomes. Orvieto et al. (
Pregnancy rate after MTX administration was 36.4%,
that is similar to normal rate showing no modification of
the characteristics of the endometrial or follicles during
IVF after MTX treatment for EP (
While the evidence from human studies is limited, results of studies that assessed the effect of MTX on AMH as an ovarian reserve marker, are controversial. Dosages of MTX, sample size and follow up period length have been suggested as factors altering the results.
Our study had some limitations that should be mentioned. It was a retrospective study with small sample size. Considering our results which were similar to those of other studies, it was not possible to definitely prove that MTX has no adverse effect on ovarian reserve and responsiveness in Iranian population.
The strength of our study was evaluation of AMH during
evaluation of ovarian reserve that was absent in a similar
study by Boots et al. (
Our results showed that single-dose MTX treatment in EP did not decrease the ovarian reserve in infertile women.