**4.4. Differential diagnosis of ectopic pregnancy**


### **4.5. Treatment**

#### **Expectant management**

Is between 47 and 82 percent effective in managing ectopic pregnancy

#### **Medical treatment**

Methotrexate, a folic acid antagonist, is a well-studied medical therapy. Side effects of methotrexate include bone marrow suppression, elevated liver enzymes, rash, alopecia, stomatitis, nausea, and diarrhea. The time to resolution of the ectopic pregnancy is three to seven weeks after methotrexate therapy.

#### **Surgical treatment**

A laparoscopic approach is preferable to an open approach in a patient who is haemodynamically stable. If the contra lateral tube is healthy, the preferred option is salpingectomy, where the entire Fallopian tube, or the affected segment containing the ectopic gestation, is removed In the pat few years laparoscopy with salpingostomy, without fallopian tube removal, has become the preferred method of surgical treatment. Laparoscopy has similar tubal patency and future fertility rates as medical treatment.

### **Follow-up and prognosis**

16 Enhancing Success of Assisted Reproduction



diagnostic laparoscopy may be required.

**4.4. Differential diagnosis of ectopic pregnancy** 



Is between 47 and 82 percent effective in managing ectopic pregnancy




Methotrexate, a folic acid antagonist, is a well-studied medical therapy. Side effects of methotrexate include bone marrow suppression, elevated liver enzymes, rash, alopecia, stomatitis, nausea, and diarrhea. The time to resolution of the ectopic pregnancy is three to

A laparoscopic approach is preferable to an open approach in a patient who is haemodynamically stable. If the contra lateral tube is healthy, the preferred option is salpingectomy, where the entire Fallopian tube, or the affected segment containing the ectopic gestation, is removed In the pat few years laparoscopy with salpingostomy, without


**4.3. Diagnosis** 


pregnancy



**Expectant management** 


**4.5. Treatment** 

**Medical treatment** 

**Surgical treatment** 



seven weeks after methotrexate therapy.

factors

During treatment, physicians should examine patients at least weekly and sometimes daily. Serial beta-hCG measurements should be taken after treatment until the level is undetectable.

#### **Adnexal mass in infertility**

There are a number of possible disorders that can cause a pelvic mass. Some are common, while others are quite unusual or even rare. The physical exam should include visualization and palpation of the abdomen. The next step is usually an imaging study, such as ultrasound, CAT scan, or MRI

#### **Differential diagnoses**


#### **Follicular cysts**

There are several different types of ovarian cysts, the most common being functional cysts. Often, ovarian cysts do not cause symptoms. Women in the age group of thirty to sixty are more prone to having ovarian cysts.The follicular cysts are easily identified on vaginal sonography, usually measure a few millimeters to a few centimeters in size, and rarely become symptomatic. If they enlarge in size they may rupture, producing transient abdominal pain. Ovarian cysts can cause several other problems if they twist, bleed, or rupture

#### **Dermoid cyst**

Ovarian dermoid cyst, also known as mature teratoma, is a non cancerous ovarian tumor, which is more commonly found in young women. Although dermoids are non cancerous, in some rare cases, they might develop into cancerous growth. Dermoid cysts may contain substances such as nails and dental, cartilage like, and bonelike structures. These growths can develop in a woman during her reproductive years. Dermoids can range in size anywhere between two to ten centimeters. It is very difficult to identify the presence of these cysts inside the ovaries as they do not produce any symptoms. They can cause torsion, infection, rupture, and cancer. These dermoid cysts can be removed with either conventional surgery or laparoscopy. Ovarian dermoid cysts do not affect the fertility of the woman.

#### **Tubo ovarian abscess**

Tubo-ovarian abscess is an advanced form of pelvic inflammatory disease most often caused by spread of bacteria from the lower genital tract. It is one of the most severe complications of PID and can lead to significant morbidity and occasional mortality. The microbial etiology of TOAs typically is polymicrobial with a mixture of anaerobic, aerobic, and facultative organisms being isolated. The most common bacterial pathogens are anaerobic. Sexually transmitted disease, early age of first sexual encounter, multiple sexual partners, douching, IUDs are at increased risk for pelvic inflammatory disease and tubo-ovarian abscess. Diverticulitis and appendicitis are also potential causes.

The Role of Endoscopy in Management of Infertility 19

patients present with sudden onset, severe, unilateral lower abdominal pain that worsens intermittently over many hours. Nausea and vomiting occur in approximately 70% of patients, mimicking a gastrointestinal source of pain and further obscuring the diagnosis. Colored Doppler sonography with its non-invasive modality detects blood flow patterns within the ovarian vascular networks and gives important information about the diagnosis of torsion. Laparoscopy surgery must be the choice for less post operative morbidity, and a better cosmetic appearance. Detorsion must be performed even in necrotic appearing adnexa because of a high rate of survival of ovaries even looking necrotic. Salpingooophorectomy may be indicated if severe vascular compromise, peritonitis, or tissue

Diagnostic laparoscopy is normally the standard procedure performed as the final test in the infertility work up before progressing to infertility treatment. For the most part, the risks associated with laparoscopy are of the same type that occurs with traditional surgery. Problems from anesthesia, bleeding and infections can occur with either type of surgery. The risk of damage to internal organs is also possible with either type of surgery. The risks of laparoscopy are minimal. Complications among young, healthy women undergoing laparoscopy are rare and occur only in about three out of 1000 cases. These complications can include injuries to structures in the abdomen such as: injury to the bowel, stomach, urinary bladder, ureters, abdominal and pelvic blood vessels, ovaries and uterus. For such injuries, a laparotomy might be necessary to stop bleeding or make repairs. Most often, these injuries occur when the laparoscope is placed through the navel. The risk of a serious complication is less than 1%. Any surgery can have an anesthesia-related complication or be associated with post-operative infection, Fortunately, all of these complications are very unusual. According to the American Society of Reproductive Medicine, one or two women out of every 100 may

develop a complication, usually a minor one. Some common complications include:

necrosis is clearly evident.

**6. Endoscopy complications** 











