DRUG, SURGERY MAY REDUCE RISKS OF TUBAL PREGNANCIES.

Byline: Linda Carroll Medical Tribune News Service

With tubal pregnancies on the rise, doctors are focusing on finding a better cure.

The trick, they say, is to knock out the life-threatening pregnancy without destroying a woman's fertility. A tubal pregnancy is a type of ectopic pregnancy in which a fertilized egg grows inside the fallopian tube, rather than in the uterus; it is often caused when a fallopian tube becomes scarred or blocked, preventing the egg from reaching its final destination in the uterine wall.

Medical therapy with a cancer drug called methotrexate may be the best choice for many women, experts said at the ninth World Congress on Human Reproduction in Philadelphia.

But, for women who desperately want to preserve their fertility, an intricate microsurgery could be the best course, said Dr. Amir H. Ansari, Obstetrics and Gynecology Residency Coordinator at the Long Island Jewish Medical Center in New Hyde Park, N.Y.

Using tiny instruments, Ansari cuts out the part of the fallopian tube that contains the tubal pregnancy. Then he delicately sews the tube back together, making sure that it remains open so that future embryos can travel through it down to the uterus.

``Since the 1970s, ectopic pregnancies have increased five-fold,'' said Dr. John Sciarra, of the Prentice Women's Hospital in Chicago. ``In part, this is because we are diagnosing ectopics earlier. But in large part, it is due to the epidemic of sexually transmitted diseases. We're seeing much more early tubal disease, resulting in ectopic pregnancies.''

For women with low levels of the pregnancy hormone known as HCG - meaning that the pregnancy is not far along - methotrexate treatment can be very successful at terminating the tubal pregnancy, according to a new study presented at the meeting.

Researchers reviewed the records of 50 patients treated with methotrexate at Chicago's Northwestern Memorial Hospital.

After an initial dose of methotrexate, the women's HCG levels were monitored. If the pregnancy hormone was still present, the women were given additional doses of the drug, said Northwestern's Dr. Catherine Stika.

Ultimately, 64 percent of the women were treated successfully with a single dose of methotrexate, Stika said. Another 14 percent avoided surgery with a second or third dose, she added.

Although the results of the study were not as promising as other reports, Stika said she would still recommend methotrexate as a first-line therapy for many women.

Physicians need to explain these results to their patients, Stika said. ``We need to be cautious,'' she added. ``We need to warn women about the potential need for surgery and multiple doses.''

Beyond the question of effectiveness are issues of cost and convenience, noted Dr. Togas Tulandi, of the Royal Victoria Hospital in Canada.

While methotrexate turns out to be the least expensive option for treating tubal pregnancy, a long follow-up period is required, Dr. Tulandi said. Surgery, on the other hand, ``is more definitive and has a shorter follow-up,'' he added.

Besides, Tulandi said, patients treated with methotrexate are more likely to develop further fertility problems. The treatment is occasionally unsuccessful and the patient ends up in the emergency room with a ruptured tube.

Nevertheless, Tulandi noted, there's no question that methotrexate is the best alternative for some patients. ``The challenge is to figure out who we should treat with methotrexate and who we should treat surgically.''

But, in patients who desperately want to preserve fertility, the best choice may be the delicate surgery to cut out the affected portion of the fallopian tube - followed by the procedure to reconnect, Ansari said.