Ectopic pregnancy, an important cause of maternal morbidity and mortality, is estimated to occur in approximately 1% - 2% of pregnancies worldwide [1] . Tubal localization accounts for 95% - 99% of ectopic pregnancies. Other localizations such as ovarian, cervical, cornual, and abdominal implants are rarely seen [2] . Chlamydia trachomatis infection of the genital tract, the most common sexually transmitted infection with a worldwide distribution, plays a key role in the occurrence of this localization [3] . Indeed, tubal infection by C. trachomatis, damages ciliated epithelium leading to the formation of intraluminal adhesions that predispose to entrapment of the zygote and the resultant ectopic implantation of the blastocyst.

Over the last 20 years, considerable progress has been made in the management of ectopic pregnancy. Conservative laparoscopic surgery is currently the cornerstone of treatment for tubal pregnancies in women who desire future fertility, while treatment with systemic methotrexate may, however, offer better prospects for fertility by avoiding surgical trauma to the tube. So what about reproductive outcomes for patients with EP? Clarifying the impact of each treatment modality on natural pregnancy outcomes to help tubal EP patients with fertility needs choose appropriate treatment. Hao et al. found that there was a significant difference in the chances of subsequent intrauterine pregnancy in tubal EP patients treated with MTX compared with those treated with surgery [odds ratios (OR) = 1.52, 95% confidence interval (CI): 1.20 - 1.92] [4] .

Several studies had evaluated fertility outcomes subsequent to medical and surgical treatment for ectopic pregnancy patients, with a cumulative incidence of intra uterine pregnancy up to 60% [2] [4] , but none in our settings evaluates outcomes of fertility after medical treatment [5] . We therefore sought to determine the outcomes of subsequent spontaneous fertility after medical treatment of patients with MTX in patients with ectopic pregnancy at two university hospitals in the city of Yaounde.

The aim of our study was to evaluate the prognosis of subsequent spontaneous fertility of patients after medical treatment of tubal ectopic pregnancy in two hospitals in the city of Yaoundé. More specifically, we sought to describe the sociodemographic and clinical characteristics of patients who had undergone medical treatment for EP; to describe the different therapeutic protocols; to determine the spontaneous conception rate after medical treatment; and to report the mean time to conception after medical treatment for EP.

The mean age of our study population was 27.8 ± 3.81 years, which is similar to the result found by Kenfack et al. in Cameroon [6] , who found a mean age of 26.46 ± 5.42 years. The most affected age group was [21 - 35] years, which is in the same line to what Dohbit et al. found in 2010 in Cameroon [7] . These similarities could be justified by the fact that the majority of our patients were single, had a higher level of education (mostly students) and that this predominant age group corresponds to a period of intense genital activity in women and to increased risky sexual behaviour in our context [8] .

The past medical history of our patients revealed that 52.9% had a pelvic inflammatory disease and the most frequently germ found was Chlamydia trachomatis (47.1%). On the other hand almost 15% of our study population had already undergone surgery for EP. Assessing risk factors for ectopic pregnancy in a population of Cameroonian women, Assouni et al. found a 13-fold increased risk of developing an ectopic pregnancy in women with PID [9] . Similarly, in a retrospective cohort of 30,450 PID patients and 91,350 controls, Huang et al. found that PID patients had a 2.121-fold (p = 0.003) higher risk of developing an ectopic pregnancy in Taiwan region [10] . All these results are supported by Xia et al. who explored the relationship between chlamydia trachomatis infections and ectopic pregnancy in a recent meta-analysis and systematic review, and found that the association between chlamydia trachomatis infections and the risk of EP showed an odds ratio (OR) of 3.03, with a 95% confidence interval (CI) of 2.37 to 3.89 [11] . Our result is therefore in line with numerous studies that have identified PID as a major risk factor for EP, due to scarring leading to tubal obstruction that interferes with egg capture and migration.

The median Fernandez score was 11, with a minimum score of 4 and a maximum score of 13, which justified the choice of medical treatment for EP according to the score recommendations; the administration route of methotrexate was intramuscular (IM) in all our patients. This result is similar to that of Amélie Gervaise et al. [12] in 2004 in France, where the preferred administration route was intramuscular in 51.6% of cases. This is due to the non-invasive and easily achievable nature of IM injection; and the single-dose protocol was used most frequently in 58.6% of cases, which is similar to the results found by Silvia Baggio et al. [2] in 2021, where the single-dose protocol was used in 71.7% of patients with fewer side effects and a similar success rate to the multi-dose protocol [13] [14] . The initial B-HCG level was <3000 in 75.7% of cases and, at D7, this level was less than 1000 IU in 51.4% of cases, with a percentage reduction in B-HCG during the first week of between 40% and 70%.

After medical treatment of EP with MTX, we observed a spontaneous conception rate of 58.6% with a recurrence rate of EP of 14.6%. Several studies have reported similar results, with post-treatment conception rates ranging from 55% to 80% [2] [4] [5] [11] [12] [15] . In trials comparing the spontaneous conception rate after expectant management, medical treatment with MTX and surgery, the spontaneous conception rate after medical treatment with MTX was slightly lower than after surgery, but the recurrence rate of EP was significantly higher in the surgery group. This suggests a better efficacy in terms of intrauterine pregnancy after medical treatment with MTX, certainly due to the non-invasive nature of the procedure and the almost complete absence of the risk of pelvic or intra-tubal adhesions associated with surgery.

The spontaneous fertility rate after medical management of EP was 58.6%, of which 73.2% were term pregnancies and 14.6% were recurrent ectopic pregnancies.

The authors declare no conflicts of interest regarding the publication of this paper.

Cyrille, N.N.C., Hilary, T.G., Robert, N.S., Kondo, A.R.N., Gregory, A., Madye, N.D.A. and Isidore, T. (2024) Evaluation of Spontaneous Fertility after Medical Treatment of Tubal Ectopic Pregnancy in Two Hospitals in the City of Yaounde. Open Journal of Obstetrics and Gynecology, 14, 175-185. https://doi.org/10.4236/ojog.2024.141016