Ectopic Pregnancy

Treatment for Ectopic Pregnancy, Ectopic Pregnancy IVF

An ectopic pregnancy is defined as a gestation that implants outside of the uterus. The most common site is in the fallopian tube, but it can also occur in the ovary, the cervix, outer surface of the uterus or elsewhere with the abdomen. An exrauterine, intraabdominal ectopic pregnancy can even develop into an advanced and even full term gestati. However, such fetuses are usually severely developmentally compromized and rarely, if ever survive.


About 1:200 naturally conceived pregnancies and 1:30 IVF gestations are ectopic. On very rare occasions (1:2,000), a tubal ectopic pregnancy occurs in combination with another pregnancy (usually in the uterus. Timely, early ssurgical removal of the tubal component often is followed by the intrauterine pregnancy progressing normally to delivery at term.


Ectopic pregnancy is one of the most dangerous complications of gestation. If undetected, the pregnancy will continue to grow and will typically rupture; resulting in calamitous intra-abdominal bleeding. If not treated quickly, such an event could be fatal.


Monitoring pregnancies both hormonally and with ultrasound technology now makes it possible to completely prevent catastrophic events associated with ectopic pregnancies. Within the last two decades, treatment of ectopic pregnancies has evolved from emergency surgery with tubal removal and blood transfusion, to out-patient surgery with tubal repair or even treatment with medication. The key with ectopic pregnancy is to diagnose early and manage the outcome instead of waiting for events to unfold.


The fertilization of the human egg normally takes place within the fallopian tube. The embryo then takes about 5 to 6 days to complete its journey to the uterus, where it implants into the endometrium. Anything that delays the passage of the embryo down the fallopian tube can result in the embryo hatching and sending its “root system” into the wall of the fallopian tube and initiating growth within the tube. One of the most common predisposing factors is pelvic inflammatory disease (PID) in which microorganisms, such as Chlamydia and Gonococcus, damage the inner lining (endosalpinx) and eventually also the muscular walls of the tube(s) by creating scar tissue.


The endosalpinx has a very complex and delicate internal architecture, with small hairs and secretions that help to propel the embryo toward the uterine cavity. Once damaged, this lining does not regenerate. This is one of the reasons why women who manage to conceive following surgery to unblock fallopian tubes damaged by PID, have about a 1 in 4 chance of a subsequent pregnancy developing within the fallopian tube. Another cause of ectopic pregnancies are congenital malformations of the fallopian tube associated with shortening of, or small pockets and side channels within, the tube. These can interrupt the smooth passage of the embryo down the fallopian tube. There has even been some suggestion that premature appearance of hormones like progesterone, which relax muscle contractions within the fallopian tube, may also create an increased risk of ectopic pregnancy.


A woman who has had one ectopic pregnancy has an almost four-fold higher risk of another ectopic implantation in a future pregnancy. With every subsequent ectopic, this risk increases dramatically. Since the lining of the fallopian tube does not represent an optimal site for healthy implantation, a large percentage of pregnancies that gain early attachment to its inner lining will be absorbed before the woman even knows that she is pregnant. This is often referred to as a tubal abortion.


When an ectopic pregnancy occurs after ART, it is most likely the result of a uterine contraction causing a carefully placed embryo to be ejected into the fallopian tube. Various strategies to reduce the risk of this occurring are typically employed. The use of ultrasound guidance to place embryos and the use of minimal fluid to transfer them helps. There is some evidence that transferring blastocysts that are ready to implant instead of earlier embryos may also reduce the incidence. Sometimes however, despite the best laid plans, ectopic pregnancies do occur. Diagnosis of an Ectopic Pregnancy


The easiest and most common method of diagnosing an ectopic pregnancy is by tracking the rate of rise in the blood levels of the “hormone of pregnancy,” human chorionic gonadotropin (hCG). With a normal intrauterine pregnancy, blood levels of hCG will usually double every two days throughout the first nine to ten weeks. However, an increase of at least 60% is still reassuring. A slower rate of increase in hCG more commonly suggests an impending miscarriage of one or more of the embryos that have implanted. However, it might be a sign of an ectopic pregnancy. Thus, the hCG levels should be followed serially until a clear pattern emerges.


The diagnosis of an ectopic is most often determined by a vaginal ultrasound examination. Performed by someone with sufficient expertise using a modern ultrasound machine, this test should reveal an ectopic pregnancy before it ruptures and becomes a surgical emergency. If the tube has already ruptured or internal bleeding has occurred, ultrasound examination will detect the presence of free fluid in the abdominal cavity, which is a more ominous sign.


If there has been a significant amount of intra-abdominal bleeding, irritation of the peritoneal membrane will cause the abdominal wall to become tense and, depending on the amount of blood in the abdomen, to distend. In such cases, any pressure on the abdominal wall will evoke significant pain and when a vaginal examination is done, movement of the cervix can be excruciatingly painful – especially on the side of the affected fallopian tube.


The most common conditions that must be ruled out when an ectopic pregnancy is suspected are: A hemorrhagic cyst of the ovary Appendicitis Acute pelvic inflammatory disease (PID) An inevitable miscarriage Solutions for Ectopic Pregnancy: Surgical and Medical Management


Surgical: In some situations, laparoscopy is performed for diagnostic purposes. This may be necessary if a woman has a heterotopic pregnancy; one embryo implanted in the uterus and one in the fallopian tube. If an ectopic pregnancy is in fact detected, a small longitudinal incision over the tubal pregnancy will allow for its removal, without necessitating removal of the tube. In such situations, it may be possible to save the normally implanted embryo. Bleeding points on the fallopian tube can usually be accessed directly and bleeding can often be stopped through the laparoscope. Sometimes the damage to the fallopian tube has been so extensive that the entire tube will require removal. On occasions where very severe intra-abdominal bleeding heralds a potential catastrophe, a laparotomy is performed to stop the bleeding more rapidly. In such cases, a blood transfusion is usually required and may be life saving.


Medical: The introduction of Methotrexate (MTX) therapy for the treatment of ectopic pregnancy has profoundly reduced the need for surgery in most patients. MTX is a chemotherapeutic that kills rapidly dividing cells, such as those present in the “root system” of a developing fetus. Low doses of MTX are used to treat ectopic pregnancy since the fetal tissue is very sensitive. Accordingly, the side effects for the treatment are minimal. It is important to confirm that the ectopic pregnancy has not yet ruptured prior to administering MTX and is not too far along to be treated safely in this fashion.


The administration of MTX is by intramuscular injection. Prior to its administration, blood is drawn to get a baseline blood hCG level. After the injection of MTX the patient is allowed to return home with strict instructions that she should always have someone with her and never be alone in the ensuing week. The concern is that if she was to be on her own and internal bleeding occurred, she might not be able to get to the hospital quickly enough. In reality, this situation rarely occurs, but it is wise to be cautious. Instructions are also given to look for early signs that might point towards a worsening situation such as the sudden onset of severe pain, light-headedness or fainting. The patient returns to the doctor’s office four days later to check the blood HCG level, noting that it may have risen a bit. Three days later (7 days after MTX), the level is checked again. By this time, the HCG level should have dropped at least 15% from the value on day 4. If not, a second MTX injection is given and the blood levels are tested twice weekly until HCG level is undetectable. Once this occurs, vaginal bleeding will usually begin within a week or two.


Recent advances in the field of ultrasound diagnosis along with the introduction of MTX therapy have revolutionized the treatment of ectopic pregnancy and have significantly reduced both the high morbidity and mortality rates previously associated with this condition. When an ectopic pregnancy occurs following infertility treatment, there is the added advantage that the physician will be on the lookout for the earliest possible signs of trouble. The performance of a vaginal ultrasound within two weeks of a positive blood pregnancy (hCG) test following IVF allows for early detection of the unruptured pregnancy and timely intervention with MTX and/or laparoscopy. 71 Comments Older Comments Aimee says: April 25, 2015 at 3:50 pm


Hi Dr . Sher, I and 35 years old and just did my first IVF cycle. Everything was text book. During the first IVF cycle we transferred three embryos that were 3 day embryos. It ended a week ago with an ectopic pregnancy. I lost my right Fallopian tube because it ruptured. We have 3 frozen embryos that were frozen as 5 day blastocysts . We want to try again but I am wondering what factors can affect or lessen the chances of another ectopic. I have about a quarter of the right Fallopian tube and my full left tube. I want to try again but I m nervous that another ectopic could happen. Does the number of embryos make the chances greater? Anything else that you suggest? Reply Geoffrey Sher says: April 25, 2015 at 6:00 pm


The chance of another ectopic should be no greater than for the 1st one (about 1:30). I suggest you try again unless you have factors predisposing to implantation dysfunction which is probably not applicable.


By definition, an ectopic pregnancy is a gestation that occurs outside of the uterine cavity. The most common site is in the fallopian tube, but sometimes it can also occur in the ovary, the cervix, or even the abdominal cavity. Estimates put the incidence of ectopic pregnancy at about one in 200 pregnancies; but it has been reported to occur in about one out of 30 pregnancies resulting from In Vitro Fertilization (IVF). Ectopic pregnancy is one of the most dangerous complications of pregnancy. If undetected, the ectopic pregnancy will continue to grow and will ultimately burst through the wall of the fallopian tube, often resulting in catastrophic intra-abdominal bleeding, which can even be fatal.


The introduction of sophisticated sonographic and hormonal monitoring technology now makes it possible to detect an ectopic pregnancy much earlier than previously, …usually well in advance of it rupturing. A decade or two ago, the diagnosis of an ectopic pregnancy, ruptured or not, was an indication for immediate laparotomy to avoid the risk of catastrophic hemorrhagic shock. This often resulted in the affected fallopian tube having to be completely removed, sometimes along with the adjacent ovary.


In the late 1980’s, early conservative surgical intervention by laparoscopy began replacing laparotomy (a wide incision made in the abdominal wall) for the treatment of ectopic pregnancy, often allowing the affected fallopian tube to be preserved and shortening the period of post-surgical convalescence. In the 90’s, early detection combined with the advent of medical management with methotrexate (MTX) has all but eliminated the need for surgical intervention in the majority of patients. If administered early enough, MTX will allow spontaneous resorbtion of the pregnancy and a dramatic reduction in the incidence of catastrophic bleeding. This was especially true in ectopic pregnancies arising from In Vitro Fertilization, where the early progress of pregnancy is usually carefully monitored with hormone levels and ultrasound.


Causes of Ectopic Pregnancy: The fertilization of the human egg normally takes place in the fallopian tube. The embryo then travels into the uterus, where it implants into the endometrial lining 5-6 days after ovulation. Anything that delays the passage of the embryo down the fallopian tube can result in the embryo hatching and sending its “root system” into the wall of the fallopian tube and initiating growth within the tube. One of the most common predisposing factors is pelvic inflammatory disease (PID) in which microorganisms, such as Chlamydia, and Gonococcus damage the inner lining (endosalpinx) and eventually also the muscular walls of the tube(s) by the formation of scar tissue. The endosalpinx has a very complex and delicate internal architecture, with small hairs and secretions that help to propel the embryo toward the uterine cavity. Once damaged, this lining can never regenerate. This is one of the reasons why women who manage to conceive following surgery to unblock fallopian tubes damaged by PID, have about a 1:4 chance of a subsequent pregnancy developing within the fallopian tube (ectopic).


Congenital malformations of the fallopian tube, associated with shortening of, or small pockets and side channels within, the tube are capable of interrupting the smooth passage of the embryo down the fallopian tube, is another cause of an ectopic pregnancy.


A woman who has had one ectopic pregnancy has almost four times as great a risk of an ectopic in a future pregnancy and with every subsequent ectopic this risk increases dramatically.


Since the lining of the fallopian tube does not represent an optimal site for healthy implantation, a large percentage of pregnancies that gain early attachment to its inner lining will usually be absorbed before the woman even knows that she is pregnant. This is often referred to as a tubal abortion.


Clinical presentation: Classically women with an of ectopic pregnancy present with the following symptoms:


1. Missed menstrual period: Although some patients will have spotting or other abnormal bleeding. The pregnancy test will be positive in such cases.


2. Vaginal bleeding. When a pregnancy inadvertently implants in the fallopian tube the lining of the uterus undergoes profound hormonal changes associated with pregnancy (primarily associated with the hormone progesterone). When the embryo dies, the lining of the uterus separates. Initially, vaginal bleeding is dark and usually is quite scanty, even less than with a normal menstrual period. In some cases, of ectopic pregnancy will bleeding is more severe, similar to that experienced in association with a miscarriage. This sometimes leads to an ectopic pregnancy initially being misdiagnosed as a miscarriage and is the reason to examine the material that is passed vaginally, for evidence of products of conception.


3. Pain. In the early stages this is typically cramp-like in nature, located on one or another side of the lower abdomen. It is caused by spasm of the muscular wall of the fallopian tube(s). When a tubal pregnancy ruptures the woman will usually experience an abrupt onset of severe abdominal followed by light headedness, coldness and clamminess and will often collapse due to shock. Her pulse will become rapid and thready and her blood pressure will drop. Miscarriage. Sometimes the woman will experience pain in the right shoulder. The reason for this is that that blood which tracts along the side of the abdominal cavity finds its way to the area immediately below the diaphragm, above the liver (on the patient’s right side), irritates the endings of the phrenic nerve, which supplies that part of the diaphragm. This results in the referral of the pain to the neck and the right shoulder. The clinical picture is often so typical that making the diagnosis usually presents no difficulty at all. However, with less typical presentations the most important conditions to differentiate from an ectopic pregnancy are: a ruptured ovarian cyst, appendicitis, acute pelvic inflammatory disease (PID), or an inevitable


4. Vaginal bleeding. When a pregnancy inadvertently implants in the fallopian tube the lining of the uterus undergoes profound hormonal changes associated with pregnancy (primarily associated with the hormone progesterone). When the embryo dies, the lining of the uterus separates. Initially, vaginal bleeding is dark and usually is quite scanty, even less than with a normal menstrual period. In some cases, of ectopic pregnancy will bleeding is more severe, similar to that experienced in association with a miscarriage. This sometimes leads to ectopic pregnancy initially being misdiagnosis as a miscarriage and is the reason that we often want to examine the material that is passed vaginally, for evidence of products of conception.


Diagnosis: The easiest and most common method of diagnosing an ectopic pregnancy is by tracking the rate of rise in the blood levels of hCG. With a normal intrauterine pregnancy, these usually double every two days throughout the first few weeks. While a slow rate of increase in blood hCG usually suggests an impending miscarriage, it might also point to an ectopic pregnancy. Thus the hCG blood levels should be followed serially until a clear pattern emerges.


A vaginal ultrasound examination usually will clinch the diagnosis by showing the ectopic pregnancy within a fallopian tube and if the tube has already ruptured or internal bleeding has occurred, ultrasound examination will inevitably detect the presence of free fluid into the abdominal cavity.


If there has been a significant amount of intra-abdominal bleeding, irritation of the peritoneal membrane will cause the abdominal wall to become hard tense and, depending on the amount of internal bleeding abdominal distention will be evident. Palpation of the abdominal wall will evoke significant pain and when a vaginal examination is done, movement of the cervix will produce excruciating pain, especially on the side of the affected fallopian tube.


Surgical Treatment: In questionable situations laparoscopy is usually performed for diagnostic purposes. If an ectopic pregnancy is in fact detected, a small longitudinal incision over the tubal pregnancy will allow its removal, without necessitating removal of the tube. (linear salpingectomy). Bleeding points on the fallopian tube can usually be accessed directly and appropriately ligated (tied) via the laparoscope. Sometimes the damage to the fallopian tube has been so extensive that the entire tube will require removal.


On occasions where very severe intra-abdominal bleeding heralds a potential catastrophe, a laparotomy (an incision made to open the abdominal cavity) is performed to stop the bleeding post haste. In such cases a blood transfusion is usually required and may be life saving.


Medical Treatment: The introduction of Methotrexate (MTX) therapy for the treatment of ectopic pregnancy has profoundly reduced the need for surgery in most patients. MTX is a chemotherapeutic that kills rapidly dividing cells, such as those present in the “root system” of the conceptus. Extremely low doses of MTX are used to treat ectopic pregnancy. Accordingly the side effects that are often associated with such chemotherapy used for the treatment of other conditions are seldom seen. It is important to confirm that the ectopic pregnancy has not yet ruptured prior to administering MTX.


MTX is given by intramuscular injection. Prior to its administration, blood is drawn to get a baseline blood hCG level. After the injection of MTX the patient is allowed to return home with strict instructions that she should always have someone with her and never be alone in the ensuing week. The concern is that were the patient to be on her own and an intraabdominal bleed were to occur, she might not readily be able to access someone who could get her to the hospital immediately. Instructions are also given to look for early signs that might point towards severe intra-abdominal bleeding such as the sudden onset of severe pain, light-headedness or fainting.


The patient returns to the doctor’s office four days later to check the blood hCG level. Three days later (7 days after MTX), the level is checked again. By this time the hCG level should have dropped at least 15% from the value on day 4. If not, a second MTX injection is given and the blood levels are tested twice weekly until hCG level is undetectable. Once this occurs, vaginal bleeding will usually ensue within a week or two.


It is important to note, especially in cases where more than one embryo or blastocyst has been transferred to the uterine cavity or fallopian tube (as with Tubal embryo transfer –TET/ZIFT), that implantation may occur in two sites simultaneously (i.e. in the fallopian tube as well as inside the uterine cavity). This is referred to as a heterotopic pregnancy. It is therefore important that before administering MTX, which will cause the death and absorption of any early pregnancy, that the physician makes certain that he/she is not dealing with a heterotopic pregnancy. In such cases, surgery is required to treat the tubal ectopic, while every precaution is taken to protect the pregnancy growing within the uterine cavity.


Recent advances in the field of ultrasound diagnosis along with the introduction of MTX therapy have revolutionized the treatment of ectopic pregnancy and have significantly reduced both the high morbidity and mortality rates, previously associated with this condition.


When an ectopic pregnancy occurs following infertility treatment, there is the added advantage that the physician will be on the lookout for the earliest possible signs of trouble. The performance of a vaginal ultrasound within two weeks of a positive blood pregnancy (HCG) test following IVF allows for early detection of the unruptured pregnancy and timely intervention with MTX and/or laparoscopy.


Please go to the home page of IVFauthority.com. When you get there look for a “search bar in the upper right hand column. Then type in the following subjects into the bar, click and this will take you to all the relevant articles I posted there. 1. An Individualized Approach to Ovarian stimulation (posted on November 22nd, 2010)


7. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas (posted on March, 21st 2012)


Consider calling 800-780-7437 or 702-699-7437 to arrange a Skype with me so we can discuss your case in detail.


Finally, perhaps you would be interested in accessing my new book (recently released). It is the 4th edition (and a re-write) of In Vitro Fertilization, the ART of Making Babies . The book is available through Amazon.com as a down-load or in book form. It can also be obtained from most bookstores.


P.S: Please go to http://www.youtube.com/watch?v=Vp3GYuqn2eM feature=youtu.be To view a video-tutorial by Linda Vignapiano RN, Clinical Manager at SIRM-Las Vegas.


Dr Al Peters (Medical Director at SIRM-New Jersey), and I ,recently established the “SIRM Reproductive Immunology Forum(SRIF) which will provide a venue where you can address and hopefully find solutions to problems relating to Immunologic Implantation dysfunction (IID) that often manifest with “Unexplained” infertility, IVF Failure and Recurrent Pregnancy Loss (RPL..


To this end we established http://www.InfertilityImmunology.com , a dedicated website where you can: • Register with SIRF • Request and receive (free of charge) a PDF copy of our book: “Unexplained” Infertility and Miscarriage : The Immunologic Link” • Be kept abreast of what is current in the IID arena • Post questions for Dr Peters and I to respond to and, • Interact with other patients on a separate discussion board dedicated to this.


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