Ectopic pregnancy occurs when the pregnancy implants outside of the uterus. It can occur in several places, but the most common place is within the fallopian tube. Pregnancy can even occur in both the uterus and the tube at the same time (heterotopic pregnancy), but this is rare, occurring in about 1/10,000 pregnancies.
Ectopic pregnancies occur in 0.25-1% of all pregnancies.
Many factors are known to increase the risk of having an ectopic pregnancy. Anything that alters the tubal function may affect fertility. Fallopian tubes aren’t like a hollow pipe. They have little hairs on the inside (cilia), which move with a wave-like motion to encourage the egg toward the uterus. If the tube becomes blocked or the cilia damaged, as often occurs following infection, then ectopic implantation is more likely. Women who have had surgery on their tubes (such as previous ectopic treatment) are at greater risk of ectopic pregnancy as well.
Embryos transferred into the uterus at IVF can find their way in to the tube and cause an ectopic. If the tubes are damaged (which may be the reason a patient is having IVF in the first place), then it is more likely that an ectopic will occur, as the cilia are less likely to deliver the embryo into the uterus.
“Every woman is pregnant until proven otherwise and every pregnant woman is an ectopic until proven otherwise”. This is a golden rule that doctors are taught and it illustrates that clinical suspicion is the best way to diagnose an ectopic. We look for a positive pregnancy test (without one a patient cannot have an ectopic!), pain in the abdomen, and vaginal bleeding.
A vaginal ultrasound scan can reliably demonstrate a pregnancy in the uterus from about 5.5 to 6 weeks onward. Once this is proven, an ectopic is once again virtually excluded (except in the case of the extremely rare heterotopic pregnancy, or pregnancy in the uterus and the tube). Occasionally a scan can show an ectopic pregnancy clearly in the tube next to the uterus.
Unfortunately, there is about an 11 to 14 day window when a pregnancy test may be positive, but it is too early for an ultrasound scan to confirm exactly where the pregnancy is located. In this case, it is important to watch for changes in hCG levels and so your doctor may order a blood test every 2 days. The hormone level should double between tests.
Once an ectopic is diagnosed, there are several different treatments. It is not possible to take the pregnancy from the tube and put it into the uterus.
The clinical signs and blood tests guide who should undergo a laparoscopy. Laparoscopy involves having a general anaesthetic and your doctor will place a telescope into the abdomen, usually at the umbilicus, and the tubes and pelvis are visualised. This is the ‘gold standard’ for diagnosing an ectopic pregnancy, but it isn’t done for everyone. At laparoscopy it may be possible to either open the tube and remove the pregnancy (salpingotomy) or to remove the tube altogether (salpingectomy). The decision on which of these options is taken is specific to each patient. Follow up with blood tests for hCG may be needed as persistent ectopic tissue can occur in a few patients.
If, after an ectopic, the tube remains (salpingotomy), there is a greater risk in the future of having another ectopic.
Expectant management is appropriate in a small proportion of patients where it is not expected that the tube will rupture. This may be appropriate if the level of hCG is falling and you are clinically well.
Medical treatment is rare and is usually with a drug called methotrexate that is given by injection. This makes the ectopic pregnancy shrink away by stopping the cells dividing. Only a few ectopic pregnancies with specific clinical indications can be treated this way. Close follow up with further scans and blood tests is also necessary.
It is easy for people, including doctors, to forget during all of the investigations and surgery that you have lost, what is for most, a much wanted pregnancy. Reaction to a pregnancy loss varies and in addition to the grief, your body will be undergoing some profound hormonal adjustments, which may make you feel very emotionally labile. Don’t be surprised if you find yourself in tears for no apparent reason. This is an ideal opportunity to take advantage of our counsellors at Life Fertility Clinic.
For more information or queries regarding any of the services offered at Life Fertility Clinic, please contact us.