Today we talk about ectopic pregnancies. I'm Doctor Mark Amos, and this is taco. About fertility Tuesday. Whether you're trying to get pregnant naturally or with assistive reproductive technology, one thing that is true is you always have the risk of an ectopic pregnancy. People who are undergoing infertility treatment, who have infertility, have a higher risk of an ectopic pregnancy. The rate of an atopic pregnancy is approximately 1% or less
for the general population. But if you have infertility, your chances are higher. So in this episode, we, talk about fertility Tuesday. We're going to talk about what an ectopic pregnancy is, how you determine it, and what the treatment is for it. An ectopic pregnancy means when the pregnancy is not inside the uterus, it's ectopic in its location. That location can be in the fallopian tube. That location can be in the cervix. It can be on the ovary, it can be in the
abdomen. It can even be in the uterus near the tube, which is called corneal ectopic, which is actually very dangerous. Ectopics, are always dangerous because they can grow and they can eventually burst the structure they're in and cause bleeding, such as a tubal pregnancy or a cervical pregnancy, or even the corneal pregnancy. All of those can enlarge and eventually rupture the structure they're in, which can lead to heavy bleeding and even
death. This is one of the reasons it's so important to follow up with your reproductive doctor, because being a fertility patient already puts you at, higher risk for ectopic pregnancies. And this is because people who are infertile have higher chances of having tubal disease. The earlier you can find the ectopic pregnancy, the better the outcomes. The later you find the ectopic pregnancy, the worst outcomes. But we'll talk about that a little bit more when we talk about treatments.
Now, one of the most common thoughts when people think of ectopic is they think the embryo is stuck. And they're true that they are stuck, but they're not stuck in the way we think of it. When we think of stuck, we think that the embryo is in a small tube and their shoulders are stuck between and can't move past it. But that's actually not what's happening. The tube is so large, we can see with our eyes, and we can even sew it together. In surgeries, an embryo is microscopic.
There's no way the embryo is getting stuck between the tubes. So what that means is that when your hysterosal pingogram, also known as the HSG, shows that your tubes are open, you still have a risk for an ectopic because it's not a narrow tube that causes the problem, it's the surface of the tube that causes the problem. So, for example, the little fimbriae or, the cilia that move the embryo down the fallopian
tube may not be working well. Or there could be like a tar tissue that's causing it to stick and it sticks to the surface, and that's why it doesn't move. Now, when it lands in the ovary or lands in the cervix, that could be for other reasons, such as it went too far in the uterus or that it never got picked up by the tube and landed somewhere. And the embryo is programmed to invade whatever tissue it lands on. Eventually, when it starts to make its own placenta. Nothing you do is
causing an ectopic. Sure, something that may have happened to you in life may put you at higher risk for ectopic pregnancies, such as endometriosis, pelvic inflammatory disease, a, history of a sexually transmitted disease. But everyone has a risk of an ectopic. It's just that certain people have a higher risk. Once youve had an ectopic, your risk for another ectopic is about 15%. Even if you removed the
tube that was affected. The reason that is because when you remove that tube, you did get rid of the tube that caused the problem. But whatever disease state you had had to come from somewhere that could be on either tube. Meaning, lets assume its something in the abdomen, like endometriosis. Well, its not like endometriosis is only going to stick to one side of your pelvis. So its possible that then both tubes can be affected. So if one is affected, its possible
the other one is too. So removing one tube doesnt really reduce your risk. In the same token, if the infection came from, lets say, the vagina, its not like the bacteria can go into the uterus and say, hey guys, were not going to the right side today, we are all going to the left. Dont go over there. No, it's going to affect both sides. And since it's going to affect both sides, it means both tubes have risk and probably both
have tubal disease. That's why I'm actually concerned, even with one ectopic, that that disease state could be in the other tube. That's one of the things I talk about with patients that we can't assume that tube, just because it's open is still working and that there could still be problems. A really interesting association with ectopic, pregnancies is smoking. People who smoke cigarettes have a higher risk of ectopics
compared to the general population. This may have to have something to do with the cilia or fimbria function, since we know smoking can also affect Cilia and the trachea. Just an interesting fact they thought you should know. So then the question is, how do you determine if you have an
ectopic pregnancy? Well, if you're with a fertility doctor, they always assume everyone has an ectopic until proven otherwise because we need to watch for a closure because our infertility patients have a higher risk of having atopic pregnancy. Usually what you do is you start by checking hcg levels early on in the pregnancy, and what you're looking for is you're looking for kind of a doubling of the rate. Now, it technically does not have to double as long as it's
going up around 67%. That's perfectly normal. And some studies have even shown as little as 55% could be normal. But what we look for is changes in the numbers. Are they going up and down? Are they plateauing and then going back up? And when we see that, then we really get concerned about an ectopic pregnancy. It doesnt matter if youre pregnant naturally with IUI or IVF. When those numbers start doing that, we start getting worried. Now, we dont want to treat at that point
because we could be harming a pregnancy. So what we do is we watched. Now, eventually the ATG levels will get to a level called the discriminatory zone. The discriminatory zone is the point where you would expect to see an embryo in the uterus as a gestational sac. And if you dont, then you would know that there must be something wrong. Now, this can be difficult because if someone got pregnant naturally and their cycles are irregular, we may not really know how far along
they are in the pregnancy. So we use those ECG values to get to that discriminatory zone, which is usually around about 1000 to 1500. If your hcg level was around 1000 1500 and there was still nothing in the uterus at that point, we would assume it is an ectopic pregnancy or pregnancy of unknown location. Now, you could think, well, what if they had twins? Then the ECG levels would be lower and it still wouldn't show because it would need to be 2000 or 3000 to show that in rib. And that's true.
But for most people, natural twinning does not occur at a high rate, usually about one in 240. Now, if the patient is taking like clomid or femara, then that's something that should be thought of, and it's not unreasonable to wait a little bit longer. Now, when we're talking about artificial insemination or ivF, we actually know the date of the pregnancy, and so the discriminatory zones are not going to be
as important because we know the date of the pregnancy. And so eventually we know we should see something by at least five weeks, three days, if not five weeks, five days. And if we don't see anything at that point in the uterus, then we know it's an ectopic pregnancy. So again, couple ways to determine ectopic. One is expecting to see a gestational sac in the uterus at the right time, which is at least by five weeks, three days to five weeks, five days.
Or if we don't know when the implantation occurred, then using a discriminatory zone, by checking ECG levels, and when they get past that discriminatory zone, at that point, you make the call that is an ectopic pregnancy. The question is, why is this so important? Well, because if you don't treat it early enough, as we mentioned earlier, it's going to cause more problems. The earlier you catch it, the safer it is and the easier the treatments are. So then what are the treatments? Well, there's a
couple. The first treatment would be called expected management, and that's something very rare that you would do. That means just watching and waiting. That's not unreasonable to do. If it's very early in the pregnancy and the ecg levels are well below 200, even if the pregnancy is at five weeks, three days and the ecg levels are very low, it's not unreasonable to keep watching. However, it's also not unreasonable to still treat. The second treatment would then be medical treatment. Medical
treatment is going to be methotrexate. What methotrexate is, is a chemotherapy agent that affects folic acid by inhibiting the metabolism of folate. It interferes with the synthesis of DNA and rna, which are the essential components of growth and reproduction of the cell. So methotrexate can potentially stop the pregnancy from going forward. It's a fairly safe drug. It's a very low dose chemotherapy agent. So there are patients that we don't recommend taking it, which I won't go into depth in
this, but for most patients they can take it. And what it will do is it will cause the pregnancy then to stop. The last treatment is surgical treatment, and that would be a laparoscopic surgery where you would go in with a laparoscope, and then you would either resect the ectopic pregnancy from the tube, or you would remove the tube that has the ectopic pregnancy in it.
70% to 80% of the time, the ectopic pregnancy is going to be in the outer portion of the tube, which means sometimes it can be removed from the tube without removing the tube. The other 20% to 30% of time, it's going to be in the smaller portion of the fallopian tube called the isthmus, and this can be sometimes more difficult to remove the pregnancy from the tube and potentially may have to remove the tube. Now, there are contraindications
to giving methotrexate. For example, if someone's breastfeeding, you cannot give it. There are certain disorders that you can't give it with, but the other thing is that it doesn't always work. And so when we give it, what happens is we have to look at the situation. Is this a pregnancy that's further along? If it is, then you
usually will just go to surgery. But if it's early enough, especially if there's no heartbeat yet, methotrexate, ah, has a very good chance of working, and that will prevent you from needing a surgery, and even more important, an emergency surgery where you get thrown into the ER and then have to have your tube removed under emergent circumstances where you're bleeding and hemorrhaging inside.
Usually when you're given methotrexate, you'll be told to stop folic acid and stop eating green leafy vegetables because those have folate in it. and you don't want to be taking something that the medicine's going against. So you would recommend stopping those. During the time you're taking the methotrexate, the chances of success of it stopping the ectopic is very high, in around 90%.
Sometimes some people need to get a second dose of methotrexate, which is normal, and then what they'll do is watch those ACG levels go down. Now, what's important is when they look at the ECG levels, a lot of people get nervous when they see they're still going up when they draw the blood. What theyre looking for is between the fourth day from the methotrexate and the 7th day from the methotrexate is if the ECG level goes down by 15%, as long as it does that, it means its
working. Now, just because the ACG levels are going down does not mean youre completely out of the woods. Ive seen people with ACG levels as low as 15 rupture their tube even after getting methotrexate therapy. So you're never 100% out of the woods. And for that reason, if there's suspicion of an ectopic pregnancy, you really don't want to be leaving town, getting on planes. You kind of want to lay
low and make sure you have someone with you. So if anything ever happens in emergency, you can get to the ER right away. But for most people, they don't end up having an emergent procedure. If the methotrexate is working, the hcg levels are dropping. Now, an interesting fact is if you go and save the tube by, using methotrexate, or remove the ectopic pregnancy without removing the tube or remove the tube, does that affect your chances then in the future of having another
ectopic? the answer is that regardless which treatment you do, you will still have the same 15% chance of having another ectopic. And that was the point I was making earlier when I said it's a disease state. So if it's on one tube, it's probably on the other tube as well. Now, once you've had an ectopic pregnancy, it's very important in the future to always get into your Ob doctor early in the pregnancy. So that way if you do have an ectopic, it can be caught early, it can be treated early.
No one wants to have surgery if you don't need it. Now, there are special circumstances where surgery is absolutely needed, such as if there's a large pregnancy with a heartbeat that's further along. But the other situation thats very uncommon, thats happened to me twice in the history of going through, as a fertility doctor, is whats called a heterotopic pregnancy. And thats where you have one pregnancy in the uterus and one pregnancy in
the tube. In that situation, you cannot give methotrexate because you would cause the pregnancy in the uterus to pass away, too, and that would be horrible. So instead, what you do is you do surgery and just remove the ectopic, pregnancy from the tube. And that way you can preserve the pregnancy in the uterus. And when I've done that every time, it's always been successful. And so it's a fairly successful procedure. In the end, the ectopic pregnancy for going through IVF is about 1%.
For the general population, it's about 1% or less. And for people who have had an ectopic pregnancy, at least one, it would be a 15% chance of another ectopic. With each ectopic, those chances keep going up by about
15%. My goal is not to scare you, to make you think youre going to get an ectopic, but just so you understand this and that if this happens, youll have a little bit of a better understanding of what may be happening, why your doctors checking those hormones so often and why theyre wanting to give you treatment, such as medical treatment or surgical treatment in all these situations, as I, always talk about, you talk to your doctor, and this conversation
needs to be with them. Not every situation is the same. Hopefully this is something that you have been interested in or something that you learned about today or maybe were worried about and now are less worried about. As always, I always appreciate everyone who listens to this podcast, and if you like it, please tell a friend about it. Give us a five star review on your favorite podcast medium. As always, I'll be back next week on, taco belt fertility.