Today we talk about when to hit the panic button when it comes to repeated ectopic pregnancies. I'm, Doctor Mark Amos, and this is taco, about fertility Tuesday. Over the next several weeks, I'm going to put a series together called when to hit the panic button. And it's going to be on multiple topics, and we're going to start it off with ectopics. And at what point do you need to hit that panic button and need
to move on to other treatments? If you like this episode, make sure you check out the other ones that are coming up in the next few weeks. So let's start off with the first part, which is ectopic. pregnancies are very scary. You can actually die from an ectopic pregnancy. So anytime you have it, you are technically hitting the panic button because you need to get to the ER immediately, because if your tube ruptures, you can bleed to death. And so again, it's always an
emergency. But what I'm talking about is if you had a nectopic, maybe one, maybe two, maybe a third one, at what point do you need to hit the panic button and move on to something else, such as IVF to reduce your risk of an ectopic? Now, have you heard one of my prior episodes? I talked about what an ectopic pregnancy is. Essentially, it's when the pregnancy is not inside the uterus. Anywhere else is considered an
ectopic. It could be in the tube, it could be on the ovary, it could even be in the cervix. It can even be on your organs if it's inside your abdomen. There's even very rare ones called corneal pregnancies, where they're actually in the tube but still in the uterus. And those can be very dangerous as well. Tubelectopic pregnancies are, going to account for about 90% to 95% of all cases within the tubal ectopics. The ampulla of the fallopian tube, which is the widest portion, accounts for about
70% of the ectopics. The next largest portion is going to be the isthmic portion of the fallopian tube, which is the narrowest portion, and that's about 12%. And then the last 11% occur around the fimbria, which are the little fingers that pull the egg towards the fallopian tube. Ovarian ectopics occur about 3%. This is a situation where the fertilized egg implants on the ovary itself and continues to grow even rarer. Are, what are called cervical topics. This is where the pregnancy is
inside the cervix and starts to grow. This can be very dangerous due to the vascularity of the cervix. And this occurs less than 1% of the time. Abdominal ectopics, which is when I was talking about where it lands on, let's say an organ, occurs in about one to 2% of ectopic pregnancies. Again, very rare and corneal ectopic pregnancies, also called interstitial ectopic pregnancies, are where the ectopic pregnancy occurs in the part of the fallopian tube that
passes through the uterine wall. This means if you're looking at abdomen, you're looking at the fallopian tube that's not in the wall. This is the portion that's in the muscle. These are very dangerous because they can look like they're in the uterus, and they usually grow much larger without detection and could potentially cause very severe complications, even death, if
they rupture because it's rupturing your uterus. Now, what's important to understand is that ectopics are anytime the embryo is not in the uterus, and, with each ectopic, there's a higher risk of having another ectopic. So in a general population, about one to 2% of people will have an ectopic pregnancy. Now, once youve had one ectopic pregnancy, your risk for another is approximately 15%. If youve had a second ectopic pregnancy now, your risk is going to be as high as about 20% to
25% of having another one. And by the time youve had the third ectopic pregnancy, your chances are around 30% to 50% of having another ectopic. this is also the point where you should be hitting the pack button and strongly considering IVF or
other interventions to reduce your risk. Now, in the prior episode, I talked about how to diagnose the next topic, and essentially, there's a thing called a discriminatory zone, where you expect the HCG levels to be at a certain number, and then you should see something in the uterus, such as a gestational sac, and that number is different between every place. So it's important for people to determine their own discriminatory
zone. Now, there are times when you might think there's an ectopic there, but there could be an abnormal pregnancy that's just abnormally rising with ACG levels. But there's this point where eventually, you know, it's not a healthy pregnancy. And you may just say, no, this isn't gonna be a healthy pregnancy. And we're concerned about the risk of ectopic. We're just gonna give treatment, which is called methotrexate, which is a chemotherapy agent.
Now, the reason this is important is cause we're getting to this idea of how do we know we did have multiple ectopics? The first thing we look at and what makes us concerned about ectopic is how the ECG levels rise when they're not rising normally. We start getting concerned. The second part is when we don't see a pregnancy in the uterus. But the question is, when do we expect it? When you're doing things like iuis or IVF, we know
exactly how far long the pregnancy is. But when you're talking about ovulating, some people ovulate irregularly. And so although they might have had a period which they thought was a period, maybe it wasn't, and maybe they didn't ovulate two weeks later, but ovulated four weeks later. And so now you think the pregnancy is six weeks along, but it's only four weeks long, and you wouldn't expect to see something in the uterus. This is where the discriminatory zone
comes in. By looking at HCG level, then you know if you should see something visible inside of the uterine cavity. The problem doctors have is this kind of waiting game. If they keep waiting to find out what happens, it could get too late and then it could rupture, and you can have a very serious situation where someone's bleeding to death.
But if you make a decision too soon prior to determining if it's an ectopic versus abnormal pregnancy, you could be hurting the pregnancy, or maybe it's just a little bit abnormal and starts going normal again. So if we rush to a diagnosis, yes, we're going to, treat more ectopics faster, but we're also going to hurt normal pregnancies if we wait too long. We can protect pregnancies more, but we have
more ruptures. And so it's very important to make this diagnosis in an appropriate, amount of time, but also being sensitive to the fact that you want to be sure. I personally have seen many patients who come in with multiple ectopics, but when I get to the actual definition and I start asking them, well, how long did they wait to see if that ECG went up? They'll tell me, well, it only went to 50. Well, 50 is a very low
number. You don't know if it's an ectopic. Then you never hit the discriminatory zone, so you wouldn't expect to see something uterus. So how do we know it just wasn't an abnormal pregnancy and there's no harm in that situation? The doctor did the right thing by giving that person methotrexate. But now the patient has this diagnosis of an ectopic pregnancy. So do they hit the panic button now, or do we not consider that in that category where it's a higher risk?
We're going to get into this a little bit further here in a minute. So, one of the things I've talked about in the prior podcast was understanding that an ectopic is not an embryo stuck in the fallopian tube. Today I had a consult where someone was asking that question, is their fallopian tubes clogged? And. And the answer is no. It's not really thinking that's clogged. Think of it more as the surface of the fallopian tube
is more like tar. And so the ectopic is getting stuck in the fallopian tube because of that, but it's not getting stuck like we think of our body being wedged in a tube. And this is because the embryo itself is very, very small. We're talking microscopic, where the flopping tube is very large. My analogy, I tell people, is think of like a football in a football stadium. How is that football going to get stuck? There's no way that football stems so wide compared to
that football. And that's kind of the same type of measurements of scale. When you talk about an embryo and the fallopian tube. And why this is important is because there's this sense of things are safe. When you do a hyster cell pingogram and you check the fallopian tubes and find out they're open, sure, they're open. That
doesn't mean that they're functional. That doesn't mean that an embryo won't get stuck because of that surface or that the little fimbrey that pulled egg towards it won't work and cause an ectopic. And this leads us, really to the question of, well, then, what causes ectopics? One of the most common reasons for an ectopic pregnancy is something that causes trouble, disease.
And this is going to be things like infections such as chlamydia, gonorrhea, mycoplasm, certain infections that can then lead to tubal disease, even a surgery that leads to infection in the pelvis can then lead to a state of tubal disease that can then lead to ectopics in the future. Other types of infection would be pelvic inflammatory disease. Now, the next category is what we call lifestyle factors. And most of these lifestyle factors affect things like the cilia that pull the embryo
down to the, uterus. The ciliary dysfunction or something that can make it change are going to be things like smoking. Smoking, we know, affects things like cilia. That's why when people smoke, they get the smokers cough, because the cilia don't work as well. And what happens is they build up stuff. They can't cough it. They have to cough it out, unlike everyone else where they're cilia work and just pull the mucus and things out of their airways. Well, the
same thing happens at the fallopian tube. Those cilia don't work as well, and that leads to ectopics. the same thing with age. As people get more mature, they have a higher risk of ectopic. And the thought is that maybe as they're aging, things don't work as well. The fimbria don't work as well. Pulling the egg towards it or the cilia are not working as well. So those are things that can actually increase your ectopic. You can't change your age, but you can quit smoking, and that is a
huge factor when it comes to, ectopic pregnancies. So if you do smoke and you have ectopic pregnancy, please stop smoking. It's one of the best things you can do to help your chances in the future. The other category is going to be physiological factors such as delayed egg transport. And this comes down to a couple of things. So one of the first ones is that when you're ovary on the right, releasing the egg, it can be picked up by
the left fallopian tube. And that distance it has to travel takes a little bit longer. And so potentially one thing that could happen is when one side picks up the egg from the other side and it's fertilized early, it's delayed in the transport into the uterus. And that can sometimes lead to an ectopic, just like the ciliary dysfunction, if it's not working well or scarring the floating tubes are preventing the cilia from
moving the embryo down. It's eventually at its implantation potential point, and it's in the fallopian tube versus in the uterus. So that's some of the stuff that can cause it. We even know that people who are infertile have higher risk of ectopics and so that's why people going through fertility even have a higher risk of ectopic pregnancies. So in the previous ectopic, pregnancy podcast, I talked about things like, what can you do about them? We talked about doing surgery.
We talked about taking a medicine called methotrexate. But the real question comes out is, how do you proactively reduce your risk of ectopic pregnancy, and when do you hit that patent button? And so when it comes to treatments, there are basically going to be a few treatments, and I'm not talking about treatments now to get rid of that topic. We discussed that before. What I'm talking about is now you've had these ectopics, you've had one of them, two of them, three of them, doesn't matter.
What are your options moving forward? And so your first option is to say, well, listen, can I just try getting pregnant again? And the answer is yes. And what you can do is you could do close monitoring, meaning watching very early with acg levels, watching very early with ultrasounds, and then you can treat it so early that the risk is lower. As I was mentioning to someone today, your risk is actually lower once you've had the next topic, because now
you know what to look for. It's no different than if you're in a bad neighborhood, you know, to look around and make sure you're not gonna get mugged. Well, same thing here. But now you know you're at risk for an ectopic, whereas when you never had an ectopic, it's like walking in a new neighborhood. You don't know it's bad. You don't know to be looking around. Now there's risk with it. Yes. With each ectopic, you have a higher risk of getting
another ectopic. So there's some concern there. But again, with close monitoring, its not an unreasonable option. Then the next option is going to be something such as bypassing the fallopian tubes. This is going to be ivF. Whether youre doing IVC or IVF, the point is youre bypassing the fallopian tubes and getting pregnant, and this will reduce your risk of an ectopic down to about 1%. Now, I know that sounds crazy. How the heck do you get an ectopic when you put the
embryo in the uterus? Well, it's because the embryo can actually move and go into the fallopian tube, and that comes right back. But if you have some type of pathology in the fallopian tube, it's not able to fall back into uterus, and that leads to another ectopic. Now, if everything was free and simple, everyone would jump straight to IVF. But it's not. And so the question then comes back to, when do we hit the panic button? so the way I would look at it is this.
Personally, I would say if you've had three, topics, you should be hitting the panic button at that point. I understand you may have to do naturally getting pregnant and can't do IVF due to cost reasons or other reasons, maybe even religious reasons. But technically, at that point, that's when you should really be hitting the pack button. I don't think after one act topic you need to, but I understand that your
situation may be very severe. So let's say your first ectopic, your tube ruptured and you almost died. Yeah. Hit the panic button. That's scary. And although the chance of that ever happening again are, very small, because now, you know, to be watching out for it, you might want to hit that pan button then and say, I, don't want to take that risk.
But for most people, if we're talking about in that topic where eventually they catch it early, you're able to take methotrexate and treat it medically, it's not unreasonable after having an ectopic to try again and watch very closely. And even after a second one, your chances are still better. It's going to work fine. And so it's not unreasonable. But by that third ectopic, you are now close to a 50% having another ectopic. now the chances aren't better that things will work. And to
me, that's when you should hit the panic button. And really, you, you should start thinking about doing other treatments, such as IVF to bypass the fallopian tubes. Now, I do understand every situation is different, and this is the part I want to talk about, which is if it is an ectopic where it's truly known, meaning you see the ectopic in another area, or it's definitely an ectopic, your doctor is 100% sure. Then count that towards those three. But there are these situations where it's kind of
undiagnosed. The ECG is going up. It doesn't get very high. It doesn't even get to 200. But what we do know is that the pregnancy is abnormal. And so your doctor is making a decision, saying, listen, we don't need to wait anymore because this will never lead to a live birth. So let's prevent the risk by giving you methotrexate. This is actually what we do with people who have the history of ectopic because we know the risk is so high and so we give them the methotrexate.
But it's also important to understand that that may not even be an ectopic. And so when we're talking about hitting this pan button on the three tries, we're talking about three actual ectopics. Ah. If you are having these very early ectopics, you may not have to hit the panic button right away because we don't truly know if they're a topic. The question is, did your doctor get to that decision fast? Really, it could just be an abnormal
pregnancy and they're losing them. Or is it the situation where it is a true ectopic? And the problem is, that's a very hard thing to wait for, because if you wait too long, you can cause harm. If you do too soon, you can cause harm to the pregnancy. Just like we talked about in the beginning. In the end, everyone has a different point than when they hit the panic button. But for the general idea, if you've had three ectopics and they are confirmed ectopics, I would tell you
panic button. In time, you need to go on to something like IVF to reduce your risk of having another ectopic, because eventually it could be very dangerous and it's probably not worth the risk anymore. But after the first, even after the second, it's not an unreasonable situation to try again and watch closely.
That's the most important part. Just make sure you have someone who's watching things closely and they know and are aware that you have a risk for that topic, and in that way it can be much safer. This means no nights alone. Make sure you have someone with you all the time and that there is a doctor following things closely. I hope none of you ever get a neck topic, but maybe you do, and this might help you make that next decision of do you need to jump straight to IVF or
can you wait? Do you have to hit that pack button? Hopefully this episode was helpful to you guys. Like I said, I'm going to be doing several of these panic button scenario type of, podcasts, and if you like them, please let me know and give me a topic you'd like me to do one on. If you know someone that this may help, please tell them about it. And if you love this podcast, as I always say, tell your friends about us. Give a five star
review on your favorite medium. But most of all, keep coming back. Every week I want to give a shout out to a patient that I saw today. She told me that she actually met up with some people and they all had Eck topics and all of them were seeing me, so she said they were the Amos fan club. That brought a huge smile to my face. I look forward to talking to everyone again next week on talk about fertility Tuesday.