Controversial Topics in Fertility Studies

Non-Surgical Treatment for Ectopic Pregnancy

Ectopic Pregnancy / Tubal Pregnancy

An ectopic or tubal pregnancy occurs when the embryo is not able to get out of the fallopian tube and into the uterine cavity in a timely fashion. In a normal situation, fertilization occurs in the distal end of the tube and the early dividing embryo will spend 4 days or 96 hours in the fallopian tube; at which time, it will quickly travel through the proximal part of the tube and into the uterus. Once in the uterus, it will float free for the next two and a half days, then implant on day 6 1/2. Some woman can have slight bleeding or spotting at this time, known as implantation bleeding. Anything that interferes with the embryo's ability to move down the tube and into the uterus will cause the embryo to "get stuck" where it will either become non-viable or continue to grow in the tube until it causes the tube to rupture and puts the patient at risk of internal bleeding, hemorrhaging and shock secondary to significant blood loss.

Causes of Ectopic Pregnancy

Tubal pregnancies occur because of damage to the fallopian tubes, which can be due to a number known or unknown causes. The most common known reasons are: previous infection from pelvic inflammatory disease (PID), STDs like gonorrhea or chlamydia or IUD use, previous tubal surgery, conceiving after having a tubal ligation, conceiving after a reversal of sterilization, external constriction secondary to scarring from endometriosis, and even after an embryo transferwhere the embryo can float into the fallopian tube and can not be brought back down into the uterus by the normal ciliary or hair-like movements of the tube.

Ectopic Pregnancy Diagnosis

In this day and age, an ectopic pregnancy should not be missed, let alone rupture. At Arizona Center for Fertility Studies, the philosophy is that every patient has an ectopic pregnancy until proven otherwise. To make sure that the patient does not have an ectopic pregnancy; as soon as any of our patients are late on their periods, even by a few days, they get a urine pregnancy test (at no charge) or a blood pregnancy test, and if positive, are scheduled for an early transvaginal ultrasound at 5 1/2 to 6 weeks, also at no charge. Once the pregnancy is confirmed in the uterus everyone can relax and they are no longer at risk of an ectopic or tubal pregnancy that can rupture and cause internal hemorrhaging.

The only exception, is in the case of a heterotopic pregnancy, where are pregnancy can occur both in the uterus and in the fallopian tube. The spontaneous incidence of this is 1 in 25,000; and with IVF, where multiple embryos are transferred into the uterus, the incidence can be as high as 1 in 1000. Although, this diagnosis is more difficult to make and seeing a pregnancy in the uterus makes you think everything is okay; if a patient is at high risk for an ectopic pregnancy, then you always have to think about the possibility of a heterotopic pregnancy.

The diagnosis of a tubal pregnancy is made by having a high suspicion for a patient at risk, no ultrasound evidence of a intrauterine pregnancy, abnormally increasing hCG levels, abdominal pain, vaginal bleeding or ultrasound evidence of a mass or pregnancy outside of the uterus.

Ectopic Pregnancy Treatment Options

Once the diagnosis is made there are several treatment options available.

1. Surgery can be done by diagnostic laparoscopy, where a laparoscope is placed through the belly button and into the abdomen under general anesthesia. If diagnosed early enough, you should always be able to save the involved fallopian tube. The procedure is done by first injecting epinephrine into the tissue around the tubal pregnancy to stop any bleeding and then making an incision over the area in the tube where the pregnancy is and allowing the pregnancy to "pop out". Any small bleeders can be gently cauterized and the tube is left open to heal normally. The thinking being, "once an ectopic, not always an ectopic", and the involved tube can have the possibility of next time carrying a pregnancy into the uterus. If diagnosed early, you should never have to have a laparotomy or open incision.
2. The other option is to avoid surgery and treat the ectopic pregnancy with methotrexate (MTX), which is a chemotherapeutic agent, that destroys rapidly dividing cells, which is what pregnancy tissue is. If you are uncertain of the diagnosis of an ectopic pregnancy, blood hCG levels are not compatible with a healthy, ongoing pregnancy, but you know that the pregnancy is not in the uterus, then an in-office D&C is recommended. This is done to see if there is any pregnancy tissue in the uterus, which would indicate that you are having a miscarriage based on the clinical findings. The tissue is sent 'STAT' to pathology for evaluation. If there isn't any tissue in the uterus, then the only other logical place for it to be is in the fallopian tube. If that is the case, then the treatment options are surgery or MTX. If the diagnosis is made early, as it can be if the thinking is "everyone has an ectopic pregnancy till proven otherwise", then MTX is a logical option. Three criteria need to be met before using MTX. This includes having the hCG levels under 10,000 IU or less, the patient is having minimum to no symptoms of pain, and if there is a mass outside the uterus on ultrasound, it has to be 3 centimeters are less. Once these criteria are met and with early diagnosis they should be, then MTX can be used to treat and eliminate the tubal pregnancy. It can be given orally for 5 days, given as an intramuscular injection at 50 mg every other day until hCG levels drop by 30% or given in a single dose of 150 mg intramuscularly. Since MTX destroys cells that are dividing rapidly, it can cause gastrointestinal side effects like nausea, vomiting, diarrhea, cold sores and abdominal pain. These are usually mild and do not occur in most patients. By using MTX, you will eliminate the need for surgery. This may decrease the risk of additional compromise to the involved fallopian tube; thus increasing the chance that it will function normally with the next pregnancy. Neither surgery or MTX will guarantee that the involved tube will function normally with the next pregnancy but at least you will be given the possibility. If the ectopic pregnancy has ruptured and the patient is bleeding internally, surgery is the only option and, most of time, if not all of time, the involved fallopian tube needs to be removed, regardless if the other tube is absent or badly damaged. This is why early diagnosis of an ectopic or tubal pregnancy is so important.