Ectopic pregnancy

Dear Professor Winston,
I’ve had one live birth followed by two ectopics/pregnancies of unknown location. It took 20 cycles to conceive the first EP/PUL (ectopic pregnancy/ pregnancy of unknown location-Ed) which was treated with methotrexate. It was at first diagnosed as a miscarriage but the pain in my RH side three weeks later prompted me to seek further medical attention. I conceived four months later after waiting the recommended time after receiving methotrexate and sadly, it was another EP/PUL treated with methotrexate again. Im assuming that the second PUL may have been on the LH side due to the pain I experienced during this time. Gestationally, I would have been 14 and 17 weeks pregnant by the time I was signed off by the hospital in both instances. Ive since had a laparoscopy and dye which revealed endometriosis in the pouch of Douglas, a fibroid and a cyst. The fallopian tubes looked fine and the dye was able to flow through them. I wondered what the chances are for me to have a successful pregnancy following my history? What are the percentages that I could have another EP/PUL? I’m happy to answer any further questions or assist in any research if required, kindest regards, B

Dear B,

Not enough information, I am afraid. What is your age, weight, how old is your child? How were the ectopics diagnosed i.e. by laparoscopy or ultrasound? And how was the Methotrexate given? By mouth, injection into your arm, or by injection into the ectopic itself? At what gestation were the ectopics diagnosed i.e. how many weeks pregnant were you? Do you have photos from your laparoscopy?

Let me have more details and I’ll do my best.

Best wishes
Robert Winston

Dear Robert,

Many thanks for responding, it really is appreciated.

I’d been trying to conceive for 20 cycles and then my period was a few days late but all pregnancy tests were negative, then I had a ‘bleed’ which I assumed was my period. On day 10 after the ‘bleed’ I was scheduled to have an HSG (a hysterosalpingogram (HSG) is an X-ray test that looks at the inside of the uterus and fallopian tubes and the area around them -Ed) as a follow-up to fertility investigations, but I decided randomly to do a pregnancy test which was positive. I was referred to our local hospital where there was nothing detected on the scan, I would have been 5/6 weeks pregnant (I ovulate late in my cycle), I had my bHCG monitored over a period of 48 hours during which time, the levels had dropped so it was assumed that I was miscarrying. Three weeks later, I had intermittent pain on my RH side which prompted me to do another pregnancy test, it was positive. As my bHCG (beta human chorionic gonadotropin level-pregnancy test -Ed) was low at 878, it was decided that I should have methotrexate which was administered through my buttocks, I would have been approx. 8/9 weeks pregnant, my levels took 6 weeks to go back to 0. On day 4 after the methotrexate was administered, I encountered intense pain on my RH side which I think affected my bowel and I am sure there is still scare tissue. There were no masses or fluid at all on the US and internal scan to indicate where the pregnancy was.

My partner and I waited the recommended three months after receiving the methotrexate and we fell pregnant on the second month of trying. Again, the pregnancy followed the same pattern as the first PUL/EP; my period was late and there was the strange ‘bleed’ again followed by a positive pregnancy test. I raised my concern with the GP who told me that I would need to wait until the 12 week scan but after another bleed, I spoke to another sympathetic doctor who referred me to the local hospital again. There was nothing detected on the scan again and I was referred to the consultant, she assumed that I’d had a chemical pregnancy but I asked for a second opinion following my history and then consent was given for my HCG to be monitored, my bHCG levels were 40 and 48 hours later, rose to 73. Further monitoring indicated that it was a failing pregnancy but it was developing very slowly. I had HCG monitoring every weeks until I received methotrexate 4 weeks later as my levels were stagnating at bHCG 847. From having a positive pregnancy test on the 16th Feb, my levels finally reached 0 on the 7th May last year. Therefore, the pregnancy was approx 16/17 weeks. I was scanned twice by US and an internal scan during this period and nothing was detected on the scan.

I had a laparoscopy and dye in July 2013, the endometriosis and cyst was removed. The endometriosis was small by comparison and it was believed that it would be detrimental to remove the fibroid as it was small in size. I’d always suspected that I had endometriosis. I don’t have any pictures unfortunately but on inspection, my fallopian tubes looked absolutely fine. I am 38, I am a non-smoker, weigh 10 stone 4 and I’m 5″6′. My Son is 5 in July and he took 6 months to conceive when I was 33, I was induced and had a retained placenta.

I had several tests over the years and they were negative for any STI’s. Prior to my Son’s birth, I had a MTOP when I was 19 and a miscarriage followed by D&C when I was 27 years and no other abdominal surgery. I had to have Lletz treatment for Stage 2/3 dyscariosis, 9 months after my Son was born.

Following other fertility investigations, my partners sperm is ‘very good’. My LH and FSH blood levels were normal although I am wondering if I have a estrogen/progesterone problem; I have sore breast right after ovulation during the luteal phase and sometimes spot before my period, my period starts between days 26-33 of my cycle and I ovulate on days 16-18. It might sound like I’m clutching at straws but is there a link between low progesterone and ectopic pregnancy, I know that low progesterone can affect implantation. My Sister had a cornual ectopic.

Best Wishes, B

Dear B,

I think you have been having ectopic pregnancies in the fallopian tubes. I am willing to bet that your fallopian tubes are damaged, possibly at a microscopic level. Loss of the ‘hair-covered’ ciliated cells in the lining of the tube is likely to be the cause, and I would love to see the any photos of your laparoscopy because often there a faint, tell-tale signs of this damage on the surface of the tube – small changes in the fine blood vessels for example. Our research clearly shows that by far the most common cause of ectopic is relatively minor damage to the tubes which does not always block them.

The other, less common, cause of ectopic pregnancy is an abnormal uterus – very possible in your case, not least because you needed a manual extraction of the placenta at your previous delivery. Very often, women who have a problem with delivery of the placenta have an abnormal uterine cavity – often a congenital m,malformation. This also makes an ectopic more likely. Moreover, any complication in removing a placenta may predispose to low grade (often symptomless) infection and this frequently affects the tubes, particularly the cornu, and also predisposes to ectopic pregnancy. Damage in the tubes, due to any kind of inflammation, is likely to be bilateral and affecting both of them.

So clearly a hysterosalpingogram, really carefully done with not too much dye, may be very informative and may reveal an abnormal cavity – and just possibly (though less likely) subtle changes in your fallopian tubes. One problem here though is the fact that you have had a loop excision of the cervical epithelium, and this can make doing an HSG a bit more difficult – but a competent radiologist with a gynaecologist should be able to sort this out.

Lastly, the fact that you have had abnormal cervical cells can predispose to a degree of infertility, and no matter what is claimed, operations on the cervix do reduce natural fertility in some women.

One of the issues your case is “what is the risk of another ectopic”? I would put it as high as 30% at least which means that if you suspect you are pregnant you should seek early ultrasound and careful monitoring. Moreover, because of my suspicion you are likely to be prone to a corneal ectopic, this is important as ectopics in the cornu are a bit more dangerous as they can cause significant bleeding internally. I do not want to frighten you as I certainly would not advise you not to seek another pregnancy. I would simply suggest that you get proper surveillance of any early pregnancy until implantation is clearly demonstrated in the right place. Incidentally, I have sometimes found the diagnosis of ectopic pregnancy to be difficult on ultrasound alone and really careful laparoscopy is frequently needed.

By the way, I know of no serious evidence that low progesterone levels cause ectopic pregnancy. And I very much doubt you have a hormone problem at all, anyway.

Warmest wishes
Robert Winston