What is an ectopic pregnancy?

Ectopic defines "an abnormal place or position". An ectopic pregnancy is a pregnancy outside the uterus as a result of an embryo being implanted outside the uterine cavity.

In a natural conception, the egg is fertilised by the sperm inside the fallopian tube. The embryo conceived than travels through the tube and then reaches the uterine cavity 3-4 days later.

The smooth muscle contractions of the fallopian tube produce oscillating movements that help the embryo move down the fallopian tube. But, there are instances where the fallopian tube is blocked or damaged, which causes the embryo transport to not be possible, and to implant in the tube, which is called tubal pregnancy. The fallopian tube is not equipped to support the growing embryo, and such a pregnancy may cause it to rupture and bleed.

The most frequent location of an ectopic pregnancy is in the fallopian tube. However, implantation may also occur in the abdomen, in the ovaries or the cervix. It may also implant between the uterine cavity and the tube, which is called corneal pregnancy and is often difficult to be diagnose.

Who is at risk for having an Ectopic Pregnancy?

Ectopic pregnancies to some degree can link to tubal diseases. The damage commonly results from prior pelvic infections like gonorrhea, chlamydia and other sexually transmitted infections (STDs), as these diseases lead to an impairment of the tube. Women who have experienced a sexually transmitted infection, are more likely to develop an ectopic pregnancy.

Also women who conceive after a previous ectopic pregnancy, tubal ligation for sterilisation and reversal of tubal ligation, have a higher risk for an ectopic pregnancy. Other conditions, which increase the risk of an ectopic pregnancy, are endometriosis and exposure to diethylstilbestrol (DES).

Recent studies have demonstrated that stimulation of the ovaries with drugs used in IVF may also increase the risk of anectopic pregnancy. In fact, the first IVF pregnancy in 1976 resulted in anectopic pregnancy. The rate of ectopic pregnancies following IVF treatment had been described to be between 2-5%, as compared to 1-2% in spontaneous pregnancy.It is possible that a genetically abnormal embryo would also be at high risk to implant outside the uterine cavity.

For more information on tubal damage and surgery, contact IVI Middle East Fertility, and an available consultantcan discuss this with you, during your consultation.

What are the symptoms of an Ectopic Pregnancy?

Women with an ectopic pregnancy may experience typical signs and symptoms of a normal pregnancy, but the following symptoms may be helpful to identify a potential ectopic pregnancy:

  • Positive pregnancy test and continuous spotting or brown discharge
  • Sharp or stabbing pain that may come and go, and change in intensity. A ruptured ectopic pregnancy gathering up under the diaphragm can cause pain in the pelvis.
  • Abnormal vaginal bleeding, heavier or lighter than the usual period
  • Weakness, dizziness or fainting
  • Intense pressure in the rectum
  • Low blood pressure

Early detection of an ectopic pregnancy may help reduce the complications, and offers the opportunity for other treatment options besides emergency surgery. Sometimes an ectopic pregnancy is suspected, even when no pregnancy on an ultrasound is visible.

A woman who is experiencing pelvic pain, irregular vaginal bleeding, possible internal bleeding, and a tender feeling in the pelvis, represents a life-threatening emergency. In this situation surgery would be required to remove the pregnancy and control the bleeding.

Fortunately, with the availability of sensitive hormone testing and ultrasound examinations most ectopic pregnancies can be identified much earlier, and many without any surgerycan be treated.

How is an Ectopic Pregnancy diagnosed?

An ectopic pregnancy is diagnosed by performing a combination of the patient′s history (date of last period), the level of the pregnancy hormone in the blood (hCG is human chorionic gonadotrophin), an ultrasound of the uterine cavity. As well as a pelvic assessment to locate pain, tenderness or mass in the abdomen.

The increase of the pregnancy hormone hCG follows a certain pattern. However, ectopic pregnancies do have a suboptimal development of the hCG hormone. Moreover, from a certain value of hCG, one has to be able to visualise the pregnancy in the uterine cavity.If a certain hCG value is detected in the blood test and the pregnancy is not seen in the uterine cavity during the ultrasound then a diagnosis of an ectopic pregnancy can be made.

Additionally, an abnormal pregnancy (ectopic, impending miscarriage) is linked with low levels of progesterone hormone. But, low progesterone levels alone are not enough to predict, the location of the pregnancy, or if it is a healthy pregnancy.

In some cases, a laparoscopy is needed to confirm the diagnosis of an ectopic pregnancy. A laparoscopy is a form of keyholesurgery, where a rigid camerainserted through a small incision in the abdominal wall, is used to examine the abdomen visually.

What are the treatment options for an Ectopic Pregnancy?

An ectopic pregnancy in any of the following ways can be done:

Observation Alone

No immediate treatment will be applied, but the condition must be closely monitored. Usually limited to women with early ectopic pregnancies, who have no symptoms and low serum hCG levels (usually < 1,000 IU/L) that decrease without treatment.

Several blood tests have to be performed to ensure that the levels of the pregnancy hormone hCG are dropping. Meaning that the ectopic pregnancy appears to be miscarrying (aborting) on its own.

If the woman experiences pain or related symptoms or the hCG levels do not drop appropriately or rise, treatment will be necessary.

Medical Treatment

In cases with hCG-level below 5000 U/l and an ultrasonographic adnexal mass below the diameter of 3.5 - 4 cm, a medical, non-invasive approach can be discussed. Therefore, the medication called Methotrexate can be administered to stop the ectopic pregnancy from growing.

Before administration, the doctor will ensure that all appropriate laboratory tests have been performed, including hCG level, liver enzymes, kidney function test and complete blood count. All risks will be discussed, along with potential side effects of Methotrexate and the patient will be under observation for 1 hour after administration.

Side effects include, nausea, vomiting, mouth sores, diarrhoea, dizziness and increased abdominal pain. Five days after the administered medication, the patient will be instructed to re-check if their hCG level is decreasing.

In case the patient is experiencing severe abdominal pain within those five days, she is advised to visit the hospital immediately.

Surgical Treatment

Today, most of the surgeries for ectopic pregnancy are performed by laparoscopy. If the ectopic pregnancy is diagnosed early, before the tube ruptures, a laparoscopic salphingostomy (the fallopian tube is opened and the pregnancy tissue is removed while leaving the tube in place) may be performed.

The treatment options may be further discussed by our IVI Middle East Fertility Consultants, in our Out Patient Clinic during the consultation visit.

Does an ectopic pregnancy affect fertility?

Yes, possibly. A woman who has had an ectopic pregnancy has a higher risk of having another ectopic pregnancy. Also, her chance of conceiving spontaneously might decrease.

Moreover, the risk of having another ectopic pregnancy may increase. Hence, many women will successfully conceive and have children in the future, either naturally or with the help of an assisted reproductive technology such as IVF (In-vitro-fertilization).

What are the chances of having another ectopic pregnancy?

There is a 10% to 15% risk of having another ectopic pregnancy. However, the risk is difficult to generalise due to differences in individual status and the extent of the damage that may have taken place.

Women with repetitive tubal ectopic pregnancies may be advised to have bilateral tubal ligation to prevent a further tubal pregnancy. After that, they may be offered to undergo an IVF treatment.

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