Prevention of Ectopic Pregnancy

Over the years certain patients really stick out in your memory. This week one of my favorite fertility veterans brought in a whole box of homemade cookies to the office. Needless to say, they were consumed within 45 minutes and I got one or two but almost lost my hand in the feeding frenzy that occurred. In any case, this young woman had really been through the ringer. Low responder, high FSH, pregnancy loss, antiphospholipid antibodies requiring Lovenox, male factor….and the list always seemed to keep growing. However, the low point was an ectopic pregnancy after an IVF cycle while she was on Lovenox. Ultimately, it all worked out and they ended up with 2 beautiful children (her own eggs) who were romping around the office this week as the cookies were being delivered.

So how do we avoid a repeat ectopic pregnancy in our patients? Well, there are some ways to try and reduce the risk but even with ultrasound guided embryo transfer, those little buggers can still float out into the tubes. There are reasons that I am losing my hair and why I am getting more grey and it is not always from my own kids.

As I try to get back in the blogging routine here is another kernel of knowledge from the book soon to be made into a major motion picture: 100 Questions and Answers about Infertility.

30. If I had a previous ectopic pregnancy, what should I do to avoid another one?

The reported incidence of tubal or ectopic pregnancy in the general population is 1%. Women who have experienced an ectopic pregnancy generally have a 10% to 15% risk for another ectopic pregnancy. The good news is that most women who have had an ectopic pregnancy will not have another one. The bad news is there are no therapies available to eliminate this risk. All women who are attempting to conceive inherently are at risk for an ectopic pregnancy. Even women with absent or obstructed fallopian tubes can experience an ectopic pregnancy if the embryo becomes implanted in the section of the fallopian tube found within the muscle of the uterus (called an interstitial or cornual pregnancy). The rate of ectopic pregnancy following IVF is usually 1% to 2%, far lower than the 15% recurrence risk with a spontaneous pregnancy. Fortunately, most ectopic pregnancies are readily diagnosed very early in pregnancy using blood hormone assays for beta human chorionic gonadotropin (HCG) combined with transvaginal ultrasonography. It is now uncommon for such pregnancies to go undiagnosed or to lead to tubal rupture, hemorrhage, or death. Most ectopic pregnancies can be treated medically using low doses of methotrexate (a type of chemotherapy that selectively destroys the pregnancy tissue), thereby avoiding surgery. This medical therapy is 80% to 95% effective.

Read More

Hydrosalpinx, hydrosalpinges and IVF

Again the weeks have just flown past with no additional blog entries by yours truly. I have no excuse really. Just too busy, too tired, too overextended…yadda, yadda, yadda. So beat me, slap me and call me dirt.

The issue of blocked fallopian tubes is a very important one, even in patients undergoing IVF. Now on the surface this makes little sense because if IVF is used to bypass the fallopian tubes then who really cares if they are abnormal? A reasonable concern and one that for many years we agreed with as we entered patients into the IVF process. But then a funny thing happened….papers started appearing that suggested that the IVF success rate was lower in patients with blocked and dilated fallopian tubes (hydrosaplinx – as described below). The logical question was then whether removal of the hydrosalpinx would cause pregnancy rates to return to the expected level and the answer was a resounding “yes”.

So now fertility MDs are often placed in the unusual situation of removing the tubes after years of training in how to fix them…go figure.

A few years ago we had a patient with bilateral hydrosalpinges as a result of several operations for Crohns disease. We had to remove her tubes with the help of her general surgeon and ultimately she conceived IVF twins. One day I was visiting her in the hospital and the residents said that she was mad that we took out her tubes needlessly since we had planned to do IVF all along….I popped into her hospital room and we chatted for a while and then I raised the topic of her tubes. In spite of many documented discussions on this topic she said that she really could not remember any such topic being reviewed. Finally, the light bulb over her held lit up and she said “Oh yes, know I remember….the tubes had that nasty fluid in them…” Bingo.

So after weeks of waiting patiently here is today’s relatively pathetic post from the book that needs to fund my 401K from here on out…100 Questions and Answers about Infertility.


28. Why should blocked fallopian tubes be repaired before IVF is attempted?

When the fimbria of the fallopian tubes become damaged, it may result in a tube that is blocked at the very distal end—the part farthest away from the uterus. If the tube then becomes filled with fluid, it is called a hydrosalpinx (“hydro” refers to water; “salpinx” refers to the fallopian tube itself). Women who have a hydrosalpinx should have their fallopian tubes either removed or cut prior to undergoing IVF. The surgery usually involves a simple outpatient procedure called laparoscopy. The tubes are cut or removed so that the tubal fluid, which would be toxic to an embryo or adversely affect the receptivity of the endometrial lining, does not flow backward into the uterine cavity, preventing implantation of the embryo.

It is now well recognized that women with an untreated hydrosalpinx have a substantially reduced chance for pregnancy with IVF. In addition, an untreated hydrosalpinx may increase the chance that a woman will experience a spontaneous abortion or miscarriage. For all these reasons, treating a hydrosalpinx should both increase the IVF pregnancy rate and decrease the chances for an early pregnancy loss. A patient with a single normal fallopian tube and a hydrosalpinx will also have a higher chance of achieving a spontaneous pregnancy after removal or ligation of the damaged tube. A hydrosalpinx, if present, is usually identified during the infertility diagnostic evaluation with a hysterosalpingogram (HSG). This simple x-ray study should be performed in all infertile women unless a diagnostic laparoscopy has already been performed. Preoperatively, we advise all patients that we recommend removal or ligation of her tube(s) if a hydrosalpinx is discovered at laparoscopy.

Read More