Question 29. If I had a previous ectopic pregnancy, what should I do to avoid another one?

Sorry for the delay in between blog posts. Unfortunately, my number one fan (my Mom) has been in and out of the hospital in Boston and I just have been too busy to sit down and do some blogging. At 87 years of age there is not a lot that can be done as she has a lot of health problems and a recent round of chemo almost did her in...But she is hanging in there and I try to talk to her every day. It has been said that gynecologists are either perverts or Mothers' boys...I will let you guess which category this Eagle Scout falls into.

Ok so back to the 2nd Edition of the 100 Q&A book (which I am currently doing final editing of for a Fall pub date)....Today we are discussing ectopics. Why? Because it is Question 29.... Let's be honest here....ectopics really stink. Patients that have had an ectopic will do anything possible to avoid another ectopic. Fortunately, with early identification most ectopics can be treated medically with methotrexate avoiding the need for a surgical procedure. However, methotrexate may not always be successful and patients can end up with an emergency surgery in spite of our best efforts.

29. 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 options available to eliminate this risk entirely except adoption. 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.

Kristin comments:

I had an ectopic pregnancy after a Clomid cycle that was monitored by my OB. I was 8 to 9 weeks pregnant and thought I was having a miscarriage when the ectopic pregnancy was confirmed at my first RE appointment. Unfortunately, the methotrexate therapy did not work, and I had to have surgery to remove my right fallopian tube. After determining that my remaining tube was not blocked through an HSG, and with the counsel of our new RE, we opted to move on to IVF. This option would offer the greatest chance for us to become pregnant and avoid another ectopic pregnancy.

When I did become pregnant through IVF, my RE agreed to a very early ultrasound to make sure that the pregnancy was in my uterus. I appreciated that my RE understood my concerns of having another ectopic pregnancy. He treated me as an individual instead of requiring me to wait until the typical 7-week mark to perform an ultrasound.

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Question 28. If I had my tubes tied, can I have them untied?

This has been a busy couple of days here at Dominion as DrD is off for a well-deserved bit of R&R. Trying to do the work of 2 doctors is kind of like clapping with one hand...but so it goes. Today I was asked again about what to do in cases of previous tubal ligation. This clinical scenario comes up fairly frequently and so it is certainly a valid question to discuss. I have not done a tubal reversal surgery in many years and usually refer all interested parties to Dr. Gary Berger in Chapel Hill, NC. In spite of Dr. Berger's office being on the Carolina blue side of the Duke blue/Carolina blue divide, he is a skilled and caring MD with an office based surgery center. His price for a tubal reversal is very reasonable and for those patients sure about going down this path I think that he is an excellent choice and well worth the trip to NC.

However, not all patients are good candidates for tubal reversal and many end up considering Natural Cycle IVF or Stimulated Cycle IVF as better choices. Plus after having an IVF baby there are no concerns about birth control as your tubes are still tied!

So here is today's Question of the Day....


28. If I had my tubes tied, can I have them untied?


Fertile women who have had their “tubes tied” (tubal ligation) may do very well and achieve pregnancy with tubal reanastomosis surgery. Pregnancy rates of 70% to 80% are noted in women who undergo a tubal reversal procedure, depending on their age, the type of tubal ligation procedure performed, and the presence (or absence) of other infertility factors.

Most often, this repair (tubal reanastamosis) requires a laparotomy, which involves a bikini-line incision of the lower abdomen. This major surgery requires 2 to 4 weeks for recovery, and most insurers do not cover it. Some physicians have reported good success with laparoscopic tubal reanastamosis, but this approach can be more technically challenging. As a consequence, most women choose to undergo a nonsurgical IVF procedure instead. Studies have shown that IVF is usually more cost-effective than surgical reanastomosis of the fallopian tubes. Specifically, if the surgery fails to establish a pregnancy, then IVF may be necessary anyway. Patients with a previous tubal ligation are usually excellent candidates for IVF, including Natural Cycle or unstimulated IVF, given their previous fertility.

However, patients who are shown to have diminished ovarian reserve with a history of a previous tubal ligation should be carefully advised of the potential for a poor response to fertility medications. In such cases, tubal reanastamosis or Natural Cycle IVF may represent more appropriate options.

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Question 27. Can fallopian tubes be repaired and why would a blocked tube be an issue if I am doing IVF anyway?

Not sure that anyone really missed me over these past 2 weeks but I was out of town for several days and am trying to catch up. This past weekend was my 25th Reunion for Princeton (see DrG in the photo with 2 of his college roomies). Note the traditional Reunion Blazer that is provided to all members of the class to wear at all Princeton events. As always, Princeton Reunions is an event that has to be seen to be believed. Needless to say, orange and black are not the most flattering colors (except at Halloween). So after overdosing on Princeton I am back and ready to catch up with my blog.

Several patients have posted regarding repairing fallopian tubes. In general, most of us have moved away from surgery and towards IVF. However, it is important to know where the blockage is in such cases. Tubes that simply fail to fill on an HSG can be further assessed by fluoroscopic tubal canalization...essentially a Roto-Rooter job performed by an interventional radiologist that is often 80-90% successful at getting a blocked tube open. Repairing the delicate end of the tube (the fimbria) is more problematic and there is a significant risk of ectopic pregnancy in such cases.

So here is today's Question of the Day from the upcoming 2nd Edition of 100 Questions and Answers about Infertility:

27. Can fallopian tubes be repaired and why would a blocked tube be an issue if I am doing IVF anyway?

Prior to the advent of IVF, surgical repair of damaged fallopian tubes was considered standard medical care. Unfortunately, most patients did not become pregnant following this procedure, and 10% to 20% experienced tubal (ectopic) pregnancies. Today, IVF has replaced reparative tubal surgery for most patients with damaged fallopian tubes for two reasons: (1) IVF is a nonsurgical treatment and (2) it results in excellent pregnancy rates, especially for patients with tubal disease.

Some patients ask, “Why is it so difficult to repair damaged tubes?” Unfortunately, the problems that cause tubal disease, such as pelvic infections, usually damage the tubal fimbria—that is, the delicate finger-like projections at the end of the tube that are responsible for capturing the egg when it is released from the ovary. Pelvic infections may also damage the entire thickness of the tube from the tubal muscle to the inner mucosal layer, leaving behind a scarred, nonfunctional organ that is not amenable to surgical repair.

In general, most patients with tubal disease are best treated using IVF. Tubal reparative surgery is usually not effective and, in fact, it may increase the woman’s risk for having an ectopic or tubal pregnancy. If a couple is not interested in IVF or if they are not deemed to be good candidates for IVF, then tubal surgery may be the only option available to them in terms of fertility treatment.

Damage to the fimbria of the fallopian tubes may result in a tube that is blocked at the very distal end—the part farthest away from the uterus. A tube that becomes filled with fluid is called a hydrosalpinx (“hydro” refers to water; “salpinx” refers to the fallopian tube itself). A hydrosalpinx is usually discovered during a hysterosalpingogram (HSG) performed as part of the infertility diagnostic evaluation. This simple x-ray study should be performed in all infertile women unless a diagnostic laparoscopy has already been performed as some assessment of the status of the fallopian tubes is a key part of the fertility evaluation. We advise all patients undergoing a laparoscopy that we recommend removal or ligation of her tube(s) if a hydrosalpinx is discovered.

Over the past decde many studies have demonstrated reduced IVF pregnancy rates in patients who have a hydrosalpinx. It has been theorized that the fluid in the tube may flow backward into the uterine cavity. This fluid may contain toxic substances that may adversely affect the receptivity of the endometrium preventing implantation. Alternatively, the fluid may actually flush the embryo out of the cavity or even prove toxic to the embryo itself. Some studies suggest that the presence of an untreated hydrosalpinx will reduce IVF pregnancy rates by 50%.

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.

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