Saturday, 21 November 2015

Ectopic Pregnancies, including with IVF

Jess mentioned in a previous post that she couldn't understand why she had had an ectopic with IVF. As many of you know, I worked for six years with the Ectopic Pregnancy Trust (and spent many more years on their site informally), answering questions like hers almost daily. I gave her some information in a long comment on her blog, but thought I would edit it a little and reproduce it here, with some additional information. I know this isn't relevant for those of us who are no longer trying to have children, but others might find their way here, and find it useful. Or it might answer questions for some of you who did have ectopics, or know someone who has had one. So I hope none of my readers mind me talking about pregnancies and loss, here where we usually focus on life after we've said good-bye to all this.

Ectopic Pregnancy

Any sexually active woman of childbearing age is at risk of an ectopic pregnancy. 1-3% of all pregnancies are ectopic (ie, not in the uterus), and 95-97% of ectopic pregnancies are in the fallopian tubes.

However, ectopic pregnancies are more likely if you have had:
  • Pelvic Inflammatory Disease - a past infection of the fallopian tubes (for example, chlamydia).
  • Endometriosis - a condition which could cause damage to the tubes
  • Abdominal surgery - any previous pelvic or abdominal operation, such as caesarean section, appendectomy or previous ectopic pregnancy.
  • An operation on the tubes - such as sterilisation
  • A contraceptive coil (IUD) fitted - the coil prevents a pregnancy in the uterus but is less effective in preventing a pregnancy in the tube.
  • Are on the ‘mini-pill’ (progesterone-only pill) or have recently come off it – progesterone only contraception alters motility of the tube
  • Use of the morning after pill with the pregnancy in question
  • Fertility treatment (IVF)
  • A previous ectopic pregnancy, and
  • If you smoke

As you can see, IVF is considered to be a risk factor. In fact, ectopic pregnancy rates through IVF are higher than in the general population. This is often because women who need to seek IVF treatment have an underlying, undiagnosed condition (that has contributed to infertility) that may heighten their risk of ectopic pregnancy. Figures are hard to get however, and of course, clinics are well-motivated to report these differently. A few years ago, we tended to use conservative statistics, stating the risk of ectopic with an IVF pregnancy to be at least 4-6%, or at least twice if not three times the rate in the general populace. But the statistics used in the UK show that the rate of ectopic pregnancy with IVF is around 10%.

When an embryo is transferred into our uterus, it doesn't implant immediately (if, of course, it is going to implant at all), which is why I am always doubly annoyed when the media uses "implants" instead of "transfers." It can float around for a day or two before implantation, and this means it can move from the transfer site. It can therefore travel up into the fallopian tube, and implant there, causing an ectopic pregnancy. Or it can implant at the entrance of the fallopian tube, causing a cornual or interstitial ectopic pregnancy.

Still, 90% of women who have ectopics go on to conceive again successfully (ie, in the right place). 50% of women who have ectopics have none of the risk factors, and will never know what caused their ectopics. So women who are looking for an answer, like me, struggle to find one.
Conditions that can lead to tubal or interstitial (at the connection of the tube to the uterus) ectopic pregnancies with IVF (or otherwise) can include:
  • tubes that are blocked or semi-blocked (so if an egg floated up, it might not get back to the uterus),
  • balding of the cilia (these little hairs that waft the egg down to uterus can gradually disappear, and so can't do their job), and
  • the fallopian tube contractions that help push the egg downwards can, on occasion, reverse. (I was told this by my own specialist, when he was trying to figure out why I had two (one, tubal, one, interstitial, neither IVF) ectopics. I don’t have any data, and he said that they could monitor me for hours, and not see one of these reverse contractions, so I cannot 100% stand behind back this last point.
  • Jess was told her cilia were pointing or directing the wrong way. I've never heard of this, and wonder how they knew, as the cilia are so tiny infertility tests can't see them. Perhaps they conducted investigations on her removed tube, or it could simply be a case of a doctor surmising, hoping to give an answer to a patient who is hungry for them.
Many of these conditions are almost impossible to diagnose. Hopefully, further research will provide further information.

For more information on ectopic pregnancies, go to The Ectopic Pregnancy Trust website
Previous posts where I talk about my own experience of ectopic pregnancies can be found here, and here.

9 comments:

  1. Thank you for writing this, for infomation-sake, and thank you for writing this:

    "When an embryo is transferred into our uterus, it doesn't implant immediately (if, of course, it is going to implant at all), which is why I am always doubly annoyed when the media uses "implants" instead of 'transfers'."

    Because it also drives me crazy. I think it reinforces the idea that IVF always works when, in fact, it doesn't.

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  2. A wonderful and resourceful post. Am bookmarking.

    Couple of thoughts:
    1) as far as cilia beating in reverse direction, they only way I know to observe this is using high-focus microscopy and using dyes. Unless they somehow got a microscope up into her tube, I'm baffled at how they would give this diagnosis. I'm not saying it's not possible, but where is the data?

    2) There's been a push for IUDs in this country. The data shows they are far more effective at preventing pregnancy than other forms of birth control. That said, I don't remember being told of the increase risk for ectopics. And this is something women should be aware of.

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    1. IUDs are a bit complicated. If you do get pregnant whilst using an IUD, then your pregnancy is much more likely to be ectopic, simply because they prevent pregnancy (very well) in the uterus, but not anywhere else. So you're right, women should be aware of this if using IUDs.

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  3. Thanks, Mali! So to clarify, they surgically removed my tube and did a pathology report on it. I'm not sure if my tube could have been saved, but I made the decision and it was backed up in surgery with the state of things that it was okay to do so. We were never going to conceive without IVF, and in my mind if there was a chance my tube was defective I wanted it GONE. Also, I'm not sure that they said for certain that the cilia was essentially sucking the embryo up the tube or just that that was one of many tubal malfunction possibilities, all involving the cilia being messed up (for lack of a precise medical term). So that inaccuracy might be on me, because I'm not so sure that they definitively said that was THE reason, just ONE of the possible reasons. Maybe the balding makes more sense... They did get to examine my tube and the products of conception pretty closely when removed, and I saw a gross but interesting picture of my tube on the metal tray, outside my body. Very surreal.

    Thank you for this incredibly detailed post, it gives a lot more information than I feel was shared with me, unless I suppressed a lot of it because of pain and grief and the fog of anesthesia.

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  4. This is so informative! Thanks!

    I do remember my doctor letting me know that an ectopic pregnancy with an IUD was possible, but that the risk was still very low. Though, for me, my chance of getting pregnant in the first place was so low that any increased risk due to the IUD was negligible.

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  5. Do you think using embryo glue during transfer could help reduce risk of an ectopic pregnancy?

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    1. I'm sorry, I honestly don't know. I haven't heard of embryo glue. Only an ectopic/IVF expert could comment on that. I wouldn't entirely trust an IVF Dr alone!

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  6. I'm impressed by your detailed knowledge of this topic -- thanks for sharing it with us! :)

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