The EPT

Why should I wait for 2 cycles before I try to conceive again?

Usually, we advise you wait for 3 months or 2 full menstrual cycles, whichever is the soonest. The first bleed that occurs in the first week or so of treatment for ectopic is not considered as a period - this is the bleed that occurs in response to falling hormones associated with the lost pregnancy.

So why wait for 2 cycles?

This allows the cycle to return and there to be a clear LMP date, to date a new pregnancy from. It also allows the internal inflammation and bruising to heal and for the necessary process of grief to surface and be worked through.

Some studies do suggest that women who conceive immediately after treatment for ectopic pregnancy are more at risk of suffering a subsequent ectopic. Furthermore, the incidence of miscarriage (which is not in any way linked to ectopic) is generally very high, with approximately a third of first trimester pregnancies ending in miscarriage, so you really do need to feel strong enough to face whatever is coming next.

This three month wait is particularly important if you have been treated with methotrexate. This is because the methotrexate may have reduced the level of folate in your body which is needed to ensure a baby develops healthily. For example, it could result in a greater chance of the baby having a neural tube defect. Low levels of folate in the mother are also associated with conditions such as hare lip, cleft palate, or even spina bifida. The drug is metabolised quickly but can affect the quality of your cells, including those of your eggs and the quality of your blood for some time after it has been given. The amount of time varies from woman to woman. The medicine can also affect the way your liver works and so you need to give your body time to recover properly before a new pregnancy is considered. The current advice is to take folic acid for several weeks before you conceive. You must not begin to take folic acid supplements until the hCG levels have fallen to below 5<mIU/mL. Once your blood hCG levels have dropped, if you wish to become pregnant again, you should recommence your folic acid supplements several weeks or months before you conceive.

When is it safe to have sex again?

This depends what you mean. It is possible to become pregnant within a very short time after being treated for an ectopic pregnancy if you have unprotected intercourse. Because it can take several weeks for your period to return and ovulation needs to take place before the period can arrive, it is possible to become pregnant even before your period has returned. We recommend waiting for 2 proper cycles or three months, whichever is the sooner, following surgery or treatment with methotrexate, to allow the body to heal and your emotions to surface and be dealt with. Having sex is itself not dangerous to you as long as you do not find it painful. Many doctors suggest waiting until after you have had your first proper period, which means waiting until around 6 weeks, to allow full healing of the muscles and by that time you should have had your first period, giving you confidence that your body is returning to its normal rhythm.

If you are being managed expectantly, or if you have been treated with methotrexate, you will be having your hormone levels measured. As hCG levels drop the risk of rupture diminishes. However, unfortunately, the risk remains even with very low levels in an ectopic pregnancy. For this reason we suggest you avoid sexual intercourse which involves penetration until the levels are down to less than 5<mIU/mL. Anything that increases intra-abdominal pressure is best avoided. Ultimately though, the decision about when to have sexual intercourse again is one for you and your partner and should be based on when you feel ready, which for some is earlier than 6 weeks or with levels less than 5<mIU/mL, and for others later. Of course this doesn’t mean you can’t find other ways to satisfy each other, if you feel up to that.

What are my chances of a future successful pregnancy?

This depends very much on the health of your tubes. It is usually possible to conceive and over all 65% of women are healthily pregnant within 18 months of an ectopic pregnancy. Some studies suggest this figure rises to around 85% over 2 years.

Are there any tests I can have done to ensure I won’t have another ectopic pregnancy?

The only tests of any real value are performed after a period of trying to conceive without success. If after a year of trying you are not pregnant (or six months if you are over the age of 35) you should visit your health care provider to discuss that. They might consider blood tests to establish evidence of ovulation and possibly a referral for a Hysterosalpingogram test (HSG). Many women wonder why this test is not offered immediately after an ectopic pregnancy but the HSG test is only usually performed after a period of trying to conceive without success, and most doctors will not consider it until you have been trying for 12 months. This is because, depending upon which sources you read, the risk of infection could possibly outweigh the potential help the test could offer you in the form of a diagnosis in the short term. If at the point of surgery there was nothing to suggest your tube(s) is/are blocked (and given that 65% of women are successfully pregnant within 18 months rising to approximately 85% of women over 2 years), doctors do not want to diminish that chance by running the risk of introducing infection with a test that may not actually be of any help or use at this stage. Some centres may also consider a procedure called a selective salpingography.

What is selective salpingography?

During the HSG test, a small diameter, flexible catheter is threaded inside the HSG catheter and, with the help of the x-ray machine, can be directed right into the opening of the fallopian tube. Once this is done, dye can be introduced directly into the fallopian tube.

With this technique, it is possible to demonstrate a normal, patent fallopian tube whose opening may be in spasm. Fallopian tubes with an obstruction can also be opened by the higher pressures which can be achieved with selective salpingography.  This procedure is normally done under mild sedation with pain relief but exactly what your clinic or health care provider prefers is something only they can tell you about.

Selective salpingography is a fairly new procedure and not available in every centre.

Is it likely I could have another ectopic pregnancy?

The overall chance of a repeat ectopic pregnancy after a first, in the UK, is about 10%. This depends on the type of surgery carried out and any underlying damage to the remaining tube(s). The risk rises again after subsequent ectopic pregnancies.

What can I do to prevent another ectopic pregnancy?

Since ectopic pregnancy is more related to past tubal damage rather than the present, there is little that can be done to prevent a future ectopic. However, if you feel that you may have ongoing problems of pelvic infection, (and it is well-known that Chlamydia trachomatis may give no symptoms) then testing and antibiotic treatment for this might help to reduce the risk of a future ectopic.

What are my chances of a future successful pregnancy after an ectopic pregnancy?

This very much depends on the condition of your remaining tube(s). The loss of a tube does reduce success rates, but you can still become pregnant and have a successful pregnancy with only one tube intact. Overall, 65% of women will become pregnant within 18 months after an ectopic.

Ovulation

When will I ovulate again?

The body is a very clever thing. Before you can have a period you have to ovulate. It is perfectly possible to ovulate within 14 days after surgical treatment and almost as soon with Methotrexate treatment, so it is important to be aware that it is possible to become pregnant without having a proper period first, if you are not using some from of contraception.

You are usually advised to wait for at least two normal cycles or three months before trying to conceive again, as this allows your body to recover from treatment and to prepare for pregnancy next time. If you have been treated with Methotrexate it is especially important to wait.

Will I still have regular periods after the removal of one or both of my fallopian tubes?

You will continue to have periods, which are likely to arrive around once every month. The Fallopian tubes play no part in controlling your period cycle. The cycle is controlled by hormones produced in different sites in the body but predominantly in the ovaries.

My ovary was removed at the time of surgery does this mean my periods will change?

No. Usually your periods will settle in to a regular cycle, even though one of the ovaries has been removed. Often the other ovary compensates and produces sufficient hormones to control the cycle.

Is it true that I ovulate on alternate sides each month?

This varies from woman to woman. Some women will ovulate from the same side each month with an occasional ovulation from the other side, while others will ovulate randomly from side to side. It depends on which ovary contains the egg that is at the right stage of development. However, it probably does not matter as an egg from one ovary can travel down the tube on the other side. In the past, the ovary on the side of the ectopic was removed as part of the operation but this is no longer carried out as it was not found to be beneficial.

I am experiencing abdominal pain several weeks/months after an ectopic pregnancy

Following an ectopic pregnancy, it is not unusual to feel pain and discomfort in the abdomen. Awareness of such feelings can be heightened as a result of the experience of losing a pregnancy. There are a number of reasons why you may be aware of the aches in your abdominal area. It could be that your normal cycle is trying to resume, the pain you are experiencing might be due to your body preparing to ovulate, or your period might be about to arrive. If after two or three months you have continuing abdominal pain, this could be being caused by scarring, known as adhesions (scar tissue that connects two or more body structures together) and may settle over time. It could be that be that your awareness of your menstrual cycle and your ovulation have been heightened. Many women report that they are aware of ovulation pain after an ectopic, when they have never experienced it before. It might simply be down to heightened perception and awareness because of the experience you have been through. If the pain is persistent and is becoming worrying, we would suggest that you keep a diary. Record in your diary when your period starts, when the pain is experienced and how the pain would be scored on a scale of 0 to 10 ( 0 being no pain, 10 being pain requiring a trip to hospital ). Keep a record of what helps the pain. These might include heat (hot water bottle), exercise, rest, pain relievers (make a note of what kind). After about 8 weeks, make an appointment with your doctor to discuss the diary records you have been keeping.

Trying to conceive following ectopic pregnancy

When can I try to get pregnant again?

You could fall pregnant within 6 weeks of an ectopic pregnancy but some studies suggest that the risk of a further ectopic, if you become pregnant in the first two cycles, might be greater. The general advice is that you should wait for 2 proper cycles or three months before you attempt to get pregnant again after surgical treatment. It is especially important to wait for three months before you try again after you have been treated with one injection of Methotrexate, as this medicine can alter your metabolism and might interfere with the cells of a developing pregnancy in a negative way. If you require two injections of Methotrexate a week apart, speak with your health care providers and establish what they believe to be the safest waiting time before you try again. Some doctors suggest a 6 month wait after two separate doses, given 7 days apart, of Methotrexate.

Why should I wait to try again after methotrexate?

Medical professionals widely agree that after treatment with Methotrexate, which is a folate antagonist, women should wait 3 months to try to conceive. It takes varying amounts of time for hCG levels to drop after treatment with Methotrexate, during which time, best practice advises the patient does not supplement her diet with oral folic acid. This is because taking substances rich in folic acid can stop the treatment from working effectively

How long will it take me to get pregnant after an ectopic pregnancy?

It is impossible to say how long it will take to become pregnant again. The time it generally takes to conceive varies considerably from woman to woman. This can be affected by factors including age, general health, reproductive health and how often you have sex (intercourse). Some women become pregnant quickly, while it takes longer for others.

According to the NHS Livewell website, the majority (84 out of 100) of couples in which the woman is under 35 will conceive naturally after one year of having regular unprotected sex, and more than that (92 out of 100) within two years.

Women become less fertile as they get older. For women aged 35, about 94 out of every 100 who have regular unprotected sex will get pregnant after three years of trying. However, for women aged 38, only 77 out of every 100 will do so.

The effect of age on men’s fertility is less clear.

Having ‘regular sex’ means having sex every two to three days throughout the month. Some couples may try to time having sex with when the woman ovulates (releases an egg). However, guidance from NICE (National Institute of Health and Clinical Excellence) advises that this causes stress and is not recommended. The EPT advice is that women trying to conceive should have intercourse 2 or 3 times between day 10 and 20 of their cycle.

Fertility problems affect one in seven couples in the UK. Many factors can cause fertility problems, including:

•  hormonal (endocrine) disorders such as problems with the thyroid or pituitary glands
• physical disorders such as obesity, anorexia nervosa or excessive exercise
• disorders of the reproductive system such as infections, blocked fallopian tubes, endometriosis or low sperm count

Some of these factors affect either women or men. Others can affect both partners. The most common causes are ovulation failure (which itself can have many causes) and sperm disorders.

In nearly one-third of people, fertility problems cannot be explained.

The EPT advises that women under 35 should seek medical advice following 12 months trying to conceive, and those over 35 should seek advice after 6 months.

Does drinking alcohol affect fertility?

In women, alcohol affects fecundability (the ability to become pregnant) by disrupting the delicate balance of the menstrual cycle. Clinical research data published in the “British Medical Journal” suggests that women, who drank socially, 1-5 drinks per week, were at a greater risk of decreased fecundability when compared to women who remained abstinent. These findings underscore the importance of remaining abstinent while attempting to conceive.

Research also suggests that alcohol disrupts the hormonal imbalance of the female reproductive system, leading to menstrual irregularities, and even anovulatory cycles (menstrual cycles where ovulation fails to occur). These changes can drastically decrease a woman’s chance of becoming pregnant and thus affect fertility.

The NHS standards watchdog, the National Institute for Health and Clinical Excellence (NICE) looks at the available evidence on the best way of treating or managing a condition and makes recommendations based on this evidence. Doctors, nurses and other healthcare professionals in the NHS are expected to follow NICE’s clinical guidelines. NICE has changed its advice for pregnant women, recommending they should drink no alcohol during the first three months of pregnancy, and if they choose to drink after this period, to have a maximum of two units once or twice a week. This recommendation about drinking alcohol during pregnancy came about as part of an update to its antenatal guidelines. This provides advice about all stages of pregnancy care, including screening, testing and check-ups.

NICE’s wording is as follows:

* Pregnant women and women planning a pregnancy should be advised to avoid drinking alcohol in the first three months of pregnancy if possible because it may be associated with an increased risk of miscarriage.
* If women choose to drink alcohol during pregnancy they should be advised to drink no more than one to two UK units once or twice a week (one unit equals half a pint of ordinary strength lager or beer, or one shot [25 ml] of spirits. One small [125 ml] glass of wine is equal to 1.5 UK units). Although there is uncertainty regarding a safe level of alcohol consumption in pregnancy, at this low level there is no evidence of harm to the unborn baby.
* Women should be informed that getting drunk or binge drinking during pregnancy (defined as more than five standard drinks or 7.5 UK units on a single occasion) may be harmful to the unborn baby.

Until 2008 the EPT advised that consuming alcohol  in moderation when planning a pregnancy was OK. However, research over the last 3 years refutes this and so we have no alternative but to suggest that women planning pregnancy or in their first trimester, should abstain from alcohol.

Is there anything I can do to improve my chances next time?

Not really, but if you have a history of abdominal pain which persists after the ectopic, then you should see your GP to make sure you do not have a persistent infection that might contribute to a future ectopic. Then it is a matter of healing and resuming normal activities. Having regular sexual intercourse, once every two or three days between period bleeds is a good way to approach future conception.

Do other people feel scared about trying again?

Yes, most people feel scared about trying again. An ectopic pregnancy is a very frightening experience in which many women thought they were going to die. Because of this, most early pregnancy units offer early scanning in the next pregnancy to make sure that all is well.

How can an egg get down the only tube I have when it’s produced on the other side where I have no tube?

Even when a tube has been removed it is usual to leave the ovaries alone. Both ovaries compete each month to produce an egg and usually the one that is pulling ahead in the race continues while the other one gives up (but not always – sometimes women will ovulate from both ovaries in one cycle or twice from one ovary but these are rare events – they do explain how we get non-identical twins so there is no disputing it can happen).

We do not fully understand the process of ovulation and we make discoveries about it all the time, most latterly that the tubes and uterus are lined with little receptor cells. It appears that at the point of ovulation these receptor cells are sent a chemical signal which literally ‘switches’ them on and they emit a signal that attracts a similar receptor in the egg and in the sperm to come and meet in the same place, ie the fallopian tube.

When we ovulate, although the egg is most likely to travel down the nearest tube, there is some evidence to suggest this is not always the case. At the point of ovulation some very delicate structures called the fimbriae begin to move gently creating a slight vacuum to suck the egg toward the end of the tube it is nearest to. So, if you have only one tube then there is only one set of receptors working and one set of fimbriae creating a vacuum and so the egg is much more likely to find its way to that tube, whichever ovary it is produced from.

Conservative estimates suggest that an egg produced on the tubeless side manages to descend the remaining tube around 15 to 20% of the time.

This means that rather than your fertility being halved – your fertility is probably no different to what it was before your ectopic – assuming fertility is the ability to produce a fertilisable egg and or quality sperm. If you can do this before ectopic you can almost certainly do it after ectopic, so rather than a reduction of fertility, it is more the case that the opportunity to conceive has been affected but not by half – by around 30%. Or looking at it another way, it means we have around a 70% opportunity of conception with each cycle, so it’s not all bad news at all!

What exactly do ovulation kits predict?

The ovulation predictor kit measures the hormone LH. A surge in LH leads to ovulation within the next 12 hours. The egg does not always get released from the ovary in spite of a surge but it is a very good marker. A positive pregnancy test around 14 days after you think ovulation occurred is the only way of establishing that it actually did. If a doctor has referred you for follicular tracking, your ovulation might be observed with ultrasound scans, but this is only done once other tests have indicated there might be a problem with ovulation. You are likely to be expected to try to conceive for around 12 months before you would be referred for testing, as the majority of women would have conceived within this time frame if they were actively trying.

Can my Home Pregnancy Test (HPT) tell me if I am ovulating and can my Ovulation Predictor Kit (OPK) tell me if I am pregnant?

The DNA that makes up the strands for hCG, which is the hormone associated with pregnancy, is only one strand different to the luteinising hormone which detects ovulation. Both hormones, at a molecular level, are nearly identical. hCG has a beta sub-unit, meaning that it has an extra molecular twist. All this means that it is possible for an OPK to detect pregnancy although this is not always reliable. It is not, however, possible to use an HPT to detect ovulation.

What tests, treatments or investigations can be done to make sure this won’t happen again?

There are no tests or investigations which can be done to assure you that you will not experience an ectopic pregnancy again. Ectopic pregnancy occurs because of some underlying damage to the fallopian tube, but the cause of the damage may never be established. Doctors would usually want you to wait to try again for a short period of time, usually suggested is 3 months after which, your doctor will probably encourage you to try again for 12 months if you are less than 35 or six months if you are over 35. Only if you do not conceive within those times would they then consider tests and investigations. The exception to this might be if the surgeon saw something during the surgical procedure to resolve your ectopic pregnancy, which he or she felt warranted further investigation more quickly.

Assisted conception

What is clomid?

Clomiphene or clomid is an extremely powerful medicine which is prescribed to some women when there is evidence of infertility.

What is the risk of ectopic pregnancy with IVF?

It is still possible to have an ectopic when having IVF. The incidence of ectopic with IVF sits at about 10% in the UK (or thereabouts) depending on the clinic. This figure differs depending upon the country you look at. This figure is higher than the incidence for the average population which is 2% in the UK and as high as 10% in the Caribbean. But it is no higher than the statistic given for the likelihood of a second ectopic after a first, which averages also at about 10% in the UK. (Alhough this figure too can be higher in some countries and possibly lower in others.)

A fertilised egg which has reached the Zygote stage, which means the cells have begun to divide, is replaced in the uterus with IVF at anything from 1-2 days after fertilisation, to 4-5 days when it has developed many more cells and is called a blastocyst. It spends several days floating around before implantation and it is possible to float into the tubes or the stump of tubes or the interstitial area of the uterus.

No one can be very sure why this happens but there is an unproved hypothesis that if the egg is encouraged along the tube by specialised cells that literally attract it on its journey from the ovary to the uterus that this could work in reverse, and if the fertilised egg is introduced in to the uterus first these specialised cells can attract the egg toward them causing it to ascend the tube rather than descend it, if it makes its way there in the first place.

What should I do in my next pregnancy?

In all cases a woman who has suffered an ectopic pregnancy should contact her GP as soon as she knows she is pregnant. Usually you will be referred to an Early Pregnancy Unit. Here it is normal to arrange an ultrasound scan at around 6 weeks to check the pregnancy is in the womb. If your period is late, if menstrual bleeding is different from normal or if there is abnormal abdominal pain, you should ask to be examined and remind the doctor if necessary that you have had a previous ectopic pregnancy.