The EPT

Bleeding

Is the bleeding after treatment or monitoring of my ectopic pregnancy my period?

The bleeding you have after surgery, or after treatment with Methotrexate, or if you are managed “expectantly”, is not actually classed as a period. This is your body expelling the thickened lining of the uterus.

Once the beta hCG levels have dropped, the chemical signals to retain the thickened uterine lining that has built up in preparation for pregnancy, are no longer being produced and so the lining of the uterus is shed. The process involves vaginal bleeding and the material may be clotty, heavy, dark in appearance or appear just like one of your normal period bleeds. The bleeding can continue for up to six weeks and it is not unusual to bleed, stop, and have spotting during this time.

How long will the bleeding last?

This varies from woman to woman but after any pregnancy loss, you can spot and bleed for up to six weeks. Providing you aren’t soaking a pad in less than an hour or the pain is so severe you can’t manage it with over the counter pain relief, you should seek reassessment.

Pain

Should I expect any pain or discomfort after my treatment and how long will it last?

Depending on which treatment you have had, a varying amount of pain or discomfort may continue for several weeks afterwards as the healing process continues and scarring continues to heal. This should lessen as time progresses. However, it is not unusual to still report some discomfort several months after an abdominal operation.

How can I tell if the pain I have means there’s something wrong?

Pain is most usually the bodies way of telling you to rest. Whether you were treated with a major abdominal operation or a keyhole procedure, some pain is normal and you should expect to take things very easily for the first week or two after keyhole surgery and for around six weeks after the major abdominal operation. Many hospitals discharge their patients with some kind of pain relief. If yours did not, then take over the counter pain remedies, a pharmacist can advise you and these are usually sufficient to help you through the first few days. Pain is however, unique to everyone and if your pain is sever and not responding to over the counter pain relief then call your doctor for advice. If your pain is associated with other symptoms, you may also need to consult with a doctor. Any of the following signs, might suggest the pain you have needs further medical assessment : -

• A rise in your normal body temperature, so a temperature of greater than 37° C (98.6° F).
• An increased vaginal discharge which smells fishy or offensively.
• Raised lumps and bumps over the puncture sites, or scar, which are redder and hotter to touch than the rest of the surrounding skin.
• Wound site which are not only weeping but appear to be oozing thick creamy or white discharge.

The wound site

What should I know about my stitches?

There are a variety of ways to close a wound after surgery. By far the most common is to use sutures or stitches, and after any kind of abdominal surgery you might expect to find stitches even in a puncture wound from keyhole surgery. These stitches can be made of different materials which means that some need to removed while others may be dissolvable.

How do I know what my stitches are made of?

If you are not sure what your stitches are made of and weren’t told whether you had to get them removed or if they will dissolve on their own, call the hospital ward that treated you and they should tell you. Dissolvable stitches are supposed to dissolve on their own between about 10 and 21 days after surgery but unfortunately dissolvable stitches sometimes don’t dissolve.

What if my dissolvable stitches don’t dissolve?

If after 21 days they are still there and you have been soaking in the bath (preferably) or showering, then you should contact the practice nurse at your surgery to perform a wound check and remove them for you. Removing a stitch takes a second and is relatively painless. You should never pull at them yourself. This can result in complications such as a would infection. If you think your stitches are stuck then when soaking in the bath you can wipe firmly over them, with a clean damp flannel, once each in a north, south, east and west direction but be careful to do no more than that.

What should I clean the wound with?

Whilst you have an open wound or stitches, you should avoid using bath oils or other strongly scented bath treats. Until the wound is healed and the stitches are gone, warm water and very gentle soap are all you should be using for your bathing needs. Other than a daily shower or bath, there should be no need to clean your wound with anything else. There is no reason not to bathe normally when you have stitches.

Should I put a plaster on my wounds?

It is better to leave the wound site uncovered. However, if the stitches pull or rub on your clothing then covering with with some low adherent dressing which is available from most pharmacies and supermarkets is recommended. You should not use any antiseptic or cream type preparations on a new scar unless it has been prescribed by a doctor.

Do I have stitches inside me?

If you had a major abdominal operation, yes you do. These stitches will dissolve on their own and you are unlikely to be aware of them. The muscle that they are uniting will take between four to six weeks to knit together like the skin wound does after a few days and this is another reason you should be taking it easy and not lifting anything for six weeks after surgery.

When will my wounds have healed?

As a general rule you should expect the wound to be clean and dry with no evidence of weeping after 10 days. If you are in any doubt about your wound site ask your doctor or practice nurse to take a look. Once the skin has healed, the scar can look quite raised and red for some weeks and months. This is not unusual but it will fade with time from red to pink and then eventually to a silvery white and become almost unnoticeable. This process can take many months, however, and as long as the wound site is comfortable, does not become sore to touch, does not begin to feel warmer than the surrounding skin and remains closed then you can be confident the wound is healed.

I don’t have stitches. What do I need to know?

There are other ways of closing a wound. Clips and staples need to be removed by a nurse or doctor, and you are normally given an appointment before you leave, or they might be removed before you leave hospital. Sometimes the wound will be sprayed with a special adhesive that seals the skin. This kind of dressing has different names but you might hear it called “opsite” dressing or plastic skin – it is a liquid plastic which sets when sprayed on to the skin and comes into contact with the air and it wears off after a few days.

Your body

Still feeling pregnant

Women often report still feeling pregnant, sometimes two or three weeks after surgery and for longer after treatment with methotrexate or expectant management. Even after surgery, where the fallopian tube is partially or completely removed, it can  take some time for the hCG Levels to drop, which along with the raised level of progesterone in your bloodstream can make some women feel pregnant, even after they have lost their baby. These feelings of still being pregnant usually subside as the hCG levels drop.

Bruising

After surgery, it is not uncommon for the area below your tummy button right down in to your pubic hair line, to be very bruised. The bruising can be very noticeable indeed. Howver, it is usually not anything to worry about and gradually fades over about six weeks.

Aching

After an operation, people often get aches and pains in places they did not expect to. The back, neck, hips and legs can all be very sore. The staff in the operating theatre take great care of you when you are asleep and try to move you in to the positions they need you to be in very gently. However, because your muscles are very relaxed as a result of the anaesthetic, sometimes muscles can ache for several days after your surgery. Take it easy, take the pain relief you were given in hospital and your aches should resolve over a few days.

Tiredness and fatigue

Anything which compromises our immune system will leave us feeling tired. Surgery is a huge event for your body to cope with and  in the first weeks after your surgery, your immune system will be pouring all of its resources into healing your wounds and keeping infection out. During this time, women often report feeling very tired. Those treated with methotrexate can feel especially tired as the medicine used depletes the body of one of the essential vitamins which helps maintain our energy levels. Taking it easy, eating small healthy meals often, and rest will all help to combat the tiredness and fatigue.

About the baby

What happened to my baby after treatment?

In an ectopic, there is often a pregnancy sac, but most often a foetus or baby as we would know it, is not developing.

If you were treated with methotrexate, this explains what has happened to your baby.

Methotrexate does prevents the trophoblast cells from dividing. Trophoblast cells are the invading cells of the pregnancy and those that form the afterbirth or placenta. It is these that rupture the tube, cause the pain and have the potential to cause internal bleeding to the mother. Once these cells no longer divide, the pregnancy is ended and the whole pregnancy sac, including any cells that might eventually have grown into a baby, is usually reabsorbed by the mother. This is normal and happens in many cases of miscarriage. You may feel pain after being given methotrexate but this is due to the pregnancy sac swelling and not due to effects on the baby. The tube, however, may remain blocked by the pregnancy tissue which can take some time to shrink. Occasionally it may not shrink and will leave a blockage in the tube, by way of a small cyst. However, the use of Methotrexate does not reduce the chances of successful future pregnancy, whatever the outcome in the affected tube.

If you were treated surgically this information may be useful.

Please be aware that this information may be difficult for some bereaved women to read.

Both the Royal College of Nurses and the Royal College of Obstetricians and Gynaecologists have produced guidelines for professionals about the importance of disposing of foetal remains in a sensitive way. As a result, many hospitals have adopted arrangements with local crematoria for the sensitive disposal but they are guidelines, and procedures vary from hospital to hospital. The Human Tissue Authority have also produced guidelines to help hospitals decide how to dispose of the remains of a baby.

We recommend that for local information, you contact the PALS department and ask what the hospital policy is on the sensitive disposal of foetal remains.

The hospital chaplain will do whatever they can to accommodate your needs in relation to your honouring your loss. They will almost certainly have a baby loss service of some kind and you might also like to see what the Baby Loss Awareness Campaign has organised in your area for the next celebrations and acts of remembrance.

The Future

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.

Post treatment – FAQs

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 such as hare lip, cleft palate, or even spina bifida or other NT defects. 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 up to 3 or 4 months after it has been given. 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 months 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.

I have been told to wait 6 months following two doses of methotrexate.

Our current medical advice, having reviewed this recently (2009), is that if you have had two injections you should wait until your hCG levels have fallen to below 5mIU/mL and then be taking a folic acid supplement for 12 weeks before you try to conceive. This means that you are normally giving yourself three to three and a half months or so before you try again.

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.

Contraception and preventing pregnancy

Which contraception can I use immediately after my ectopic pregnancy?

Women are advised to avoid pregnancy usually for two complete cycles or three months after experiencing an ectopic pregnancy. This waiting time is an opportunity for the body to recover from treatment and to begin to grieve for the loss of the pregnancy. However, how to prevent pregnancy can be a issue for some women.  Allowing the body to recover, ovulation to occur and the first period to arrive is often suggested by doctors the ideal waiting period before women begin to have full penetrative intercourse (sex) again. Some couples, however, feel they want to have sex before this time and that is when the issue of contraception needs to be considered.

If you are still waiting for your first period but decide to have intercourse, then the suggested method of preventing pregnancy is one of the barrier methods (cap, condom, diaphragm, femidom). Introducing a synthetic hormone in the form of a contraceptive pill before this prevents the body from ovulating and establishing a normal pattern.

After the first period has arrived, either continuing with barrier methods or the combined contraceptive pill are usually the methods of choice.

Which contraceptive can I use in the longer term?

This question presents a considerable dilemma and it is one that affects almost all post-ectopic women.

IUDs or coils are renowned for preventing pregnancy in the uterus but are not effective in preventing pregnancy elsewhere.  The reason they are suggested as an unsuitable method in a woman who has suffered ectopic is because the ectopic has already indicated that there was damage to the tube that was affected – this suggests that the remaining tube may also be damaged.

With a coil in place, the sperm and egg can still meet in the fallopian tube – and fertilisation can and often does take place. When things then progress as they should and the egg arrives in the uterus, the coil makes it a hostile place and so conception does not continue because implantation cannot happen. The egg expires and is passed in normal menstrual blood (you can’t see it, it’s smaller than a pinprick, and is in fact not visible to the naked eye). The problem with a coil is that if you have a damaged tube(s) and the fertilised egg gets stuck, the fallopian tube will temporarily be an environment where implantation can take place (although it shouldn’t) and it can result in a subsequent tubal ectopic pregnancy.

A Mirena coil is thought to be more suitable than one of the other coils because it releases a small dose of progesterone – progesterone prevents ovulation in many instances, but not all. Unfortunately it is not foolproof and women do become pregnant with a Mirena in situ. However a Mirena coil is a progesterone only contraceptive, and these are contra-indicated for women with a history of ectopic pregnancy.

Progesterone Only Contraceptives (POCs) are associated with a higher incidence of ectopic pregnancy. The advice of our medical advisers here is as follows:

“Delaying conception is advisable because we know one of the actions of synthetic progesterone is to thicken the mucal secretions of the fallopian tubes and we have no definitive information on how long it takes for this action to be reversed and so believe it may contribute to ectopic pregnancy.”

There is no definitive research to refute or verify this hypothesis but the advice is based on the knowledge we do have about the actions of synthetic progesterone and its known link to ectopic pregnancy.

Progesterone Only Contraceptives include contraceptive implants (if used, we recommend delaying conception for several months after removal), the mini-pill or progesterone only pill, contraceptive injections (such as depo provera) and the Mirena Coil.

In control groups, women on the combined oral contraceptive were no more likely to suffer ectopic pregnancy, when they stopped taking it, than women who were not on the pill in the first place – thus suggesting that the oral combined contraceptive pill is NOT linked to ectopic pregnancy. However, there was a noted increase in the rate of women who suffered ectopic pregnancy if they became pregnant whilst taking the progesterone only contraceptive pill and it is now listed as one of the precautions in the product data. Likewise, the morning after emergency contraceptive pill is now available as a progesterone only pill and there is an increased risk of ectopic pregnancy with this form of contraception. Again this is noted in the product data.

For women with a history of ectopic pregnancy, unless the risk outweighs the potential benefits, we suggest that the barrier methods (cap, condom, diaphragm, femidom), the combined oral contraceptive or Natural Family Planning are the most suitable alternatives.

With all contraception, you and the prescribing clinician need to ask the same question – do the benefits of this to the individual outweigh the risk? Doing this means that you can decide upon the most suitable method of contraception for you as an individual and it might be that you decide on one of the methods which is usually advised against. The issue really is about what suits you and how much you need to prevent pregnancy.

Pain

Should I expect any pain or discomfort after my treatment and how long will it last?

Depending on which treatment you have had, a varying amount of pain or discomfort may continue for several weeks afterwards as the healing process continues and scarring continues to heal. This should lessen as time progresses. However, it is not unusual to still report some discomfort several months after an abdominal operation.

What are adhesions?

Any abdominal surgery has the risk of post-operative adhesions.

An adhesion is a band of scar tissue that binds two parts of your tissue together. They should remain separate. Adhesions may appear as thin sheets of tissue similar to plastic wrap or as thick fibrous bands.

The tissue develops when the body’s repair mechanisms respond to any tissue disturbance, such as surgery, infection, trauma, or radiation. Although adhesions can occur anywhere, the most common locations are within the stomach, the pelvis, and the heart.

Abdominal adhesions are a common complication of surgery, occurring in up to 93% of people who undergo abdominal or pelvic surgery. Abdominal adhesions also occur in 10.4% of people who have never had surgery. Most adhesions are painless and do not cause complications, but are believed to contribute to the development of chronic pelvic pain.

Adhesions typically begin to form within the first few days after surgery, but they may not produce symptoms for months or even years. As scar tissue begins to restrict motion of the small intestines, passing food through the digestive system becomes progressively more difficult.

Pelvic adhesions may involve any organ within the pelvis, such as the uterus, ovaries, fallopian tubes, or bladder, and usually occur after surgery. Pelvic inflammatory disease (PID) results from an infection (usually a sexually transmitted disease) that frequently leads to adhesions within the fallopian tubes.

It is a good idea to keep a ‘pain diary’ so that if you find the situation does not ease over a few months, you can go back to your doctor with dates, times and evidence of how it is affecting you. This can be very helpful to medical practitioners when deciding upon how to manage the symptoms.

Is it normal to still have sore breasts a few weeks after my operation?

You may get sore breasts immediately after and for some weeks after the operation as they get used to not being pregnant. They may get sore again leading up to the next period.

For how long will I feel and look bloated? Why am I bloated?

Bloatedness is a reaction to the operation and the inflammation following this. The length of time it continues varies, but it should settle within 6 weeks. If it continues for longer it may be a sign that you have some ongoing infection and you should see your GP.

Is there likely to be scar tissue and will this affect my future chances?

After any abdominal operation there is some scar tissue. The abdominal scars should make no difference to your future chances. The tube that was operated on may have been removed, or at least damaged from the operation, but pregnancy is usually achieved through the other tube anyway, irrespective of whether or not the tube was salvaged. Sometimes adhesions form in the abdomen as a result of surgery and these can sometimes compromise the remaining tube, but only time will tell. Even so, overall, 65% of women are pregnant again within 18 months of an ectopic pregnancy and some studies suggest that more women (around 85%) are pregnant after 2 years.

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 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 to go see your doctor to discuss the diary records you have been keeping.

Follow-up

Other people had their blood monitored since leaving hospital. Should I?

If you are treated medically with Methotrexate or if you had your tube salvaged, you need to have your blood monitored as the risk of persistent ectopic is greater. If you had your tube removed the risk is low and blood testing is not normally necessary, although some doctors do check it once either prior to the woman leaving hospital, or after a week or so to make sure levels are dropping.

Do I need a check up with my GP, practice nurse or hospital after my ectopic?

Not really. It is useful to check around 6 weeks to make sure all is well and that your periods are starting again. Many hospitals offer a follow up appointment but some do not. If you haven’t been given a follow up appointment at the hospital, your GP can do a post operative checkup for you, but as long as you feel OK, there is no real medical need to see a doctor. You may find it beneficial to talk through what happened with a medical professional, and this is the most usual reason for wanting to see a doctor at this stage. If you have been allocated a follow up appointment at hospital this usually involves the doctor reviewing your medical notes, enquiring as to your health and recovery since the operation and discharging you. Only rarely will the doctor examine your tummy or look at your scars.

I am having a follow-up appointment. What should I ask?

You may have had several questions come to mind since your treatment and if you haven’t already done so it is a good idea to write them down – better still write them out twice and give one list of questions to the doctor and keep the other yourself and mark them off, noting the replies as the doctor answers you. Did the doctor see any obvious reason why you had suffered the ectopic pregnancy at the time of surgery? Any damage to the fallopian tube for example. Was there any evidence of scar tissue or adhesions elsewhere in your abdomen? Did your remaining tube look healthy and intact? How long would the doctor consider it reasonable for you to try to conceive without success before he or she would see you again?  Will you need a separate referral for this? If and when you are next pregnant, what sort of support or early pregnancy screening will be available to you?

Getting back to normal

Can I take a shower and when can I have a bath following surgery?

Normally, you can shower 24 hours after an operation on your abdomen (tummy) and take a bath after 48 hours. It is a good idea to make sure someone is around when you get into the bath, in case you find it uncomfortable or tricky to get out. Don’t rub or wash the scars – gentle washing in warm water with a mild soap or body wash gel, avoiding the actual scars, is all that is needed. If for some reason it is not advisable to take a bath, you will usually be told this as part of your discharge information. If you are in any doubt, ring the ward from which you were discharged  and ask them. Dissolvable stitches often rely on the patient taking regular baths to help the stitches dissolve.

I’m really tired all the time. Is this normal and how long should it take to feel myself again?

Some people take longer to recover than others. It depends on how much blood you lost and what operation you had. The bigger the operation and the more blood lost, the longer it takes to feel yourself again. Usually you should be fully recovered physically by 6 weeks, but in some people it may take longer. As long as you are making progress, you should not worry.

Methotrexate can also leave you feeling quite exhausted in the first early days of treatment and you should take things gently, at a slower pace, until your energy levels return.

When can I start to do exercise?

This depends on how you were treated and, if you had an operation, the type of surgery you had. If you had keyhole surgery, you could start gentle exercise within 2 weeks of the operation. If you had open surgery then you should wait 6 weeks for your abdomen to heal. If you were treated with Methotrexate you should not resume exercise until your hCG levels are falling consistently and are in the low 100′s. Exercise like swimming is usually safe, as long as the wounds are healing or your hCG levels are low, as this is a non-impact sport.

Will I be safe to drive?

Depending upon the type of surgery you had you are very likely to be advised not to drive. The length of time you are advised not to drive for will depend upon the surgery you had. You will also need to check with your insurers when they consider it safe for you to drive after the more major procedure of laparotomy because different brokers’ and underwriters’ policies vary. Driving is not prohibited after medical treatment with methotrexate or expectant management but you should feel comfortable to be able to do an emergency stop before you take control of any vehicle.

When can I return to work?

This depends on the way you were treated and what type of work you do. In some cases you could return to work with a few weeks if you had keyhole surgery and your job is not too strenuous, but you may feel tired and find it difficult to cope. Coming back part-time, if this is an option, may be a good idea. Women treated with Methotrexate sometimes work through the treatment but others find managing the loss of a baby in this way too difficult to work through. In general, after 6 weeks you should be able to return to most jobs from a physical point of view, but some women take more time off to help them deal with the psychological impact of their loss.

Can an ectopic pregnancy affect menstruation and subsequent menopause?

There is no evidence that an ectopic pregnancy affects menstrual periods or changes the timing of menopause. However, women often report an irregularity in their cycle following an ectopic pregnancy and, if it was necessary to undertake surgery on the ovary or remove one of the ovaries, this can result in menopause developing slightly earlier. However, the impact does not appear to be significant.

Is it safe to breastfeed following methotrexate?

The advice given to mothers who are taking regular oral doses of methotrexate, not for an ectopic pregnancy but to treat another entirely different condition, is NOT to breastfeed during their treatment.

Methotrexate is excreted into breast milk in low concentrations. The significance of this is not yet known. However, because the drug may accumulate in neonatal tissues, breast feeding is not recommended in long-term use of methotrexate. The American Academy of Paediatrics considers methotrexate to be contraindicated during breast feeding because of several potential problems, including immune suppression, neutropenia, adverse effects on growth, and carcinogenesis.

HOWEVER, the advice for women who have had Methotrexate for the treatment of ectopic pregnancy is different. In this case, Methotrexate is usually given as a one off dose (or occasionally two doses) by injection into a large muscle. It antagonises folic acid (vitamin B9) and causes it to be excreted, depleting the body of this essential vitamin.

If your baby is less than a year old and if breast milk is the sole source of nutrition, we advise avoiding breast feeding for at least four weeks following treatment with Methotrexate. If your child has been weaned, and is taking a balanced diet of mixed foods with an occasional breast feed for comfort, you may choose to start feeding again sooner than this.

In ectopic pregnancy, when one dose of methotrexate has been given, the risk is not the accumulation in neonatal tissues. The risk is that the milk will be of poor quality and of little nutritional use, due to the missing essential vitamins on which the body depends to support the division of rapidly dividing cells. This is very significant in small children as they are growing and relying on this crucial process.

Bleeding, periods and ovulation

Is the bleeding I had after treatment or monitoring of my ectopic pregnancy, my period?

The bleeding you have after surgery, treatment with Methotrexate or if you are managed “expectantly”, is not actually classed as a period. This is your body expelling the thickened lining of the uterus. Once the beta hCG levels have dropped, the chemical signals to retain the thickened uterine lining that has built up in preparation for pregnancy, are no longer being produced and so the lining of the uterus is shed. The process involves vaginal bleeding and the material may be clotty, heavy, dark in appearance or appear just like one of your normal period bleeds. The bleeding can continue for up to six weeks and it is not unusual to bleed, stop, and have spotting during this time.

When will I ovulate again?

The body is a very clever thing and 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 form 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 (please see the top of this page for details on the reasons we advise this).

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.

When can I expect a period after my ectopic and will it be painful?

Your periods can take a while to re-establish and they can re-start anything between 2 and 10 weeks after surgery, or once hCG levels have fallen below about 100mIU/mL. Most women find that their period arrives sometime around week 6 or 7 after surgery, and at some time in the 4 weeks after their hCG levels have fallen to 0 if treated with Methotrexate.

The first period may be more painful or less so than usual, heavier or lighter, last for longer or shorter than usual – there really is no set pattern. You should be able to manage the discomfort with over-the-counter pain relief and should not be soaking a pad in less than an hour. If this is not the case, you should seek medical attention. Your periods may be a little irregular or erratic but broadly speaking, doctors consider periods of between 23 to 42 days to be within normal parameters. If the first day of your last period was more than 42 days ago, make an appointment with your doctor to discuss the possible reasons for this.

Following surgery, we usually advise you wait for 2 of these cycles before trying to conceive again, to allow your body to heal and your emotions to surface and be dealt with. In the case of treatment with Methotrexate, we advise you to wait for at least 3 months after the last injection and if you had two injections some doctors suggest 6 months.

Will I still have a period every month after removal of one of my tubes?

You will continue to have normal periods every month. A period is the shedding of the lining of the womb. The presence of the tubes makes no difference to this. Periods continue even if both tubes have been removed. In fact, periods usually continue normally even in the very rare cases when one of the ovaries is removed as part of the surgical process.

Will my periods return to the normal after my ectopic – before they were 25/26 days – this time I’m 30 days (I’ve checked I’m not pregnant) is this all right?

The first period can occur up to 6 weeks after the ectopic pregnancy although it may not be like your normal period. It might be heavier or lighter and it may be more painful than normal. The period after that is usually more like your normal pattern. However, although there is no medical reason for it, women do often report some irregularity to their cycle for several months after an ectopic pregnancy.

Is it normal to have pain during ovulation after my ectopic?

After surgery for an ectopic pregnancy you may have some adhesions which might cause some pelvic pain and pain at ovulation but this usually settles.

Do I need counselling?

Counselling can be extremely effective at the right time but it is not a quick fix and it won’t take away the pain of first grief. That experience of grief, scary as it may be, is healing and forms part of your own recovery from one of the most significant events likely to have happened in your life. We urge women who have experienced the loss of an ectopic pregnancy to please be gentle with yourself and allow yourself the time you need to grieve. For more information about grief and counselling please follow this link.

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.

Can I see my medical records?

Yes, you can.

If you wish to view your health records, it may not be necessary for you to make a formal application to do so. Nothing in the law prevents health professionals from informally showing you your own records. You could make an informal request during a consultation, or by ringing the surgery or hospital and arranging a time to visit and see your records.

However, if you wish to make a formal request to see your health records under the Data Protection Act, you should apply in writing to the holder(s) of the records. If you wish to see your GP records, you should write directly to your GP or to the practice manager. If you wish to see your hospital records, you should write to your hospital Patients Services Manager or Medical Records officer.

You may be charged a fee. The maximum fee (March 2010) that can be charged to provide access and a copy of your records is:

• records held totally on computer: up to a maximum £10 charge,
• records held in part on computer and in part manually: up to a maximum £50 charge, and
• records held totally manually: up to a maximum £50 charge.

The maximum fee that can be charged to provide access to your records (where no copy is required) is:

• records held totally on computer: up to a maximum £10 charge, unless the records have been added to in the last 40 days, when no charge can be made,
• records held in part on computer and in part manually: up to a maximum £10 charge, unless the records have been added to in the last 40 days, when no charge can be made, and
• records held totally manually: up to a maximum £10 charge, unless the records have been added to in the last 40 days, when no charge can be made.

You are entitled by law to receive a response no later than 40 days after your application is received and any relevant fee has been paid. You will then be given an appointment to see your records.

If you have requested a copy of your records, it should be written out in a form that is understandable to you – this means that abbreviations or complicated medical terms should be explained. If you still don’t understand any part of the record, the health professional holding the record should explain it to you.

For more information on accessing files, please look at this patient information leaflet. Please also see this BBC article on electronic medical records.

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.