It is not infrequent to have a suspected ectopic pregnancy following any type of fertility treatment, including IVF (1/200 chance).
An ectopic pregnancy is highly suspected when your BHCG is above the detection threshold to see a gestational sac by ultrasound, yet no sac can be seen in the uterus. An ectopic is also suspected when your levels of HCG are fluctuating up and down and not following the expected minimal pattern of increase (60% every 48 hours or doubling in 3 days). The presentation is more worrisome when accompanied by pelvic discomfort and spotting, especially if the ultrasound report comments on a possible mass in the adnexa (although this is not an unusual finding in patients with stimulated ovaries due to fertility drugs). The presence of significant free fluid in the pelvis increases the likelihood of a leaking ectopic pregnancy.
The only sure ultrasound diagnosis to confirm an ectopic is the visualization of a gestational sac with a yolk sac or fetal heartbeat outside the uterus.
If the diagnosis of ectopic pregnancy is made early with a clinically stable patient, surgery (laparoscopy) can be avoided by administering medical treatment in the form of Methotrexate injection.
Methotrexate is the drug used to terminate an ectopic pregnancy by stopping and preventing the growth of placental tissue. It stops the growth of rapidly dividing cells. Side effects are related to its negative effects on healthy tissue with fast-dividing cells somewhere else in the human body including the liver, bone marrow, and bowel lining tissues. With proper dosing and careful monitoring, side effects are minimized. Side effects include abdominal cramps, nausea, diarrhea, inflammation of lung tissue and possible mouth sores. Pain at the injection site is common. Changes in liver enzymes and blood counts can also occur.
Contraindications to medical treatment for an ectopic are: BHCG >10000, complex enlarging mass in the adnexa >4 cm, high clinical suspicion of an ectopic with impending rupture, or clinically unstable patient. There should also be no medical contraindication to receiving methotrexate.
The dose of methotrexate is based on body weight and height (total body surface area). The drug is administered via a deep intramuscular injection. A second injection is sometimes indicated if the levels of BHCG do not drop as expected.
Laparoscopic intervention is indicated in those situations where medical treatment is contraindicated, or when medical treatment fails, as evidenced by a continued rise of the BHCG or increasing abdominal pain and bleeding.
Instructions for patients on methotrexate:
Refrain from sexual activity for 2-3 weeks after the injection. Do not try to conceive until the HCG level has disappeared by the next period. Avoid alcoholic beverages. Stop any vitamin containing folic acid. Do not take Aspirin or anti-inflammatory drugs. Tylenol for pain control is safe within the recommended doses.
Follow up instructions after the methotrexate injection:
Return to the clinic for blood work and assessment in 4 days and then 7 days after the initial injection. A second injection will be sometimes indicated if HCG change is not satisfactory.Your blood sample will be hen taken weekly until HCG levels become undetectable.
Rhogam is needed if you are more than 5 weeks pregnant and your blood group is Rh-negative.
If you develop unexpected severe abdominal pain, or feel dizzy and unwell with faintness and palpitation, seek medical attention immediately or go to the nearest emergency room.