Struggling with treatment decision

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1

Hi,

I was diagnosed with an ectopic pregnancy a week ago. I initially chose an expectant management approach. Since that time, my hcg levels have stayed the same and the pregnancy has stayed the same size.

I’ve been given the option to continue with this approach and ‘wait and see’ if it’s changed by next week. Or I could chose medical management or surgery to remove the tube.

I am really struggling to make the decision because I want to do what is best for my future fertility (and whatever is best in terms of avoiding an ectopic happening again) but without knowing if there’s damage in my tube(s) it’s unclear which option that is.

I am struggling with how long expectant management seems it would take (given that over one week there’s been no ‘progress’). But with medical management I don’t want to have to wait 3 months until I can try to conceive again (or 6 months if two doses are needed) and with surgery I worry that removing the tube may not be the best decision, especially if it isn’t actually damaged (I know that most woman who have the surgery do go on to have a normal pregnancy).

I don’t know how I go about making this choice.

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Hi Autumn4,

I’m sorry you are going through this. I just found out that my levels have reached 0 after expectant management. But I also struggled to make the right decision as my doctor was really pushing for surgery despite my levels being below the 40s. So I went and did a lot of research to help me make my decision. Obviously, I am not a doctor so it is always good to check with your doctor.

Regardless of the treatment (expectant, medical, surgical), the risk of recurrent ectopic is pretty much the same - around 10%.

Expectant: There has been some studies to show that future fertility outcome is better and the time to conceive again is also shorter. However, the studies are fairly recent and still limited so the overall significance of the findings remains unclear. A potential bias to the positive results could also be that if you are able to manage the ectopic pregnancy expectantly, it may be because it wasn’t severe enough in the first place and therefore your chances aren’t affected that much for future outcomes.

Medical: I haven’t really read much about it as my doctor ruled it out for me due to pain. However, if you’ve had an ectopic before, it is recommended to go down the medical and surgical route to minimise the risk of a third ectopic. I am assuming that the future fertility outcome is similar to expectant although this one will come with its side effects.

Surgical: I think this is a very common treatment because the belief is that once you’ve had a tubal ectopic pregnancy, you have sustained permanent damage to your reproductive system. Consequently, the risk of having another ectopic should in theory increase unless you remove that tube. However, that’s not what the literature found. In terms of fertility, because your tube can still pull an egg from the other ovary, there should be a reduction in fertility of only 10-15% (I think). And if you choose surgery, you should also take into consideration the potential side effects.

I chose expectant management against my doctor’s advice because I thought that if my chances of recurrent ectopic remains at 10%, whether I go down the route of expectant vs surgery, I would rather keep both tubes and not do anything to add another risk factor for recurrent ectopic (surgical intervention in your pelvis) and reduce my fertility. However, if I have another ectopic in the same tube next time I fall pregnant, I will probably choose surgery.

I hope this helps.

Regardless of your decision, as this website says, your chances remain the same. Although from what I’ve seen, doctors can have different opinions so do ask lots of questions to make an informed decision. Don’t feel pressured in choosing any of these options.

Good luck!

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Thank you so much for your reply and for taking the time to write your understanding of the three different options. It is very helpful!

I think we must have read some of the same journal articles as I recognise a lot of what you summarised so nicely from my own reading.

I think I have made the decision that I will give it another week and see what my hcg levels do - if they show signs of decreasing I will stick with expectant management, but if they have not decreased or have increased then I may choose surgery (and doc may recommend an intervention if that happens anyway).

Again, thank you so much for taking the time to write, I really appreciate it.

All the best

4

Dear Lyn,

I am so sorry to hear of your ectopic pregnancy and loss.

Unfortunately I am not medically trained so cannot give you specific advice on your treatment options.

Autumn is correct in saying there is little evidence or research into outcomes following treatment for ectopic pregnancy. In terms of future successful pregnancies, studies do not show a significant difference between treatment routes, whether surgical, medical using methotrexate or expectant management.

What I will say is that methotrexate is used as it is less invasive than surgery, although I appreciate it can be a long drawn out process.

Also in terms of the wait for trying to conceive following methotrexate, some doctors mistakenly think that because they have administered a second dose of methotrexate they must also double the recovery time for the body. However even in a second dose of methotrexate, the dose is still much lower than the treatment for other conditions and is still metabolised by the body very quickly.

Our medical advice is that if you’ve had two injections, you should rely on your blood hCG results as an indicator of what is happening in your body and wait until your levels have fallen to below five in the blood test and then restart taking folic acid supplements for 12 weeks before trying to conceive.

It may be comforting to know that the chances of a further ectopic after the first in the UK is 10%. So that’s 90% chance of the embryo being in the right place next time.

Treatment options are usually discussed with your medical team and depend upon many factors including your general health, How high your hCG levels are, if there is any evidence of free fluid in your abdomen and pain levels. I would therefore advise talking through all of your concerns with your medical team.

Sending much love,

Karen x