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Q: LAPAROSCOPIC SALPINGECTOMY FOR ECTOPIC PREGNANCY ( Answered,   0 Comments )
Question  
Subject: LAPAROSCOPIC SALPINGECTOMY FOR ECTOPIC PREGNANCY
Category: Health > Women's Health
Asked by: inquisitive1234-ga
List Price: $50.00
Posted: 12 Nov 2006 06:36 PST
Expires: 12 Dec 2006 06:36 PST
Question ID: 782063
I am a 34 year old female that just had my right fallopian tube
removed due to an ectopic pregnancy.  I had no factors that would have
put me at risk for an ectopic that I am aware of and was told it just
happens sometimes.
I was diagnosed after having some bleeding with a transvaginal
ultrasound at 5 1/2 weeks(diagnosed Oct. 10th)a fertiized egg was
evident in my right tube. I had option of surgery or less invasive
treatment with methotrexate.  I chose methotrexate as both the Dr. and
I felt this was best option for me.  I was never given another
sonogram after initial diagnosis but beta levels were checked
regularly (about 2 x's a week). Had 1st methotrexate at 5 1/2 weeks
oct 12th.  Beta levels did not drop and had 2nd dose  a week later oct
20th.   I was told that my levels had dropped to come in as scheduled
that Friday oct 27th(a week after the 2nd treatment). The Thursday
before I was to go in for blood work I had severe pain and felt dizzy
oct26th.  I went to the emergency room and called my Dr. While in the
emergency room both the nurse and technician who performed sonogram
were very surprised that I was never given a follow up sonogram to see
if the methotrexate was working.  It seems that although my beta
levels were dropping there was still a heartbeat and live pregnancy. 
I began bleeding and once the dr. arrived had emergency laparoscopic
salpingectomy (removal of right tube.  My tube was bleeding out and
was irrepairable.
My 1st question Is it normal to treat with methorexate only and no
sonogram during treatment?  (I was not having any pain during the
treatment)

My second question I had a previous pregnancy diagnosed with trisomy
18 that we decided to terminate february 10th 2006 at 14 weeks.  Could
the termination have created any complications making me likely to
have an ectopic pregnancy?

Lastly what are my chances of getting pregnant without fertility
treatment with only one fallopian tube(I did not have any trouble
getting pregnant with both of these pregnancies)and how long should I
wait.  My Dr. said I could start to try after my next period. I
decided to wait 6 months after 1st time (based on how I felt
emotionally)  I had read that you should wait 3 months after treatment
with methotrexate so now I am concerned that my Dr. is too laid back
and not sure what to do.
Thank you in advance for taking time to research and answer
Answer  
Subject: Re: LAPAROSCOPIC SALPINGECTOMY FOR ECTOPIC PREGNANCY
Answered By: keystroke-ga on 12 Nov 2006 17:14 PST
 
Hello inquisitive1234,

Thank you for your question.

"My 1st question Is it normal to treat with methotrexate only and no
sonogram during treatment?  (I was not having any pain during the
treatment)"

I have found some documentation that recommends that a course of
methotrexate for ectopic pregnancy should be followed by both blood
tests and ultrasound.  I have also found many accounts that detail
methotrexate treatment and make no mention of ultrasound treatment but
only recommend checking beta levels.  This indicates that an
ultrasound is not necessary but is recommended by some sources. 
Therefore, it is up to the individual physician to decide on a course
of treatment that is best.  Most sources agree that beta levels are
the best and most reliable indicator to indicate whether a pregnancy
exists (because often the pregnancy does not show up visually on an
ultrasound).

Methotrexate is usually much more convenient and preferable to
surgery, but the trade-off is that it does not have as high a success
rate as surgery does.

Net Doctor UK
http://www.netdoctor.co.uk/diseases/facts/pregnancyectopic.htm

"An alternative treatment to surgery is a medicine called methotrexate
(Maxtrex), which decreases the growth of cells in the ectopic
pregnancy (unlicensed use). As a result the pregnancy shrinks and
eventually disappears. The advantage of methotrexate is that it avoids
the need for surgery but success rates with methotrexate tend to be
slightly lower than with surgery. Occasionally, both surgery and
methotrexate will be necessary."

McGill University-- Ectopic Pregnancy.
http://sprojects.mmi.mcgill.ca/gynecology/ecpy6methfrmd.html

"As with all medical treatment, there are risks and side effects.
Despite observing low and declining -hCG levels in the blood, tubal
rupture still can occur. With severe pelvic pain, monitoring of vital
signs (heart rate, blood pressure, respiratory rate, temperature) and
hematocrit (proportion of red blood cells in blood) can help
differentiate between tubal abortion (usually 3-7 days after therapy
and lasting less than 12 hours) and tubal rupture."

In treatment descriptions, ultrasound is recommended when cramping,
pain or other abnormal symptoms occur, but it does not seem that it is
required as standard in the course of treatment.  Usually, the beta
levels are monitored and are sufficient cause to know whether the
pregnancy is terminated or not.  Here are a few different medical
organizations' description of methotrexate treatment-- the first
excerpts include descriptions of the use of ultrasound alongside
treatment, while the second section indicates that treatment alongside
methotrexate is mostly outpatient and only monitored by blood tests,
as you experienced.

----------

Ultrasound Used--

Merck Manual-- Ectopic Pregnancy
http://www.merck.com/mmpe/sec18/ch263/ch263e.html

"If unruptured tubal pregnancies are ? 3.0 cm in diameter, no fetal
heart activity is detected, and ?-hCG level is < 5,000 mIU/mL ideally
but < 15,000 mIU/mL certainly, women can be given a single dose of
methotrexate
50 mg/m2 IM. ?-hCG measurement and ultrasonography are repeated on
about days 4 and 7. If the ?-hCG level does not decrease ? 15%, a 2nd
dose of methotrexate
or surgery is needed. About 10 to 30% of women treated with methotrexate
eventually require a 2nd dose. Success rates with methotrexate
are about 87%; 7% of women have serious complications (eg, rupture).
Surgery is indicated when methotrexate
is inappropriate (eg, ?-hCG level > 15,000 mIU/mL) or ineffective."

McGill University-- Ectopic Pregnancy.
http://sprojects.mmi.mcgill.ca/gynecology/ecpy6methfrmd.html

"If there are no serious symptoms (such as severe abdominal pain),
-hCG measurements and transvaginal ultrasonography are performed
twice in the first week and then once every week."

----------

Ultrasound Not Used--

UpToDate Patient Information
"Patient information: Ectopic (tubal) pregnancy"
by Togas Tulandi, MD
http://patients.uptodate.com/topic.asp?file=pregnan/5154

"After the injection, the woman may experience abdominal pain or
cramps, which can usually be controlled with nonsteroidal
anti-inflammatory medications (eg, ibuprofen). hCG levels are
monitored once weekly until the level has fallen to less than 10
mIU/mL. In 20 percent of women, a second dose of methotrexate is
necessary; this is recommended if the day 7 hCG level has not fallen
by at least 25 percent. In some cases, multiple doses of methotrexate
are required.

Methotrexate is most successful in women who have an ectopic pregnancy
without symptoms (eg, pain), and whose hCG level and ultrasound
results fall within specified limits. When used in appropriate
situations, treatment with methotrexate is successful 92 to 98 percent
of the time... If treatment with methotrexate is unsuccessful, tubal
rupture can occur. This complication can be avoided with close
monitoring and surgical management, if needed."

American Society for Reproductive Medicine
Patients' Guide
http://www.asrm.org/Patients/patientbooklets/ectopicpregnancy.pdf

"With early diagnosis of an ectopic pregnancy, medical (non-surgical)
treatment with the drug methotraxeate can be used. To be a candidate for
methotrexate therapy, a patient needs to be in stable condition with no evidence
of internal bleeding or severe pain. She also needs to maintain communication
with her physician during the treatment protocol and return for follow-up blood
tests after treatment.

...Methotrexate is given as a single intramuscular shot or as a series
of shots and pills over several days. Most early ectopic pregnancies
can be successfully
treated with methotrexate, often leaving the tube open. Success is largely based
on the size of the ectopic pregnancy seen on the ultrasound exam and the level
of hCG found on the blood test. Women with large ectopic pregnancies, rapidly
rising and/or high levels of hCG (> 10,000 IU/L) are less likely to respond to
single dose methotrexate therapy and, therefore, may be considered candidates
for multiple dose methotrexate regimens or surgical treatment. If methotrexate
is successful, hCG levels should decline to zero over the next two to six weeks.
If the hCG levels do not fall, methotrexate treatment may be repeated or the
pregnancy may be removed surgically."

The following published journal article details methotrexate treatment
that is monitored by beta levels and not ultrasound.  No ultrasound is
conducted until the patient returns and complains of cramping.  Beta
levels are considered to be accurate indicators of tissue presence.

American Medical Association
http://archfami.ama-assn.org/cgi/content/full/9/1/72

"A literature review and phone consultation with specialists at 2
regional university hospitals yielded reports of successful treatment
with intramuscular methotrexate. The patient agreed to this treatment
option and was given a single intramuscular dose of methotrexate at 50
mg/m2 body surface area.1 She was admitted for several days'
observation owing to the risk of sudden hemorrhage. A Foley catheter
with a 30-mL balloon was kept at the bedside for emergency cervical
tamponade. Her course was notable only for increased bleeding 1 day
after receiving methotrexate without substantial change in pelvic
examination findings or hematocrit level.

Her outpatient follow-up examination showed a gradual decrease in her
quantitative {beta}-HCG level, which was 2560 IU/L 7 days after
treatment with methotrexate, 390 IU/L after 17 days, and 164 IU/L 24
days after treatment. The patient presented 28 days after treatment
with severe cramping. An endovaginal ultrasound examination showed
persistence of the gestational sac with some low-level echoes but no
discernible fetal pole or heartbeat."

From what I can tell of what happened, your beta levels had indeed
dropped although you were still pregnant by the end of two weeks on
methotrexate.  This can occur and is usually a symptom of a failing
pregnancy, which is why your doctor would have been led to believe
that the treatment was working.

American Association for Clinical Chemistry
http://www.labtestsonline.org/understanding/analytes/hcg/test.html

"In non-pregnant women, hCG levels are normally undetectable. During
early pregnancy, the hCG level in the blood doubles every two to three
days. Ectopic pregnancies usually have a longer doubling time. Those
with failing pregnancies will also frequently have a longer doubling
time or may even show falling hCG concentrations. hCG concentrations
will drop rapidly following a miscarriage. If hCG does not fall to
undetectable levels, it may indicate remaining hCG-producing tissue
that will need to be removed."

Women's Health Information
http://www.womens-health.co.uk/mtx.asp

"How is the Treatment Given?

By a single injection. Your health care provider will then need to
keep a check on the hormone levels, as before, to ensure they fall
appropriately.

The hormone levels frequently rise in the first week and it will take
between two and four weeks for them to fall to normal. Your healthcare
provider will make arrangements to see you in the Gynaecology clinic
after the hormone test has fallen completely. It may be useful to
arrange an X-ray examination to check that your tubes are open (a
hysterosalpingogram or HSG)."

-------------------

"My second question I had a previous pregnancy diagnosed with trisomy
18 that we decided to terminate february 10th 2006 at 14 weeks.  Could
the termination have created any complications making me likely to
have an ectopic pregnancy?"

The abortion could indeed a risk factor for ectopic pregnancy.  Pelvic
surgery, such as an appendectomy, slightly increases the later risk of
ectopic surgery for a woman. I found two studies that found a clear
link and three studies that did not. Here are the complete risk
factors associated with ectopic pregnancy:

Strong evidence of association:

*Previous ectopic pregnancy
*Pelvic inflammatory disease
*Endometriosis
*Previous tubal surgery
*Previous pelvic surgery
*Infertility and infertility treatments
*Uterotubal anomalies
*History of in vitro exposure to diethylstilbestrol
*Cigarette smoking

Weaker evidence of association:

*Multiple sexual partners
*Early age at first intercourse
*Douching

Source:

American Family Physician
"Ectopic Pregnancy"
http://www.aafp.org/afp/20000215/1080.html

Here is a scientific, published study concerning whether a history of
previous abortions affects women's later rates of ectopic pregnancy. 
I found two studies which believe this is so and two studies which
found no causation, but suggested perhaps a correlation (i.e, women
who had had previous abortions were more likely to have other risk
factors that cause ectopic pregnancies, rather than the abortions
themselves.)

American Journal of Public Health
March 1998
"Risk of ectopic pregnancy and previous induced abortion."
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=9518971

"CONCLUSIONS: This study suggests that induced abortion may be a risk
factor for ectopic pregnancy for women with no previous ectopic
pregnancy, particularly in the case of women who have had several
induced abortions."

Here are some other studies which found the same link:

Human Reproduction, July 1995
"Induced abortions and risk of ectopic pregnancy."
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=8582994

Here are some studies which found no connection:

Obstetric Gynecology
"The relation between induced abortion and ectopic pregnancy."
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=9083304

"CONCLUSION: We found no evidence that having one or more induced
abortions increases a woman's risk of having an ectopic pregnancy."

Acta Obstetric Gynecology Scandinavia
"Evaluation of induced abortion as a risk factor for ectopic
pregnancy. A case-control study."
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=9049289

--------

"Lastly what are my chances of getting pregnant without fertility
treatment with only one fallopian tube(I did not have any trouble
getting pregnant with both of these pregnancies)and how long should I
wait."

About 30% of women who have had ectopic pregnancies experience a
difficult time getting pregnant again.  Women with one fallopian tube
can have a successful pregnancy rate of over 40%.

Those are overall figures. For women who never had a problem
conceiving before removal of the fallopian tube, the percentages can
be much higher and some sources estimate that level to be over 70%.

Amazing Pregnancy
http://www.amazingpregnancy.com/pregnancy-articles/272.html

"If you have never had difficulty getting pregnant, the normal
pregnancy rate after salpingectomy is 70-85%.  If you had difficulty
conceiving prior to the removal of your fallopian tube the normal
pregnancy rate is about 10%."

Net Doctor UK
http://www.netdoctor.co.uk/diseases/facts/pregnancyectopic.htm

"As a general guide, after one ectopic pregnancy, 20 per cent of women
will experience another ectopic pregnancy, 30 per cent will not become
pregnant again and 50 per cent will have a successful pregnancy inside
the womb."

Kids' Health
http://www.kidshealth.org/parent/pregnancy_newborn/pregnancy/ectopic.html

"What About Future Pregnancies?

Approximately 30% of women who have had ectopic pregnancies will have
difficulty becoming pregnant again. Your prognosis depends mainly on
the extent of the damage and the surgery that was done.

If the fallopian tube has been spared, the chances of a future
successful pregnancy are 60%. Even if one fallopian tube has been
removed, the chances of having a successful pregnancy with the other
tube can be greater than 40%.

The likelihood of a repeat ectopic pregnancy increases with each
subsequent ectopic pregnancy. Once you have had one ectopic pregnancy,
you face an approximate 15% chance of having another."

The chance of a next pregnancy also is determined by what condition
your remaining fallopian tube is in. If it has any damage, it will be
less likely to be able to function properly and deliver the egg.

Channel 4 Family
http://www.channel4.com/health/microsites/F/family/baby/ectopic.html

"Statistically, even if one Fallopian tube is removed you have a 50%
chance of having a future normal pregnancy. If the tube was saved the
chance increases to around 60%. With both tubes removed IVF treatment
can still offer some hope of a successful pregnancy."

Sources:

Mayo Clinic
"Fallopian tubes: Can I get pregnant with only one?"
http://www.mayoclinic.com/health/pregnancy/AN00088

Search terms:
ectopic pregnancy methotrexate ultrasound
ectopic pregnancy chemotherapy
pelvic surgery abortion
ectopic pregnancy methotrexate 
methotrexate ultrasonography ectopic
one fallopian tube pregnant

If you need any additional clarification, let me know and I'll be glad
to assist you.

--keystroke-ga

Request for Answer Clarification by inquisitive1234-ga on 17 Nov 2006 12:44 PST
Question on how long should I be waiting till trying again.  My Doctor
said ok to try after next cycle.  I had read that you should wait 3
months after methotrexate.

Clarification of Answer by keystroke-ga on 09 Dec 2006 14:39 PST
Hello inquisitive1234,

I apologize profusely, but I just saw your request for clarification. 
The email systems are broken and so researchers unfortunately do not
receive any notice of clarifications.

You should wait three to six months, since you had what is considered
to be major abdominal surgery.

"Ectopic pregnancy"
http://www.babycenter.com/refcap/pregnancy/pregcomplications/229.html

"Most caregivers will advise you to wait at least three months after
major abdominal surgery for your body to heal. (Your risk of having
another ectopic is also higher while you're healing.)"

"Ectopic Pregnancy"
http://se.babycenter.com/pregnancy/complications/ectopic/

"'We normally advise women who've had a laparoscopy to wait three to
four months before trying to conceive again. If you have had abdominal
surgery, it's best to wait for six months to allow scarring to heal',
says Dr Watson."

Thank you for your patience!  I apologize again for the delay in
seeing your clarification.

--keystroke-ga
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