Ectopic Pregnancy
Hello again.
I want to start with the real story and discuss the details next time. Many of you will relate to this because it covers many aspects of ectopic pregnancy.
The patient is a very nice married woman, young and healthy. She had been trying for about a year and her basic problem was lack of ovulation. She did a couple of Clomid cycles before meeting me, and since all of her testing was negative we felt that a few more Clomid IUI cycles would be best for her. The subsequent cycles looked good on paper, but no pregnancy resulted, therefore she wished to proceed to IVF.
Being young with many resting follicles, we started on a relatively low dose of FSH, 150 units, which worked out well. She made many eggs and had 2 above average embryos transferred, with no luck. Actually, her first beta was positive, but over the next 2 weeks it rose and quickly fell. For her second IVF we modified the protocol a little, she again made many eggs, and had embryos that looked a little better. 2 were frozen.
Her first beta was 10, a low number. 6 days later it went to 198, and 5 days after that it fell to 141. So we were not sure where the pregnancy was, uterus or tube, and as hard as it is not to have a normal pregnancy, when things don’t look good, a falling beta can be a relief. But, she came back a week later and the beta was up to 1108: bummer. Usually, once it starts to fall it continues to do so, a rise like this is unusual, and can’t be good.
Ultrasound showed a small ectopic without a fetal pole or heartbeat and there was no internal bleeding. After reviewing the options, she received methotrexate, which I told her had a 90% cure rate with one injection. All looked ok, however her next hCG level was even higher. Her ultrasound remained unchanged and she was not bleeding, so the decision was made to give another methotrexate injection, which I told her takes care of the problem most of the time. Her next beta was slightly lower, but the others following showed a nice decrease. We were on our way to resolution.
Unfortunately she had a trip planned out of the country to see her relatives and I had to tell her she could not travel. So this poor woman started her IVF cycle mid March, and two months later was still getting treatment for a pregnancy that was doing nothing but delaying any other treatments and worrying her with the low possibility of rupture despite treatment and falling betas.
And then what happened? Despite her beta falling to ¼ of the previous levels, she ruptured the tube, developed internal bleeding and needed emergency laparoscopy to remove her tube.
What a pile up of bad circumstances. Any of her events taken alone (the low beta at her first pregnancy test, multiple methotrexate treatments, the long uncertain waiting time, the cancelled trip, the surgery, the loss of a tube) are tough on anyone. But to get all of this happening to the same person over a relatively short period of time is excessive.
She will take a break and then continue on, she has some nice frozen embryos and things still look good. She is young, makes plenty of eggs, has nice embryos and we remain very hopeful for success.
We will go through some details about ectopics next time. I would like to thank this woman for giving the ok to tell her story. I think many other women will be able to relate to and learn from her ordeal.
Dr. Licciardi
I want to start with the real story and discuss the details next time. Many of you will relate to this because it covers many aspects of ectopic pregnancy.
The patient is a very nice married woman, young and healthy. She had been trying for about a year and her basic problem was lack of ovulation. She did a couple of Clomid cycles before meeting me, and since all of her testing was negative we felt that a few more Clomid IUI cycles would be best for her. The subsequent cycles looked good on paper, but no pregnancy resulted, therefore she wished to proceed to IVF.
Being young with many resting follicles, we started on a relatively low dose of FSH, 150 units, which worked out well. She made many eggs and had 2 above average embryos transferred, with no luck. Actually, her first beta was positive, but over the next 2 weeks it rose and quickly fell. For her second IVF we modified the protocol a little, she again made many eggs, and had embryos that looked a little better. 2 were frozen.
Her first beta was 10, a low number. 6 days later it went to 198, and 5 days after that it fell to 141. So we were not sure where the pregnancy was, uterus or tube, and as hard as it is not to have a normal pregnancy, when things don’t look good, a falling beta can be a relief. But, she came back a week later and the beta was up to 1108: bummer. Usually, once it starts to fall it continues to do so, a rise like this is unusual, and can’t be good.
Ultrasound showed a small ectopic without a fetal pole or heartbeat and there was no internal bleeding. After reviewing the options, she received methotrexate, which I told her had a 90% cure rate with one injection. All looked ok, however her next hCG level was even higher. Her ultrasound remained unchanged and she was not bleeding, so the decision was made to give another methotrexate injection, which I told her takes care of the problem most of the time. Her next beta was slightly lower, but the others following showed a nice decrease. We were on our way to resolution.
Unfortunately she had a trip planned out of the country to see her relatives and I had to tell her she could not travel. So this poor woman started her IVF cycle mid March, and two months later was still getting treatment for a pregnancy that was doing nothing but delaying any other treatments and worrying her with the low possibility of rupture despite treatment and falling betas.
And then what happened? Despite her beta falling to ¼ of the previous levels, she ruptured the tube, developed internal bleeding and needed emergency laparoscopy to remove her tube.
What a pile up of bad circumstances. Any of her events taken alone (the low beta at her first pregnancy test, multiple methotrexate treatments, the long uncertain waiting time, the cancelled trip, the surgery, the loss of a tube) are tough on anyone. But to get all of this happening to the same person over a relatively short period of time is excessive.
She will take a break and then continue on, she has some nice frozen embryos and things still look good. She is young, makes plenty of eggs, has nice embryos and we remain very hopeful for success.
We will go through some details about ectopics next time. I would like to thank this woman for giving the ok to tell her story. I think many other women will be able to relate to and learn from her ordeal.
Dr. Licciardi
posted by Dr. Licciardi at 6:44 AM
10 Comments:
This story is very sad. Thanks to your client for sharing. I hope things work out for her.
Compliments on your blog, from a doctor, and also a patient. I like that you don't dumb down issues, and your compassion comes across also.
Can you tell me if in your experience there is a link between infertility, infertility treatments (I have PCOS, my husband had total teratozoospermia on his first semen analysis) and neural tube defects? My only pregnancy has been courtesy of Clomiphene and unfortunately the baby had anencephaly.
In addition, at what point would you counsel such a couple to proceed to IVF? I'm still only 30, but it's a little difficult to be patient when my only pregnancy so far ended so horribly.
can you tell me doctor how things like this ( http://www.thenewsroom.com/details/336032/Health?c_id=kg ) happen? shes having babies at 60
Dr. Licciaridi,
Can you speak a bit about luteal phase defects? I started spottin gon day 9-10 after ovulation so my doc put me on Clomid last month. Unfortunately, I started spotting on day 11 after ovulation. Is this still too short for a suffficient luteal phase?
Sad story, but being young, etc. must make the future more hopeful. I am coming to the end of our journey and would love to read comments on when to give up. There are so many stories about the 7th IVF that worked, or experimental treatments such as IVIg or cytoplasmic donation, etc. How do you know when it is time to say, "I have done all I can" and move on?
Our first child died shortly after birth due to a "bad luck" genetic defect (according to geneticists - chromosomes were normal) three years ago. Since then we have done 4 fresh IVF cycles, had 2 first trimester miscarriages, 1 chemical, 36 embryos with none to freeze. These were at a clinic that has 80% live birth rate with donor eggs putting back an average of 2 embryos. My RE is convinced it is due to my age (currently 39) but what if he is wrong? How do you know when you are giving up too soon? How do you separate the fraudulent treatments from the valid ones?
What is the general condition of a fallopian tube that has had an ectopic that was treated with methotrexate? Is the tube as functional as it was prior to the ectopic? The odds of another are higher once you've had one so I wonder if it's better to just cut the tube out once there's been an ectopic. The patient is then able to move on to another IVF a bit quicker and the risk of future ectopic would be lower.
Would love to hear your thoughts on this.
I know this is an older blog, but I had 2 pregnancies cut short because of them being ectopic. The first seemed normal and then I had the fluctuating beta results. It was treated with Methotrexate. Then 3 months later I had another ectopic. This time my tube had extruded and I did not know I was pregnant. My tube was removed do to the extrusion. I was later told that my baby was developing properly, and it was right at the edge of the opening to the uterus.
Doctor my wife Beta HCG count is 36.5. Any chances?
I have suffered an ectopic and had an unusual outcome. Please visit my blog...maybe you can help me get some answers.
www.ergowrite.blogspot.com
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