Doctor, how can I not have an ectopic pregnancy? This is a question almost always asked by patients who come to the clinic with ectopic pregnancy. Every patient with ectopic pregnancy has a heart-wrenching experience, so how to avoid ectopic pregnancy and still get pregnant and have a healthy baby becomes a knot in the minds of some of these patients. We hope the following words will help to untie your knot.
1. What is ectopic pregnancy? Is ectopic pregnancy the same thing as ectopic pregnancy?
In a normal pregnancy, the fertilized egg lays in the lining of the uterine cavity. When the fertilized egg lays outside the body of the uterus, it is called ectopic pregnancy, which is customarily referred to as “ectopic pregnancy”. Strictly speaking, it is more accurate, objective and scientific to call ectopic pregnancy than ectopic pregnancy, because the gestation sites of cervical pregnancy, horn pregnancy, cesarean scar pregnancy and intermyometrial pregnancy are still inside the uterus, so it is not appropriate to call ectopic pregnancy, but it is ectopic pregnancy.
2. Does ectopic pregnancy refer to tubal pregnancy?
No, but tubal pregnancy is the most common, accounting for more than 90% of ectopic pregnancies, which is related to the physiological mechanism of pregnancy. Under normal circumstances, the egg is discharged from the ovary and picked up by the umbrella of the fallopian tube, and then stays in the abdomen of the fallopian tube waiting to unite with sperm to form a fertilized egg, which is then sent to the uterine cavity for implantation and development through the peristalsis of the fallopian tube. In addition, ectopic pregnancy can also occur in the cesarean scar, horn of the uterus, ovaries, cervix, and abdomen due to abnormal wandering implantation site of the fertilized egg. Even rarer is mixed pregnancy, which refers to the coexistence of intrauterine and ectopic pregnancy, or simultaneous pregnancy in both fallopian tubes with 2 fertilized eggs forming, which may be associated with an increase in IVF.
3. What causes ectopic pregnancy?
There are many causes of ectopic pregnancy, the main ones are as follows.
(1) Chronic inflammation such as pelvic infections, sexually transmitted diseases and pelvic inflammatory diseases leading to structural and functional abnormalities of the fallopian tubes. Inflammation is one of the main causes of ectopic pregnancy and tubal infertility. Most pelvic inflammatory diseases occur in sexually active women, and patients often have a history of sexually transmitted diseases (e.g., mycoplasma, chlamydia, gonococcal infection) and repeated uterine surgeries (e.g., abortion), all of which are high-risk factors for the development of ectopic pregnancy.
Both nonspecific bacterial infections and specific pathogens such as mycoplasma, chlamydia, and gonococcal infections from tuberculosis or sexually transmitted diseases can cause adhesions in the mucosal folds of the fallopian tubes, narrowing of the lumen, impaired cilia function, and/or secondary scarring in the fallopian tubes or adhesions around the fallopian tubes, resulting in ectopic pregnancy due to obstruction of the fertilized egg in the fallopian tubes. In addition, adhesions around the fallopian tubes secondary to appendicitis, pelvic peritonitis or endometriosis, distortion of the fallopian tubes, narrowing of the lumen and weakening of the peristalsis of the tube wall, which affect the operation of the fertilized egg, are also common causes of ectopic pregnancy.
(2) History of previous tubal surgery. Previous tubal surgery such as conservative surgery for tubal pregnancy (i.e. surgery for ectopic pregnancy with preservation of the fallopian tubes), tubal plastic surgery, anastomosis and tubal ligation followed by recanalization or fistula formation can delay or prevent the fertilized egg from entering the uterine cavity due to peri-tubal and pelvic adhesions, tubal distortion, tubal lumen narrowing or scar narrowing at the surgical site, leading to ectopic pregnancy.
(3) Abnormal development and function of the fallopian tubes. The development of the fallopian tube is thinner, longer and more flexed than normal, the wall muscle fibers are dysplastic, the mucosal cilia are dysplastic, the double tubes, the parametrium, etc., or the compression and traction of pelvic tumors make the fallopian tube thinner and more tortuous, which can affect the operation of the fertilized egg. Dysregulation of the balance of estrogen and progesterone or disturbance of phytoconstitution due to psychological factors can also affect the peristaltic function of the fallopian tubes, leading to ectopic pregnancy.
When the fallopian tubes are not fully functional, poor tubal cilia activity affects peristalsis and reduces the ability to transport the fertilized egg, which is also an important factor in the occurrence of ectopic pregnancy.
(4) If pregnancy occurs after IUD contraceptive failure, it is mostly ectopic pregnancy. It is controversial whether the use of IUD causes an increase in the incidence of ectopic pregnancy, and whether IUD placement causes pelvic infection has not been fully determined.
(5) Endometriosis accounts for a significant proportion of the etiology of ectopic pregnancy and is mainly associated with pelvic adhesions caused by endometriosis.
(6) The incidence of ectopic pregnancy after in vitro fertilization-embryo transfer assisted reproduction technique (i.e. IVF) is about 2% to 5%. This is also a very confusing thing for patients. How can an ectopic pregnancy occur when the embryo is placed in the uterine cavity? Many patients come to “IVF” to avoid ectopic pregnancy. This may be due to two reasons. The second is that after the embryo is transferred into the uterine cavity, it does not immediately settle in the endometrium, but generally has to travel around the uterine cavity for a period of time to find the most suitable location before it can settle. Ectopic pregnancy can occur. In patients with bilateral salpingo-oophorectomy, there is still a possibility that the fertilized egg may be implanted in the bilateral horn of the uterus.
In addition, the incidence of ectopic pregnancy increases due to the use of ovulation-promoting drugs and the transfer of multiple embryos after IVF, especially the incidence of simultaneous intrauterine and ectopic pregnancies is significantly higher.
(7) Abnormal embryo development and fertilized egg wandering. Embryonic malformations or low sperm counts and high abnormal sperm counts can also increase the risk of ectopic pregnancy. In ectopic pregnancies there is often an abnormal number of chromosomes and structural malformations in the embryo itself. Fertilization of the egg in one fallopian tube and its passage through the uterine cavity into the opposite fallopian tube is called fertilized egg wandering. If the egg wanders for a long time and grows too large to pass through the fallopian tube and settle there, it causes a tubal pregnancy; and if the egg wanders into the abdominal cavity, it causes an abdominal pregnancy.
(8) Ovulation abnormalities and reproductive tract malformations. Ovarian pregnancy results from fertilization of an ovum that has not been expelled from the ovary. Cervical pregnancy can occur when the ovum travels too fast in the uterine cavity or when the ovum develops slowly and descends to the cervix, or when the endocervical lining is defective and scar formation occurs.
(9) If pregnancy occurs after the failure of oral emergency contraceptive pill, it is mostly ectopic pregnancy. Emergency contraceptives (e.g., yutin) are mostly progestogen-only contraceptives, which significantly inhibit tubal peristalsis and increase the proportion of tubal pregnancies. It has been reported that 1 in 10 pregnancies resulting from failure of oral emergency contraception are ectopic pregnancies.
(10) Other causes include smoking, previous pelvic surgery, exposure of the uterus to estrogen, and vaginal douching, which can also lead to an increased incidence of ectopic pregnancy.
4. How to treat ectopic pregnancy?
The treatment methods for ectopic pregnancy mainly include three kinds.
(1) Drug conservative treatment, mainly using methotrexate (MTX) embryocidal therapy, which has the advantages of being non-invasive and less painful to the patient.
Disadvantages are.
(i) It is only suitable for a small number of patients with ectopic pregnancy.
(ii) There is a possibility of treatment failure, and surgery is still required if treatment fails.
(iii) long treatment time.
(4) The possibility of subsequent ectopic pregnancy.
(2) Conservative surgical treatment, including tubal incision and retrieval and extrusion of the tubal umbilical pregnancy, has the advantage of preserving the affected fallopian tube, and if the function of the tube recovers well after surgery, pregnancy can still be conceived through this tube, which is more suitable for infertile women with abnormalities in the opposite fallopian tube. Disadvantages are.
① the possibility of subsequent re-ectopic pregnancy.
(ii) It is only suitable for some patients.
(iii) the possibility of persistent ectopic pregnancy.
(3) Radical surgical treatment refers to tubal resection on the affected side, with the following advantages
(i) complete removal of the ectopic lesion, avoiding the occurrence of persistent ectopic pregnancy and the recurrence of ectopic pregnancy in that side of the fallopian tube; this procedure can be chosen for infertile women with normal fallopian tubes on the opposite side.
② It is suitable for all patients with tubal pregnancy, especially for patients without fertility requirements. Recent studies suggest that some epithelial ovarian cancers originate from the malignant transformation of the cells at the umbilical end of the fallopian tube and implantation onto the ovary.
The disadvantages are.
(i) Removal of the affected fallopian tube may affect the function of that side of the ovary to some extent, but this is still inconclusive and lacks evidence-based medical evidence.
② For patients with fertility requirements, it may reduce the chance of subsequent conception, but if the opposite fallopian tube is normal and other infertility factors are excluded, even removal of one tube does not reduce the probability of subsequent conception. One comparative study found that in women with tubal pregnancy, there was no statistical difference in the chances of re-pregnancy between the two groups when comparing patients who had their tubes removed with those who had their tubes preserved.
Therefore, from the point of view of protecting oneself from another ectopic pregnancy and ovarian cancer, it is not a bad idea to opt for removal. Even if both fallopian tubes are gone, you can still have a chance to have a child with the help of modern assisted reproduction techniques (IVF).
There is no consensus on the effect of the treatment of ectopic pregnancy on the recurrence of ectopic pregnancy. The choice of treatment method depends on the patient’s condition, taking into account the location of the ectopic pregnancy, the size of the mass, the presence of rupture and intra-abdominal bleeding, the blood HCG value, the patient’s general condition, the requirement for fertility, and the conditions for follow-up; secondly, the decision should be made through adequate doctor-patient communication, taking into account the patient’s wishes. At present, the vast majority of surgeries can be accomplished through minimally invasive laparoscopic surgery.
We recommend.
(1) For patients with recent fertility requirements, choosing laparoscopic surgery is beneficial for future pregnancies because it can simultaneously check the patency of the contralateral fallopian tube and the pelvic cavity, so that infertility factors can be detected and treated in a timely manner, which is beneficial for future pregnancies. As to whether to preserve the affected fallopian tube or not, it is decided according to the patient’s condition and her wishes.
(1) Conservative surgery can be considered for patients with unruptured tubal jugular pregnancy with low blood HCG value, small ectopic pregnancy mass, abnormal contralateral fallopian tube, good follow-up and willingness to keep the tube, but there is a risk of repeat ectopic pregnancy and persistent ectopic pregnancy.
(2) For patients with intraoperative examination suggesting severe tubal lesions, abnormal development or severely impaired function of the affected tube, or patients with normal contralateral tube, it is recommended to perform tubectomy on the affected side to avoid increasing the chance of recurrence of ectopic pregnancy.
(2) For patients without fertility requirements, if they are eligible for conservative drug treatment and if they are afraid of surgery, they can choose conservative drug treatment. If surgical treatment is necessary, it is recommended to perform tubectomy on the affected side. In order to avoid the recurrence of ectopic pregnancy in the future and to provide better contraception, the opposite tube can be ligated at the same time during surgery.
5. What should I pay attention to after ectopic pregnancy surgery?
At present, most of the ectopic pregnancy surgeries are done through laparoscopic surgery, which is less traumatic and faster to recover after surgery. After the recovery of gastrointestinal function, a normal diet is appropriate, with foods rich in protein and vitamins, and there is no need to eat foods that are specially tonic (such as cordyceps, etc.), and avoid spicy and stimulating foods, cold foods (such as crabs, etc.) and hot foods (such as beef and mutton, etc.).
For patients with ectopic pregnancy, it is more important to know that the blood HCG should be monitored regularly until it is normal (about once a week). Especially for patients who have undergone conservative surgery, if the HCG does not drop or rises continuously during the monitoring process, the possibility of persistent ectopic pregnancy should be considered and additional medication should be given if necessary.
6. Is there a high chance of recurrence of ectopic pregnancy after a history of ectopic pregnancy?
The probability of recurrence of ectopic pregnancy after one ectopic pregnancy is high and is called repeat ectopic pregnancy. It is a pregnancy that occurs outside the uterine cavity in the fallopian tubes, ovaries, abdominal cavity, cervix or broad ligament after the first ectopic pregnancy has been treated surgically or conservatively with medication, and its incidence is generally 10% to 40%. After surgical treatment of the first ectopic pregnancy (salpingo-oophorectomy, salpingo-oophorectomy, extrusion of the cystic gestation), a series of “sequelae” such as pelvic adhesions may delay or prevent the fertilized egg from entering the uterine cavity, leading to repeat ectopic pregnancies.
In addition, the absorption of the pregnancy or the healing process of the diseased fallopian tube will affect the normal peristalsis and the ciliary function of the mucosa during the conservative treatment (medication) or conservative surgery (tubal preservation surgery) of the previous ectopic pregnancy. The greater the number of ectopic pregnancies, the greater the risk of a second ectopic pregnancy. Some studies have reported that the probability of repeat ectopic pregnancy after one ectopic pregnancy is 15% to 30%, and after two ectopic pregnancies, the probability of repeat ectopic pregnancy rises to 32%.
7.Can I still get pregnant naturally after ectopic pregnancy?
This should be analyzed specifically according to the patient’s condition. At the beginning of life, a person has made a backup of the fallopian tube, an important organ. Therefore, simply speaking, if the patient’s other fallopian tube is functioning normally, or if the affected tube is healing well and its function is restored, there is still a possibility of natural conception.
8. Can I avoid ectopic pregnancy by IVF?
No. As we have already mentioned, ectopic pregnancy is still possible after assisted reproductive technology. It is unreasonable for some patients to ask for IVF in order to avoid ectopic pregnancy.
9. How to deal with the next pregnancy after ectopic pregnancy treatment?
Case: A patient has had two ectopic pregnancies and has been using contraception for 5 years for fear of another ectopic pregnancy.
In clinical work, we often come across such patients who have been using contraception for many years for fear of another ectopic pregnancy and are caught in a strange circle: wanting to get pregnant → fear of ectopic pregnancy → continuous contraception. In the process of contraception, the patient tried her best to treat the inflammation, repeatedly for several years, and sought treatment from various sources, including Chinese and Western medicine, as well as prescriptions and recipes, all of which were used. It took a lot of energy, wasted money and, importantly, lost the best period of fertility. It is not known that the fear of eating to death, do not eat fear of starvation, this phrase is to describe the mood of this part of the patient.
I say: eating does not necessarily lead to death, not eating definitely leads to death of hunger (pregnancy does not necessarily lead to ectopic pregnancy, not being pregnant is definitely not having a child). It can be said that so far, there is no 100% effective method to prevent ectopic pregnancy, and the best method is to ligate the fallopian tubes, which can minimize the incidence of ectopic pregnancy. For patients with fertility requirements, this is obviously not a good solution.
Although there is no foolproof way to prevent ectopic pregnancy, early detection and treatment can be achieved. In other words, if you can’t prevent ectopic pregnancy, you can only try to nip it in the bud. Fear is not a solution, and contraception is a negative attitude. For the above patient who wanted to have a child but was afraid of ectopic pregnancy, a positive attitude would be.
(1) Actively treat the ectopic pregnancy when it occurs and eliminate the inflammation.
(2) Discontinue contraception at the time allowed by the doctor, and before preparing for the next pregnancy, the couple should have a preconception checkup, exercise, stop bad habits, and plan the pregnancy.
(3) After the release of contraceptive measures, the couple should have normal sexual intercourse and undergo infertility-related examination after six months to one year of infertility.
(4) Based on the results of the infertility-related tests, decide on the next method of pregnancy assistance.
For every patient with a history of ectopic pregnancy, the risk of another ectopic pregnancy is present. It is best to be informed of the risks and sensible in the process of active pregnancy preparation.