Listen to this conversation on The Egg Whisperer podcast:
Welcome to the Egg Whisperer show. In this episode, we’re joined by Dr. Laura Londra. Dr. Londra is from Columbus, Ohio, and there’s no better expert to talk to us about Ectopic pregnancy.
Dr. Londra completed a subspecialty fellowship in reproductive endocrinology and infertility at John Hopkins University. Her clinical research focused on factors affecting pregnancy outcome after IVF.
Before her fellowship, she attended Wayne State University in Detroit where she did her residency and she’s board certified in both OB-GYN and reproductive endocrinology and fertility.
Dr. Aimee: Would you tell us a little bit about yourself and about your practice?
Dr. Laura Londra: Well. I’m originally from Argentina, from South America, so I still have a little bit of an accent.
I came here after finishing medical school in Argentina. My practice is in Columbus, Ohio, and is affiliated with Ohio State University, which is, as you know, one of the largest state universities in the country.
We do a little bit of teaching with the residents. We practice with a large population of patients. We are a well-established practice with four partners. I joined about five years ago.
Dr. Aimee: And what made you go into medicine and more specifically fertility medicine?
Dr. Laura Londra: There are no physicians in my family. I realized that I wanted to be a physician mainly because of the experience that my mother and my family had with our OB-GYN. My mom trusted him. I trusted him. I saw how much he loved our family.
After medical school OBGYN was where I felt most comfortable. And then reproductive endocrinology was an obvious choice because I liked a little bit of surgery. Understanding hormones and IVF is what I do most.
Dr. Aimee: First question, what is an ectopic pregnancy?
Dr. Laura Londra: An ectopic pregnancy is essentially a pregnancy that implants outside of the uterus. The most normal spot where the pregnancy should implant is at the top of the uterus, which we call the fundus.
Sometimes pregnancies will implant in other structures. Most commonly in the fallopian tube. When a pregnancy implants in there it can be dangerous and life-threatening.
Sometimes in a very low number of cases pregnancies can implant in the lower portion of the uterus, which is cervical pregnancies. Sometimes it will implant between the uterus and the fallopian tubes, and sometimes even in the ovaries. And those are much, much less common.
The ectopic pregnancy that occurs in the fallopian tubes is the most common. Unfortunately, it’s a non-viable pregnancy.
Dr. Aimee: How are they diagnosed? How would you know you have an ectopic pregnancy?
Dr. Laura Londra: Sometimes you can tell that something is not completely right by the levels of the hormone of pregnancy and if they are not rising at a normal rate. But this alone isn’t enough to diagnose pregnancy as ectopic. We also look at an ultrasound. Sometimes it’s several labs and ultrasounds. This is the difficult part.
Dr. Aimee: I mean, you and I have very few emergencies in the middle of the night for our patients. An ectopic pregnancy is one of the few emergencies that we deal with, so that’s why we always want to make sure that we’re diagnosing an ectopic pregnancy before it turns into an emergency.
What kind of treatment options are out there for women once diagnosed with an ectopic pregnancy?
Dr. Laura Londra: The treatment for ectopic pregnancy, as you know, has changed a lot in recent years. The treatment has shifted from surgery being the first option, to becoming a medical treatment.
In the past, patients would present as an emergency with pain and bleeding and as a real-life threatening emergency. Today, this tends to be a bit different. Yes, it’s an emergency and something that is very much time-sensitive, even if the patient is not in the emergency room.
However, surgery is not the first answer. We have two types of treatment. The one we most commonly do is with a medication called methotrexate which helps dissolve those cells and resolve the issue. Sometimes we will need to use laparoscopy and surgery.
Dr. Aimee: Are there any women who might have a higher risk of ectopic pregnancy? What in general, are some of those risk factors, if there are any?
Dr. Laura Londra: The main risk factors are always any previous history of problems in the fallopian tubes, having an infection, chlamydia, or any sort of pelvic inflammation.
Also, there are some other conditions such as endometriosis that sometimes can cause scar tissues surrounding the fallopian tubes and the ovaries. Smoking is a risk factor.
Also, patients undergoing fertility treatment often have a high risk of ectopic pregnancy.
Dr. Aimee: Why is that? What is it about fertility treatments that might give them a higher risk?
Dr. Laura Londra: Well, it’s mainly because some of the risk factors for infertility are also risk factors for ectopic pregnancy. This issue may be a hormonal imbalance between estrogen and progesterone. That sometimes can be a factor.
So even women who have perfectly normal fallopian tubes and don’t smoke could still have an ectopic pregnancy. And this is the part when there are so many unknowns as to why this happens.
Dr. Aimee: What advice would you give to someone who’s worried that they have a tubal blockage before they even try and get pregnant? If they have one of the risk factors that you mentioned, is there something that they could do to learn more about their fallopian tubes first?
Dr. Laura Londra: As part of a fertility evaluation I find the hysterosalpingogram most helpful because that gives you a good view of the fallopian tubes. Also, we want to understand the shape of the uterus.
If you’re a patient that needs to have a laparoscopy for any reason, usually it’s a good idea to ask the surgeon to also check your fallopian tubes. They are usually able to pass a contrast fluid and see the fallopian tubes which we call chromopertubation.
Dr. Aimee: Let’s say you have a patient who’s had an ectopic, regardless of whether it was medically treated or surgically treated.
How would you counsel her about her risk of having another one in the remaining tube?
Dr. Laura Londra: When you have had an ectopic pregnancy (if you compare yourself with another person who has not) then statistically speaking, yes, you have a higher risk of having an ectopic pregnancy. But overall this is still a low risk. Thank God. So ectopic pregnancy is one of those things that happens infrequently.
It’s about 1–2% of all pregnancies that end up being ectopic.
Yes, you have a higher risk of having an ectopic pregnancy, but I always tell patients, even with that higher risk, you’re still more likely to have a normal intrauterine pregnancy.
The main thing is to check your hormone levels as soon as you get a positive home pregnancy test. Your OB will order a quant and do an ultrasound.
Dr. Aimee: So, it’s important to call your OB ahead of time, remind them that you have a history of ectopic, and request early pregnancy monitoring.
I mean, you and I, this is what we do, but a lot of OBs in the area, they may not see patients until they’re eight to 10 weeks pregnant, and that could be too late to diagnose an ectopic.
Dr. Laura Londra: Exactly. The sooner you know, the less invasive treatment you can do, and the more success you’re going to have in treating that pregnancy with medical treatment and avoiding surgery.
Dr. Aimee: So I’d love to talk about some of the research you’ve done. You’re very well published and you published a beautiful study on ectopic pregnancy after IVF. Can you talk to us a little bit about your study and what you found?
Dr. Laura Londra: Sure. I’m not sure if fertility patients are aware, but all IVF cycles are reported at the national level. So there’s a huge database that collects information about cycles, about patients’ characteristics, and what has been the outcome of those pregnancies and what treatment was done.
So that is really helpful when we are trying to look for something that is really infrequent. There are no animal models where we can study ectopic pregnancy so it’s really hard to learn more about it.
We looked at several years worth of IVF cycles, which included more than a hundred thousand pregnancies. We analyzed the outcome when we transferred an embryo in, comparing a fresh cycle to a frozen embryo cycle.
We did find a difference. There was more ectopic in fresh transfers vs. frozen or donor transfers. This speaks to the possibility of the hormone imbalances which may be predisposing women to ectopic pregnancies. This is true even as we take every precaution to put the embryo in the right place. Sometimes hormonal levels that might be predisposing someone to have an ectopic pregnancy. For some women, this means the embryo may migrate and implant in the fallopian tube.
Dr. Aimee: Yeah. Well, I mean, I think that’s a really good finding for people, especially women who’ve had a history of ectopic pregnancy when they’re reviewing their IVF options with their physician, especially in those patients. Perhaps they should be considering a frozen embryo transfer.
Do you think that’s something that could help?
Dr. Laura Londra: I think, yes, I think so. OB outcomes tend to be better with frozen transfers in many ways.
Dr. Aimee: What would happen if you had an ectopic and the diagnosis was missed? What kind of complications can arise from that?
Dr. Laura Londra: It’s life-threatening. For many years it’s been the main cause of maternal mortality in the first trimester, particularly in places where there is no good access to frequent labs or monitoring.
An ectopic pregnancy was my very first case as an OB-GYN resident. The patient didn’t know when her last cycle was, and wasn’t sure she was pregnant, but was having pain and feeling hypotensive. The next thing you know, we’re in the OR, and removing her fallopian tube.
Dr. Aimee: Wow. You literally saved her life. So what I want to do right now is do a bit of fertility or ectopic Myth-busting.
So here they, here I go, truth or myth. Is that okay with you? Yeah. Here we go.
A woman who has a blocked fallopian tube cannot get pregnant with IVF. Truth or myth?
Dr. Laura Londra: Of course, that’s a myth. When patients present with fallopian tube issues I like to tell them that IVF was created for them.
Someone with “tubal infertility” is really the perfect patient for IVF. Sometimes if there has been an issue in the fallopian tubes, or they’ve had inflammation for a long time, there could be fluid that’s accumulated. In that case, we may remove the fallopian tube before we put an embryo there. But, really fallopian tubes are not needed for IVF. And usually these patients have a pretty good response to IVF.
Dr. Aimee: So next one, truth or myth. You can’t get an ectopic pregnancy after IVF because you don’t need the tubes when you do IVF.
Dr. Laura Londra: I know. It doesn’t make sense. But it is possible. Of course, if you have a tubal ligation then those are the patients that have very close to a zero chance of ectopic pregnancy.
Dr. Aimee: Okay. Here’s another one. If your HCG is over 1500, then it’s always an ectopic pregnancy. (and what that means, for those of you who don’t know, that’s kind of the “discriminatory zone,” where you can see a pregnancy most likely in the uterus and if a pregnancy is not seen in the uterus).
Dr. Laura Londra: Myth. So the concept of a discriminatory zone has changed over time because the resolution of the ultrasound has changed and we have learned a lot more.
To deem it a pregnancy, you have to see a gestational sac in the uterus. So there is usefulness in having the correlation between the hormone level (or the quant) and the ultrasound. But the zone has been moved upwards a bit, because safety first, we want to make sure that we wait and see how things go and determine it’s a non-viable pregnancy before we move on to treatments.
Dr. Aimee: So it could be viable, but it could also be a miscarriage or abnormal pregnancy growing in the uterus as well.
Dr. Laura Londra: Exactly. This is why it’s so important that we look at the labs and ultrasounds closely.
Dr. Aimee: And looking at progesterone levels too. So progesterone can also be another test that guides us that the progesterone level is really low under three, for example. That could be a sign that it’s almost always an ectopic.
Okay. Here’s the next one. If your HCG is rising normally, it can’t be an ectopic pregnancy, truth, or myth.
Dr. Laura Londra: Well, it’s also a myth. It’s amazing how sometimes a patient has perfectly rising lab hormone readings and then an ectopic happens. At the same time, we may have the opposite where numbers aren’t rising fast and you do go and find a gestational sac in the ultrasound.
Sometimes we have a pregnancy of unknown location because we don’t see a sac through ultrasound, but your hormone levels are rising.
Dr. Aimee: I call pregnancy of unknown locations for our patients HCG hell. It’s like hell for our patients to not know what’s going on.
It’s really devastating.
Dr. Aimee: Here’s our last one. Truth or false, you can’t have a ruptured ectopic pregnancy if your urine pregnancy test is negative.
Dr. Laura Londra: Well we don’t go with what a urine test at home says. We can do them, but we need to see the hard facts and do quant with labs.
Dr. Aimee: The blood levels are going to be way more sensitive.
Those urine tests don’t always pick up the low levels that they can, and the blood test and the low levels are still assigned that you’re pregnant and could still have an ectopic. So, we definitely don’t take anything for granted. Our patient’s health is always number one to us.
So Laura, thank you for providing expert advice on ectopic pregnancy.
Can you tell our audience where they can find you?
Dr. Laura Londra: Thank you so much for having me. I love to talk about ectopic pregnancy. I practice in Columbus at Ohio Reproductive Medicine.
Dr. Aimee: Would you tell us about your international practice? I imagine you have a lot of international patients as well.
Dr. Laura Londra: I was pleasantly surprised when I moved to Ohio; I because I had thought that I might not see that many patients from other places. And it has been really interesting for me because I see patients who speak Spanish (which I’m very comfortable with) and I’ve been able to see patients from other countries, too.
And so, it has been really great. It’s always interesting to see how culturally different patients approach their building a family, and the different views and wishes that they have. And so that is something that I really enjoy.
Dr. Aimee: Thank you again and for everyone who’s listening or watching.
Have a great day everybody, and we’ll see you back here again soon. Bye!
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