Concerns Regarding Methotrexate Therapy
Monday, October 15, 2007
Kenneth F. Trofatter, Jr., MD, PhD
Hi Dr. T. I've been given conflicting answers by different gynecologists and rheumatologists in regards to methotrexate "wash out period" and pregnancy and frankly, I'm worried. Some say it's safe to get pregnant 3 months post methotrexate others say 4-6 months. Here's my scenario: I've been on methotrexate 25mg sc weekly dose, last dose being June 28, 2007. My LMP (last menstrual period) was Sept 8, 2007, and I just found out I was pregnant yesterday. Although it's been almost 4 months since my last dose of methotrexate, I'm very concerned about my child’s risk of teratogenicity. What are the chances of this happening? What would the best course of action be? Also, would folinic acid help, in my case, to decrease the chances of birth defects? Thanks
Chances are you will be just fine. When methotrexate is given by injection, peak serum concentrations are reached within 30-60 minutes. The drug is metabolized by the liver and excreted, mostly, by the kidneys. The half life ranges between 3 to 15 hours depending on the dose, chronicity of therapy and, obviously, liver and kidney function. Methotrexate does have some metabolites that may hang around “for an extended period of time” but the general consensus is that it is “safe” to get pregnant after at least one complete ovulatory cycle following the last dose. In your case, you are well beyond this recommended period and are, therefore, probably at no greater risk for fetal malformations than either the general population or other predisposing risk factors you and your partner bring into the pregnancy. There is no need for folinic acid, but since methotrexate is an antagonist of dihydrofolate reductase, I hope you started supplemental folic acid before conception and, if not, get some today! If you have regular cycles and your LMP was September 8, your baby’s neural tube should be closing even as we speak, and there probably is still time to decrease the risk for certain congenital heart defects! Best of luck to you and thanks for reading…
Dr T
Hello Dr. My question is regarding what is considered normal for betaHCG levels following MTX treatment for my ectopic pregnancy. On October 2, I was admitted to the hospital with abdominal pain and slight bleeding for the two weeks prior (last period was Aug 24). Tested positive for pregnancy with beta-hCG level at 960. Ultrasound showed nothing in the uterus. Beta-hCG tested again on October 5 was 1544 with ultrasound showing a small (1.1cm mass) in the right cornua (still nothing in the uterus). Beta-hCG tested on October 6 was 1797. Referred to OBGYN at ER for MTX treatment for ectopic pregnancy, for which an injection of 50mg was given same day (my weight 49.8kg). Beta-hCG tested on 10/10 was 2040 and I have not had the pain and abdominal cramping my Dr had prepared me for. My question is whether it is normal for the beta-hCG level to continue rising 4 days after MTX injection? Shouldn't it be falling? Scheduled for another blood test on October 13 but I was wondering when I should be worried that the MTX treatment is not working? I am 25 years old and would like to conceive in the next few years; thus, I would like to preserve both my tubes if possible and avoid surgery. Thank you kindly for your time and consideration.
This is an excellent question. You would certainly be a good prognosis candidate for methotrexate therapy with your relatively low hCG levels and no evidence of rupture or of an embryo with cardiac activity. Various studies have followed the course of hCG and progesterone over time after methotrexate administration for ectopic pregnancy. One study out of Brazil (Elito Junior, et al., Rev Assoc Med Bras. 1998;44:11-5) demonstrated an increase in beta-hCG titers between days 1 and 4 in 50% of women following methotrexate therapy. However, more than 85% of women had a decline of at least 15% by day 7. These findings were confirmed in a more recent study by Gabbur and colleagues (Am J Perinatal 2006;23:193-6). So what you described in your case is not at all unusual. Most studies demonstrate that it takes a mean of about 4 weeks before hCG levels become undetectable. Serum progesterone levels drop more quickly than hCG levels and some investigators have suggested using this as another parameter to predict the success of methotrexate therapy for ectopic pregnancy (Saraj, et al., Obstet Gynecol. 1998;92:989-94). Thank you for your question and I hope things turn out well for you!
Dr T
Labels: Ectopic pregnancy, methotrexate therapy
62 Comments:
At Fri Oct 19, 06:19:00 AM 2007,
Anonymous said…
Hi Dr T. Not surprisingly, you were absolutely right! BetaHCG was tested again on 10/18 following the second injection of MTX and showed that it had dropped by more than 20%. Now its just a matter of weekly blood tests until it gets down to zero. Thanks for everything! TC
At Fri Oct 19, 08:08:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
Hi TC: Thanks for letting me know. Kinda figured everything would be okay! Take care my friend! Dr T
At Tue Oct 23, 01:23:00 PM 2007,
Anonymous said…
have searched the web for some help and found it here my story is exactly the same am going for another scan tommorrow to check mx is working your tory has given me some reassurance that i dont need surgery thanks
At Wed Oct 24, 08:24:00 AM 2007,
Anonymous said…
Hello Dr T. TC here again. Some good and bad news. The bad news is that I ended up needing surgery after all. Started having severe abdominal pain on 10/21 that was not getting better even with 2 Tylenol 3s every 4 hrs; it was actually getting more intense by the end of the day so I went to the hospital. An u/s revealed a lot of free flowing fluid and they suspected a rupture (even though by this time my betaHCG had already fallen to 600)! Laparoscopic surgery was performed. I awoke from the 2 hr surgery frightened and confused with three small incisions on my abdomen. I asked the nurse what they found and all she told me was that I could ask the Dr when I see him 6 weeks from now. My husband asked the nurse to page the Dr so we could find out more (i.e did they remove the ectopic, was anything else removed, etc.) With some prodding, we were able to find out that the ectopic was removed, though it was not in the cornua as they thought, which is a good thing because both tubes and my uterus remain intact, and they also found a cyst on my left ovary, which they also removed. So I guess that is the good news -that I get to keep both my tubes and all of my uterus. Unfortunately, I did not receive any post-operative information upon being discharged 1 hr after my surgery. Can you advise how long I should expect to be off work (desk job)and how long before a complete recovery but mostly when is this pain from the incisions and bloating from the CO2 gas going away? My web search turned up conflicting answers, ranging from 4 days to 3 weeks. Also, I was prescribed Triatec30 (first time I've seen this one) and told to take 1 every 4 hrs as needed. Can you advise whether this is the same as Tylenol 3s and whether I can take 2 every 4 hrs as the 1 pill isn't doing anything for the pain. One last question, I still have Apo-naproxen and PMS-Docusate Sodium from my MTX treatment. Would it help (and is it safe) to keep taking these for the inflamation and constipation? As always, I am truly grateful for your kindness, support, time and advice. You really go above and beyond and I think its amazing what you do for your readers. For anonymous Oct 23, I'm glad my story was able to help you, even if just to know that you are not alone in your experience and that it is normal for the HCG levels to rise slightly at first. I hope my update doesn't freak you out. From what I have read here and elsewhere, MTX is a very effective treatment in something like 85-95% of women -I've just had a string of bad luck lately(that darn Murphy's law). And things did turn out okay as everything is intact. Just remember to monitor your HCG levels until they get to zero and to seek medical attention if the pain suddenly intensifies and the pain meds don't seen to work. Best of luck to you. I hope everything works out! TC
At Fri Oct 26, 03:24:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Oct 23: You're welcome. I hope things turn out okay and thanks for reading! Dr T
At Fri Oct 26, 03:33:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
Hi TC: Sorry you ended up in the O.R. It is not unusual to feel pain as the pregnancy tissues die in response to the methotrexate and some people will actually rupture their ectopics at that point. You are probably feeling better already and most folks will return to work within a week after having a laparoscoy. After you talk to your doctor, please let me know what you find out. Where was the ectopic? Was it actually in a tube and they removed it by 'linear salpingostomy', thereby preserving your tube? Did it abort out the fimbriated end into the abdomen (that's a long way from the uterine cornua where they originally thought the pregnancy was implanted)? Was it an ovarian ectopic? Was there blood or simply fluid in your abdomen? Had you ruptured an ovarian cyst (the corpus luteum)? I really am curious about all this because you did not follow the 'expected course' and I like to learn from these things too! Anyway, good luck to you. Thanks for being such a good reader. I have appreciated your comments. Dr T
At Mon Nov 12, 08:23:00 PM 2007,
Anonymous said…
I had two methotrexate injections (10/12 & 10/19) but ended up having surgery to remove the ectopic on 10/22. They saved the tube and said the other one looked fine. Three doctors said 3 different things about trying to conceive. One said to wait 6 months, one said to wait 3 months after levels get to zero, and one said we could TTC after my first period.
I’d like to know your opinion on me getting pregnant this menstrual cycle. Per calculations, I would be conceiving 4 weeks post injection and almost 4 weeks post op. Since my surgery I've been taking 2 mg of folic acid every day (Doctor recommended) because of the methotrexate.
I really appreciate your input. From what I’ve read, it sounds like the methotrexate doesn’t stay in your system very long and doesn’t pose a health risk for trying to conceive 4 weeks after the injection. If I am at risk for another ectopic because my body needs time to heal after surgery, I’d like to know that, too.
At Tue Nov 13, 06:21:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Nov 12: You are actually at greater risk for another ectopic than you are at risk for complications related to the methotrexate at this point! It might not be a bad idea to wait another month or so, although that might not decrease your risk for another ectopic(for whatever reasons the last one occurred, not just because of 'healing' or scar tissue). Best of luck to you and thanks so much for reading. Dr T
At Tue Nov 13, 08:58:00 PM 2007,
Anonymous said…
Thank you very much for the response to my questions about methotrexate on November 12. (I had two injections and ended up having surgery) Just have a follow up question.
My Doctor said there was no specific reason for my ectopic other than my age, I’m 36. The procedure was done by laparoscopy and she said my left tube looked healthy. She was able to save the right tube by making an incision on the tube and removing the pregnancy. She said the methotrexate must have started doing its job because she was able to just pick the pregnancy out.
Two years ago I had to terminate my first pregnancy at 5 weeks. It was unplanned and I was taking medication that caused defects. That was a normal uterine pregnancy. This ectopic was my second pregnancy and was planned.
I understand that my chances of another ectopic are now increased, but are they higher right after surgery? (Swelling, etc...) Am I still at risk from the methotrexate?
Again, I appreciate your opinion.
At Wed Nov 14, 08:35:00 AM 2007,
louise said…
Just writing to ask your opinion on a very long complicated case. I had a miscarriage on oct7th at about 6 weeks a scan showed it was complete the next day. I was given antibiotics for a urine infection and went home. I felt poorly for a week or so and then began to feel very pregnant again on the 2nd & 3rd week I did a test on the 21st day after my miscarriage and it was still positive. hospital did beta hcg test which showed 48 and a scan showed a thickening of 14mm .
tested 3 days later beta hcg 272,4 days later I had a scan which showed abnormal sac psuedo sac?. as I felt unwell with a slight burning sensation on the left side of my tummy they kept me in. Hcg tested again same day as scan and was up to 1200 consultant decided to give Methrotrexate and treat as eptopic(this was 7th nov).I asked a few times if it was a new conception or from the miscarriage and they gave me different answers saying eptopic the whole time or unidenticle twins or molar pregnancy. anyway I then went home feeling a bit unwell again same burning feeling and lightheaded ,sick ,headaches etc.On the 12th of nov hcg tested again told get back in afew hours that evening my leg felt numb and cold and burning seemed alittle stronger not painful but very aware of it. I phoned again next morning and told them and they called me in. Still no hcg results but did another blood test and a scan. The scan showed the same psuedo sac? as before I think a little bigger and also a new fetal sac measuring around 6 weeks but no pole or heartbeat.
All of the consultants have admitted to being very confused and have discussed with senior consultant they say I am a mystery. I have been asked to wait until friday 16th for another scan and hcg so they can see what it is in my uterus. On questioning the consultant admitted that I will have to have surgery whatever the outcome and the new fetus would be deformed.My family are concerned that I have been left again still with a possible eptopic and I am so confused. Why wasn't the new sac seen 1 week ago would they have still given me methrotrexate? Anmy ideas or knowledge would be appreciated
At Wed Nov 14, 06:00:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Louise Nov 14: It appears you hCG levels were doubling at the rate of a normal pregnancy, so most likely you conceived again (although it could still be an ectopic pregnancy that you conceived). Our big worry when someone has a rising hCG so soon after any pregnancy is that they have choriocarcinoma. That is a cancer of 'placental' cells and can be deadly if not treated appropriately. Methotrexate is usually very effective in completely treating choriocarcinoma, although I doubt that is you problem, you still need to be evaluated for that under these circumstances. Good luck to you and let us know how things turn out. Dr T
At Wed Nov 14, 06:16:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Nov 13: What the tube looks like on the outside is not as important as what it (and the other tube) look(s) like on the INSIDE. My suggestion would be to wait a couple of months and give all the inflammation and trauma resulting from the surgery and the pregnancy achance to die down before trying to get pregnant again. With regard to the methotrexate, you will probably be completely safe after one complete cycle. I would still recommend starting extra folic acid (1 to 4 mg per day) in anticipation of another pregnancy because of the methotrexate. That will reduce your risks even further for certain fetal malformations. Good luck next time around and let us know how you do! Dr T
At Wed Nov 28, 08:05:00 PM 2007,
Anonymous said…
Hi Dr T: TC here with a follow-up from my Oct 24 posting. I had the follow-up with the surgeon today. Turns out the ectopic was in the right tube, very close to the ovary, and not the left cornua as originally thought. Also, it turns out that part of my right tube needed to be removed during the surgery and the cyst they removed was the corpus luteum. The surgeon told me that my future chances of a normal pregnancy are not significantly reduced (only by 20%) since both my ovaries remain intact and the ectopic was not due to any defects or abnormalities in the reproductive structures. He also said that because the ovaries are actually closer to each other than people think, the eggs from the right ovary can still be transported by the left tube. I'm really worried though. From what I've read on the internet, this is very rare and the removal of a tube reduces the chances of future pregnancies to about 50%. What do you think? Your advice and expertise on this would be greatly appreciated. Thanks again for everything. TC
At Tue Dec 04, 12:11:00 AM 2007,
Anonymous said…
Please can someone help me, i had a dose of methotrextae for an ectopic on the 21st sept, then had a bleed on the 16th oct, this may have been a period or late effects of injection. I had a blood test on the 30th nov which shows that i am approx 6 weeks pregnant. What effects can this have on my unvborn baby and how long would the meto stay in my system for. I wish i had waited another month and am worried as pregnancy is all i have ever wanted. Please place an answer if you can.
At Tue Dec 04, 08:55:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To TC Nov 28: I sort of suspected you didn't actually have a cornual ectopic, that's why I asked. TC, if the left tube REALLY is normal inside, then having the right one removed (partly or entirely) because of the ectopic pregnancy should not significantly reduce your fertility. However, if there is abnormality in the left tube or conditions on the left side similar to thise that led to the ectopic on the right, then your fertiliy could be reduced or your risk increased for another ectopic on the 'good' side. If you do not conceive again in a reasonable period of time, IVF may be your best bet! Good luck and thanks for updating us on your situation! Dr T
At Fri Dec 14, 03:33:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Dec 4: Sorry it has been so long since you left your comment, but I just received it in my mailbox. Chances are you will do just fine. The methotrexate should have been eliminated over that month. You would be at even lower risk if you were taking a prenatal vitamin and extra folic acid, but you are beyond the point in the pregnancy where that would make much of a difference. I would suggest that you have first trimester screening at 11-12 weeks, a MSAFP screen at 16 weeks and a 'targeted' ultrasound at 18-20 weeks to look for fetal abnormalities. Let us know how things turn out. Good luck to you! Dr T
At Sun Dec 16, 12:55:00 PM 2007,
Julia said…
Hello Dr T, I am really pleased to have found this site. I am writing to you from New Zealand. I was given an injection of Methotrexate two days ago to treat an ectopic pregnancy. We have been told not to try to conceive for 100 days and I have been prescribed birth control pills. This pregnancy came about after a year of trying and as I am in my thirties being told to wait 100 days feels like a lifetime. My hcg level was low (600) and the mass small (9mm) so I am confident I will only need this one injection . My question is this: from the reading I have done it appears that the American protocol is to wait at least ONE ovulatory cycle before attempting to conceive after a Methotrexate shot. Is this correct? It seems the protocol in New Zealand is 100 days - or three months. My husband and I don't want to be irresponsible but at the same time I am anxious about my increasing age and I really feel like every month counts. We are contemplating ignoring the advice of our local Drs and waiting until I have had only two menstrual periods before we attempt to concieve again. Do you have any advice on this? Is three months just an ultra, ultra conservative approach or is there a sound, research-based reason behind this advice? I appreciate all and any thoughts you may have on this matter. Many thanks to you, Julia.
At Mon Dec 17, 11:52:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Julia Dec 16: I think your doctors are just takimg an "ultrasconservative approach." By 2-3 months, there should be no risk of teratogenicity (birt defects) from the dose(s) of methotrexate we use to treat an ectopic pregnancy. You are actually at greater risk for another ectopic (for whatever reasonss you might have had that led to the recent one) than you are for problems related to the methotrexate at that point. Once the ectopic is cleared, begin taking some extra folic acid and B vitamins and that will reduce the risk from the MTX even more. Best of luck with your next pregnancy and thanks for writing from halfway around the world! Dr T
At Mon Mar 10, 06:12:00 AM 2008,
Anonymous said…
Hi Dr T. January 17th I was diagnosed with a miscarraige and by Feburary 7th I had a D&C as was still bleeding on and off. My results from the D&C showed no presents of HCG so new diagnoses was an etopic. Feburary 12th had the methrotrexate shot and sent home to recover. My four day blood draw showed a rise in HCG to just under 500 and seven day draw show a drop to 360. March 3rd HCG level was just 23. My doctor is very happy with my progress as my last cycle was December 6th. As of March 5th I have been diagnosed with two cysts one 5.3cm in size both on my left ovary, sometimes quiet painful. Currently on the watch and wait so go back in six weeks. I had a cyst in my early teens and am now 35, my doctor want me to go on the pill to prevent me ovulating. My husband and I wish to try for a third child and I had hoped to concieve in this year just summer to be sure I was recovered. It has been along path for us and just wish to be healthy again. I am being seen by a military doctor at a military hospital as I am over seas.
At Fri Mar 14, 03:03:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Mar 10: It sonds like you are being successfully treated for you ectopic pregnancy by the methotrexate. It is probably not a bad idea NOT to get pregnannt for 4-6 months to allow the tube a chance to heal and the inflammation to die down. Although you still will be at increased risk for another ectopic (simply because you have already had one), that will minimize your risks. The birth control pills may be a benefit in that regard. Good luck and hope things turn out better the next time. Dr T
At Fri Mar 21, 03:35:00 PM 2008,
Anonymous said…
Hi Dr. T. I have found your comments very helpful in my situation. I would like some advice, if you don't mind...I am a 32 year old mother of 3, and I've never had any problems with any pregnancies. I was just diagnosed and treated with methotrexate for an ovarian ectopic. This is my question... when I was diagnosed my doctor showed me the ultrasound (which was transvaginal) and showed me the ovary and the 3 cm mass in it. he explained that this was most likely an ovarian ectopic, with a chance that it could be a hemmorhagic cyst...but with nothing found in the uterus, there has to be an ectopic somewhere, as my hcg levels were still rising, after I had had severe bleeding, cramping, dizziness and blood in the abdomen. My levels are now down to zero, 3 weeks after the shot. I asked him about trying to conceive again. I read that the reoccurance rate for ovarian ectopics is very low, if none...he told me that it could have been at the end of the tube, next to the ovary because it is hard to tell the difference on an ultrasound.. could he just be playing it safe? if this was in the ovary, i feel safe to try again... if not, maybe I should just be content with the 3 I already have... it is such a health risk to me... is this common among doctors? should he have been able to tell by a transvaginal ultrasound? I was 7 weeks from the first day of my last period when I had the ultrasound. Thank You for any advice that you may have.
At Tue Mar 25, 06:53:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Mar 21: You could have had an ovarian ectopic or that could have been simply a hemorrhagic corpus luteum and you might have 'aborted' the ectopic ut the end of the tube. Regardless, I still believe you are increased risk for a recurrence, but probably less than the 20% usually quoted to women who have had tubal ectopic pregnancies. If you do decide to get pregnant again, very early ultrasound at 5-6 weeks can usually confirm an intrauterine pregnancy and if that is not seen, earlier therapy for another ectopic might save you what you went through this time. Remember, teh biggest risk of an ectopic is not suspecting you could have one! Thanks for writing and best wishes. Dr T
At Mon Mar 31, 05:22:00 PM 2008,
Anonymous said…
Hi,
I had MTX inj 3/27 for ectopic, as expected HCG levels rose from 2300 to 2600 on day 4. Just wondering if it is known why there is an increase initially. Also, this ectopic is in a reconstructed tube (tubal ligation and re-enastomosis both in 2003) Do you think surgery was indicated to just get the bum tube out or would you have suggested MTX first, I had no pain or bleeding only the absence of IUP and no doubling of HCG levels. US showed possible luteal cyst or tubal preg close to L OV.
I would like another child and have had 2 intrauterine pregnancies since 2003.
Thanks, CKK
At Fri Apr 04, 07:48:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To CKK: The hCG level frequently rises initially, but yours is low enough that I anticipate you will have a good response to one or two doses of MTX and not require an operative procedure. If you do have to go to the O.R., I would suggest "just getting the bum tube out!" Good luck and let us know what happens. Dr T
At Mon Apr 07, 02:23:00 PM 2008,
Anonymous said…
Hi Dr. T. I also have had an ectopic pregnancy treated with two doses of methotrexate. I am now in my fourth week..and my HCG is going down finally. I do have a cramp like pain on the ectopic side that is very mild, but constant that goes down to my groin and leg..Is this normal? When my HCG is at zero...I should wait one ovulatory cycle and start taking my prenatal..should I take extra folic acid besides my prenatal..if yes how much? thank you your blog has been very helpful!!
At Mon Apr 07, 05:20:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Apr 7: Unusual discomfort very frequently occurs with ectopic pregnancies following methotrexate therapy. How high was your hCG, how far along were you, and how big was the ectopic? The reason I ask, if there was a signifivany mass and very slow resolution of the ectopic, you might want to wait at least 2-3 months before trying to conceive again - give all the inflammation a chance to resolve and as much of the 'normal' tissue anatomy to return as possible. Remember, you will still be at risk for another ectopic in te range of 20%. You can begin the folic acid (2-4 mg per day) after your next ovulatory cycle. Best of luck to you and thanks for reading! dr T
At Mon Apr 07, 09:00:00 PM 2008,
Anonymous said…
Hi again Dr. T....to answer your questions...I was 5 weeks one day pregnant...my HCG were as follows...week 1 800ish (shot of metho)...week 2 1777 (got second shot of metho)...week 3 958...week 4 900...week 5 400. hopefully that made sense...at my second shot of methotrexate the ectopic was 3 mm. I believe that is the untis. thank you again for your help!
At Tue Apr 08, 10:49:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Apr 7: Sounds like you were a very good candidate for the MTX. Again, I would support waiting until after your first ovulatory cycle to restart a prenatal vitamin and you can include extra folic acid at that time (2-4 mg/day). Waiting for at least 2-3 months after that before you try to conceive is also probably prudent to minimize your risks for another ectopic pregnancy. Good luck and thanks again for reading. Dr T
At Tue Apr 08, 01:24:00 PM 2008,
Anonymous said…
Hi Dr. T...I just have one more question for you...how often do you see birth defects in babes of mom's who had a history of taking the methotrexate for ectopic pregnancies. Does this increase our risk for future babes with birth defects?? It is pretty scarey to think it might...thank you.
At Tue Apr 08, 03:30:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Apr 8: The half-life of the methotrexate is very short so within a month there should be no risk from having taken a couple of doses. And, taking folic acid reduces that risk even further. Remember, MTX is a folate antagonist and one reason we don't want you taking prenatal vitamins and extra folic acid while you are getting MTX is because they will diminish its efficacy. You will be fine if you follow your current 'plan'! Dr T
At Wed Apr 16, 12:28:00 PM 2008,
Dana B. said…
Hi Dr.
I've never posted here before so I'm hoping I'm posting in the right place to get a response from you.
My dilemma is this: In November '07, I became pregnant. At 8 wks it was determined to be ectopic. I had no pain at the time that I was given my 1 (only 1) Methotrexate shot, but developed significant pain in the 5-7 days following the shot and ended up in the ER (just scared that it could still rupture...but it didn't.) between the time I received the shot and the time I started bleeding. After I did start bleeding, my HCG went down to 0 quickly, so my dr. wasn't concerned at all. HOWEVER...
...I continued to have pain around my left tube for a good 2 months after ward, to the point where I wasn't able to work (I'm on my feet and active at my job.). In the last month and a half I have gone back to work but can only handle 4-5 hour shifts without ending up in pain again. Working out, and sometimes even having intercourse with my hubby, seem to aggravate it also.
I have spent HOURS online researching to find any info on how long recovery can take in cases similar to mine and can't really find out anything. My dr. is clueless as to what's going on, as they can't see my tubes with an ultrasound - guess they're too small. My husband and I would like to ttc again SOON (!!) as it's been nearly 4 months since I received the methotrexate shot, but we're scared to try again as long as I'm still tender in that area.
Any idea what might be going on? I'd SO appreciate any input you can give.... I SO want my body to get back to normal... Thank you so much for your help.
~DB
At Sun Apr 20, 06:21:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To DB: You probably have some pelvic adhesions either from the ectopic or from whatever caused you to have the ectopic to begin with. I would suggest that you have a diagnostic laparoscopy performed by someone who is capable to fix any problems they discover before you try to conceive again. Good luck and let us know what you find out. Dr T
At Thu Apr 24, 09:52:00 AM 2008,
Anonymous said…
Dear Doctor,
I was diagnosed with an ectopic at the end of December and received the methotrexate in early Jan. My numbers went down very fast, they were low to begin with. I just found out I am pregnant again and I have gone through two complete cycles. I am very nervous because I started my prenatals about a month ago and is that enough folic acid? Should I take an additional folic acid pill just be safe?
At Thu Apr 24, 03:22:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anaonymous Apr 24: You should be fine from the standpoint of the methotrexate, but a little extra folic acid early in pregnancy isn't going to hurt either! Folic acide can minimize risks of cardiovascular and spinal abnormalities. Best of luck. Dr T
At Fri Apr 25, 07:07:00 AM 2008,
Anonymous said…
Thank you Dr T! This site has been so helpful. When does the Neural Tube form? I am around 4 weeks pregnant (from the first day of my last period). Is it too late to take extra folic acid now? Also, does it take a long time after the methotrexate for your folate levels to return to normal? For instance, I had the shot in January, and started taking my prentals in March. Thank you for all of your help!
At Fri Apr 25, 11:02:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous apr 25: The neural tube closes by 26-28 days after CONCEPTION (or about 6 weeks from the onset of your last menstrual period. The heart continues to develop until 9-12 weeks and it too is sensitive to the effects of folic acid. So, go haeda and take it! It certainly will not hurt! Thanks for reading. Dr T
At Fri Apr 25, 02:08:00 PM 2008,
Anonymous said…
Hi Dr. T.....I am also wondering how soon do your Folic acid levels return to normal following one or two shots of methotrexate?? Also....is it possible to get a lab test to check your folic acid levels once you have a 0 HCG and one complete ovulatory cycle??
thanks for your help!
At Fri Apr 25, 06:24:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Apr 25: Methotrexate is a folic acid antagonist, but it does not affect folic acid levels. But folic acid does inhibit the activity of methotrexate. The half-life of methotrexate is short. Within a month of your klast does it should be, basically, all gone. As a safety measure, take an extra 2-4 mg per day and the methotrexate should not affect another pregnancy at this point. Best of luck to you. Dr T
At Tue Apr 29, 04:39:00 PM 2008,
Anonymous said…
I was diagnosed last Thurs with an ectopic. My HCG was 6,000. I was given an injection of MTX at that time. I just found out my levels from my bloodwork yesterday and it went to 9,000. I understand that it is normal to have an increase, however I'm concerned with how high my numbers are. I start having persistent pain last night on my left side, which is where the ectopic is. I had an ectopic in 2006 which led to emergency surgery to remove my right tube. I had very few symptoms or pain, even though by the time I got into surgery I had already begun to rupture. I call the on call dr and he told me there is no need to worry. Easier said then done! I know that my levels were high and that the MTX might not work at that level. Please tell me your opinion on this. Should I go to the ER or am I overreacting?
At Thu May 01, 07:22:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anaonymous Apr 29: If your pain has persisted or increased, you should see your doctor or go to the ER, especially if the pain has become more diffuse in your abdomen. This is rupturing of the ectopic until proven otherwise and you are correct, at that level, and with your past history, you are at greater risk for that even if the MTX works. Good luck and I hope things turn out OK. Dr T
At Sat May 03, 03:45:00 PM 2008,
Anonymous said…
Just wanted to give you an update since my last comment on 4/29. I went and saw my dr on Wed and she assured me all was fine. So I got my blood work done on Thurs (day 7) and my levels went to 10,000. The dr sent me to the ER and they did an ultrasound. There was a heart beat and the fetus was 6.5 in size. Needles to say, I had surgery. Luckily I hadn't ruptured yet. I guess the moral to the story is to trust your instincts no matter what they tell you. I should have insisted to the on call dr that I wanted to go to the ER on Tuesday.
Thanks for listening!
At Tue May 06, 04:07:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous May 3: I am just glad everything turned out okay, not ideal, but still okay! Thanks for letting me know. Dr T
At Thu May 08, 08:51:00 AM 2008,
Anonymous said…
Hello, I just had my MTX injection on Tuesday evening (6:30pm). My beta confirmed I was pregnant on April 28th (hcg level was 232 and first day of last period was 3/24). Next beta (4/30) was 248 so we knew it wasn't a good pregnancy. Beta on 5/2 was 242 so my doctor was concerned it was ectopic but too small to see anything in ultrasound. I had no pain or bleeding all along and have not had any conditions that I know of that have damaged my fallopian tubes. We did one more beta on 5/5 and it was 368, so we decided to move forward with the MTX since my dr believed there was a 60% chance that this was an ectopic pregnancy (and a 99.5% chance that even if it wasn't ectopic, it would soon end). I'm 33 and very much want children so I didn't want to risk damaging anything. My question is, what is normal bleeding now? I began lightly spotting an hour after the MTX and have been spotting and bleeding steadily since but nothing particularly heavy. And I've had no significant cramping yet. I feel bloated and a bit crampy (like during my period) but nothing like I imagined with a miscarriage. Is this normal? Also, is there any non-invasive way I can find out if this was, in fact, ectopic or if I have scarring in my tubes. It took us 3 months to get pregnant so I'm hoping that we won't have a problem getting pregnant (and carrying to term) again. Thank you very much for your time.
At Fri May 09, 08:02:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous May 8: It can take 7-10 days before the hCG levels start to drop and longer until they are negative. There are various ways to evaluate the inside of the uterus and tubes, but you should probably wait a mont or more after this is all over before you have that done. Ask your doctor about your options and if he/she has a specialist in reproductive endocrinology and infertility with whom they consult. Best wishes and thanks for reading. Dr T
At Sun May 11, 06:46:00 PM 2008,
Anonymous said…
Thank you for the response to my May 8 question. I'm just curious why you're recommending a reproductive endocronologist & infertility specialist. My doctor thinks that if this was an ectopic, it was just an unlucky thing that happened. Is there something in the hcg levels that I gave you (or my situation in general) that would make you think that I have an additional issue?
Also, I had a follow-up with my dr on Friday and he said that we can start trying to conceive again after my next menstrual cycle. Do you recommend waiting longer than that?
At Tue May 13, 05:54:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous May 11: I recommended an REI because you asked if there is any way to find out about "scaring" of the tubes. They specialize in the evaluation and are experts in the treatment of tubal abnormalities. You still might consider this before trying to get pregnant again. Dr T
At Thu May 15, 06:13:00 AM 2008,
klingme said…
i too have had the methotrexate injection, i recieved the injection on may 13th. I was not informed of any side effects or drug interactions, which i am finding online. many sites advise to avoid alcohol and nsaids while on treatment. if i only have the one injection how long does treatment last??? and what can i safely take for pain??? the doctors advised me that they didnt think the pregnancy was in my tubes, is there anyway to find out where it is? acording to the doctors i would be 9weeks today, my hcg levels at last check (monday) were only around 1700. oh also had a d&c this past friday. I am also a little curious as to what is going to happen to the pregnancy, will i have to pass it? thanks so much!
At Fri May 16, 02:53:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Klingme: If they didn't think the pregnancy was in a fallopian tube, I would like to know what they saw on ultrasound (even at that low hCG) and what they found with the D&C. Also, if they did the D&C and got out pregnancy tisssues, why did they treat you with methotrexate?!? Anyway, let's just assume you had a pregnancy in a tube...it usually takes 4-6 weeks for the hCG levels to return to negative...and no, you may have bleeding, but you will not pass the pregnancy under those circumstances...it will be simply reabsorbed. You can take tylenol for your pain. If that doesn't work, talk with your doctor. Good luck! Dr T
At Thu Jun 19, 05:38:00 PM 2008,
Anonymous said…
Hi Dr T. I have recently been diagnosed with an ectopic pregnancy and had a shot of methotrexate. This is a devastating and terrifying experience for me and I am trying to find answers. I understand that an ectopic pregnancy may happen even when there are no known risk factors. In my case, I had a HSG done 9-10 days before I conceived. My tubes were clear and everything had looked normal. I am 35 years old, so I understand that perhaps the cilia in my ectopic tube may not be efficient and maybe that's what must have caused the ectopic. I also understand that there are currently no tests to evaluate whether the cilia are working properly.Now coming to my questions..(these may be stupid and crazy questions)..1)When an embryo is 1 or 2 days old and it is moving down the tube, can an orgasm and the resulting uterine contractions cause it to move further back into the tube? 2)I ovulated from the left ovary but the ectopic is located in the right tube. Does the fact that the right tube had to stretch to reach and grab the egg mean that the embryo in the right tube had to travel a greater distance to reach the uterus?
Thanks. Clueless in Colorado
At Sat Jun 21, 07:44:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
Dear Clueless: no question is stupid and yours are good ones. I know folks have debated for years if pregnancy picked up by the tube on the side other than the one you ovulated on increase the risk for ectopic pregnancy. I think there is an association, but I do not know for sure. A bigger question is perhaps, why didn't the tube on the same side pick up the egg? Is there some pathology there that has set you up for an ectopic on BOTH sides!?! BTW, if orgasm caused ectopics, the rate for the same would be extraordinarily high, so I doubt that is a concern either. Dr T
At Mon Jun 23, 08:16:00 AM 2008,
Anonymous said…
Hi Dr.T. I have had an ectopic for almost 2 months now. My hcg levels were fairly low around 2,000. After 1st MTX shot they continued rising to about 4000, and then took a 2nd dose, and reduced to 1800, then 1300, but last check only reduced to 1180 and the sac didn't change size (2.5cm and may have slightly grew). I have occassional bleeding and cramps, but the last reading has depressed me since not going down very fast, and now wondering if i should do surgery instead (almost 4+ weeks and no major change)?
How long should one wait before going to the surgery option even if you are candidate for MTX. Second, should I have them remove the tube are try to save it. Worry a repaired tube may only increase my chances of another ectopic? Tks for any info you can share on this.
At Thu Jun 26, 09:42:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous June 23: If the levels haven't dropped significantly in the next week or so, or if they rise, your doctor will have to decide if more MTX might work or if a laparocopic procedure is indicated. I anticipate they will recommend the latter. That will also give them a chance to look at the other tube. If the other tube looks good, the better part of valor may be to completely remove the bad one, although that still does not gurantee that you wouldn't get another ectopic on the other side. You do not appear to be in any danger at this point. Best of luck to you and let us know how things turn out. Dr T
At Mon Jun 30, 07:02:00 AM 2008,
Anonymous said…
Hi Dr. T. It has been so refreshing to find your site. I was diagnosed with an ectopic in March '08 after bleeding in my 5th week of pregnancy. HCG levels were always low (under 250) but rising even after my dr. used the "rocket method." So I ended up needing two separate doses of methotrexate given two weeks apart. My levels were back down to zero within 2 weeks, and I've had very normal 28-day cycles ever since. Two weeks ago my doctor conducted an HSG. One tube looked totally open, but the other tube did not show the dye flushing out into the uterus as it should. The tube looked normal (no ballooning or abnormal shape), however. He kept asking me to lie on my right side during the HSG to get the dye to go down the tube, but it didn't seem to work. (Does this mean the tube "of concern" is on the right?) My doctor said that I can either have surgery to determine what's going on with that tube, or I can try again to conceive again and see what happens. My questions: What are the different possibilities for this sort of HSG outcome? My doctor mentioned that sometimes the dye just prefers the path of least resistance and may be opting to flow down the super-open tube. Or he said that I may have scar tissue from the ectopic or my tube may be attached to the ovary. Is it possible that my tube has always been this way? I have had 3 pregnancies that implanted in my uterus (one ended in miscarriage, though). The other question: Is it a good idea to only try and conceive on the month that I ovulate from the "good side?" And if he had me lying on my right side during the HSG, is this the trouble tube? I always get mid-cycle pain. This month, for instance, I ached on my left side during ovulation. Is it worthwhile to try and conceive when I ovulate on the good side? What's the correlation between the ovary that releases the egg and the tube that carries it? My dr. seemed to think that this would be a fruitless exercise. But I don't want to go through this again and am happy to try whatever might work. Any thoughts?
At Tue Jul 01, 11:17:00 AM 2008,
Anonymous said…
Hi Dr. T. I'm Being treated for eptopic and had MTX on 6/4. In the ultrasound they did not identify where the eptopic was but thought maybe in left tube near ovary. They also found a 1.9mm mass near my ovary. They are not sure if it is attached to my tube or not, but said it was not attached to my ovary. on 6/24 HCG was 587 from 1875 on 6/4. I am having sharp pains in the left ovary/tube area. Had ultrasound again on 6/30, and they measured the mass to 1.5 x 1.6 x 1.7mm., and no sign of eptopic in tube. Since I am having pain could this be from the eptopic still dying off or maybe from the mass? I am going to see Dr. tommorrow to determine if surgery should be done to remove mass near ovary. My Dr. originally said it was a corpus novum cyst and would go away in six weeks, but it has been six weeks, and it is still there? Do you think the mass could be the eptopic? I'm very concerned and not sure if I need another shot of MTX or surgury. Any thoughts. Thanks I'm very worried about the mass/pain.
At Tue Jul 01, 06:17:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous June 30: I think you need to clarify with your doctor which tube did not fill during the HSG. Yes, that tube could be partially or completely blocked from the recnt ectopic or from whatever caused you to end up with an ectopic to begin with or it might just have been what your doctor said - basically an artefact of the study. Regardless, having had one ectopic, your risk is increased that you could have another - as high as 10-20%. It is less likely that the tube "has always been this way." If you know whcuh side you are ovulating from by midcycle pain, then it might slightly reduce your risk for another ectopic by trying to conceive only when ovulation is on the side of the 'unaffected' tube - I put that in quotes, because that tube could still have a subtle problem as well that increases your risk for another ectopic. It does not sound like surgery will help very much at this time, so when you are ready, go ahead and try to conceive and take your chances! Dr T
At Tue Jul 01, 06:19:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous July 1: It is not unusual at all to have some pain as the ectopic pregnancy responds to the methotrexate. That mass could be either the ectopic or the ovulatory site from which the pregnancy came (I am betting it is the former). Regardless, unless the mass ruptures (usually signalled by more sever and more diffuse abdominal pain), as long as the hCG is dropping, you probably do not need to have surgery. Good luck and thank you for reading. Dr T
At Fri Jul 04, 04:10:00 PM 2008,
Anonymous said…
From anonymous July 1: I got a copy of the radiologist report from my Dr. on 7/1 and it said a simple cyst is in the left ovary & in the left adnexa adjacent to the ovary lies an echogenic focus(mass)and contains central blood flow. Impression: Echogenic mass adj. to lft. ovary, suspicious for ectopic pregnancy. No heart beat confirmed. Dr. said they can't see my tube on an ultrasound, Does this sound like it might be in or outside my tube? Not sure what to think? On 7/2 my HCG is now at 216. Can you tell me if it is normal that the mass is still approx. the same size and has not gotten smaller? How long should it take for the pregancey to break up. I'm concerned because my hormone levels are getting lower and the mass is still the same size. Thanks for your help as my main Dr. is on vacation and next appt. is 7/16.
At Sat Jul 12, 07:48:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous July 1: The ectopic is most likely to be in that tube. It is not at all unusual for the mass to take longer to resolve. The important thing is that the hCG level is low and continues to fall. Hang in there and be patient. You should be fine. Dr T
At Thu Jul 17, 01:02:00 PM 2008,
Anonymous said…
Dear Dr. T,
I have recently been semi diagnosed with an ectopic pregnancy 7/17 and received one dose if IM methotrexate. my first hcg 7/7 was 276 then 2 days later 531. 2 days later only 594. already concerning. ER visit on 7/12 showed a hcg of 1318 but nothing visible on transvaginal ultrasound except a large amount of fluid in my posterior pelvis area suspicious for a ruptured ectopic pregnancy. MD states nothing in my uterus, tubes, ovaries, or cervix. 1 day later hcg 1584. 1 day later 2478 transvaginal us nothing again. 1 day later hcg 2051. 1 day later hcg 3032. now to my question, what is happenning, where is the pregnancy, why are my hcg levels going up and down. I was having some bleeding early around the hcg level of 531 but not much since just some dull abdominal cramps. I am so confused as to where the pregnancy is and how it got wherever and why its not visible on ultrasound. also will my body just absorb the pregnancy after the methotrexate? how much should i anticipate to bleed from the drug and how soon should i start bleeding. i get my blood drawn again at 4 and 7 days 7/21 and 7/24 to check my hcg levels. thanks again i love this site. natalie in ohio.
At Fri Jul 18, 05:48:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To natalie: If you have an hCG greater than 3000 and no pregnancy is seen inside the uterus by ultrasound, then you (probably)have an ectopic pregnancy somewhere. It could be in a tube, on the ovary, or even implanted in the abdominal cavity. You may well require more than one dose of MTX. If the MTX is successful, your body will simply absorb the pregnancy. Best wishes and please let us know how things turn out. Dr T
At Sun Jul 20, 10:27:00 PM 2008,
Anonymous said…
From Anonymous July 1, Hi Dr. T. I have another question. As of 7/15 my HCG is at 22 and on 7/18 I started having dull low back pain and dull throbbing pain in the left ovary area where the eptopic is suspected to be as well as light bleeding. Remember that I also have a cyst in my left ovary. I'm wondering if it is normal to still be having pain when the HCG is so low. Can the pain be from the cyst in the ovary or most likely the pregnancy. I appreciate your advice. Thanks
At Tue Jul 22, 06:31:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous July 20: The pain is most likely from involution of the ectopic pregnancy. That might be associated with some bleeding and cramping, but usually it is not life-threatening. Hang in there a little longer. Dr T
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