Symptoms Accompanying Methotrexate Therapy for Ectopic Pregnancy

Saturday, March 08, 2008

Kenneth F. Trofatter, Jr., MD, PhD

Below is a comment with questions from a reader who is undergoing methotrexate therapy for a tubal ectopic pregnancy. Ectopic pregnancy has been on the rise over the past 30-40 years and current rates are in the range of 1-2 per 1000 pregnancies. Fortunately, with early diagnosis, facilitated by rapid quantitative assays for hCG (human chorionic gonadotropin, the ‘pregnancy hormone’ measured in most pregnancy tests) and ultrasound, the death rate accompanying ectopic pregnancy has dropped dramatically during the same time period. A pregnancy should be visible within the uterus by transvaginal ultrasound by the time the hCG level reaches 2000 mIU/ml (5-6 weeks, or 1-2 weeks after the first missed menstrual period). The advantage of early diagnosis has been the option to consider ‘medical therapy’ with methotrexate prior to rupture of the ectopic that usually necessitates a surgical procedure. This option for therapy has gained well-deserved popularity in recent years, so there are many readers who may benefit from the comments below…

• At Wed Mar 05, 07:30:00 AM 2008, Anonymous said…

Hi, I had an ectopic pregnancy and I had gone through the methotrexate treatment just this past Sunday. How long roughly should my cramping and bleeding last? I also just started to have today pressure in my very lower abdomen region and also my bum region is this normal, its not extremely painful but is quite annoying? Also today I had a almost like a blood clot come out when I went to the washroom but it was more mucousy-like. Is this something that will happen? This is my first pregnancy ever and well this whole thing is scary because I have gotten no definitive answers on anything. Basically what should I be going through while this drug does its thing? What is considered normal and how long does it last?

• At Wed Mar 05, 10:32:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

Many women who receive one or more doses of methotrexate for medical treatment of an ectopic pregnancy report cramping abdominal pain during the first 2 to 3 days (sometimes longer) of treatment. This is one of the most common side-effects of therapy. However, more severe and diffuse pain should be reported to your doctor because this can be a sign that the ectopic pregnancy has ruptured.

Vaginal bleeding and passage of mucous, such as you describe is also quite common. Progesterone produced by the corpus luteum (site of production of the egg that became the pregnancy) and the pregnancy hormones that are produced, even with an ectopic pregnancy, cause changes (decidualization) of the lining of the uterus in excess of that which occurs during a menstrual cycle. When the pregnancy is interrupted by the methotrexate, there is usually a heavy ‘withdrawal bleed’. In addition to the bleeding and ‘cramping’ (or “pressure” sensation associated with the distention of the fallopian tube or accompanying blood in the abdomen), occasionally, women will develop nausea, vomiting, indigestion, and feel tired, lightheaded and dizzy.

However, if you were selected by the recommended standard criteria for receiving medical therapy with methotrexate, there is a 70-95% chance that you will not require surgery. Selection criteria for methotrexate therapy include a patient who is hemodynamically stable, has no evidence of tubal rupture or significant amount of blood in the abdomen, has a tubal diameter of no more than 4 cm, understands the risks of the therapy, and is willing to return for follow-up. Resolution of the ectopic pregnancy using methotrexate results in tubal patency rates in the range of 80%, comparable to, if not higher than, those seen with surgery.

Remember that for whatever reason you had an ectopic pregnancy this time, you are at increased risk for another one with a future pregnancy, so always seek out early prenatal care when you think you might be pregnant and inform your provider that you had an ectopic pregnancy in the past. Recurrence rates overall are in the range of 20%. Conditions that increase the risk for recurrence include history of or evidence of previous pelvic inflammatory disease (PID), history of ruptured appendicitis, particularly if this was accompanied by rupture of the appendix, pregnancy after reconstructive tubal surgery or tubal ligation, pregnancy despite the presence of an intrauterine device, pregnancy with progestin-only oral contraceptives, and a history of infertility requiring ovulation induction. Interestingly, women who undergo in vitro fertilization have a risk for ectopic pregnancy in the range of 2-5% and this risk is even greater if they have had known ‘tubal factors’ and undergone reparative surgery for the same.

Incidentally, do not take any vitamin supplements that contain folic acid (like prenatal vitamins!) while you are undergoing treatment because the methotrexate works as a potent folic acid antagonist and you do not want to decrease its effectiveness. Report any unusual side-effects to your doctor and return for appropriate follow-up. The greatest risk of an ectopic pregnancy is not being aware that you might have one and ignoring the typical signs and symptoms that usually accompany it. Best of luck to you. You will probably feel much better within the next 7-10 days.

Dr T

Labels: Ectopic pregnancy, methotrexate therapy

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120 Comments:

At Sun Mar 09, 08:18:00 PM 2008, miraclebaby said…

Dear Dr. T,
I didn't see an email address, but I have a few questions for you. I posted a while back asking about my miscarriage history and incompetent cervix. As I suspected, Kaiser will not refer me to a specialist until I have 3 early miscarriages in a row. Since my first one was late and I had a full-term pregnancy (by God's grace and an amazing perinatologist) with my daughter, they are only doing a few things at this point. Antibiotics for my husband and I at the beginning of the cycle that we try, progesterone supplements for me as soon as I find out I am pregnant, and chromosomal blood tests for husband and I. Mine came back normal. I am being seen by a regular OB. I hope this is a good plan at this point, but I am gun-shy to try without the help of a specialist. Does the current plan sound like a good one?

And off the topic, but on one you know much about:

I mentioned in my last comment about wanting to go into nursing. However, I have a secret dream about becoming an MD and specializing in Perinatology so I can help women who hare going through what I have. Most of the time I don't share this dream with anyone because I feel they would laugh me out of the room. Very few extended family members have finished college, and I would be the first in my immediate family to graduate (in the event that I do). Having been through the rigors of med-school and the demands of being a physician, would you mind sharing a blog entry on your journey through school? Is there any advice you could offer as to increasing my odds of getting into school as a non-traditional student? I am 27 and only in my 3rd term of college. So far I have a 4.0, but I am taking classes at community college. Portland State University is 70 minutes away in good traffic, and we are tight on finances (my husband didn't graduate from college, either). Will taking a good chunk of my pre-med requirements at community college hurt my chances even if my GPA remains strong? I hear that it would, but rumors fly around on the internet. What kinds of volunteer opportunities are out there for people who are interested in this particular area of medicine? Are there ways to find out more about it in a hands-on way so I can decide if I really want to go for it? And finally, is it impossible to get through med-school and residency as a mother of young children? People might think I'm crazy, but I'm losing sleep at night because I feel if I don't try I will always wonder what I could have accomplished if I had tried.

Sorry for all the questions! I probably have a million more, but I'll let you be:) Thanks in advance for your help.
At Wed Mar 12, 09:49:00 PM 2008, Anonymous said…

Dear Dr.my name is natasha and i had an ectopic pregancy where i lost my tube as a result,later i had two healty boys with one tube,after the baby was born i underwent a ligasation,now at age 33 i would like to have another baby,however i was told that i don't stand a chance as reviseing the ligasation could result in my tube being severler damaged and since i only have one i am a bit scared,i am willing to go for tests and do whatever it takes to have a healty baby.please help me if you can i am desparete
At Sun Mar 16, 06:14:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Natasha Mar 12: There are specialists in Reproductive Endocrinology and Infertility who can counsel you regarding the feasibility of a tubal reanastamosis (reversing the tubal ligation) vs simply undergoing in vitro fertilization (harvesting eggs from your ovaries using ultrasound guidance, fertilizing them in the laboratory with your partner's sperm, and then putting the embryos back into your uterus). At your age, the latter may be your better option, but it is expensive. Best of luck and thanks for reading. Dr T
At Sun Mar 16, 08:54:00 PM 2008, JaneDoe said…

I was treated on Thursday with Methotrexate for a cornual ectopic and my Dr told me that I have none of the "risk factors" for an ectopic and she would not have expected this would happen and that I was very unlucky this time as cornual ectopics are very rare as well. This is my first pregnancy and I have no idea how to assess my risks going forward. Does the 20% chance of having another extopic apply to me if there are no risk factors such as prior PID etc? Also is my age a factor? I have just turned 38. My husband and I got pregnant in the first month we tried without any intervention.
At Fri Mar 21, 07:08:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Jane Doe: Yes, once you have had an ectopic pregnancy, the risk of another is in the range of 20% even in the absence of identifiable risk factors. Good luck to you! Dr T
At Tue Apr 22, 06:07:00 PM 2008, Missy Impatient said…

I had only one metho treatment on march 3/08 and I was only approx 4 weeks at the time of finding out, my hcg was only 295 and went to 5 by the 13th so really within the next days it was zero, I have had a period now on Apr/4/08 and it was as normal as the others. I have been back on 1mg of folic for over a month and also the other pre-natels as well, what is your thoughts on trying to conceive now, I took a Ovulation test on the 18th and it came back positive for the LH, could I attempt to try again this time around. I dont want to be irresponsible but not one doctor from the time this happened to now has given me a normal answer instead I have had a bunch of different answers. Please give me your thoughts.
At Sat Apr 26, 03:46:00 PM 2008, Anonymous said…

Any idea how long it takes after the methotrexate shot before I will start bleeding, etc? I had my shot 2 days ago, when my hcg was 5,000 with a cornual pregnancy
At Wed Apr 30, 05:55:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Apr 26: It can take 7-10 days before you start bleeding (sometimes longer). Hopefully, the hCG will start to drop dramatically soon in anticipation of that. Good luck. The MTX takes awhile to work. Dr T
At Sun May 04, 12:08:00 AM 2008, Anonymous said…

Dear Dr. T
I had a ectopic pregnancy diagonised on feb 18 2008 my HCg was 9000 then i was given the methotrexate shot one time and one the 2nd HCG read at around 4000 my level continued to drop dramatically, for the first month the doctor said everythings seems fine. YET now it is April and my levels are dropping slower and are in the 70's i have ask the doctor questions regarding this but he says not to worry as long as the levels are going down. Im considering getting a second opinion from another doctor or should is this normal almost 3 months later and my HCG is still not 0.
thank-you,
WORRIED
At Tue May 06, 04:37:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To worried: That is a low level, so I doubt this represents choriocarcinoma - more likely a 'chronic ectopic'. If the level increases at all, I would recommend consultation and/or ruling out another perganncy and if the levels persist and are low, considering a second course of methotrexate with VERY careful follow-up afterwards. Dr T
At Wed May 07, 07:26:00 PM 2008, Kassie said…

Hi Dr. T,
I have had two periods since my methotrexate therapy on 2/7/08 but they were only 2 weeks apart, 3/13 and 3/29. Since then some spotting 4/16 4/17 and now nothing. According to my calculations I am late over a week for my period. Is it possible that the spotting was a period? If not, is it normal for my body to be so inconstant after the methotrexate?
thanks for your help.
At Thu May 08, 05:05:00 PM 2008, Anonymous said…

Dr. T, I really appreciate you getting back to me . I will go in Friday to get another Beta check to see if the levels are continuing to drop. In the mean time I wondering what is the difference between a chronic ectopic pregnancy and a ectopic pregnancy I briefly researched online and Im wondering if it is a chronic ectopic will i have to go through surgery; or is methotrexate still used in those cases.

Thanks Again,
worried
At Fri May 09, 08:14:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Kassie May 7: Are you pregnant again? MTX does not cause irergular periods, but lots of other things can, including stress. Let us know what happens. Dr T
At Fri May 09, 08:15:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To worried again: At that low level of hCG, methotrexate should work. Dr T
At Sat May 10, 08:46:00 AM 2008, Kassie said…

Hi Dr. T,

Thanks for getting back to me so quickly. I have take two tests both showing up negative so I do not think I am pregnant. However, I have had quite a bit of discharge, light cramping. Not sure what that is about? I have been a bit stressed, sad actually over all this so maybe that is it. Should I take another pregnancy test? Do I just wait? Any thoughts?
At Mon May 12, 06:31:00 AM 2008, Anonymous said…

Question: I had the methotrexate shot back in February - since I have had two periods, but no symptoms of ovulation, breast tenderness or swelling which prior to the shot I have always had. Can the shot affect my hormones? Should I see a doctor regarding this?
At Tue May 13, 05:45:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

Kassie: Stress can affect ovulation, so it might be better just to wait things out for the time being. Unfortunately, you could also ovulate (and get pregnant) unexpectedly so if that is not something you are ready to do yet, consider some effective form of contraception until you are! Good luck and I hope your spirits improve soon! Dr T
At Tue May 13, 05:47:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous May 12: I do not believe a short course of MTX should affect your 'hormones' or ovulatory capability. The residual 'pregnancy hormones' and the stress of the whole situation might. If you haven't started ovulating again within 6 months, let your doctor know. Dr T
At Thu May 15, 03:16:00 PM 2008, Anonymous said…

Hi Dr T,

Is it normal for woman to feel discomfort in the same area of thier ectopic pregnancy. I had one in feb 08 and I still feel discomfort in the area, As far as a know my levels are back to normal. I had a doctor give me a examination and he said didnt feel a cyst any suggestions
At Fri May 16, 01:56:00 PM 2008, Anonymous said…

I went to get my beta HCG levels on the friday as I said and they came back 40 and this is from an ectopic pregnancy that was diagnosed 3 months with the treatment of methotrexate. The doctor told me not to worry they are dropping slower but its ok. The original level was 9000. the problem is I am worried and I dont feel as though this is normal from reading up on this,, Any suggestion for me ?

Thanks Again,
Worried
At Fri May 16, 02:59:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous May 15: It is not unusual to have some ongoing discomfort and if the ectopic was bleeding internally, you may have developed some adhesions (scar tissue) between the tube and other pelvic structures. Dr T
At Fri May 16, 05:51:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To worried again. It is still falling but you are correct - it has been so slow! I think you're are fine, but you might ask your doctor to arrange for a second opinion with a gynecologic oncologist. Best wishes. Dr T
At Sat May 24, 05:50:00 PM 2008, Anonymous said…

Hi Dr. T,

I was wondering what happens in the situation where a woman gets pregnant before her levels are return to 0 after having a ectopic pregnancy? will the pregnancy be a normal pregnancy? or is the fetus (baby) at higher risk for have problems? thanks so much u have been so helpful in your answers to previous questions I've read.
At Tue May 27, 06:28:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous May 24: If the pregnancy is in the uterus, there is a very good chance that a low level of hCG will not affect the implantation. It is always better to wait for the ectopic to resolve completely and the tube to heal, but if you managed to conceive, more power to you at this point (and good luck too)! Dr T
At Sat Jun 28, 05:38:00 AM 2008, pudgierx said…

Dearest Dr. T,
I had a single dose of methotrexate shot 2 weeks ago. My HCG as of last thursday was reported to be 9. I was wondering if it was normal to still have a very sore lower back and bad stomach cramping, at times in the tube area. Do I still have a chance of rupture if the HCG went down to a 9?
At Fri Jul 04, 07:57:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To pudgierx: It is unlikely that you are risk for complications related to rupture at this time. It is not all unusuall to have some adhesions and discomfort out of proportion to the hCG level because it caould also be due to a problem that preceded and put you at risk for tthe ectopic to begin with. If it persists for a month or more after your hCG is gone, your doctor might consider a diagnostic laparoscopy anyway. Best wishes! Dr T
At Fri Jul 04, 02:42:00 PM 2008, Anonymous said…

Dr. T,

I had methotrexate treatment two weeks ago for an ectopic pregnancy. As of July 2nd, my numbers had decreased from 264 to 68. I have had cramping and light bleeding today (which just happens to be the day prior to when my next period was due). Is this possible with my my numbers still at 68? I'm nervous that the cramping is an indication that something is wrong.

Any advice would be very much appreciated.

Thanks.
At Sat Jul 12, 07:51:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous July 4: It is not uncommon to have pain for several weeks after MTX therapy for an ectopic pregnancy. You are VERY unlikely to get in trouble with an hCG of 68. Hang in there! Dr T
At Mon Jul 14, 01:03:00 PM 2008, Anonymous said…

One more question. Is it unusual to have an hCG of 22 three weeks after tx with MTX? It was at 68 almost two weeks ago and today it is still 22. What is a "normal" amount of time for it to go to 0?

Thanks!
At Mon Jul 14, 06:54:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous July 14: It can take 4-6 weeks. It does not take many placental cells to give you an hCG of 22. If that rises, you may need another dose of MTX. Dr T
At Wed Jul 16, 05:35:00 PM 2008, Anonymous said…

my hcg levels are going down i had my shot on june 20 i didnt start bleeding til the 5th of july til 13th i stoped now it is july 16th and i am cramping really bad again and spotting is there something wrong or is this normal?
At Fri Jul 18, 05:17:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous July 16: Your course seems a little unusual at this point. What are your most recent hCG levels? Dr T
At Sat Jul 19, 09:07:00 AM 2008, cjt said…

I had a shot of methotrexate on June 16 to treat an ectopic pregnancy. Is it possible to get pregnant during the time that my HCG level is going down and returning to normal? I've been having unprotected intercourse and am not sure if ovulation was possible until after my next period.
At Wed Jul 23, 11:18:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To cjt: It may be possible, so why tempt fate - use something for contraception over the next couple of months. Give your body a chance to heal from the ectopic. Now that you have had one, you are at a 15-20% risk of having another and the outcome next time might not be so good! Dr T
At Tue Aug 05, 11:23:00 AM 2008, Anonymous said…

Is methotrexate ever administered in a non-ectopic pregnancy? By way of background, I'm an IVF patient. My HCG level failed to rise normally. My six week sono showed a very tiny mass as well as a fibroid close to the uterine wall and the mass. The mass had disappeared by the second sono several days later. My doctor believes that the fibroid is to blame and that was not an ectopic pregnancy. However, I was given a methotrexate shot as my HCG levels were not decreasing on their own. I have now gone from 694 to 197 in the span of a week and half. I have also started bleeding (3 days now).
At Thu Aug 07, 12:58:00 PM 2008, Monica said…

Dr.T, I was administered Methotrexate for a disagnosed ectopic pregnancy on Friday July 25th. (the day prior to the shot, my levels had not doubled the series of beta tests and had reached a high of 3850). That following Monday, I went in for my blood to be drawn again and with those results, my levels had peaked to 6950...4 Days after receiving the shot. I then went again on that follwing Friday (August 1st) and they had gone down by 15%. Yesterday, I received more recent beta results and while my Numbers are still going down, they are doing so very slowly. (As of Monday 2 weeks and 2 days after the shot, my levels are still up at 4860).

I am concerned that I am still nauseated and have extreme breast tenderness. And the fact that I have had no bleeding or spotting of any kind.

Could there be any chance that I am still pregnant? Or am I possibly a candidate for surgery?

Any advice would be helpful!
~Very Concerned
At Thu Aug 07, 01:00:00 PM 2008, Anonymous said…

Hi Dr. I was in contact with you on this blog a couple months back, my issue was a very slow HCG drop from feb of this year. I went to a specialist as you suggested he said nothing was wrong. YEt I recenty went to get another ultrasound due to small pain in the same area, oddly enough the tech said the same shape or "cyst",,from the ultrasound in feb is still there in the same location!! I got my blood levels read last week it was at 5. Now Im WORRIED all over again, is it likely that I will need surgery to get this removed? or do i even need surgery at this pount?? THis all started in febuary. Could it be the pregnancy never dissolved but my HCG levels went down. I am clueless as what to do next. Oh and will this effect me having babies in the future?? i currently have none .
At Thu Aug 07, 07:19:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Aug 5: Yes, more and more providers will use methotrexate in situations of nonviability, especially when ther is some uncertainty as to the location of the pregnancy. It will expedite resolution of a pregnancy that didn't get off the ground in your case rather than prolonging that process over weeks and weeks. I am sorry for your loss. Dr T
At Thu Aug 07, 07:22:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Monica: Your doctor might want to repeat the ultrasound and then give a second dose of MTX. You are still at increased risk for requiring surgery, but at present the hCG levels are dropping and it does not sound as if the ectopic has ruptured. Good luck! Dr T
At Thu Aug 07, 07:25:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Aug 7: If you have a persistent adnexal mass, then perhaps a diagnostic laparoscopy is in order. At the same time, a hysteroscopy could be done and the patency of your tubes evaluated to try to answer your questions regarding prospects for spontaneous future pregnancies. I wish I had a crystal ball to tell you what is going on, but I ain't that good! Let us know what you find out! Dr T
At Fri Aug 08, 10:00:00 AM 2008, Anonymous said…

i was diagnosed with ectopic pregnancy aug.4th. aug.5th i got the methro.injection. one in each buttcheek. it is now the 4th day and im not bleeding yet. i had my shots around 11:15am aug.5th. shouldnt i ve starting to bleed now? does this mean ill need another injection? B4 i got the shots my hcg level was 3900..im not sure the amount in the injections they gave me.i get more blood work today and then again monday to see if they dropped...is it possible i just might not bleed until closer to the 7th day?
At Sat Aug 09, 05:45:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Aug8: Be patient. You may not bleed at all for 7-10 days. The key will be to see what happens to the hCG levels over the next week or so. Hang in there. Odds are you will do just fine at that starting hCG level. Good luck! Dr T
At Thu Aug 21, 02:53:00 PM 2008, Anonymous said…

Hi I had MXT shot 9 days ago for ectopic pregnancy, my most recent hCG level was 68. My question is in relation to alcohol- is it safe to drink at this stage, or should I continue to avoid it? I have only been able to find info about this in relation to use of MXT in RA patients. Obviously if I can't drink I won't, but just want to be sure. Also I have been given conflicting info regarding lenght of time before trying to conceive again- what is your recommendation? Thanks for your help
At Wed Aug 27, 06:01:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Aug 21: Most if not all of the MTX should be gone by now. I still recommend that women with ectopic pregnancies wait at least 3 months before trying to get pregnant again. Give some time fo all the inflammation and tissue damage to die down. You are still at a 15-20% chance of another ectopic for whatever reasons caised you to have this one, so don't force the issue at this point - I think waiting may minimize your risks. Dr T
At Fri Aug 29, 08:41:00 AM 2008, Ellen said…

I was diagnosed on 8/25 with a possible ectopic pregnancy. On 8/26 I got a second ultrasound to confirm and was told I needed the methotrexate shot which I received around 12:30 am on 8/27. My hcg level was 7100 and the "mass" measured 2.5 cm. I still have not started to cramp or bleed and I am terrified. I had surgery years ago for endometriosis and had one ovary removed so I am desperately hoping this injection works and my tube can be saved, since this is my only tube, so I can try again in the future. Also, another thing I just can't shake is hoping I did the right thing. They told me that there was a sac in my uterus but it only measured around 4 weeks and I was supposed to be 5 weeks where the mass in my tube measured the 5 weeks I was supposed to be. they also said that at an hcg of 7100 they should have been able to see a baby and a heartbeat and not just a small thickening sac and fluid. Are they right? Did I make the right decision? Please tell me what you thing. I can't stop thinking about this and lie in bed at night wondering if I did the right thing.I didn't want to lose my tube but I certainly didn't want to lose a healthy pregnancy either. Thank you so much!
At Mon Sep 01, 11:51:00 AM 2008, Anonymous said…

I am 41 years old and was given Methotrexate for an ectopic pregnancy on Aug 8.I never experienced pain at all, and only had a small amount of bleeding and the some spotting since. At 2 week checkup (Aug 21), my hgc was at 68, everything appeared normal, and my doctor told me that I could pretty much resume normal activities, (exercise, etc.) 3 days ago, I started bleeding and I assumed that I had started my period, even though I experienced none of the normal symptoms I usually do with my period. The problem is the bleeding has become excessive for me to the point I am even feeling weak. I wasn't even bleeding like this when I originally went to my doctor and discovered the ectopic pregnancy. Could this be a normal period, just heavier than usual? Or should I be concerned and could there be something else wrong? No, I have not had sex at all.
At Tue Sep 02, 05:02:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Sept 1: Odds are you are just having a heavy withdrawal bleed from the pregnancy hormones that stimulated the endometrium, but OMG girl, when that sort of thing happens, you NEED to call your doctor! If you are still bleeding heavily and feel weak, please do! Dr T
At Tue Sep 02, 06:47:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Ellen: At that hCG level, they shoudl have clearly seen definitive evidence of an intrauterinepregnancy. So, this is probably an ectopic, but that is an awfully high hCG level and you could still lose that tube. If you do, it may actually be for the best because of the damage that would make it highly likely that you would have another ectopic. Your best (and safest) bet may well be in vitro fertilization (and you do NOT need your tubes for that!). Good luck and let us know how things turn out. Dr T
At Wed Sep 03, 06:02:00 AM 2008, Anonymous said…

Hi,

Is it normal to have pain in the area of an ectopic after it has resolved? My husband and I have just started trying again and I have been having dull pain where we think the ectopic was. I had an ectopic back in June, was treated with methotrexate and things cleared up quickly. My highest hcg was 268, so I'm not sure how much damage I could have had to the tube. (if that is where it was, they never found it. I'm anxious now that we are trying. We want to conceive so badly. I just want some positive thoughts that we might be able to conceive with no further complications. Any thoughts would be appreciated!

Thanks.
At Wed Sep 03, 08:41:00 PM 2008, Zeke said…

Dr. T.,
This is my first pregnancy and it is not going well. I am 35 yrs. old and confused. I found out I was pregnant on 8-9-08. My counts did not rise quickly on the first two HCG tests. About a week later they soared to 2900. Well, on 8-26 they dropped to 2700. We prepared for the worst. On 8-28-08, it happened, so we thought, a miscarriage. I took the mass to the docs. office the next day and they sent it to the lab. However my counts only dropped to 2600. The lab results showed that the mass was not pregnancy tissue and not a product of conception. Well, what was the mass? I took it in water, is the lab right? The doctor wants me to have the surgery or the MXT injection and I am leaning towards the latter. However, she wants it like tomorrow. Can I wait a few days to see of the levels go down on their own? What is the rush? Will this inhibit my chances of getting pregnant again? We are concerned.
Thanks for all your help! Zeke
At Wed Sep 03, 08:59:00 PM 2008, Zeke said…

Dr. T.,
I am a first timer, 35, and scared. My levels rose slwoly but then on 8-26-08 my HCG levels dropped from 2900 to 2700. We began to prepare for the worst. On 8-28-08 I thought it happened, a miscarriage. I took the mass to the doctor's office the next day. The lab said it was not pregnancy tissue and no product of conception. So, my doc. thinks I am still pregnant with an ectopic. She spoke to me about the surgery and the MXT injection. I am leaning to the MXT injection but I have a few questions. What was the mass? If it took my levels a while to rise, won't it take them a while to drop? Why is she rushing me to make a decision by tomorrow...one day after we talked? I am worried about getting pregnant again since I am "older" in the pregnancy world. Thanks for your help!
Zeke
At Sat Sep 13, 01:17:00 AM 2008, Anonymous said…

Hello Doctor. I was diagnosed with an ectopic pregnancy as of 8/3. I went through the series of Methotrexate shots and as of 8/28 my Hcg level was still at 400. It started at 13,455, which is very high. I had a normal period starting 8/29 and ending 9/4. Problem is I have been having unprotected sex with my husband as we really want a baby now. I havent given birth in 14 years. I took a pregnancy test today and it read positive. Is this because my Hcg levels are still high or could I possibly be pregnant again? What are the chances that this is a normal pregnancy and not another ectopic? Please help. MIzz cali
At Mon Sep 22, 10:06:00 AM 2008, Anonymous said…

Dear Dr. T, 38 days ago I started bleeding and cramping; despite the heavy bleeding (and passing tissue) my hCG levels kept going up. An ultrasound confirmed an ovarian ectopic pregnancy and 18 days ago I was treated with methotrexate. Before treatment my hCG levels were 3490 and 4 days after, the levels dropped to 3289. I now test every 7 days, as the hospital has not called me back, I assume my hCG levels are falling. I have a follow up OBGYN appointment in 3 weeks - however I have some questions now that I need help with. (1) can I reassume taking my prenatals (PregVit with 1 mg of folic acid)? If methotrexate has a 3 to 15 hour half life, then, by 18 days after treatment, the methotrexate should be completely gone. Is my reasoning correct? [I want to start taking it – as I would really like to try to conceive again after my next period] (2) I need to have my wisdom tooth out – and, as with the question above, can I have strong pain medication/ anesthesia (typical for wisdom tooth removal)? (3) I bled for 20 days before the methotrexate treatment; and stopped the morning before (I also passed a tissue that resembled a semi-translucent sac). Prior, the u/s was showing a mass on the ovary approx. 1.5 x 1.3 x 1.5. Should I be bleeding more? If my hCGs are falling, then where has the "mass" gone? I haven't had any pain nor bleeding. Will it "flush out" with my next period? Please help; I hate not knowing!
At Tue Sep 23, 05:09:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Mizz cali: I hope you are NOT pregnant again. Please wait until you have had a completely negative hCG and a couple of months to recover from the ectopic. That will decrease the already high risk you have for another ectopic. Good luck and use something for contraception for the next couple of months. Dr T
At Fri Sep 26, 01:23:00 PM 2008, Anonymous said…

how are chronic ectopic pregnancies treated? i recently got an ultrasound done post an ectopic pregnancy in february my levels droped slowly but finally got to 0 in august. the august ultrasound results say findings are most consistent with a chronic persistent ectopic pregnancy I dont see the doctor any time soon ,, do you have any suggestions?
At Thu Oct 02, 11:06:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Sept 3: You probably have some adhesions secondary to the inflammatory reaction that can occur around an ectopic pregnancy. Adhesions can be very filmy strands of scar tissue between the tube or other structures in the pelvis and bowel or omentum or much enser nabds of scar tissue. Anying that stretches on the adhesions and the inner lining of the abdomen may cause pelvic discomfort, pain, and even nausea. If the symptoms persist, your doctor might consider a diagnostic laparoscopy, especially if you have difficulty conceiving in the future. Dr T
At Thu Oct 02, 11:12:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Zeke: I am sorry for the delay in my response, but the folks at Healthline have just forwarded your comments to my email address. The mass could have simply been an organized blood clot. If your hCG levels were still elevated, but not rising, your pregnancy is not going to be a good one and you could have either a 'blighted' intrauterine pregnancy or an ectopic pregnancy. I am sure the issue is resolved by this point, but I would have probably repated the hCG levels and an ultrasound and then either treated you primarily with MTX or done a D&C first to see if there had been an intrauterine pregnancy and if not, then proceeded with the MTX. Again, I am sorry for my delayed response. If you get this, can you let us know how things turned out? Dr T
At Thu Oct 02, 11:17:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Sept 22: I would hold off on the prenatal vitamins with folic acid until your doctor has decided whetehr or not you will need a second course of MTX. Any type of pain medication you might need for the wisdom teeth is not going to affect your response or be contraindicated because of the ectopic pregnancy. You will not "pass" the ectyopic pregnancy. It will be simply resorbed inside your abdomen. Hopefully you will not get too many adhesions at the point of the ectopic or as a consequence of intraabdominal bleeding. Let us know how things turn out. Dr T
At Thu Oct 02, 11:20:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Sept 26: If your hCG is now negative, hen the 'ectopic pregnancy' is no more. However, you may have had damage t the tube that is permanent and which might increase your risk for another ectopic or for infertility. If you have trouble getting pregnant or develop pain, I would recommend that you have a diagnostic laparoscopy done by an individual with experience in more sophisticated operative laparoscopic surgical techniques. Thanks for reading. Dr T
At Sat Oct 04, 02:30:00 PM 2008, Anonymous said…

Hi Dr. T.,
Thanks for the response. I have since had the MTX shot and my levels are down to 146. I am going weekly to get my levels tested and hping to have cycle soon. How long should that take? I have never been more wanting to have a cycle than now. I was told that the cramping would be bad but when should I expect that too? Lastly, when can I try to conceive again?

Thanks again, Zeke
At Mon Oct 06, 04:14:00 PM 2008, Anonymous said…

Hi Dr. T,

I'm hoping you can give me some insight into my experience with a suspected ectopic pregnancy. My LMP was August 12th, and I began what I thought was a period on September 8th. It only lasted for four days (with no bleeding on the third day), and was lighter than my normal periods. On September 16th, I had more spotting and at that time took a hpt which came back positive. I had a blood test that same day, and my levels were 404. I had a repeat test on the 18th, and my levels were 636. My doctor told me at that time that the pregnancy was probably not normal, and sent me in for an ultrasound to rule out an ectopic pregnancy on the 18th.

The ultrasound showed what appeared to be a small gestational sack, so my doctor ordered another round of blood tests which I took on September 22nd. My levels were at 646 on the 22nd, so my doctor was convinced that I was not having a normal pregnancy. On Saturday, the 27th, I began to have light spotting, with some intermittent heavier bleeding and clots, and I have had lighter bleeding ever since. I assumed I had passed the pregnancy.

I had another bloodtest on September 29th, and my levels increased to 808, so my doctor once again becamse concerned about an ectopic pregancy. I had another ultrasound on Thursday, October 2nd, and the ultrasound technician informed me and my doctor that there was no signs of a pregnancy in my uterus or in the tubes, and that my uterus was empty. My doctor had me go to the ER where my levels were tested again and they were at 1100. At that time, I was informed that there was still a slight chance that I was actually carrying a viable pregnancy, but that it was highly unlikely and that I should take a round of MTX just in case. I opted to take the MTX and now I am just waiting for the results of my latest quant, which I took this morning (the 6th).

My question is, does this sound like an ectopic pregnancy to you or a miscarriage? My doctors have been unable to give me any answers, and I'm concerned that I did have a viable pregnancy and that it was a mistake to take the MTX. I'm also concerned that they saw "something" in my uterus at 5.5 weeks, but later saw nothing anywhere else. What could this all mean? Thank you so much for your time.

-Tisha
At Tue Oct 07, 05:57:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

Zeke: I would recommend waiting at least 2-3 months to give all the tissue damage and inflammatory reaction from the ectopic a chance to resolve. That will decrease your risk somewhat for another ectopic although that risk can be as high as 20% or more regardless of what you do. Good luck! Dr T
At Wed Oct 15, 11:51:00 AM 2008, Darci said…

Dr. T., It has been over 4 weeks since I received methotrexate for an ectopic pregnancy. My hCG levels are dropping textbook perfect-from over 6000 now down to 290. However, I continue to have moderate to severe pain in my abdomen and my hemoglobin continues to drop, although not as significantly as a couple of weeks ago. I have been hospitalized twice as my hemoglobin dropped from 11.5+ to 9.8, but had only a 'moderate' amount of blood in my abdoment. I stabilized while in the hospital and was given the choice to have surgery or go home (I went home).

Now a couple of weeks later, the pain is bad enough that I cannot walk normally, but not as bad as it has been; however,my hemoglobin is now 8.9. Should I be worried that I am still bleeding internally? I am wary of taking iron supplements because of possible constipation-I already have so much bladder and intestinal pain assumingly from the blood that is still in my abdomen. I keep managing to avoid surgery, but I can't take the ongoing pain for much longer. The doctor I first saw with symptoms has been following me and wants to avoid surgery, but another doctor from his practice was leaning toward surgery when I was in the hospital. I would really appreciate your ideas and suggestions. Thanks!
At Thu Oct 16, 08:42:00 AM 2008, Anonymous said…

Hi Dr. T.,

I was treated for an ectopic back in June/July with one does of MTX. I bled for most of June prior to the shot, then again for about a week in July about 2 weeks after the shot and I had what I thought was a very short cycle Aug 11-12th. I have since not had a period. I'm on CD 66 today. Have you ever heard of such a thing after an ectopic? I had long cycles before the pregnancy (38 days or so) but this is getting ridiculous. My doc says to wait 90 days and she'll give me meds to kick start. I am just really concerned that I have something bad going one. We really want to get pregnant soon, and I'm very anxious.

Any advice would be much appreciated.

Thanks!
At Fri Oct 17, 05:31:00 PM 2008, Anonymous said…

Trish,
I had a very similar situation. I actually passed "something" and I thought that I had a miscarriage but obviously not. However, my quants were just like yours at first but after the passing of "cells" they dropped slightly. I knew something was wrong and all the ultrasounds and blood work began. however, when I went for my ultrasound there was nothing anywhere. I had the MTX shot and my counts are finally down to 10. It took about 5 weeks for this to happen. I also just started a MC and am looking forward to trying to concieve soon. As for the 5.5 weeks where they saw something. They may have but the embryo probably did not implant in the uterus and then shifted somewhere. I know it is REALLY weird but please believe that the pregnancy probably was not vaible. I knew I was pregnant but we never saw anything. We were like where is it but there was never an answer for that either. Hang in there and it will get better. If the doctors thought in any way that you could have carried the baby to term, normally, then they would not have suggested the MTX. Just know that you are not alone.
Zeke
At Sat Oct 18, 10:14:00 AM 2008, Kanjepe said…

Hi Dr T

My summary is

Free floating ecoptic pregnancy removed by laporoscopy 19th September - beta HCG 4000 - they did not remove the fallopian tube but assumed they removed all of the ectopic as if had moved from the left fallopian tube outside in the abdomen once they operated

21st Sept. beta HCG reduced to 800+

I continued to experience dizziness and breast tenderness so returned to hospital 2 weeks later

3rd October beta HCG 263

Dizziness persisted

17th October beta HCG 500+

I have now had a second Vaginal US to check that I havent conceived again (as I had a normal period on the 1st September so didnt know I was preganct - we were still trying to conceive right before the ectopic was found).

I have been advised to start Methotrexate on 20th October as the consultant feels it is some left over placenta tissue.

Two things concern me.

Could the recent rise over two weeks of HCG level be indicative of a second pregnancy conceived around the time of the ectopic removal or is it far to low to be indicative of that ?

That I was informed that with methotrexate you cannot try for another baby for at least three months after receiving the treatment - presumably due to the folic acid antagonist properties?

I am 33 and this would have been my first pregnancy and we are keen to try again as soon as we can.

Would appreciate your advise on why this would happen and if its a common occurence and what the possible causes may be...
At Sun Oct 19, 07:54:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

Tisha: About all I can tell you with this information is that it did not appear that you had a viable pregnancy - whether it was in your uterus or in a tube probably vcannot be ascertained at this point unless you had a D&C that showed evidence of an intrauterine pregnancy. Even then, sometines you can have both! But that is very rare. It i not unusual to see what appeasr to be an early, empty sac in the uterus even with an ectopic - this can be an accumulation of blood or fluid. Anyway, hope you are getting better. Best wishes and thanks for writing. Dr T
At Mon Oct 20, 08:47:00 AM 2008, Anonymous said…

Dr.T

My wife had an tubal pregnancy last year and received the MTX shot which didn't work. She ended up having surgery. Now 1 and 1/2 years later we have been diagnosed again with a tubal pregnancy. She just received the shot again and after 3 days her numbers are still going up. We were told that this is normal. When should we expect numbers to decrease and do you happen to know what the chances are that the shot wouldn't work again?

Thanks,
J & J
At Mon Oct 20, 08:50:00 AM 2008, Anonymous said…

Dr. T

I ment to also ask if you knew of any books or websites that would give a list of foods that have no or very little folic acid. Our doctor instructed us to avoid foods with folic acids becaue of our recent MTX shot, but we are having an impossible time located any sort of lists of foods without folic acid.

Thanks,
J & J
At Mon Oct 20, 02:32:00 PM 2008, Anonymous said…

Dear Dr. I had methotrexate on Friday night with a hcg level of 1064...today is Monday and the level is 1200 My gyno said that if the level doesn't go down on Thursday I'll need surgery..what are the chances that it will go down? I don't want surgery!
At Tue Oct 21, 06:21:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Zeke Oct 17: Thanks for your excellent comment. Dr T
At Tue Oct 21, 06:25:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Kanjepe: Most likely there are still placental cells present somewhere (i.e., in the tube) still making hCG. It is unlikely you conceived that quickly and I would highly recommend waiting the 2-3 months before getting pregnant againand then starting folic acid prior to conception. If you don't, you may be at even higher risk for another ectopic pregnancy. That risk is 15-25% anyway. Good luck and let us know how things turn out. Dr T
At Tue Oct 21, 06:28:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To J&J: Usually they will start to fall by 7 to 14 days out if the MTX is going to work. What hCG level did you start with? Good luck and let us know how things turn out. Dr T
At Wed Oct 22, 08:32:00 AM 2008, Anonymous said…

Dr. T,

Thanks for the response. We started out around 650 when we took the shot (5 days ago). My wife had bloodwork 3 days out and it went up to 975 range. Today after 5 days from receiving the shot it went up 300 points from two days ago to 1275 range. The doctor is going to give another shot of MTX. We are worried that my wife doesn't respond to the MTX since last year when this happened it didn't work and ended up rupturing.

As you can see the numbers are not doubling every 2 days, but they are still rising. She is having very light cramping and we are worried about another rupture like last time. Is it bad for her health to receive 2 mtx shots so quickly?

Thanks,
J&J
At Mon Oct 27, 01:26:00 PM 2008, Anonymous said…

Hello Dr T.

I had an ectopic pregnancy and i was given 2 shots the 2nd one on sept 5th and my level was down to 9 on Oct 1st and i also started bleeding on that day and bled for 4 days. My cycles before the ectopic were 30-35 days.. on Oct 20th we had sex and the condom tore, i know my period isnt due until the end of this week but is there any way i can check so soon if i may be pregnant or not? what are the chances that i may be pregnant.. i am so scared
At Tue Oct 28, 05:57:00 PM 2008, Anonymous said…

Dear Dr. T,
Just this afternoon my dr. confirmed my tubal pregnancy and gave me the methotrexate injection. My hcg levels had risen from about 570 the 17th of this month to to over 1000 yesterday. I am terrified of a rupture before the medicine is able to work. What are the chances that this can happen? The dr. said to be cautious of severe abdominal pain and now every little pang I feel, I hold my breath. I've had light bleeding for the past several days but its worse today. Would I definitely know if I ruptured? Its painful, right? Thank you for any info.
So scared
At Thu Oct 30, 03:34:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Oct 20: It an take 7-10 days before the hCG levels show a significant drop. If you are not symptomatic, even if the levels do not begin to drop within a week, you can always opt for a second dose of the MTX before needing surgery. Dr T
At Thu Oct 30, 03:36:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To J&J: Usually it is not very risky to receive two courses of MTX and very few women will not respond to that at your wife's low hCG levels. Good luck and let us know how things turn out. Dr T
At Sat Nov 01, 09:11:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Darci: Sorry but I just recently got your comment in my mailbox. I hope things have gotten better by now either by tincture of time or surgery. At the high level of hCG with which you started, failure of the MTX or subsequent rupture of the ectopic even with the hCG levels dropping can occur. You could have blood in the abdomen and most likely do (or did) but you might also have adhesions from the ectopic pregnancy or even prior to the same. With the pain and the dropping hemoglobin, surgey was probably indicated. Hope you are doing better now and please take your iron! Constipation should be the least of your worries at this point. Dr T
At Sat Nov 01, 09:35:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Oct 16: Sorry for the delayed response. If you had prolonged cycles prior to your pregnancy, you may have a hormonal imbalance such as that related to polycystic ovary syndrome that can get progressively worse with time. Other hormonal conditions for which you should be evaluated are thyroid disease and hyperprolactinemia. I doubt any of the problems you are having related to your delayed onset of menses is related to the ectopic pregnancy. You can "kick start a period" but wouldn't you rather try to find out WHY you are having a problem to begin with? Best wishes. Dr T
At Sat Nov 01, 09:35:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Oct 16: Sorry for the delayed response. If you had prolonged cycles prior to your pregnancy, you may have a hormonal imbalance such as that related to polycystic ovary syndrome that can get progressively worse with time. Other hormonal conditions for which you should be evaluated are thyroid disease and hyperprolactinemia. I doubt any of the problems you are having related to your delayed onset of menses is related to the ectopic pregnancy. You can "kick start a period" but wouldn't you rather try to find out WHY you are having a problem to begin with? Best wishes. Dr T
At Tue Nov 04, 08:13:00 PM 2008, Anonymous said…

Dear Dr. T,

I would like to get your thoughts around what I have experienced the last 2 months. I am 32 years old and this was my first pregnancy. On Sept 5, I found out I was pregnant. I was about 4 weeks at this time. When I went for blood test, the doctor informed me that beta was low. To make the long story short, the highest my beta count ever got was 330. I started spotting on the 18th so I went to the hospital. The DR. tested my blood and my hcg went down to 233. He mentioned that I was going through an early miscarriage and scheduled me for an ultrasound on the 20th. during the U/S, they found a complex mass measuring about 3.4 x 2.8 x 1.9 cm posterior and inferior to the right ovary. They mentioned that it was quite a distance from the ovary and was suspecious that this may be an intra-abdominal ectopic pregnancy so they sent me to see the OB who did a full examination on me. They did not find a fetal pole or heartbeat nor did they find anything in my uterus. I did not have any pelvic pain and my spotting has now turned into a period-like bleeding. The OB did not think I did have an ectopic and sent me for another U/S the following day. No change on the U/S but my hcg went down to 149 so the OB sent me home and just told me to rest. I was also asked to get my blood tested again after 10-14 days. My heavy bleeding lasted about a week then I spotted for another 3 more weeks. When I went to get my blood tested however, I had the following readings:

Oct 4 - 270
Oct 7 - 250
Oct 14 - 230
Oct 18 - 136
Oct 21 - 81

I went back to my OB on the 24th of Oct because I was concered about my never-ending spotting and my HCG level. The OB recommended that I get the MTX shot to stop the spotting. I was given one dose on Oct 26 - my hcg level was 76 and by Oct 30, my level was down to 35. My concern now is was this an ectopic pregnancy? Before I try to conceive again, would you recommend that I get tested to see if my tubes were blocked? Your insight would be greatly appreciated.

Thanks. MC
At Fri Nov 14, 10:07:00 AM 2008, Anonymous said…

Dear Dr. T,

Do you recommend a HSG after an ectopic pregnancy to see if there is an issue with the tubes? We want to try and conceive in a few months and wanted to see if this is something that should always be done first... Thanks!
At Wed Nov 26, 11:13:00 AM 2008, natalie said…

Dear Dr.T My name is natalie I had and ectopic last year 1/25 and now I have another ectopic 11/18. I was given the first shot of methotrexate but my beta level went up to 4396 so they given me a second dose of it. Is it normal to experience dry mouth, nasal, and vaginal area. After 3 days I am having cramping is that normal does that mean the beta level is decreasing.
At Fri Nov 28, 09:03:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Nov 14: Not necessarily unless you have trouble conceiving again. Besides, there may be subtle damage to the tubes that will not be detected by an HSG that still increases your risk for another ectopic pregnancy. Just be cautious early in another pregnancy to confirm that the pregnancy is in the uterus very early. Best wishes! Dr T
At Tue Dec 09, 01:24:00 AM 2008, Anonymous said…

Dr. T, I found out I was pregnant in early November, this past friday Dec. 5, I started spotting in the morning, by the afternoon I went into the ER because it was heavier, darker, and I started passing clots the size of new born kittens. They did an ultrasound and ran blood work, they didn't see anything in my uterus, and suspected I had an ectopic pregnancy that hadn't ruptured yet. They gave me Methotrexate, and sent me home. I am still bleeding, the amount is comparable to my normal period but it's more the consistancy of bloody snot. I was wondering if that was normal and how long the bleeding usually last? my HCG at the time they gave me the injection was 12318, but I don't know about my recent draw yet.

Thank you,
Lady D
At Wed Dec 10, 08:55:00 AM 2008, Anonymous said…

Dear Dr. T,

Thank you for this blog. It is a great source of information.

I have Premature Ovarian Failure and was given a 5% chance of conceiving. A week ago, I found out I was pregnant. I am now 5 weeks and the Drs. believe the pregnancy might be ectopic on or near my ovary. My HCG has fallen to 100. If it doesn't continue to fall on its own, I will get the MTX shot next week. My questions are:

1) What are the chances of my miscarrying naturally? Can that happen with an ectopic pregnancy? (Or only if the pregnancy is in my uterus, which the Drs. couldn't rule out since I am not very far along?)

2) What should I expect if I miscarry at 5 - 6 weeks?

3) Does having the ectopic decrease my already low chances of conceiving in the future? I had no risk factors for ectopic before this pregnancy but know that the ectopic risk will increase. I'm also concerned about waiting months to try again since I have so very few eggs left.

Thank you very much for your time! It makes me feel better just to know that others are going through this too.

:) CP
At Wed Dec 17, 07:32:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Oct 28: At those low hCG levels, chances are that you will do just fine with the MTX. You may still have pain, but frank rupture is less likely and yes, you will feel a lot of pain if you do rupture. Dr T
At Sun Dec 21, 04:33:00 PM 2008, smpmay said…

Dear Dr. T.

I was diagnosed with an ectopic pregnancy on 12-12-08. My HCG doubled at a normal rate until it reached 1430 on 12-8-08... from 12-8-08 until 12-12-08 my counts maintained between 1430 and 1560. (at this point I was 6 weeks, four days pregant) I had two ultrasounds, both confirming no gestational sac in my uterus, uterus lining was not thickened, uterus did not change size, etc. My tubes did not appear enlarged, no fluid in my abdomen, and the tech could not find a gestational sac anywhere. I was given two injections of Methotrexate on 12-15-08, started bleeding next day, and it stopped 12-20-08. I have been nauseous and tired, but those are my only side effects. I have gone for a follow up HCG quantative this past Friday, although I havent been given the results yet. I am wondering how long the drug will stay in my system, how long should I wait until I try to conceive again, and when the nausea will go away? My doctor is on vacation and the OB nurse doesnt seem as familiar with this drug/treatment.

Any information you can provide is incredibly appreciated. Reading all of the online posts is making my head spin, and trying to find answers feels like I am searching for a needle in a haystack.

It is honorable of you to help random online strangers by answering questions.

Thank you again,

Susan
At Thu Jan 15, 10:30:00 PM 2009, Anonymous said…

hello, with an etopic pergancy how far along can you get in the pergancy until something serious happens? I'v had an etopic not to long ago and now I am peragnate again. I should be about 5-7 weekd far along am I still at risk?
The worried!
At Tue Jan 20, 05:02:00 AM 2009, Rachel said…

Dr T ~ Like may others, I've just been thru an ectopic pg.
- My LMP - 11 Nov 08.
- On 07 Dec, day of MX shots, my hCG was 7,000+.
- Day 4's hCG was 9,000+
- Day 7's 5,900+ YAY! no 2nd MX!
My problem is this - I still have loads of soreness at initial movement like getting up from sitting or out of bed - it actually takes my breath away. I feel just like I did after a c-section. Now, for 3 days, my uterus is contracting - thinking this is a good thing - but, after cramping my uterus area feels like a 10 lb weight. actually uncomfortable. Is all this quite the norm after MX? I only heard from the Dr that some mild discomfort might occur. What about prolonged soreness? I look like an elderly lady when walking - can't stand up straight due to soreness/pressure and my gait is rather slow.
Also, any chance of a rupture this late in the game? My next labs are in 3 days.

Thank you SO MUCH for your time and input!
At Sat Jan 24, 04:35:00 PM 2009, Missy Me said…

Dr. T,
I had a + HPT on 1/13, began spotting on 1/16. This didn't worry me as I has it with my first pregnancy and I have a beautiful 3 1/2 year daughter now. I began to feel lower pelvic pain and right sided pain on 1/19, saw the CNM and an HCG was ordered which was 1410 and u/s showed a thickened uterine lining but no sac. On 1/21, I began to experience increasing pain and bright red spotting. The second HCG was only 1800 and repeat u/s showed empy uterus but no clear location of an EP. The OB and radiologist felt strongly it was ectopic. I received the MTX injection that night. By 24 hours I was having horrific right sided and pelvic pain but no increase in bleeding. The next day 1/23 I sawn the OB, hgb was stable as were my vitals. Repeat u/s didn't show any rupture or free fluid. I was sent home with pain meds. The severe pain continued another 12 hours and is now subsiding. It still hurts to move, cough, or touch my belly on the right. I cannot ambulate wihout pain. Is this normal?? I had an HCG done today but do not have the results yet.
At Mon Jan 26, 04:53:00 PM 2009, Coli Coe said…

I received MTX shot 5 years ago for an ectopic pregnancy. My levels continued to rise after 48 hours. I was told that was normal and should be expected but shortly after I was at the ER. My tube had burst, the pregnancy was removed and the tube could not be saved. Now I have another ectopic pregnancy and was given the MTX shot again 1-17-09. My levels rose after 48 hours but then on day 7 they went down. I have been bleeding since 1-9-09 with cramping and clotting beginning on 1-18-09. Tonight I am experiencing a sharp pain in my left side where my still existing tube remains. I am afraid that after loosing one tube I will loose my chances of ever having a healthy pregnancy. Can my hcg levels start to rise again after beginning to drop? AM I still at risk of another tube eruption?
At Wed Feb 11, 09:54:00 PM 2009, Anonymous said…

Hi Dr. T.,
I received the methotrexate shot on Dec. 3, 2008 for a diagnosis of an ectopic pregnancy. As of today, I still haven't received my period, but my beta hcg level is going down. Is this normal?
At Thu Feb 19, 11:30:00 AM 2009, Ivy L. said…

I'm glad I found this Dr. T. My doctor looked as confused as I was when I mentioned pressure in my anus and what felt to be light "labor" cramps in my lower back and abdomen 2 weeks after my MTX treatment. I know see it's nornal. My doc said it wasn't associated. I am now in the process of trying to have a tubal reversal b/c this whole thing has left me feeling sad about the loss baby that could have been. My question is does the MTX treatment severely damage the tubes? Thank you for your time.
At Tue Mar 03, 01:26:00 PM 2009, Tab said…

Hello, i hope you can help me. I was told that i had an ectopic pregnancy and given 50mgs of methotrexate. Four days later my homo level was still going up. I then went to get a vaginal ultrsound, my Dr found a "normal pregnancy" what will this drug methotrexate do to my baby?
At Wed Mar 18, 10:53:00 PM 2009, Anonymous said…

Hello,
Just posted my comment and wnat to give some more information. I was diagnosed of an ectopic pregnancy after the ultra sound report on 18/1/09.the beta hcg levels were:

17/1/09 - 8924.97
I had methotrexate50mg on 18th.(about 18hours afterwards)

21/1/09 - 12213.56
25/1/09 - 7372.51
29/1/09 - 3318.8
1/2/09 - 2405.86
5/2/09 - 1051.41
14/2/09 - 800.0
21/2/09 - 104.37
14/3/09 - 25.16

My reports say that i got pregnant in 2nd week of december.I had an i-pill(levnogestrel).I had my periods on the due date then.
Even in january I had periods(Around 11th)almost on due date but it was negligible.After methotrexate I had bleeding which started on 21/1/09.It was bright red.Then even in febfruary my periods came on due date 19th(my cycle is of 28 days).This time it was maroonish.And this month i didnt get my periods.Is this okay?
The usg reports of 14/2 shows that there was a large hemorrhage in the left ovary and shows large hemorrhagic follicle measuring 4.1*4.0*4.1cm with a volume of 37.00 cc.and the ultrasound of 21/2 shows in the left ovary a simple cyst measuring 3.7*3.4*3.1 with a volume of 21/0cc.

I shall be grateful if u can look to my case and tell me about it.
This was my first pregnancy.I am of 30 years.
At Mon Apr 13, 09:45:00 AM 2009, Anonymous said…

Hi Dr. T,
I have been researching ectopic pregnancy for over three weeks now. Your site has truly helped me but I'm still concerned. I discovered on March 13, 2009 that i have an ectopic pregnancy. My numbers are very low. My first hcg was an 11 on my first test. My doctor stated that she had never seen an 11 before and requested another test the following week. The hcg level went to 14. Again she ordered another test one week later and that hcg level was a 13. Finally received an ultrasound on April 1 and another test which the level was 13 again. The ultrasound showed nothing but they did see that I had an enlarged liver. My doctor said that had nothing to do with the pregnancy. She gave me two options- to let nature take its course and see if my body will take care of the situation itself or treat me with methotrexate therapy. I am so confused. With the level so low is there still a risk if I choose no treatment at all? Should i choose methotrexate therapy although my levels are low? What should I do? I am getting married in July 2009 and I would like to try to conceive before my 27 birthday in October. I do have one child already but the more the merrier. What course of treatment should I take?

Thank You,
So confused
At Sat May 16, 10:57:00 AM 2009, Anonymous said…

Dr. T,
I had a miscarriage at 7 weeks in April. I had a d & C and received 1 dose of methotrexate for a suspected ectopic pregnancy, however the pathology showed a small amount of pregnancy tissue and, therefore; an ectopic pregnancy was ruled out. My level dropped from 3700 to 13 in 10 days and they did not want to repeat anymore bHCG levels. I began to take my prenatal vitamins again at that time and just had my first period 5 weeks post d & c/methotrexate. Is it safe for us to try to conceive when I ovulate this cycle (7 weeks post methotrexate)? I have had two normal pregnancies and this is my first miscarriage so they are assuming it is not related to any preexisting condition.
Thank you!
At Mon May 18, 11:10:00 PM 2009, Anonymous said…

I have a Question for Dr. T I have had a dose of metho for an ectopic. I did not want any more children but was in the process of being matched to be a surrogate. I became pregnant while on the IUD. It would have been removed as soon as I was matched with a couple. My question is how long after having the drug can I start transfers? I am not using my eggs. Thank you Surrogate Mom
At Sat May 30, 06:19:00 PM 2009, Anonymous said…

Dear Dr. T
I had an injection of methotrxate on 5/29 and have had cramping but no bleeding. How long does it take for the bleeding to start and how long will it last???
At Tue Jul 14, 03:10:00 PM 2009, Anonymous said…

Dear Dr. T,

I've had a shot of methotrexate about 4 weeks ago and my hCG levels have been decreasing weekly, last week when I went for a blood test, my beta results came back as 10. I had been taking diet pills for about 4 days that contained folic acid but I stopped as soon as I saw that. I was wondering if that could have any effect to the decreasing hCG levels? And I also starting bleeding again, it's a dark color, is this normal to happen when my hCG level is at 10? Should it be completely cleared by this week? Thanks
At Sun Aug 16, 12:33:00 PM 2009, Anonymous said…

dr t
i have missed abortion on 30/5/2009 and then my period was supposed to be on 6/7/2009 and then i didnt show up and then i had hcg test it was 50 and started to rise uptill 12000 and there was no gestational sac so the doctor thought it was an ectopic pregnancy and gave me methotrexate injection 50 mg single dose and after 2 days sac appeared so i thought that methotrexate will cause abortion and i waited for 2 weeks i went to make ultrasound so it showed living gestational sac with living feutes and good pulse so im 10 weeks now i have known that methotrexate can cause deforms and major anomalies what should i do??
At Tue Aug 18, 11:56:00 AM 2009, Anonymous said…

Dear Dr. T,
I was treated last week with a single dose of methotrexate, but 4 days later, my levels went from around 2800 to 6300. I went back into the hospital for an ultrasound and they found a sac (with no heartbeat) in my left tube that measured 1.7 cm. I received a second dose of methotrexate and am waiting until Thursday to see what my levels are. In the meantime, I keep feeling a slight pull/pressure in my left lower abdomen and I'm wondering if this is normal or cause for concern. I'm not in any pain, but am concerned about it rupturing. Are their any signs I should be aware of or does a rupture generally occur without warning? Thank you so much.
At Tue Sep 15, 04:13:00 AM 2009, vanessa said…

hi doctor! i had a metho shot on aug. 31 and since i've gone to different docs cause of medicaid issues i dont know if my hcg levels are low or if the ectopic pregnancy is still there. my concern besides that is that i have had unprotected sex twice! is there a chance of me getting pregnant ? if there is, will the methotrexate harm the baby? would i have to get a methotrexate shot for that one too? i would really appreaciate your answer.
At Fri Sep 18, 01:08:00 AM 2009, cpsingh said…

Patient is 30year old with no child yet.

Past history of left sided ectopic which ruptured on 07.12.08 & salpingectomy left sided was done

12.06.09 – LMP , regular cycle of 30 days

20.07.09 – beta hcg – 139.70 mU/ml
22.07.09 - beta hcg – 367.80 mU/ml

23.07.09 – inj hcg 5000 iu i/m

27.07.09 – TVS :(by Dr.Vikas Gupta)
· thickened endometrium-16.4mm
· No gestational sac noted in uterus
· No free fluid in cul-de-sac

30.07.09 - inj hcg 5000 iu i/m

10.08.09 – TVS :(by Dr. Archana Kumar)
· single irregular anechoic intra-uterine gestation sac without embryonic
echoes & Y.S.
· G.S. is approx. – 8.3mm , corresponding to 4 week 6 days
· Cardiac activity not visualized
· Decidual reaction is poor
· No free fluid in pouch of Douglas
( I think, it was probably pseudosac which was wrongly interpreted as intra uterine pregnancy by Dr. Archana Kumar)

11.08.09 - beta hcg – 22500 mU/ml

12.08.09 - inj hcg 5000 iu i/m

18.08.09 –TVS :(by Dr. Archana Kumar)
· single well defined complex mass of approx. 30x33mm seen in Rt adnexa.
· Mass is showing moderate vascularity
· No evidence of live embryo or YS seen inside the mass
· U/S findings are more in favour of Right adnexal ? Ectopic pregnancy

18.08.09 – TVS (by Dr.Vikas Gupta)
· there is evidence of 36.5x25.2mm sized centrally anechoic peripheral echogenic focal lesion noted at proximal most part of right fallopian tube abutting right side of uterus with increase vascularity on Doppler -? Right sided early ectopic pregnancy ?? nature.
· Endometrium thickening – 16.5mm
· Minimal free fluid in cul-de-sac.

21.08.09 - beta hcg – 12060 mU/ml

21.08.09 –TVS (by Dr. Monika Saxena)
· evidence of thick walled ~30x29mm sized echogenic lesion with central gestational sac & fetal pole inside of CRL measuring~7.0mm is noted at right adnexa just at cornuotubal end of uterus with increase peripheral vascularity.
· No cardiac activity in fetal pole suggesting Ectopic pregnancy at right fallopian tube just at its origin from uterus
· Endometrium thickening – 22.0mm
· Mild free fluid in cul-de-sac

27.08.09 –TVS (by Dr. Monika Saxena)
· evidence of thick walled ~30x30mm sized echogenic lesion with central gestational sac & fetal pole inside of CRL measuring~7.0mm is noted at right adnexa just at cornuotubal end of uterus with increase peripheral vascularity.
· No cardiac activity in fetal pole suggesting Ectopic pregnancy at right fallopian tube just at its origin from uterus
· Mild free fluid in cul-de-sac

27.08.09 - beta hcg – 7660 mU/ml

28.08.09 – First shot of inj methotrexate 50mg i/m
30.08.09 – Second shot of inj methotrexate 50mg i/m

08.09.09 – TVS(by Dr. Monika Saxena)
· evidence of thick walled ~33x42mm sized echogenic lesion with central gestational sac & fetal pole inside of CRL measuring~7.0mm is noted at right adnexa just at cornuotubal end of uterus with increase peripheral vascularity.
· No cardiac activity in fetal pole suggesting Ectopic pregnancy at right fallopian tube just at its origin from uterus
· No free fluid in cul-de-sac
· Endometrium – 7.0mm

08.09.09 - beta hcg – 545 mU/ml

11.09.09 –Repeat shot of inj methotrexate 75mg i/m
13.09.09 – inj methotrexate 75mg i/m

methotrexate in ectopic pregnancy is said to be responding well if beta hcg level is falling down (more than 15%) but what happens to gestational mass?
Ø In how much time it (gestation mass) is resolved/aborted?
Ø Up to what time we should wait for ectopic to be resolved/aborted from tube(when beta hcg is declining)
Ø With declining beta hcg , whether its(gestation mass) size reduces gradually or not
Ø How can we know the response of methotrexate in respect to gestation mass

In this above particular case , kindly comment on the course & fate of gestation mass on treatment with methotrexate and how to measure response of methotrexate in respect to gestation mass.
Kindly give your valuable advice on further course of treatment & line of management in this above mentioned particular case.
At Tue Sep 22, 10:44:00 AM 2009, punkin said…

Hi Dr T,
I rcvd a methotrexate shot on 9/17 for a possible ectopic pregnancy. This was due to no sac on u/s. Had my blood drown on 9/21. I rcvd a call this morning from doc office stating my hcg went from 4000 to 5754 (9/17-9/21). What does mean?
At Wed Sep 23, 01:15:00 AM 2009, cpsingh said…

in continuation of post sent on 18sept09 , please consider the following more current details also.

21.09.09 – TVS(by Dr. Monika Saxena) – FINDING SAME AS previous USG on 08.09.09
21.09.09 - beta hcg –84.10mU/ml

kindly clear my doubts and give your expert opinion.
At Thu Oct 01, 05:16:00 AM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To Vanessa sep 15: First, ou need a doctor. Second, you need an hCG level. Third, you need to get some form of contraception before you do get pregnant again in the near term. If you only had a single shot of MTX in August, it is unlikely that it would affect a pregnancy at this time, but your body needs a chance to heal to minimize your risks for another ectopic. Good luck.
Dr T
At Thu Oct 01, 05:20:00 AM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To punkin sep 22: It is not unusual for the hCG to continue to rise for the first week after receiving the MTX. If it doesn't start to fall after that, you may need a second course of therapy. Best wishes!
Dr T
At Thu Oct 01, 10:50:00 PM 2009, cpsingh said…

doctor, kindly reply my queries(posted on 18 sept & 23 sept ). i am still waiting for your kind advice. plz reply soon.
At Sun Oct 04, 03:25:00 PM 2009, Leena said…

I got pregnant with our first IUI cycle. On week5 of pregnancy,
My HCG WAS 2355 and prog 37.
On week6 hcg 2520 prog 33 and I had my first ultrasound at the same day(week6), They found no pregnancy sac inside or outside the uterus. They ordered a uterus biopsy searching for pregnancy tissues due to possibility that the pregnancy sac could be hidden behind my pre-existing fibroid, which came back inconclusive(Nurse told me, they may not be able to take samples from all areas of the uterus). I have no pain or bleeding or any other symptoms.
They decided to give me methotrexate shot as a treatment of a POSSIBLE ectopic pregnancy?
1-Can you please explain to me why it is a possible ectopic pregnancy if my HCG started to go down which could be indication of Miscarriage for a sac hidden behind the fibroid?
2-If we assumed it is an ectopic pregnancy with no symptoms ,then why did not they wait to resolve by it self as the hcg levels are dropping with no symptoms?
Thanks
At Mon Oct 05, 07:13:00 PM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To cpsingh: I am sorry, I thought I had responded to your notes. The ectopic pregnancy "mass" will not be aborted in the usual sense of passing the pregnancy tissues out through the uterus. They will be slowly absorbed over time once they die. The time that takes depends on the size of the mass and it will be gradual. You will know the MTX has worked if the hCG levels continue to drop until they are zero. It will take some time (probably several months) for the mass to resolve completely. Even then, there will likely be residual damage of the tube that will increase the risk of another ectopic pregnancy. I wish you the best.
Dr T
At Mon Oct 05, 07:16:00 PM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To Leena: At that level of hCG any intrauterine pregnancy, good or bad, should be visible. The fact that there is no evidence of any pregnancy inside the uterus, and with that abnormal rise in the hCG, your doctors are probably correct to assume this is an ectopic pregnancy and offer to treat you with MTX. Ectopic pregnancies are often hard to visualize at that level of hCG unlike intrauterine pregnancies. Good luck to you.
Dr T
At Fri Oct 09, 05:36:00 PM 2009, Anonymous said…

Dear Dr. T,
I'm not sure how long it takes for a response but hopefully only a few day...I found out on Monday the 5th I was pregnant-my hcg levels were 64/18 which they saiid the 18 was low and then put me on Progesterone supplements. Wed. the 7th my HCG level did not double it only went to 91 and my progesterone went down to 15. Obviously this is not good. So today on Fri. the levels were still not promising...hcg still didn't double-138 and prog stayed the same around 15. We are scared about ectopic and now they are giving me an ultrasound on Mon and possible meth injection tues-wed. I would be almost 6 weeks when they give me the meth shot-Is that too risky to be along that far or is that correct timing?? very scared at this point. They also told me to continue the progesterone supplements thru the weekend and I may stop it on Mon the day before the injection? does that seem correct? Thank you.
At Sun Oct 11, 05:40:00 PM 2009, LEENA said…

Thanks a lot for your prompt response.
I have 2 more questions please!!
I had my first Metho dose on Oct2( my initial HCG was 2520 with no sac in or outside the uterus and with no symptoms), I got only slight spotting after this shot. On Oct9th my HCG were 2700 so I got another metho shot.
I am so worry that the second dose is not working as I still didn’t get any bleeding till now!! 1-In case the second metho shot didn’t work then what is the next treatment do you recommend(is it safe to take third dose of the methotrexate?)
2-Am I currently at risk of ectopic pregnancy rupture ?
At Fri Oct 16, 06:23:00 PM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Oct 9: That is a VERY low level of hCG for 6 weeks so I doubt you are at much risk even if this is an ectopic pregnancy (it could also simply be a 'blighted' intrauterine pregnancy). At that level of hCG I doubt they will see anything inside the uterus and probably nothing outside even if an ectopic is there. You are not too far along to get MTX but I am not entirely sure you even need it. Good luck and let us know how things turn out.
Dr T
At Fri Oct 16, 06:26:00 PM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To Leena: It takes time for the MTX to work and usually two shots will take care of the problem at that level of hCG. Ectopic pregnancies can certainly rupture even after starting MTX treatment, so let your doctors know if you start having an increase in abdominal pain. You are probably going to do just fine and, hopefully, will not need surgery to manage the ectopic. Best wishes again...
Dr T
At Mon Nov 02, 01:53:00 PM 2009, Anonymous said…

Hi i had an ectopic about 3 weeks ago and i bled not even a week after the injection of methotrexate and i have been bleeding for 11 days now... I was wondering how long does that continue and how soon can i look for nothing down there...Please help me.
At Tue Nov 03, 06:11:00 PM 2009, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Nov 2: The bleeding depends on the size and the location of the ectopic pregnancy and the amount of decidual reaction (response to pregnancy hormones) in the endometrium (the inner lining of the uterus).It can vary from very little bleeding to intermittent bleeding for 4-6 weeks.
Dr T

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Symptoms Accompanying Methotrexate Therapy for Ectopic Pregnancy

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