Early in pregnancy, at your first prenatal appointment, your healthcare provider will typically perform a vaginal ultrasound to confirm two things: 1) the gestational age of the pregnancy, and 2) that the embryo implanted in your uterus and not somewhere else (like the cervix, tubes, or ovaries), where it isn't viable. Why the latter? In about 2% of pregnancies, implantation can happen outside the uterus (most often within the fallopian tube) — this is what's called an ectopic pregnancy.
When ectopic pregnancy (rarely) happens, it can be a very painful experience — both emotionally and physically. In this article, we'll break down what you need to know about ectopic pregnancy, including:
- Ectopic pregnancies are rare medical emergencies that cannot be carried to term or transplanted into the uterus.
- An ultrasound at your first prenatal appointment will confirm where the pregnancy implanted, which is one key reason why those appointments are so important.
- Yes, you can get pregnant after an ectopic pregnancy — but the risk of recurrence after one is around 10%. The sooner an ectopic pregnancy is treated, the fewer implications there may be for future fertility.
Now, let's get into the specifics around ectopic pregnancy, from signs to risk factors to impact on future pregnancies.
What is an ectopic pregnancy?
In a standard pregnancy, after the egg is fertilized, the resulting embryo makes its way down the fallopian tube and implants in the uterine wall. In the rare event of an ectopic pregnancy, however, the embryo implants and begins developing before it makes it to the uterus, 90% of the time in a fallopian tube — hence the commonly used synonym, "tubal pregnancy."
Fallopian tubes are on average 11-12 centimeters in length, and they aren't designed to accommodate a growing fetus. So, when an embryo implants there, it can actually cause the tube to rupture and lead to internal abdominal bleeding. Less commonly, ectopic pregnancies can also occur in other structures that can't support a growing embryo, like the ovary, the abdominal cavity, or the cervix.
Although sometimes talked about separately, an ectopic pregnancy is a type of miscarriage — and should be treated as such. "We should be counseling them and providing them with the same — if not more — support that we do for patients who have miscarried," says OB-GYN and Modern Fertility medical advisor Dr. Jennifer Conti, MD, MS, MSc. "Imagine having this huge loss and having to undergo sudden surgery."
What are the symptoms of an ectopic pregnancy?
At the beginning, an ectopic pregnancy presents like a regular one. You might have symptoms like nausea, breast/chest tenderness, cramping, a missed menstrual period, and vaginal bleeding. If you experience vaginal bleeding in early pregnancy, though, it's always important to reach out to your healthcare provider — they can run tests to exclude ectopic pregnancy and miscarriage.
- Lower back pain
- Abdominal pain or pelvic pain (especially if it's on one side)
- Shoulder pain (if there's a lot of internal bleeding in the abdomen)
- Weakness, dizziness, or fainting
If you experience any of the above symptoms during an early pregnancy, don't hesitate to seek medical attention immediately.
How do you know if you have an ectopic pregnancy?
Once you've confirmed your pregnancy and you've already begun prenatal appointments, your healthcare provider will perform a transvaginal ultrasound (that's when an ultrasound probe is placed into your vagina in order to visualize the organs) to check where the pregnancy is growing.
Other tests or exams you might have include:
- A pelvic exam: This exam is conducted in order to assess areas of pain and tenderness, or feel for the presence of a mass. But these findings don't necessarily indicate an ectopic pregnancy, so further measures will need to be taken.
- A pregnancy test: You'll be given a blood test in order to determine the amount of human chorionic gonadotropin (hCG), the pregnancy hormone, in your body. In early pregnancy, the amount of hCG you have approximately doubles every two days, so you'll be given another pregnancy test two days later to see if the levels are plateauing or dropping — a drop could indicate an ectopic pregnancy or another type of abnormal pregnancy (like a miscarriage).
- A transvaginal ultrasound: In the first 3-5 weeks after conception, or 1-3 weeks after your missed period, your healthcare provider can use a transvaginal ultrasound to see if your pregnancy is growing inside the uterine cavity. It can also indicate if there's blood or fluid that might indicate an ectopic pregnancy in your abdomen. Your healthcare provider may be in search of a mass near your ovaries, fallopian tubes, and cervix, as opposed to the absence of an embryo in your uterus.
What are the treatment options for an ectopic pregnancy?
An ectopic pregnancy can't be relocated into the uterus because extracting an embryo from its implantation site would traumatize the embryo to the point where it's no longer able to grow. For this reason, and to avoid complications for the pregnant person, an ectopic pregnancy will need to be terminated.
Exactly how an ectopic pregnancy is terminated depends on a variety of factors:
Option 1: Methotrexate: If an ectopic pregnancy is detected early on, you may be given a shot of methotrexate — a safe and effective injection that stops a pregnancy from growing. The pregnancy is then absorbed by the body, which takes about 4-6 weeks. You'll need to see a doctor for follow-up tests to be sure that the procedure was successful (another shot can be given if your hCG levels haven't decreased significantly after the first).
Option 2: Laparoscopic surgery: If a fallopian tube has ruptured, the pregnancy is further along, or there are other lab abnormalities, one of two types of surgeries via laparoscopy (using small incisions and a camera as a guide) may be needed:
- In a salpingostomy (also called a fimbrioplasty), an opening is made in the fallopian tube so that the pregnancy can be taken out. (The suffix "-ostomy" means artificial opening.) "This is a less common option these days as leaving behind the damaged tube does not increase chances of fertility when compared to removing the tube entirely," says Dr. Conti.
- In a salpingectomy, the entire fallopian tube, along with the ectopic pregnancy, is removed ("-ectomy" means surgical removal).
Option 3: Observation: If a pregnant person is early on in the ectopic pregnancy, without symptoms of tubal rupture, and with declining hCG levels, a healthcare provider might opt for observation instead of medical intervention because the pregnancy may end on its own. This is only an option if the pregnant person can report for weekly pregnancy tests and continues to be asymptomatic.
What are the risk factors for ectopic pregnancy?
The causes of ectopic pregnancy aren't completely known, but, according to the Mayo Clinic, it may have to do with prior damage to the fallopian tubes or abnormal development of the fertilized egg.
While half of those who have ectopic pregnancies have no known risk factors, there are certain circumstances that can increase the likelihood of having one:
- A previous ectopic pregnancy: If you've already had an ectopic pregnancy, the risk of having another is around 10%, depending on whether or not you have other risk factors.
- Surgery on your fallopian tubes, including tubal ligation: One large-scale study indicated that those who had their tubes tied before age 30 via bipolar tubal coagulation (a common method of tubal ligation) were 27 times more likely to have an ectopic pregnancy than those who had a different procedure (like postpartum partial salpingectomy). If you decide to have a tubal ligation to permanently prevent pregnancy, you can talk with your healthcare provider about the right surgical method for you.
- Some types of sexually transmitted infections (STIs): A 2011 study by researchers at the University of Edinburgh suggested that women who had chlamydia were more at risk for ectopic pregnancy, possibly because of an increased amount of a particular protein that increased the likelihood of tubal implantation.
- Pelvic inflammatory disease (PID): Pelvic inflammatory disease (PID) is an infection of the uterus, fallopian tubes, ovaries, and cervix that, when untreated, can result in scarring of the fallopian tubes. That scar tissue can prevent the fertilized egg from getting all the way through the fallopian tube to the uterus, and can cause it to implant in the fallopian tube instead.
- Endometriosis: The adhesions and scarring that accompany the condition endometriosis can interfere with an embryo's ability to reach the uterus.
- Smoking: According to researchers at the University of Edinburgh, women who smoked and had ectopic pregnancies had twice the amount of PROKR1, a protein that when present in the uterus helps the embryo implant. When it shows up in the fallopian tubes, however, it prevents the embryo from being transferred to the uterus.
- Being older than 35: While it's not known exactly why age increases the likelihood of ectopic pregnancy, it may have to do with the risk of chromosomal abnormalities, the odds that one will contract an STI or PID at some point in their life, and changes in the function of fallopian tubes.
- Use of an intrauterine device (IUD): Getting pregnant with an intrauterine device (IUD) is very rare (fewer than 1 in 100 IUD users get pregnant in a year), but when it happens, it's more likely to result in an ectopic pregnancy. "To be clear," adds Dr. Conti, "it’s not that the IUD itself increases the risk of ectopic pregnancy — it’s that if your IUD fails, the pregnancy that develops has a greater chance of being extra-uterine."
- Use of assisted reproductive technology (ART), such as in vitro fertilization (IVF): The likelihood of ectopic pregnancy during fertility treatment may be increased by factors such as age, structural issues with the fallopian tubes, and how many embryos are transferred. But just because there's potentially a higher risk does not mean ART treatments don't lead to healthy pregnancies for many people.
Can you prevent an ectopic pregnancy?
No — there's no way to prevent an ectopic pregnancy. That said, it's important to remember that they're rare. Still, it's always a good idea to discuss any concerns with your healthcare provider, especially if you do have any of these risk factors or experience bleeding during early pregnancy. You might be advised to make lifestyle changes, such as quitting smoking and getting tested regularly for STIs (which would reduce the risk of PID and therefore ectopic pregnancy).
Can ectopic pregnancy cause infertility or impact future pregnancy outcomes?
Having an ectopic pregnancy doesn't mean you can't get pregnant in the future, but an ectopic pregnancy may lead to scarring in the fallopian tubes and make conception more challenging. The sooner an ectopic pregnancy is treated, the higher the odds are that the fallopian tube won't be damaged.
All that said, ectopic pregnancy does make it more likely that you'll have another one in a future pregnancy: about 10% more likely. Letting your healthcare provider know about past ectopic pregnancies and getting that first early ultrasound will ensure early detection and treatment.
For some people, depending on the extent of damage in the fallopian tubes and history of ectopic pregnancies, IVF may be recommended to bypass the tubes entirely.
Can the treatment of ectopic pregnancy impact future fertility?
According to the American College of Obstetricians and Gynecologists, all available evidence demonstrates that methotrexate won't have an effect on future fertility. 9 out of 10 times, the fallopian tube where the pregnancy implanted will remain unobstructed after treatment.
What about surgical treatment? One 2016 systematic review and meta-analysis found that fertility outcomes were comparable between a salpingostomy and a salpingectomy. What's important to note here, though, is that IVF may be recommended if there isn't at least one functioning, open fallopian tube.
Do you have to wait to try to get pregnant again after an ectopic pregnancy?
"Depending on the type of treatment, you may need to wait some time to ensure the beta-hCG levels (hCG measured via blood test) have completely resolved," says Dr. Conti. "That way, you can tell the difference between an ectopic pregnancy wherein the methotrexate isn't completely working versus a new pregnancy altogether."
The bottom line on ectopic pregnancy
Ectopic pregnancies are rare, but when they do occur, they need to be treated immediately to prevent complications and to maximize the chances of future pregnancy. Reach out to your healthcare provider right after you get a positive pregnancy test so you can schedule prenatal care — and any time you have concerns about ectopic pregnancy or other complications. And remember to let your provider know about your medical history so they can develop the right care plan for you.
There's no right or wrong way to emotionally heal from an ectopic or other pregnancy loss. Always try to prioritize self-care and your mental health, and don't hesitate to reach out to a trusted professional when you need support. Our Pregnancy Loss channel in our free online community is also always here for you.
This article was medically reviewed by Dr. Jennifer Conti, MD, MS, MSc.