What are the causes of ectopic pregnancy? Are uterine defects the most common cause?

Inflammation of the organs of the pelvis minor

The most common cause of ectopic pregnancy is a history of inflammation of the pelvic organs - including clastic inflammation of the appendages, or the much less typical, often scanty inflammation on the background of Chlamydia Trachomatis infection.

2. endometriosis

Another of the common causes of fallopian tube obstruction is endometriosis, causing local inflammation and predisposing the patient to the formation of pelvic adhesions.

3. post-operative adhesions

Another possible cause of fallopian tube obstruction is postoperative adhesions. Any abdominal surgery can contribute to:

formation of adhesions of the perianal area,
overgrowth of the fallopian tubes,

the formation of adhesions in the pelvis, especially if the procedure is accompanied by inflammation, such as diffuse appendicitis.

For obvious reasons, gynaecological surgeries are associated with the highest risk of fertility-restricting adhesions. Extirpation of myomas located in the uterine horn may be associated with the possibility of puncturing and closing the intramural part of the fallopian tube.

4. Fallopian tube malformations

Extremely rare causes of fallopian tube obstruction include malformations - bilateral agenesis of the fallopian tubes or congenital obstruction of the tubes. Uterine malformations are not a cause of ectopic pregnancies.

Does the risk of ectopic pregnancy increase above a certain age? If so, why?

Age alone is no more a risk factor for ectopic pregnancy than other factors, the likelihood of which increases with age. For example, the risk of a history of infection or a history of surgery.

The risk of ectopic pregnancy increases with the onset of sexual life and, consequently, with a history of pelvic infections. According to observations made among teenage, sexually active female residents of Warsaw, about 10% of the examined teenage girls have already had Chlamydia Trachomatis infection, which may generate fallopian tube obstruction in these patients, predisposing them to ectopic pregnancy.

Is it possible to predict in advance that a woman may be prone to ectopic pregnancies?

Yes and no.

1. ULTRASOUND

During a traditional TV ultrasound examination, we cannot assess the patency of the fallopian tubes, i.e. evaluate their function. The only fallopian tube pathology that we can then diagnose with close to 100% efficiency is hydatidiform - that is, a dilated fallopian tube filled with serous content with an overgrown abdominal part. A hydrocele of the fallopian tube is a remnant of an old, past inflammation of the appendage. In addition, during TV ultrasound, we can indirectly assess the presence of adhesions of the ovarian region by examining the mobility of the ovary (its sliding) when the pressure of the transducer changes during the examination. This is an indirect method, i.e. giving the possibility of suspicion rather than diagnosis.

2. SonoHSG

The possibility of evaluating the uterine cavity and assessing the patency of the fallopian tubes is possible during the sonoHSG tests, or hysterosalpingosonography. It involves the insertion of a special catheter into the uterine cavity and the administration of an appropriate contrast fluid, assessing the shape of the cavity, evaluating the flow of contrast through the fallopian tubes and the outflow of contrast through the abdominal orifices into the peritoneal cavity.

What are the symptoms of ectopic pregnancy? When can a woman "know" that a pregnancy is abnormal?

The symptoms of ectopic pregnancy are non-specific. Sometimes an ectopic pregnancy is asymptomatic. But often patients report:

pain,
a feeling of pushing on stool,
weakening,
bleeding from the genital tract.

Sometimes the patient feels sudden severe abdominal pain and significant weakness. This may mean that the ectopic fallopian tube pregnancy has ruptured and the patient is bleeding into the peritoneal cavity. In a life-threatening condition, she should be taken to the operating table.

Symptoms depend on the location of the pregnancy and its progression. The classic diagnostic test is TV ultrasound, a serial β-hCG test. The absence of a pregnancy on TV ultrasound with a β-hCG level of more than 15,000 mIU/ml leads us to diagnose a so-called PUL (Pregnancy of unknown location), i.e. a pregnancy of unknown location requiring increased observation of the patient in hospital.

IMPORTANT
Symptoms depend on the location of the pregnancy and its progression. The classic diagnostic test is TV ultrasound, a serial β-hCG test. The absence of a pregnancy on TV ultrasound with a β-hCG level of more than 15,000 mIU/ml leads us to diagnose a so-called PUL (Pregnancy of unknown location), i.e. a pregnancy of unknown location requiring increased observation of the patient in hospital.

How is the removal of an ectopic pregnancy carried out?

Depending on the location of the pregnancy and the β-hCG value, the patient is qualified for the use of a drug - methotrexate (in the various available administration regimens) or a surgical procedure - usually laparoscopy. During laparoscopy, the pregnancy itself is removed - with an attempt to preserve the fallopian tube or the fallopian tube with the pregnancy. The decision is made intraoperatively and based on the patient's medical history.

Is it possible to get pregnant again after an ectopic pregnancy?

Normal pregnancies after an ectopic pregnancy do occur, but the probability is lower than in the population of healthy patients. The risk of ectopic pregnancy in a patient who has previously been diagnosed with an ectopic pregnancy increases several times.

Can ectopic pregnancies cause infertility?

Ectopic fallopian tube pregnancies, and consequently impaired function and function of the fallopian tube(s), are a classic cause of infertility. Fallopian tube factor infertility accounts for approximately one third of all cases of partner infertility. According to various studies, this frequency ranges from 15-40%.

Can an ectopic pregnancy also occur after IVF?

Ectopic pregnancy can also occur after the insemination procedure in vitro. This happens very rarely, but it is possible.

During the transfer, the embryo is ultimately placed in the uterine cavity (approximately 2/3 of the height of the uterine cavity). However, the embryo has the capacity for transport and can therefore move into the fallopian tube. If implantation occurs there, we speak of an ectopic fallopian tube pregnancy.

In the situation of caesarean sections, additionally, a relatively new type of ectopic pregnancy is a pregnancy in a caesarean section scar. The transferred embryo has the opportunity to implant in the area of the caesarean scar which is favoured by the current scar defect.

Cervical pregnancy is also treated as an ectopic pregnancy, even though the cervix is part of the uterus. However, the normal development of a pregnancy located in both a caesarean section scar and a cervical pregnancy is impossible and, in addition, poses a risk to the life and health of the mother.

You can read about the impact of ectopic pregnancy on a woman's fertility in the article: https://www.invimed.pl/ciaza-pozamaciczna under "What are the effects of ectopic pregnancy on a woman's fertility?".

Substantive consultation:

Dr Anna Niesłuchowska-Hoxha, MD - Gynaecologist-obstetrician specialist at InviMed Katowice