Fertility Docs Uncensored is hosted by Dr. Carrie Bedient from the Fertility Center of Las Vegas, Dr. Susan Hudson from Texas Fertility Center, and Dr. Abby Eblen from Nashville Fertility Center. In this episode, the Fertility Docs walk listeners through what typically happens after a positive pregnancy test following IVF. The doctors explain how early pregnancy is monitored, beginning with the first pregnancy blood test about two weeks after embryo transfer and continuing with repeat hormone testing every few days to ensure appropriate rises. They discuss what doctors look for on early ultrasounds, why some patients need closer monitoring, and how different outcomes such as viable pregnancies, biochemical pregnancies, ectopic pregnancies, or abnormal intrauterine pregnancies are identified and managed. The episode also covers when patients go back to their OB/GYN once a pregnancy is progressing normally. The doctors answered many common questions patients search for after seeing that first positive test. Questions such as what happens after a positive IVF pregnancy test and how often pregnancy hormone levels are checked come up frequently. They explain how much hCG should rise in early pregnancy and what it means if it does not increase appropriately. The episode addresses when the first ultrasound is done after IVF and what doctors are hoping to see at five to six weeks of pregnancy. They discuss what an ectopic pregnancy is, how it is diagnosed, and why it can be difficult to distinguish early on from an abnormal intrauterine pregnancy. Other common concerns include what a biochemical pregnancy means, how abnormal pregnancies are treated, and when expectant management may be appropriate. Finally, the hosts review how long fertility clinics typically follow patients during early pregnancy and when care is transferred to an obstetrician.

Episode Transcript:

Susan Hudson (00:00)

You’re listening to the Fertility Docs Uncensored podcast, featuring insight on all things fertility from some of the top rated doctors around America. Whether you’re struggling to conceive or just planning for your future family, we’re here to guide you every step of the way.

Abby Eblen MD (00:21)

Hi everyone, we’re back with another episode of Fertility Docs Uncensored. I’m one of your hosts, Dr. Abby Eblen from Nashville Fertility Center. And today I’m joined by my lovely and entertaining co-host, Dr. Susan Hudson from Texas Fertility Center

Susan Hudson MD (00:34)

Hello everyone.

Abby Eblen MD (00:34)

and Dr. Carrie Bedient from the Fertility Center of Las Vegas. Hey, how you guys doing?

Carrie Bedient MD (00:38)

Hi! How’s it going?

Susan Hudson MD (00:41)

Doing good.

Carrie Bedient MD (00:42)

Good. .

Abby Eblen MD (00:43)

Well, we’re trucking along past the new year, kind of moving on.

I think when you do that, it makes you reflect on maybe things that you hadn’t thought about with the hubbub of all the holidays. So I was just thinking about bucket list things I want to do. I was just curious, what’s some of your bucket list items that you have, or at least one of them anyway?

Carrie Bedient MD (01:02)

I want to go to the Maldives and stay in an overwater bungalow with my husband.

Abby Eblen MD (01:05)

How does that differ from a bungalow that you stayed in last month? 

Carrie Bedient MD (01:13)

My husband was not there, it was my mother, which I love my mother to bits, but I’m pretty sure the experience would be different. I hope so. Seriously hope so.

The better part of 24 hours just to get there. And then when you factor in the time change and all of that, it’s something where I think you gotta have the better part of a week and a half, two weeks to be there. And I just do not have that in my life right now. I think it’s going to be the better part of 10 years before I get there, but I’ll wait. And it’s fortunate because it’s going to take me that long to save up to go.

Abby Eblen MD (01:47)

So which way do you fly and where exactly is it located?

Carrie Bedient MD (01:51)

So you fly up and you go the other way around the world.

Abby Eblen MD (01:55)

You always fly up, don’t you? That’s bad to fly down.

Susan Hudson MD (01:56)

Anytime we fly down, that’s not a good thing. So, that’s not an actual cartography direction.

Carrie Bedient MD (02:06)

Well, no, you do have to fly up and then you do have to fly down because if you don’t fly down you’re falling down and that is an even bigger problem. I honestly don’t know because it is still so far at the bottom of the bucket that I haven’t even bothered looking. Yeah, I looked at the, I’ve priced out airplane tickets a couple times and I’m like, yeah, like we’re, I’m a ways away from this. So if anybody, if anybody out there owns a travel agency and they need somebody to go take pictures for them or something and help with a sponsored trip, I am your girl. I will put on makeup for these pictures. This is how much I am, I am into this. I will actually put on real makeup to make your pictures look good for the Maldives, which I would not be the model that anyone would choose.

Abby Eblen MD (02:33)

Did they have reproductive endocrinologists there?

Maybe you could do locums in the Maldives. That’s where we go visit as a doctor and we work, but we also get to enjoy being

Carrie Bedient MD (02:59)

Yes! Ooh, I like this.

What’s on your list, Susan?

Susan Hudson MD (03:08)

So I was trying to think of good bucket list things, but as you were talking about this, besides the fact that I’ve always had this love affair with, the part in Twilight, and they go to the island and it’s that type of thing. I love that. But I have a bucket list of I want to go on a yacht. I do not want to own a yacht. I need a friend with a yacht to invite me to go enjoy said yacht. I don’t know why. I think it was kind of inspired by, went to, what’s the place in the Bahamas, the water. Yes, yes. So we went to Atlantis one time and it was actually for one of those ASRM ESHRE meetings. Those meetings where the Americans and the Europeans and fertility together. They were down there, but it was March so it was kind of cold but we walked around a lot and there’s this one area where there’s all the yachts that are docked and it was amazing people watching and I’m just like I just I just I just want to go and see what it’s like to be on a yacht. I don’t know what it is but it’s just it’s it’s a bucket list thing

Carrie Bedient MD (04:20)

I take it motion sickness is not in your list of things to deal with in life?

Susan Hudson MD (04:25)

Not anything significant. I do pretty well. I mean, of course, if things are rocky, yes, I might get a little, but I think I would be fine.

Carrie Bedient MD (04:32)

Okay, Abby, what’s your list?

Abby Eblen MD (04:34)

I’m not a cold weather person at but I really want to see the Northern Lights. And I think my interest got stoked just because now in Nashville, we have a direct flight between Nashville and Iceland. So a lot of people have gone there that I know, well, not a lot, but a few people I know have gone there and have seen the Northern Lights. But you have to hit it at the right time, because even if you’re Iceland, you may not see the Northern Lights.

And the other thing that stoked my interest, and I swear I’ve never heard of this before until last there was a couple of times last summer, last May, where people in Arkansas saw Northern Lights and people in Tennessee saw them and I just happened to be in New York at my son’s graduation and unfortunately they saw him here in Nashville, Tennessee and I didn’t get to see him so I was really bummed. So now it’s my mission in life, I really wanna see the Northern Lights.

Susan Hudson MD (05:22)

I’d like to see Northern Lights too. There have been some times that I’ve traveled up north and I’m like, maybe this is the time. It hasn’t been the time yet for me either. So I get ya. I’m with you girl.

Abby Eblen MD (05:28)

Yeah.

All right, well maybe we can take a field trip and go see the Northern Lights.

Carrie Bedient MD (05:36)

The next FDU annual meeting will need to be in Iceland or Greenland or whatever

Abby Eblen MD (05:40)

There you go, there you go.

Carrie Bedient MD (05:43)

Whatever land is way up north, higher Canada, wherever, we’ll go there.

Abby Eblen MD (05:46)

Yeah, Somewhere up right, so got a question, Susan?

Susan Hudson MD (05:49)

Hi Docs, I’ve been listening to your back catalog during my second egg retrieval and ordered your book. Thank you so much for listening and thank you for ordering our book, The IVF Blueprint. Boy, I wish I found it before my first retrieval, what a wonderful resource. My question is about weight. When I first came to my REI, I was at my heaviest, BMI of 32.

My OBGYN recommended I lose weight and my PCP, who is an obesity specialist, started me on a GLP-1. I lost 30 pounds, decreasing my BMI to 27. I am 35 with an AMH of 0.33. What are your thoughts on how this can impact my egg retrieval? My OBGYN indicated that the anti-inflammatory aspects of the drug could help counter suspected endo.

I see info about trying to conceive FET and weight but not retrieval. Should I lose more weight before my third retrieval? Egg freezing, 6M2 so far. Thank you.

Carrie Bedient MD (06:47)

One of the big things that weight does to impact retrieval is to influence the technicality of it. When you are someone who’s carrying extra weight, when we are putting you to sleep for a retrieval, for the most part, we’re not using, full intubation. A lot of times you’re still breathing on your own. Maybe you’ve got an oral airway or an LMA, which are much lighter methods of maintaining your airway during anesthesia. You being able to maintain your breathing and oxygenation is super important. Well, when you’re carrying extra weight, your body is having to work harder to do that. And that has two implications. Number one, we’re all a little bit more on edge about are you getting oxygenation appropriately, which patients are because we’re very careful, but we’re never going to sacrifice your breathing ability for the ability to get more eggs. Where that can play in is that when women are working harder, their chest is moving up and down more prominently. And that means that their abdomen is moving up and down as well. And what that amounts to is the ovaries sliding in and out of our field of view. We’ve got an awfully long needle in there and we’ve gone directly into the ovary, into the follicles, to drain that fluid. You only get so much time when somebody is breathing like that to drain the fluid. And a lot of times we will go in drain the fluid, and particularly in a case where we’re not gonna get a whole lot, we will rinse and flush in order to get the highest probability of getting that egg out. Well, if you’ve got somebody breathing and their ovary is moving, you get…hopefully most of that follicle drained before it moves out and once it’s out and collapsed you can’t really get back into it. There’s the other concern which is the even bigger one where if your needle is no longer capped by the ovary what’s going to slip into its path. Is that a little bit of bowel? Is it a little bit bladder? Is it a blood vessel? And none of those things we want to get involved with in any way, shape or form. We always appreciate when someone is easier to oxygenate when they’re not carrying extra weight because it makes it easier for us to do our job. that’s one big way that weight can have an impact on a retrieval in an egg cycle.

Abby Eblen MD (08:56)

When you mentioned inflammation, I think inflammation is a little bit of a nonspecific term.

Susan Hudson MD (09:01)

One thing that I did want to bring attention to, she was willing to know about the anti-inflammatory aspects of using a GLP-1 during an egg retrieval. And what’s the most important thing is also directly tied to anesthesia is that being on GLP-1s increases the risk of you having some reflux.

Contents from your stomach coming up and potentially going back into your lungs and in most circumstances most anesthesiologists especially in the situation where we are not fully Intubating you are going to want you off the glp1 for one to two weeks prior to egg retrieval. I think decreasing inflammation due to losing weight great, okay, but using a GLP-1 for anti-inflammatory effects in some relationship to decreasing endometriosis, I would venture to say that if there’s any information about GLP-1’s decreasing endometriosis, that is very, very, very early information and nothing I would hang my hat on. And number two, realize if you pull up on whatever internet search engine you want to and put in your GLP-1 of choice, the first thing that’s going to pop up is a black box warning saying you should not be taking this medication while you are trying to conceive. Realize that GLP-1s are what we call neuroendocrine modulators, which the endocrine system includes your reproductive system. And quite frankly, we do not know how this positively or negatively affects pregnancy and pregnancy outcomes. So GLP-1s are great for helping you lose weight, but we don’t encourage people to be necessarily using them while we are actively involved in helping you get pregnant.

Abby Eblen MD (10:56)

Well said, you have to look at the risk and benefits of everything and by far the risk of being on a GLP-1 inhibitor at that point outweigh the benefits. agree.

Susan Hudson MD (11:06)

We just don’t know, there’s not enough information.

Carrie Bedient MD (11:08)

It’s well worth having a more in-depth discussion with your doc so that you guys can figure out the right plan for you because there are fertility patients who will really greatly benefit by them, but you need to make sure that you’ve talked about the timing of everything with your doc so that they can go through, here’s what we know, here’s what we don’t know, here are the things that are going to really have an impact on your cycle and how we can put everything together.

Abby Eblen MD (11:32)

All right, so we are gonna talk about our topic today, what happens after a positive pregnancy test. And I think patients feel like they kind of won the ball game and you have, so that’s a good thing. we don’t really know for sure how things are gonna end until we follow you more closely with lab tests and things like Susan, tell me when somebody in your practice gets that positive pregnancy test, what are the next steps for that person?

Susan Hudson MD (11:58)

Some of this is gonna vary from practice to practice. Not every practice does things exactly the same. Not every doctor within a practice is going to do things exactly the same. But one of the first things that we’re going to wanna make sure we have is when we say positive pregnancy test, that’s a little nondescriptive and that could have been a urine pregnancy test or a UPT or it could have been a blood pregnancy test. If you’ve only had a urine pregnancy test, we’re going to want to get numbers. So when we get a blood pregnancy test, we’re gonna get what’s called a quantitative, not qualitative, a quantitative hCG level. So we’re gonna get an actual number related to the pregnancy hormone level. So sometimes when you have blood pregnancy tests, they say positive or negative. We don’t wanna know just positive or negative. We want to know where is that level at this point in time.

Most of us are probably going to order a progesterone level to see what the progesterone level is. Now, with that being said, please let me get on a soapbox for a moment. Realize that

Abby Eblen MD (13:00)

You never do that. You never get on the soapbox. What are you talking about?

Susan Hudson MD (13:05)

Never! Never! If you get a progesterone level, realize that is a spot check in time. Progesterone levels go up and down many many many many times a day. If we get a quote good progesterone level, whatever your doctor may consider that to be, it’s reassuring, but it’s not all encompassing. But the same thing goes to a quote lower progesterone level.

If you repeated that progesterone level in 45 minutes, hour and a half, it could be completely different. So a lot of people hang their heart on these progesterone levels and it’s like, no! And realize just take it with a grain of salt. And depending on if you’re taking progesterone, realize that vaginal progesterones are not necessarily reflected in blood progesterone levels. So there’s lots of things that go into it.

The true value of a progesterone level is telling us if you ovulated or not, not necessarily how good or how successful this pregnancy is going to be.

Abby Eblen MD (14:06)

Carrie, why do we care about a positive progesterone or a high progesterone level? What does that tell us?

Carrie Bedient MD (14:11)

Progesterone is required to support the pregnancy in those early days. Ultimately, progesterone is going to be produced by the placenta to get the pregnancy through the majority of the time that a woman spends pregnant. However, in those early days, the placenta doesn’t exist yet. It’s going to take a few weeks for that system to get up and running. As a result, the corpus luteum, which is the space that the egg releases from, is responsible for being a hormone factory. So prior to ovulation, that little cystic space is the house for the egg. After ovulation, it converts into a factory and it’s producing not only the estrogen but the progesterone. And so when someone is getting pregnant completely on their own or with the presence of a follicle, their body is making some of the progesterone or in some cases, all of the progesterone.

When we’re doing an IVF cycle in particular, especially with a programmed frozen embryo transfer cycle, there’s no progesterone that’s being made. That’s why we check those levels so consistently, frequently, meticulously, slash obsessively in order to make sure that those levels are in a reasonable range and that if we need to play with your progesterone and increase those levels, we can do that.

Abby Eblen MD (15:18)

Susan, when do we usually check hCG levels? At what stage do we start checking and how do we do that?

Susan Hudson MD (15:26)

So it depends on how you get pregnant.

If you’ve done a IUI cycle or natural cycle, we’re usually going to do that first pregnancy hormone level about two weeks after we think you have ovulated. If you have done IVF and you had an embryo transfer, that pregnancy test is generally when you would be approximately four weeks pregnant. So  when you ovulate in a natural cycle, technically, by period dating, if you figured this out, you would be two weeks pregnant, even though you weren’t. Everybody who gets pregnant, you get two free weeks of pregnancy, surprise, surprise. And then that’s, that’s generally how we calculate things from there. At that point we expect you to have either a truly positive or a truly negative pregnancy test.

Susan Hudson MD (16:25)

There’s something about spring that feels like possibility. The days are brighter, everything feels a little lighter, and for many of you, this may be the season you’re thinking about the next steps in your fertility journey. If IVF has been on your mind, we want you to feel hopeful, but also informed. At Fertility Docs Uncensored, we spent years answering your questions and helping patients navigate IVF with clarity and confidence. And we took everything we’ve learned, plus the thoughtful questions you’ve sent us and created one comprehensive, easy to understand guide, the IVF Blueprint.It walks you step by step through the IVF process in the same straightforward down to earth style you know from us. We explain what to expect, how decisions are made, and what really matters so you can move forward feeling steady and supported. Whether you’re just starting to explore treatment this spring or already in the middle of it, the IVF Blueprint is designed to help you feel empowered every step of the way.

You can find it in print, ebook, and audiobook with a special conversation from the three of us at the end, wherever books are sold, and at FertilityDocsUncensored.com. If this season feels like a fresh start, let it be the one where you move forward with clarity, confidence, and real hope.

Abby Eblen MD (17:43)

Carrie, I get the question oftentimes, well, what’s a good level? What’s a normal level? do we follow that? How do we know that it’s going to continue to stay normal?

Carrie Bedient MD (17:52)

Really depends on what type of manner you got pregnant in, what other medications were going on, and the biggest one, which is how far out are you from…conception and the theoretical time of implantation. So for the most part, when we’re doing a frozen embryo transfer, or we’re checking a pregnancy test for the first time, whether it’s 10 days after a transfer or two weeks after an insemination, whatever it may be, we’re hoping for a level that’s about 100 or higher. Now, most of us will tend to defer to the higher the better.

And so we have gotten levels that are in the 200s, 300s, even sometimes 400s on one of those first checks. And that is a single snapshot in time. And while looking at a snapshot is lovely, we want a flip book. And in order to get a flip book, we are checking multiple levels over the course of time. As long as somebody’s got a level that’s roughly 100 or greater, we tend to be fairly relaxed.

But a couple of days can make a difference here. If you’re day nine instead of day 10, it’s gonna be a little lower than that. If you’re day 11 instead of day 10, it’s gonna be a little bit higher than that. And ultimately, regardless of what the level is, we tend to follow it. A single snapshot can’t tell you if you’re catching something in the midst of it falling off a cliff or in the midst of the hot air balloon rising. And you really need the big picture here to know is this level normal? And the other thing that factors into this, especially if someone has gotten pregnant on their own or even with an IUI, we’re basing everything off of the last menstrual period in those cases where it’s a less scheduled programmed way of getting pregnant and bodies do whatever the hell they want to do.

And sometimes that means an early or a late implantation. It means that the period you thought you had really wasn’t the period. It was just a little bit of early pregnancy bleeding and every variation on that that you can come up with. And so that single snapshot to show, yes, the hCG level is above five is helpful, but it’s very much not the entire story.

Abby Eblen MD (19:51)

Susan, how do we follow the levels and what do we expect to see?

Susan Hudson MD (19:54)

We follow pregnancy hormone levels at an interval of generally two to three days. Some of it’s going to depend on what day of week it is and things like this. But we expect at least a 60 % rise over 48 hours. And anything below that, is very concerning for a non viable pregnancy, either an impending miscarriage or potentially a pregnancy in the wrong place, ectopic pregnancy.

Abby Eblen MD (20:27)

How do we figure that out? How do we know that the pregnancy’s where it should be at the right time?

Carrie Bedient MD (20:33)

As we’re watching those levels increase, there becomes a threshold at which we expect to see something on an ultrasound. Now, if we do a pregnancy level, let’s say 10 days after a transfer, sometimes patients will say, okay, when do I get my first ultrasound? Can I come in, in two days when I get my repeat test? And the answer is, well, you could, but it’s not going to show anything because it’s far too early. It takes until the hCG level hits an approximate threshold, usually roughly 1500 or greater for something to be seen on a vaginal ultrasound. For an abdominal ultrasound, it’s usually more in the area of about 5000. Now those numbers will vary and as technology gets better and better, they’re probably going to continue to drop. But general rule of thumb is it takes an hCG level roughly around 1500 till you can see something. And so we do just like we’re doing serial hCG levels, we’re getting serial ultrasounds and watching progress.

Abby Eblen MD (21:26)

Susan, say somebody came in at that point and they saw a gestational sac and the uterus at that point in about five What would you do at that point?

Susan Hudson MD (21:34)

First of all, we can only truly call a gestational sac, which is a fluid collection within the lining of the uterus. We can actually only truly call it a gestational sac if we see a second structure within it called the yolk sac. Carrie was talking about that earlier. That is something that does help produce progesterone as the placenta is developing.

If you see both of those structures and it’s in the uterus, that gives you lot of reassurance at five, five and a half weeks that the pregnancy is in the right place. And then generally people would schedule another ultrasound at a one to two week interval. And again, this is kind of where different practices do different things. I generally do my first ultrasound around six, six and a half weeks unless the person is at a higher risk for an ectopic pregnancy or a pregnancy in the wrong place. If you’re in that ectopic pregnancy risk category, those are people that I generally see around five and a half weeks because the earlier we see it, the more options we have to ideally treat a pregnancy in the wrong place safely, effectively, and hopefully as least invasively as possible.

Abby Eblen MD (22:49)

Carrie what is an ectopic pregnancy.

Carrie Bedient MD (22:50)

I would say that it is not growing where it should be. Most commonly that means in the tubes, but doesn’t have to be limited to the tubes. Sometimes it can be growing in the abdominal cavity. Sometimes it can be growing on the ovaries. Sometimes it’s implanted very low and it’s trying to grow in the cervix. Really it’s trying to grow someplace where it doesn’t have the necessary blood supply or space or support that it would be getting within the uterus. so ectopic pregnancies are incredibly dangerous because what many people don’t realize is just the amount of blood flow that a pregnancy requires. There is a massive diversion of blood flow and a massive increase in the volume of blood within a pregnant woman. When you have that directed into a place that isn’t terribly stable. When I think of when I think of ectopic pregnancies that are scary, usually the cervical ectopics are the one that come to mind for me because they are harder to see, they’re harder to get at, and they really have the capacity to bleed an incredible amount. But any ectopic pregnancy has the potential to be extraordinarily scary. Cornual ectopics where they’re tucked in the portion of the uterus where it’s two, but it’s still surrounded by all the uterine muscle. 

That’s a scary place as well because that will cause problems and when it ruptures, which it will do if left unchecked, it’s a very vascular area and it’s something, ectopic pregnancies are one of the most serious things that can happen within an OB-GYN practice of any sort. We are obsessive. If we have any suspicion that there could be one, we want to know about it as soon as possible. And by default, our patients with fertility issues, they’re more likely to have two issues, so they’re more likely to get ectopics, and so we tend to be very compulsive about looking for them from a very early point.

Abby Eblen MD (24:41)

If the patient comes in at five weeks, can you just do an exam and tell if they’ve got a ectopic pregnancy then?

Susan Hudson MD (24:47)

Sometimes. When you’re talking about exam, you’re I’m generally talking about an ultrasound. And if at five, five and a half weeks, we see nothing in the uterus that looks like a gestational sac, potential yolk sac forming, or we see a mass in the pelvis, that’s not actually inside the uterus, those are things that can let us know that there definitely is a pregnancy in the wrong place. Sometimes we can even see blood or free fluid in the pelvis because the ectopic pregnancy is starting to cause bleeding even maybe before the patient may be symptomatic with pain and that type of thing. We’re sitting there looking at hormone levels, how have they been rising? Where are they currently? What should we be seeing at this point in time? What are your risk factors?

And then also weighing different types of potentially treating an abnormal pregnancy of potentially unknown location, but we know that it’s truly abnormal. In other words, not going to result in a baby, but potentially miscarriage versus ectopic pregnancy.

Abby Eblen MD (25:53)

When I have that come to the office and follow us around as part of their residency, I usually tell them the rule with an ectopic is there is no rule. I’ve seen it all. I’ve seen people get to a really high hCG level before they become symptomatic. I’ve seen it ruptured a really early stage. It’s really scary. I think as a physician, we tend to scare patients to death when hormone levels don’t go up well.

we don’t mean to do it, but we know that it could result in a really significant issue for you, an emergent surgery. We have to think worst case scenario. That’s why we typically bring you back. And a lot of times we bring you back every couple of days. Once we get in that zone where we’re starting to worry about it, we don’t want to let you out of our sight because if we have you come back in three or four days, unfortunately in that amount of time, something bad could happen.

Really every two days is about the length of time that we spend or let you wait between visits. Carrie, say we make the diagnosis of an ectopic pregnancy in the tube, what are our next steps?

Carrie Bedient MD (26:56)

Depends on what the story is. Typically at that point, if you’ve got any travel plans, we’re telling you to cancel them. And this is part of the reason why even though we want you to be present and around in the process leading up to a transfer, an IUI, we want you to be around afterwards too, because until we get confirmation that that pregnancy is definitively growing in the uterus where we’ve got both the gestational sac and at the very least a yolk sac to confirm it’s where we want it to be, we don’t want you going that far out of our reach because we want to make sure if something happens, we can help you. So once we know that we’re concerned and we’ve solidified that diagnosis, Depending on what the situation is, we can either give you medication or we can do surgery. And the medication is called methotrexate. The surgery is typically a salpingectomy, sometimes a salpingostomy. And there’s a newer treatment out there where you give letrozole for about 10 days. And so it really depends on what your clinical situation is. Someone who’s in a lot of pain, they’re headed towards surgery right away.

Someone whose levels are pretty low and we’ve caught it very, very early, that’s more manageable by medications. Salpingectomy is taking out the whole tube versus a salpingostomy which is making a little hole, flushing the pregnancy out, and then repairing the tube. Do you guys do, which of those, if you have the choice, do you prefer to do?

Susan Hudson MD (28:14)

If in doubt, take it out.

Abby Eblen MD (28:14)

Salpingectomy

The concern with leaving the fallopian tube in, and I did those more as a resident than I ever have as an attending or as a fertility physician, it’s because when you go in, the pregnancy grows in the wall of the fallopian tube. If you make a slit in the fallopian tube and you try and shell out that tissue, first of all, it’s really vascular and really bloody, it bleeds a lot.

And it’s just really hard to tell if you’ve gotten it all. And particularly if it’s growing in the wall of the fallopian tube, you just don’t really know until after the surgery, you start falling the hormone levels again. And I’m sure we’ve all been in the situation where you think you’ve gotten it all and you tell the patient you’ve gotten it all and you start falling the hormone levels and the hormone levels start going back up again. And then you end up having to go back in and do a second surgery to remove the whole tube. Generally a tube like that’s going to be pretty damaged from all the manipulation of the tube.

Good chance it may not be a functional tube anyway, and certainly higher risk of having another ectopic in that same tube. So most of us feel like the better part of Valor is just to take the tube out, particularly if there’s a tube on the other side that looks really healthy and looks like it would be a place where a good pregnancy could start. So I take it out.

Susan Hudson MD (29:24)

There was a study about five or so years ago that actually showed that pregnancy outcomes of people who had had ectopic pregnancies were better in people who had just had that tube out. And so though it may seem a little illogical that you’re better off with one tube, but you really are better off with one tube and the absence of a bad tube than one tube and another tube that could be causing you problems.

Carrie Bedient MD (29:52)

Usually damaged tubes are much scarier than flat out blocked or absent tubes. I would take an absent tube any day of the week and twice on Tuesdays because when one’s damaged, forget. Fallopian tubes will hold a grudge. If you so much as look at them cross-eyed, they will pick up their toys and go home. And the uterus will take a ton of abuse. can push babies out. It can recreate its lining from scratch every single month. But I swear those tubes are so fickle and so persnickety and you just don’t want to mess with them.

Abby Eblen MD (30:24)

There’s one other type of abnormal pregnancy that we haven’t talked about. So we’ve talked about pregnancy of unknown location. We’ve talked about the tubal or ectopic pregnancy. What’s a biochemical pregnancy?

Susan Hudson MD (30:34)

So biochemical pregnancy is a pregnancy where levels go up and then they go down before we have any evidence within the uterus that the pregnancy was there. It’s a form of a miscarriage. Technically, it could be a self-resolving ectopic pregnancy, but in most cases because one an eight pregnancies result in miscarriage that often it’s just a pregnancy that had implantation and then just didn’t have enough of whatever whether it was the right components of chromosomes or some other development and then it fails before we see anything inside the uterus.

Abby Eblen MD (31:15)

Carrie, if we have an abnormal pregnancy in the uterus, say that five week pregnancy, say we followed that patient, they came back to the office a week or so later, we saw no change, or say we even saw a heartbeat at one point and unfortunately the fetal heartbeat stopped, what are the options for those patients?

Carrie Bedient MD (31:31)

There’s generally three. One of them is to do expectant management. This means sit back and do nothing. You stop any supportive medications you’re on and you let nature take its course. The advantage of that is that there is no intervention. The disadvantage of that is that there’s no intervention. And sometimes this can happen very quickly and sometimes it won’t happen at all. It could take weeks to happen. I would say most of the time in fertility offices, this is not a very popular option because people have already been waiting forever in a day to get pregnant and waiting even longer with a pregnancy that they know is not going forward is not high on their to-do list. Another option is to do medications and this is typically something called misoprostol which is a medication that you can take either by mouth or place vaginally.

and it brings on the cramping of a miscarriage. When I’m talking about patients with doing this, typically what I’ll say is take it around noon on a Friday. Friday night is gonna suck. It’s the worst cramps ever. Think worst period of your life. Last for about five, six-ish hours is the worst of it. And then after that, it normally subsides. And some people will have bleeding every day until their uterus completely clears out and their hCG level drops. Some people will have hardly any at all. And everything in between. And sometimes we need to have people take a second dose of medication. It doesn’t work the first time always. I think if you look in the literature it’s about a 15 % fail rate.

I would say at least from personal experience, we’re catching them so early that our fail rate is a lot lower than that. But I think if you’re out in the wild just getting pregnant on your own, a different story than in a fertility office. And then there’s the option of doing a D&C, which is a surgical procedure where we go in and clear out the contents of the uterus in order to speed things along. The advantage of that is that it’s very timed, it’s very controlled, but the disadvantage is it’s a surgical procedure. There’s theoretical risk that you could get scar tissue after that. It’s pretty rare, especially in the hands of a fertility specialist, where a lot of times we’re doing this under ultrasound guidance. We are only doing suction. We’re not doing much sharp curatage, which the suction is a lot gentler on the uterine walls, but those in general are the three options that we can go for.

Susan Hudson MD (33:40)

If it’s an early miscarriage before eight weeks, sometimes I’ll do that even with hysteroscopy where I’ll put the little telescope’s instrument inside the uterus and remove the failing pregnancy that way.

Abby Eblen MD (33:40)

One of the things too that can happen, and doesn’t happen often, but sometimes you can have retained tissue, particularly if the pregnancy implants off to the right or the left side, not right in the middle of the cavity, or if the uterus is tilted back like a sharp curve at the top, sometimes the tissue can be missed. But doing it under ultrasound guidance is certainly helpful. And then if you can do it hysteroscopically, that’s great too. But sometimes it’s limited because it’s very bloody when you put the telescope in and you just can’t see anything.

We’ll end on a positive note. Susan, say that person with a five week pregnancy comes in, we see a yolk sac, they come back a week later and voila, we see a baby with a heartbeat. What are the next steps after that?

Susan Hudson MD (34:28)

So first of all, know, at the point that you have a baby with a heartbeat, there’s 95 % chance that things are gonna go in the right direction. So take a deep breath. But with that deep breath, I would not necessarily shout out to the wind. It is still an early ultrasound, losses can happen. People are always like, can I tell everybody? And I’m like, I would tell whoever I would tell about a loss. As you go through your pregnancy, that circle gets bigger and bigger.

It’s not a hard and fast thing and different people share at different rates. There’s not a right or wrong, but it’s something to think about. If we see a baby in a heartbeat, I think a lot of us will probably repeat an ultrasound in two weeks, make sure everything’s looking good. And also at that first…appointment where you see a baby in a heartbeat, I usually recommend my patients start looking for whoever is going to deliver their baby. This is so important because realize your reproductive endocrinologist as much as they love you, they are not going to deliver your baby. Most REIs do not deliver babies anymore. 

Carrie Bedient MD (35:39)

If we’re on an airplane and it’s me or the flight attendant, I gotcha. Anything failing that? Probably not.

Susan Hudson MD (35:48)

Exactly.

So we do recommend you call your OBGYN’s office, make an appointment about four weeks out. Most OBGYNs are going to get booked out about a month. And so it’s good timing. So in two weeks, you see your REI for that repeat ultrasound. Two weeks from there, you’ll establish care with your general OBGYN.

Abby Eblen MD (36:09)

Very good. Well, this has been a very interesting and good topic because I know we talk a lot about how to get pregnant, but we don’t talk about what happens

All right, well, very good to our audience. Thanks for listening and subscribe to Apple Podcast to have next Tuesday’s episode pop up for you automatically. Also be sure to subscribe to YouTube. It really helps us spread reliable information and helps us communicate with as many people as possible.

Carrie Bedient MD (36:32)

Visit fertilitydocsuncensored.com to submit questions and sign up for our email list. Pick up your copy of the IVF Blueprint today at Amazon, Barnes & Noble, or your favorite bookstore, and check out our Instagram and TikTok for quick hits of fertility tips between episodes.

Susan Hudson MD (36:46)

As always, this podcast is intended for entertainment and is not a substitute for medical advice from your own physician. Subscribe, sign up for emails, and we’ll talk to you soon. Bye.