{"version":"1.0.0","segments":[{"startTime":0.72,"endTime":3.55,"body":"Today we talk about when to hit the panic"},{"startTime":3.59,"endTime":6.51,"body":"button when it comes to repeated ectopic"},{"startTime":6.55,"endTime":9.046,"body":"pregnancies. I'm, Doctor Mark"},{"startTime":9.086,"endTime":11.99,"body":"Amos, and this is"},{"startTime":12.038,"endTime":14.466,"body":"taco, about fertility Tuesday."},{"startTime":26.886,"endTime":29.798,"body":"Over the next several weeks, I'm going to put a"},{"startTime":29.822,"endTime":32.366,"body":"series together called when to hit the panic"},{"startTime":32.406,"endTime":34.966,"body":"button. And it's going to be on multiple"},{"startTime":35.006,"endTime":37.758,"body":"topics, and we're going to start it off with"},{"startTime":37.782,"endTime":40.758,"body":"ectopics. And at what point do"},{"startTime":40.782,"endTime":43.718,"body":"you need to hit that panic button and need"},{"startTime":43.742,"endTime":46.686,"body":"to move on to other treatments? If you like this"},{"startTime":46.726,"endTime":49.678,"body":"episode, make sure you check out the other ones that are coming up"},{"startTime":49.702,"endTime":52.414,"body":"in the next few weeks. So let's start off with the first"},{"startTime":52.47,"endTime":55.214,"body":"part, which is ectopic. pregnancies are very"},{"startTime":55.294,"endTime":58.144,"body":"scary. You can actually die from an ectopic"},{"startTime":58.184,"endTime":60.944,"body":"pregnancy. So anytime you have it, you"},{"startTime":60.984,"endTime":63.656,"body":"are technically hitting the panic button because you need to get to the"},{"startTime":63.68,"endTime":66.56,"body":"ER immediately, because if your tube ruptures, you can"},{"startTime":66.592,"endTime":69.12,"body":"bleed to death. And so again, it's always an"},{"startTime":69.152,"endTime":72.152,"body":"emergency. But what I'm talking about is"},{"startTime":72.168,"endTime":75.104,"body":"if you had a nectopic, maybe one, maybe"},{"startTime":75.144,"endTime":78.048,"body":"two, maybe a third one, at what"},{"startTime":78.096,"endTime":80.712,"body":"point do you need to hit the panic button"},{"startTime":80.848,"endTime":83.752,"body":"and move on to something else, such as IVF to reduce"},{"startTime":83.808,"endTime":86.772,"body":"your risk of an ectopic? Now, have you heard one"},{"startTime":86.788,"endTime":89.414,"body":"of my prior episodes? I talked about what an ectopic"},{"startTime":89.454,"endTime":91.886,"body":"pregnancy is. Essentially, it's when the"},{"startTime":91.91,"endTime":94.794,"body":"pregnancy is not inside the uterus."},{"startTime":95.174,"endTime":97.622,"body":"Anywhere else is considered an"},{"startTime":97.638,"endTime":100.154,"body":"ectopic. It could be in the tube,"},{"startTime":100.534,"endTime":103.23,"body":"it could be on the ovary, it could even be in the"},{"startTime":103.262,"endTime":106.046,"body":"cervix. It can even be on your organs if it's"},{"startTime":106.07,"endTime":108.846,"body":"inside your abdomen. There's even very rare ones"},{"startTime":108.87,"endTime":111.404,"body":"called corneal pregnancies, where they're actually"},{"startTime":111.904,"endTime":114.784,"body":"in the tube but still in the uterus. And those can be very"},{"startTime":114.824,"endTime":117.804,"body":"dangerous as well. Tubelectopic pregnancies are, going"},{"startTime":117.804,"endTime":120.348,"body":"to account for about 90% to 95% of all"},{"startTime":120.396,"endTime":122.644,"body":"cases within the tubal"},{"startTime":122.724,"endTime":125.3,"body":"ectopics. The ampulla of the"},{"startTime":125.332,"endTime":127.836,"body":"fallopian tube, which is the widest portion, accounts for about"},{"startTime":127.9,"endTime":130.748,"body":"70% of the ectopics. The next"},{"startTime":130.796,"endTime":133.388,"body":"largest portion is going to be the isthmic portion of the"},{"startTime":133.476,"endTime":135.804,"body":"fallopian tube, which is the narrowest portion, and that's about"},{"startTime":135.844,"endTime":138.834,"body":"12%. And then the last 11% occur"},{"startTime":138.874,"endTime":141.45,"body":"around the fimbria, which are the little fingers that pull the"},{"startTime":141.482,"endTime":144.21,"body":"egg towards the fallopian tube. Ovarian"},{"startTime":144.242,"endTime":146.906,"body":"ectopics occur about 3%. This is a"},{"startTime":146.93,"endTime":149.57,"body":"situation where the fertilized egg implants on the ovary"},{"startTime":149.602,"endTime":152.53,"body":"itself and continues to grow even rarer."},{"startTime":152.602,"endTime":155.444,"body":"Are, what are called cervical topics. This is where the pregnancy is"},{"startTime":155.5,"endTime":158.324,"body":"inside the cervix and starts to grow. This can be very"},{"startTime":158.38,"endTime":161.284,"body":"dangerous due to the vascularity of the cervix. And"},{"startTime":161.3,"endTime":163.76,"body":"this occurs less than 1% of the time."},{"startTime":163.908,"endTime":166.752,"body":"Abdominal ectopics, which is when I was talking about where it lands"},{"startTime":166.784,"endTime":169.528,"body":"on, let's say an organ, occurs in about one to 2% of"},{"startTime":169.552,"endTime":172.104,"body":"ectopic pregnancies. Again, very rare"},{"startTime":172.28,"endTime":174.792,"body":"and corneal ectopic pregnancies, also called"},{"startTime":174.864,"endTime":177.784,"body":"interstitial ectopic pregnancies, are"},{"startTime":177.8,"endTime":180.536,"body":"where the ectopic pregnancy occurs in the part of the fallopian tube that"},{"startTime":180.576,"endTime":183.296,"body":"passes through the uterine wall. This means if you're looking at"},{"startTime":183.336,"endTime":186.232,"body":"abdomen, you're looking at the fallopian tube that's not in the wall."},{"startTime":186.344,"endTime":189.168,"body":"This is the portion that's in the muscle. These are very"},{"startTime":189.232,"endTime":192.13,"body":"dangerous because they can look like they're in the uterus, and"},{"startTime":192.138,"endTime":195.106,"body":"they usually grow much larger without detection and could potentially"},{"startTime":195.146,"endTime":198.018,"body":"cause very severe complications, even death, if"},{"startTime":198.042,"endTime":201.02,"body":"they rupture because it's rupturing your uterus. Now, what's important"},{"startTime":201.068,"endTime":203.716,"body":"to understand is that ectopics"},{"startTime":203.836,"endTime":206.828,"body":"are anytime the embryo is not in the"},{"startTime":206.852,"endTime":209.086,"body":"uterus, and, with each ectopic,"},{"startTime":209.802,"endTime":212.402,"body":"there's a higher risk of having another ectopic."},{"startTime":212.514,"endTime":215.314,"body":"So in a general population, about one to 2%"},{"startTime":215.37,"endTime":218.138,"body":"of people will have an ectopic pregnancy. Now, once"},{"startTime":218.162,"endTime":220.962,"body":"youve had one ectopic pregnancy, your risk for"},{"startTime":220.994,"endTime":223.366,"body":"another is approximately 15%."},{"startTime":223.946,"endTime":226.834,"body":"If youve had a second ectopic pregnancy"},{"startTime":226.97,"endTime":229.586,"body":"now, your risk is going to be as high as about 20% to"},{"startTime":229.626,"endTime":232.578,"body":"25% of having another one. And by the time"},{"startTime":232.602,"endTime":235.578,"body":"youve had the third ectopic pregnancy, your chances"},{"startTime":235.642,"endTime":238.326,"body":"are around 30% to 50% of having another ectopic."},{"startTime":239.216,"endTime":241.952,"body":"this is also the point where you should be hitting the pack"},{"startTime":241.984,"endTime":244.872,"body":"button and strongly considering IVF or"},{"startTime":244.904,"endTime":247.624,"body":"other interventions to reduce your risk. Now, in the prior"},{"startTime":247.68,"endTime":250.496,"body":"episode, I talked about how to diagnose the next topic,"},{"startTime":250.536,"endTime":253.136,"body":"and essentially, there's a thing called a discriminatory zone,"},{"startTime":253.296,"endTime":255.96,"body":"where you expect the HCG levels to be"},{"startTime":256.088,"endTime":258.544,"body":"at a certain number, and then you should see something in the"},{"startTime":258.56,"endTime":261.224,"body":"uterus, such as a gestational sac,"},{"startTime":261.4,"endTime":264.328,"body":"and that number is different between every place. So it's"},{"startTime":264.352,"endTime":266.848,"body":"important for people to determine their own discriminatory"},{"startTime":266.912,"endTime":269.496,"body":"zone. Now, there are times"},{"startTime":269.576,"endTime":272.544,"body":"when you might think there's an ectopic there, but there"},{"startTime":272.56,"endTime":275.39,"body":"could be an abnormal pregnancy that's just abnormally"},{"startTime":275.438,"endTime":278.342,"body":"rising with ACG levels. But there's"},{"startTime":278.374,"endTime":281.318,"body":"this point where eventually, you know, it's not a healthy pregnancy. And you may"},{"startTime":281.342,"endTime":284.294,"body":"just say, no, this isn't gonna"},{"startTime":284.31,"endTime":286.918,"body":"be a healthy pregnancy. And we're concerned about the risk of"},{"startTime":286.942,"endTime":289.806,"body":"ectopic. We're just gonna give treatment, which is called"},{"startTime":289.846,"endTime":292.266,"body":"methotrexate, which is a chemotherapy agent."},{"startTime":292.686,"endTime":295.598,"body":"Now, the reason this is important is cause we're getting to this idea"},{"startTime":295.622,"endTime":297.862,"body":"of how do we know we did have multiple"},{"startTime":297.894,"endTime":300.822,"body":"ectopics? The first thing we look at and what makes"},{"startTime":300.854,"endTime":303.378,"body":"us concerned about ectopic is how the"},{"startTime":303.402,"endTime":306.378,"body":"ECG levels rise when they're not rising"},{"startTime":306.442,"endTime":308.954,"body":"normally. We start getting concerned."},{"startTime":309.13,"endTime":311.994,"body":"The second part is when we don't see a pregnancy in the uterus. But"},{"startTime":312.01,"endTime":314.762,"body":"the question is, when do we expect it?"},{"startTime":314.954,"endTime":317.818,"body":"When you're doing things like iuis or IVF, we know"},{"startTime":317.882,"endTime":320.658,"body":"exactly how far long the pregnancy is. But when you're talking about"},{"startTime":320.722,"endTime":322.81,"body":"ovulating, some people ovulate"},{"startTime":322.858,"endTime":325.682,"body":"irregularly. And so although they might have had a period"},{"startTime":325.754,"endTime":328.668,"body":"which they thought was a period, maybe it wasn't, and maybe"},{"startTime":328.692,"endTime":331.388,"body":"they didn't ovulate two weeks later, but ovulated four weeks"},{"startTime":331.412,"endTime":334.38,"body":"later. And so now you think the pregnancy is six weeks along, but"},{"startTime":334.388,"endTime":337.38,"body":"it's only four weeks long, and you wouldn't expect to see something in"},{"startTime":337.388,"endTime":340.18,"body":"the uterus. This is where the discriminatory zone"},{"startTime":340.228,"endTime":342.756,"body":"comes in. By looking at HCG level,"},{"startTime":342.916,"endTime":345.7,"body":"then you know if you should see something visible inside"},{"startTime":345.748,"endTime":348.732,"body":"of the uterine cavity. The problem doctors have"},{"startTime":348.804,"endTime":351.508,"body":"is this kind of waiting game. If they keep"},{"startTime":351.572,"endTime":354.486,"body":"waiting to find out what happens, it could get too"},{"startTime":354.526,"endTime":357.454,"body":"late and then it could rupture, and you can have a"},{"startTime":357.47,"endTime":360.026,"body":"very serious situation where someone's bleeding to death."},{"startTime":360.486,"endTime":362.878,"body":"But if you make a decision too soon"},{"startTime":363.022,"endTime":365.79,"body":"prior to determining if it's an ectopic versus"},{"startTime":365.838,"endTime":368.798,"body":"abnormal pregnancy, you could be hurting the"},{"startTime":368.822,"endTime":371.598,"body":"pregnancy, or maybe it's just a little bit abnormal and"},{"startTime":371.622,"endTime":374.534,"body":"starts going normal again. So if we rush to a"},{"startTime":374.55,"endTime":377.33,"body":"diagnosis, yes, we're going to, treat more"},{"startTime":377.354,"endTime":380.134,"body":"ectopics faster, but we're also going to hurt"},{"startTime":380.326,"endTime":383.118,"body":"normal pregnancies if we wait too long."},{"startTime":383.238,"endTime":386.094,"body":"We can protect pregnancies more, but we have"},{"startTime":386.126,"endTime":389.118,"body":"more ruptures. And so it's very important to make this"},{"startTime":389.158,"endTime":391.788,"body":"diagnosis in an appropriate,"},{"startTime":392.35,"endTime":394.79,"body":"amount of time, but also being sensitive to the"},{"startTime":394.814,"endTime":397.694,"body":"fact that you want to be sure. I personally have"},{"startTime":397.726,"endTime":400.614,"body":"seen many patients who come in with multiple ectopics,"},{"startTime":400.686,"endTime":403.678,"body":"but when I get to the actual definition and I start"},{"startTime":403.718,"endTime":406.606,"body":"asking them, well, how long did they wait to see if that"},{"startTime":406.622,"endTime":409.174,"body":"ECG went up? They'll tell me, well, it only went"},{"startTime":409.206,"endTime":411.966,"body":"to 50. Well, 50 is a very low"},{"startTime":412.022,"endTime":414.718,"body":"number. You don't know if it's an ectopic. Then"},{"startTime":414.838,"endTime":417.726,"body":"you never hit the discriminatory zone, so you wouldn't expect to"},{"startTime":417.742,"endTime":420.614,"body":"see something uterus. So how do we know it just wasn't an abnormal"},{"startTime":420.646,"endTime":423.214,"body":"pregnancy and there's no harm in that"},{"startTime":423.246,"endTime":426.078,"body":"situation? The doctor did the right thing by giving that"},{"startTime":426.118,"endTime":428.338,"body":"person methotrexate."},{"startTime":428.798,"endTime":431.778,"body":"But now the patient has this diagnosis"},{"startTime":432.238,"endTime":435.158,"body":"of an ectopic pregnancy. So do they hit the panic button"},{"startTime":435.198,"endTime":438.078,"body":"now, or do we not consider that in that"},{"startTime":438.118,"endTime":440.766,"body":"category where it's a higher risk?"},{"startTime":440.942,"endTime":443.31,"body":"We're going to get into this a little bit further here in a minute."},{"startTime":443.454,"endTime":446.446,"body":"So, one of the things I've talked about in the prior podcast"},{"startTime":446.502,"endTime":449.158,"body":"was understanding that an ectopic"},{"startTime":449.318,"endTime":451.878,"body":"is not an embryo stuck in the fallopian"},{"startTime":451.918,"endTime":454.63,"body":"tube. Today I had a consult where someone"},{"startTime":454.774,"endTime":457.438,"body":"was asking that question, is their fallopian"},{"startTime":457.478,"endTime":460.42,"body":"tubes clogged? And. And the answer is no. It's"},{"startTime":460.444,"endTime":463.444,"body":"not really thinking that's clogged. Think of it more as"},{"startTime":463.476,"endTime":466.108,"body":"the surface of the fallopian tube"},{"startTime":466.268,"endTime":469.084,"body":"is more like tar. And so the ectopic is"},{"startTime":469.116,"endTime":472.036,"body":"getting stuck in the fallopian tube because of that,"},{"startTime":472.052,"endTime":474.988,"body":"but it's not getting stuck like we think of our body being wedged"},{"startTime":475.028,"endTime":477.644,"body":"in a tube. And this is because"},{"startTime":477.796,"endTime":480.532,"body":"the embryo itself is very, very small. We're talking"},{"startTime":480.58,"endTime":483.048,"body":"microscopic, where the flopping tube is very large."},{"startTime":483.588,"endTime":486.492,"body":"My analogy, I tell people, is think of like a football in a"},{"startTime":486.5,"endTime":489.326,"body":"football stadium. How is that football going to get stuck?"},{"startTime":489.382,"endTime":491.886,"body":"There's no way that football stems so wide compared to"},{"startTime":491.902,"endTime":494.734,"body":"that football. And that's kind of the same"},{"startTime":494.806,"endTime":497.734,"body":"type of measurements of scale. When you talk about"},{"startTime":497.806,"endTime":500.738,"body":"an embryo and the fallopian tube."},{"startTime":501.118,"endTime":504.11,"body":"And why this is important is because there's this sense of things"},{"startTime":504.174,"endTime":507.046,"body":"are safe. When you do a hyster cell"},{"startTime":507.062,"endTime":509.774,"body":"pingogram and you check the fallopian tubes and find out they're"},{"startTime":509.806,"endTime":512.774,"body":"open, sure, they're open. That"},{"startTime":512.806,"endTime":515.58,"body":"doesn't mean that they're functional. That doesn't mean"},{"startTime":515.604,"endTime":518.468,"body":"that an embryo won't get stuck because"},{"startTime":518.508,"endTime":521.388,"body":"of that surface or that the little fimbrey that"},{"startTime":521.428,"endTime":524.34,"body":"pulled egg towards it won't work and"},{"startTime":524.364,"endTime":527.244,"body":"cause an ectopic. And this leads us, really to the question"},{"startTime":527.276,"endTime":529.852,"body":"of, well, then, what causes ectopics?"},{"startTime":530.02,"endTime":532.836,"body":"One of the most common reasons for an ectopic pregnancy"},{"startTime":532.892,"endTime":535.524,"body":"is something that causes trouble, disease."},{"startTime":535.716,"endTime":538.452,"body":"And this is going to be things like infections such"},{"startTime":538.5,"endTime":540.35,"body":"as chlamydia,"},{"startTime":540.524,"endTime":542.94,"body":"gonorrhea, mycoplasm, certain"},{"startTime":543.004,"endTime":545.884,"body":"infections that can then lead to tubal disease,"},{"startTime":546.076,"endTime":549.076,"body":"even a surgery that leads to infection in"},{"startTime":549.092,"endTime":551.948,"body":"the pelvis can then lead to a state of"},{"startTime":551.988,"endTime":554.66,"body":"tubal disease that can then lead to ectopics in the"},{"startTime":554.684,"endTime":557.588,"body":"future. Other types of infection would be pelvic"},{"startTime":557.628,"endTime":560.396,"body":"inflammatory disease. Now,"},{"startTime":560.452,"endTime":563.328,"body":"the next category is what we call"},{"startTime":563.788,"endTime":566.308,"body":"lifestyle factors. And most of these lifestyle"},{"startTime":566.348,"endTime":568.708,"body":"factors affect things like the"},{"startTime":568.748,"endTime":571.42,"body":"cilia that pull the embryo"},{"startTime":571.564,"endTime":574.506,"body":"down to the, uterus. The"},{"startTime":574.562,"endTime":577.514,"body":"ciliary dysfunction or"},{"startTime":577.706,"endTime":579.962,"body":"something that can make it change are going to be things like"},{"startTime":580.05,"endTime":582.61,"body":"smoking. Smoking, we know,"},{"startTime":582.754,"endTime":585.722,"body":"affects things like cilia. That's why when"},{"startTime":585.77,"endTime":588.074,"body":"people smoke, they get the smokers cough, because the"},{"startTime":588.106,"endTime":590.278,"body":"cilia don't work as well."},{"startTime":590.658,"endTime":593.37,"body":"And what happens is they build up stuff. They"},{"startTime":593.394,"endTime":596.35,"body":"can't cough it. They have to cough it out, unlike everyone"},{"startTime":596.414,"endTime":599.246,"body":"else where they're cilia work and just pull the mucus and"},{"startTime":599.262,"endTime":602.206,"body":"things out of their airways. Well, the"},{"startTime":602.222,"endTime":605.054,"body":"same thing happens at the fallopian tube. Those cilia don't work"},{"startTime":605.086,"endTime":607.218,"body":"as well, and that leads to ectopics."},{"startTime":608.236,"endTime":610.668,"body":"the same thing with age. As people get more"},{"startTime":610.708,"endTime":613.604,"body":"mature, they have a higher risk of ectopic. And the thought"},{"startTime":613.636,"endTime":616.604,"body":"is that maybe as they're aging, things don't work as well. The"},{"startTime":616.636,"endTime":619.556,"body":"fimbria don't work as well. Pulling the egg towards it or the cilia are"},{"startTime":619.572,"endTime":622.118,"body":"not working as well. So those are things that can"},{"startTime":622.158,"endTime":625.134,"body":"actually increase your ectopic. You can't change"},{"startTime":625.166,"endTime":627.942,"body":"your age, but you can quit smoking, and that is a"},{"startTime":628.03,"endTime":630.904,"body":"huge factor when it comes to, ectopic pregnancies. So"},{"startTime":631.056,"endTime":633.704,"body":"if you do smoke and you have ectopic pregnancy,"},{"startTime":633.856,"endTime":636.712,"body":"please stop smoking. It's one of the best things you can do to help"},{"startTime":636.8,"endTime":639.784,"body":"your chances in the future. The other category is"},{"startTime":639.816,"endTime":642.688,"body":"going to be physiological factors such"},{"startTime":642.728,"endTime":644.908,"body":"as delayed egg transport."},{"startTime":645.288,"endTime":648.272,"body":"And this comes down to a couple of things. So one of the first"},{"startTime":648.32,"endTime":651.276,"body":"ones is that when you're ovary on the right,"},{"startTime":651.392,"endTime":654.276,"body":"releasing the egg, it can be picked up by"},{"startTime":654.292,"endTime":657.284,"body":"the left fallopian tube. And that"},{"startTime":657.356,"endTime":660.06,"body":"distance it has to travel takes a little bit longer."},{"startTime":660.244,"endTime":663.044,"body":"And so potentially one thing that could happen is when one"},{"startTime":663.076,"endTime":665.988,"body":"side picks up the egg from the other side"},{"startTime":666.108,"endTime":669.084,"body":"and it's fertilized early, it's delayed"},{"startTime":669.116,"endTime":672.116,"body":"in the transport into the uterus. And that can sometimes lead to"},{"startTime":672.132,"endTime":674.572,"body":"an ectopic, just like the ciliary"},{"startTime":674.62,"endTime":677.324,"body":"dysfunction, if it's not working well or"},{"startTime":677.396,"endTime":680.332,"body":"scarring the floating tubes are preventing the cilia from"},{"startTime":680.38,"endTime":683.354,"body":"moving the embryo down. It's eventually at its"},{"startTime":683.386,"endTime":686.082,"body":"implantation potential point, and it's in the"},{"startTime":686.09,"endTime":688.906,"body":"fallopian tube versus in the uterus. So that's some of the"},{"startTime":688.922,"endTime":691.906,"body":"stuff that can cause it. We even know that people who"},{"startTime":691.922,"endTime":694.85,"body":"are infertile have higher risk of ectopics"},{"startTime":694.994,"endTime":697.658,"body":"and so that's why people going through fertility even have a higher"},{"startTime":697.698,"endTime":700.29,"body":"risk of ectopic pregnancies. So in the"},{"startTime":700.314,"endTime":703.264,"body":"previous ectopic, pregnancy podcast, I talked about things"},{"startTime":703.296,"endTime":706.056,"body":"like, what can you do about them? We talked about doing surgery."},{"startTime":706.232,"endTime":709.108,"body":"We talked about taking a medicine called methotrexate."},{"startTime":709.848,"endTime":712.256,"body":"But the real question comes out is, how do you"},{"startTime":712.312,"endTime":715.248,"body":"proactively reduce your risk of ectopic"},{"startTime":715.288,"endTime":717.616,"body":"pregnancy, and when do you hit that patent"},{"startTime":717.672,"endTime":720.344,"body":"button? And so when it comes to"},{"startTime":720.376,"endTime":723.344,"body":"treatments, there are basically going to be a few treatments, and I'm not"},{"startTime":723.376,"endTime":726.2,"body":"talking about treatments now to get rid of that topic. We"},{"startTime":726.224,"endTime":728.752,"body":"discussed that before. What I'm talking about"},{"startTime":728.8,"endTime":731.408,"body":"is now you've had these ectopics,"},{"startTime":731.568,"endTime":734.39,"body":"you've had one of them, two of them, three of them, doesn't matter."},{"startTime":734.584,"endTime":737.514,"body":"What are your options moving forward? And so"},{"startTime":737.546,"endTime":740.394,"body":"your first option is to say, well, listen, can I just"},{"startTime":740.426,"endTime":742.85,"body":"try getting pregnant again? And the answer is"},{"startTime":742.874,"endTime":745.634,"body":"yes. And what you can do is you could"},{"startTime":745.666,"endTime":748.554,"body":"do close monitoring, meaning watching"},{"startTime":748.586,"endTime":751.386,"body":"very early with acg levels, watching very"},{"startTime":751.482,"endTime":754.386,"body":"early with ultrasounds, and then you can treat it"},{"startTime":754.482,"endTime":757.386,"body":"so early that the risk is lower. As"},{"startTime":757.402,"endTime":760.002,"body":"I was mentioning to someone today, your risk is"},{"startTime":760.05,"endTime":762.914,"body":"actually lower once you've had the next topic, because now"},{"startTime":762.946,"endTime":765.874,"body":"you know what to look for. It's no different than if you're in a"},{"startTime":765.906,"endTime":768.33,"body":"bad neighborhood, you know, to look around and make sure you're not gonna get"},{"startTime":768.354,"endTime":771.274,"body":"mugged. Well, same thing here. But now"},{"startTime":771.306,"endTime":774.25,"body":"you know you're at risk for an ectopic, whereas when"},{"startTime":774.274,"endTime":776.81,"body":"you never had an ectopic, it's like walking in a new"},{"startTime":776.834,"endTime":779.466,"body":"neighborhood. You don't know it's bad. You don't know to be looking"},{"startTime":779.522,"endTime":782.194,"body":"around. Now there's risk with it. Yes."},{"startTime":782.266,"endTime":785.138,"body":"With each ectopic, you have a higher risk of getting"},{"startTime":785.178,"endTime":787.938,"body":"another ectopic. So there's some concern there. But"},{"startTime":787.978,"endTime":790.602,"body":"again, with close monitoring, its not an"},{"startTime":790.65,"endTime":793.458,"body":"unreasonable option. Then the"},{"startTime":793.498,"endTime":795.746,"body":"next option is going to be something such as"},{"startTime":795.922,"endTime":798.706,"body":"bypassing the fallopian tubes. This is going to be"},{"startTime":798.762,"endTime":801.634,"body":"ivF. Whether youre doing IVC or"},{"startTime":801.666,"endTime":804.266,"body":"IVF, the point is youre bypassing the"},{"startTime":804.282,"endTime":806.978,"body":"fallopian tubes and getting pregnant, and this will"},{"startTime":807.018,"endTime":809.354,"body":"reduce your risk of an ectopic down to about"},{"startTime":809.426,"endTime":812.322,"body":"1%. Now, I know that sounds crazy. How"},{"startTime":812.37,"endTime":814.986,"body":"the heck do you get an ectopic when you put the"},{"startTime":815.002,"endTime":818.002,"body":"embryo in the uterus? Well, it's because the"},{"startTime":818.05,"endTime":820.954,"body":"embryo can actually move and go into the fallopian"},{"startTime":820.986,"endTime":823.906,"body":"tube, and that comes right back. But if you have some type"},{"startTime":823.922,"endTime":826.786,"body":"of pathology in the fallopian tube, it's not able to"},{"startTime":826.802,"endTime":829.642,"body":"fall back into uterus, and that leads to another"},{"startTime":829.69,"endTime":832.442,"body":"ectopic. Now, if everything was free and simple,"},{"startTime":832.57,"endTime":835.474,"body":"everyone would jump straight to IVF. But it's not."},{"startTime":835.666,"endTime":838.514,"body":"And so the question then comes back to, when"},{"startTime":838.546,"endTime":841.448,"body":"do we hit the panic button? so the way I would look at it is this."},{"startTime":842.118,"endTime":845.008,"body":"Personally, I would say if you've had three, topics, you"},{"startTime":845.048,"endTime":847.848,"body":"should be hitting the panic button at that"},{"startTime":847.888,"endTime":850.504,"body":"point. I understand you may have to"},{"startTime":850.536,"endTime":853.4,"body":"do naturally getting pregnant and can't do"},{"startTime":853.424,"endTime":856.208,"body":"IVF due to cost reasons or other"},{"startTime":856.248,"endTime":858.872,"body":"reasons, maybe even religious reasons. But"},{"startTime":858.92,"endTime":861.784,"body":"technically, at that point, that's when you should really be hitting the pack"},{"startTime":861.816,"endTime":864.64,"body":"button. I don't think after one act topic"},{"startTime":864.664,"endTime":867.256,"body":"you need to, but I understand that your"},{"startTime":867.312,"endTime":870.202,"body":"situation may be very severe. So let's say your"},{"startTime":870.25,"endTime":873.042,"body":"first ectopic, your tube ruptured and you"},{"startTime":873.09,"endTime":875.834,"body":"almost died. Yeah. Hit the panic"},{"startTime":875.866,"endTime":878.866,"body":"button. That's scary. And although the chance of"},{"startTime":878.882,"endTime":881.742,"body":"that ever happening again are, very small, because now, you know, to"},{"startTime":881.758,"endTime":884.454,"body":"be watching out for it, you might want to hit that pan"},{"startTime":884.494,"endTime":887.15,"body":"button then and say, I, don't want to take that risk."},{"startTime":887.73,"endTime":890.69,"body":"But for most people, if we're talking about in that"},{"startTime":890.73,"endTime":893.442,"body":"topic where eventually they catch it"},{"startTime":893.466,"endTime":896.208,"body":"early, you're able to take methotrexate"},{"startTime":896.354,"endTime":899.3,"body":"and treat it medically, it's not"},{"startTime":899.34,"endTime":902.316,"body":"unreasonable after having an ectopic to try again and"},{"startTime":902.348,"endTime":905.268,"body":"watch very closely. And even after a second"},{"startTime":905.324,"endTime":907.764,"body":"one, your chances are still better. It's going to work"},{"startTime":907.812,"endTime":910.772,"body":"fine. And so it's not unreasonable. But by that"},{"startTime":910.836,"endTime":913.34,"body":"third ectopic, you are now close to a"},{"startTime":913.38,"endTime":916.096,"body":"50% having another ectopic. now the"},{"startTime":916.12,"endTime":919.08,"body":"chances aren't better that things will work. And to"},{"startTime":919.112,"endTime":922.112,"body":"me, that's when you should hit the panic button. And really,"},{"startTime":922.208,"endTime":924.946,"body":"you, you should start thinking about doing other treatments,"},{"startTime":925.09,"endTime":927.778,"body":"such as IVF to bypass the fallopian"},{"startTime":927.826,"endTime":930.642,"body":"tubes. Now, I do understand every"},{"startTime":930.698,"endTime":933.634,"body":"situation is different, and this is the part I want to talk about,"},{"startTime":933.674,"endTime":936.282,"body":"which is if it is an"},{"startTime":936.298,"endTime":938.922,"body":"ectopic where it's truly known, meaning you see the"},{"startTime":938.938,"endTime":941.554,"body":"ectopic in another area,"},{"startTime":941.714,"endTime":944.57,"body":"or it's definitely an ectopic, your doctor"},{"startTime":944.602,"endTime":947.354,"body":"is 100% sure. Then count that towards"},{"startTime":947.394,"endTime":950.128,"body":"those three. But there are these situations"},{"startTime":950.176,"endTime":952.016,"body":"where it's kind of"},{"startTime":952.12,"endTime":954.728,"body":"undiagnosed. The ECG is going"},{"startTime":954.776,"endTime":957.764,"body":"up. It doesn't get very high. It doesn't even get to 200."},{"startTime":958.104,"endTime":961.048,"body":"But what we do know is that the pregnancy is abnormal."},{"startTime":961.176,"endTime":964.032,"body":"And so your doctor is making a decision, saying, listen, we"},{"startTime":964.048,"endTime":967.0,"body":"don't need to wait anymore because this will never"},{"startTime":967.112,"endTime":970.088,"body":"lead to a live birth. So let's prevent the risk"},{"startTime":970.216,"endTime":973.048,"body":"by giving you methotrexate. This is actually what we do with people"},{"startTime":973.096,"endTime":975.584,"body":"who have the history of ectopic because we know the risk is so"},{"startTime":975.624,"endTime":978.4,"body":"high and so we give them the methotrexate."},{"startTime":978.592,"endTime":980.724,"body":"But it's also important to understand that"},{"startTime":981.344,"endTime":984.096,"body":"that may not even be an ectopic. And so when we're"},{"startTime":984.12,"endTime":987.096,"body":"talking about hitting this pan button on the three tries, we're talking"},{"startTime":987.12,"endTime":989.184,"body":"about three actual ectopics. Ah."},{"startTime":990.784,"endTime":992.808,"body":"If you are having these very early"},{"startTime":992.856,"endTime":995.664,"body":"ectopics, you may not have to hit the panic"},{"startTime":995.704,"endTime":998.592,"body":"button right away because we don't truly know if"},{"startTime":998.608,"endTime":1001.072,"body":"they're a topic. The question is, did your doctor get to that decision"},{"startTime":1001.168,"endTime":1004.124,"body":"fast? Really, it could just be an abnormal"},{"startTime":1004.164,"endTime":1006.584,"body":"pregnancy and they're losing them. Or"},{"startTime":1006.924,"endTime":1009.676,"body":"is it the situation where it is a true"},{"startTime":1009.7,"endTime":1012.492,"body":"ectopic? And the problem is, that's a very hard"},{"startTime":1012.548,"endTime":1015.332,"body":"thing to wait for, because if you wait too long, you can"},{"startTime":1015.348,"endTime":1018.18,"body":"cause harm. If you do too soon, you can cause"},{"startTime":1018.212,"endTime":1021.14,"body":"harm to the pregnancy. Just like we talked about in the beginning."},{"startTime":1021.252,"endTime":1024.236,"body":"In the end, everyone has a different point than when they hit the"},{"startTime":1024.26,"endTime":1026.264,"body":"panic button. But for the general"},{"startTime":1026.684,"endTime":1029.612,"body":"idea, if you've had three ectopics"},{"startTime":1029.668,"endTime":1032.604,"body":"and they are confirmed ectopics, I would tell you"},{"startTime":1032.724,"endTime":1035.684,"body":"panic button. In time, you need to go on to something like"},{"startTime":1035.724,"endTime":1038.564,"body":"IVF to reduce your risk of having another ectopic,"},{"startTime":1038.604,"endTime":1041.412,"body":"because eventually it could be"},{"startTime":1041.428,"endTime":1044.424,"body":"very dangerous and it's probably not worth the risk anymore."},{"startTime":1044.724,"endTime":1047.292,"body":"But after the first, even after the second,"},{"startTime":1047.468,"endTime":1050.34,"body":"it's not an unreasonable situation to"},{"startTime":1050.372,"endTime":1053.348,"body":"try again and watch closely."},{"startTime":1053.396,"endTime":1056.378,"body":"That's the most important part. Just make sure"},{"startTime":1056.426,"endTime":1058.854,"body":"you have someone who's watching things closely"},{"startTime":1059.194,"endTime":1061.874,"body":"and they know and are aware that you have a risk for that"},{"startTime":1061.914,"endTime":1064.434,"body":"topic, and in that way it can be much"},{"startTime":1064.474,"endTime":1067.338,"body":"safer. This means no nights alone."},{"startTime":1067.426,"endTime":1070.274,"body":"Make sure you have someone with you all the time and that there is a"},{"startTime":1070.314,"endTime":1073.234,"body":"doctor following things closely. I hope"},{"startTime":1073.274,"endTime":1075.65,"body":"none of you ever get a neck topic, but"},{"startTime":1075.682,"endTime":1078.586,"body":"maybe you do, and this might help you make"},{"startTime":1078.61,"endTime":1081.586,"body":"that next decision of do you need to jump straight to IVF or"},{"startTime":1081.61,"endTime":1084.212,"body":"can you wait? Do you have to hit that pack button?"},{"startTime":1084.348,"endTime":1087.292,"body":"Hopefully this episode was helpful to you guys. Like I"},{"startTime":1087.308,"endTime":1090.224,"body":"said, I'm going to be doing several of these panic button"},{"startTime":1090.524,"endTime":1093.274,"body":"scenario type of, podcasts, and"},{"startTime":1093.654,"endTime":1096.582,"body":"if you like them, please let me know and give me a topic you'd like"},{"startTime":1096.598,"endTime":1099.526,"body":"me to do one on. If you know someone that this may"},{"startTime":1099.55,"endTime":1102.334,"body":"help, please tell them about it. And if you love this podcast, as I always"},{"startTime":1102.374,"endTime":1105.214,"body":"say, tell your friends about us. Give a five star"},{"startTime":1105.254,"endTime":1108.054,"body":"review on your favorite medium. But most of all, keep coming back."},{"startTime":1108.094,"endTime":1110.794,"body":"Every week I want to give a shout out to a patient that I saw"},{"startTime":1110.834,"endTime":1113.762,"body":"today. She told me that she actually met up with some people and they all"},{"startTime":1113.778,"endTime":1116.73,"body":"had Eck topics and all of them were seeing me, so she said"},{"startTime":1116.762,"endTime":1119.134,"body":"they were the Amos fan club."},{"startTime":1119.634,"endTime":1122.546,"body":"That brought a huge smile to my face. I look forward to"},{"startTime":1122.57,"endTime":1125.218,"body":"talking to everyone again next week on talk"},{"startTime":1125.266,"endTime":1126.474,"body":"about fertility Tuesday."}]}