Trying to Conceive Again

While there is no clear, researched evidence on how long a couple should wait to try to conceive after having treatment for ectopic pregnancy, we and other medical professionals advise that it may be best to wait for at least three months or two full menstrual cycles (periods) before trying to conceive for both physical and emotional reasons. The bleed that occurs in the first week or so of treatment for an ectopic pregnancy is not your first period. It is the bleed that occurs in response to falling hormones associated with the lost pregnancy.

Physically, this timeframe is to allow your cycle to return to normal and for there to be a clear period to date a new pregnancy from. The date of the first day of the period is what is used to decide when to scan a new pregnancy; information that is invaluable in ensuring you are not suffering from another ectopic pregnancy.

The first proper period you have after an ectopic pregnancy may be heavier than usual and the second more like your usual period. A normal period would suggest you are hormonally ready to be able to try to conceive. Having two periods can also give an idea of menstrual cycle length, which may be different for a few months after your ectopic before settling back into its usual rhythm.

This wait allows the internal inflammation and bruising from the ectopic and any associated treatment to heal.

In addition to the physical aspects of ectopic pregnancy, many people also feel an intense emotional impact. Taking time before trying to conceive again enables the necessary process of grief to surface and be worked through. The emotional recovery that is often needed can be significant and many underestimate this aspect. 

If you have had either one or two injections of methotrexate, you should wait until your hCG levels have fallen to below 5mIU/mL (your doctor will advise you when this is through blood or urinary tests) and then take a folic acid supplement for 12 weeks before you try to conceive.

This is because the drug may have reduced the level of folate in your body which is needed to ensure a baby develops healthily. The methotrexate is metabolised quickly but it can affect the quality of your cells, including those of your eggs, and the quality of your blood for up to three months after it has been given. The medicine can also affect the way your liver works and so you need to give your body time to recover properly before a new pregnancy is considered. A shortage of folate could result in a greater chance of a baby having a neural tube defect such as cleft lip and palate, or even spina bifida or other neural tube defects.

If you have had medical management followed by surgery, you can start taking a folic acid supplement again once your doctors have confirmed that all of the pregnancy has resolved. This is particularly important if you have been having blood tests to check hCG levels after your surgery. You can start to try to conceive again 12 weeks after the date that the methotrexate was administered.

The NHS website has more information on vitamins, supplements, and nutrition during pregnancy. 

Before your first period arrives, you will ovulate. The period when it returns will indicate that you are ovulating again. It is possible to ovulate 14 days after surgical treatment and during methotrexate treatment, so it is important to be aware that it is possible to become pregnant without having a period first, if you are not using some form of contraception.

When a person has only one Fallopian tube, they are still able to get pregnant from an egg released by the opposite ovary as an egg from one ovary can travel down the Fallopian tube on the other side. Approximately one-third of pregnancies are a result of pick-up of the egg from the ovary on the opposite side to the remaining Fallopian tube. It may be reassuring to know that when you ovulate from the ovary by the removed Fallopian tube which is opposite to the remaining Fallopian tube, it is not a ‘wasted’ cycle.

An ovulation predictor kit measures Luteinising Hormone (LH). A surge in LH leads to ovulation within the next 12 hours. The egg does not always get released from the ovary in spite of a surge but it is a very good marker. A positive pregnancy test around 14 days after you think ovulation occurred is the only way of establishing that it actually did.

Urinary ovulation predictor kits are used typically daily around the time ovulation may be expected. A conversion from a negative to a positive reading would suggest that ovulation is about to occur within 24–48 hours, giving two days to engage in sexual intercourse or artificial insemination with the intention of conceiving.

As sperm can stay viable in the female reproductive system for several days, LH tests are not recommended for contraception, as the LH surge typically occurs after the beginning of the fertile window.

We naturally assume that we will ovulate from alternative ovaries each month (left ovary, right ovary, left, right etc.) This is not true and varies. Some will ovulate from the same side each month with an occasional ovulation from the other side, while others will ovulate randomly from side to side.

Both ovaries compete each month to produce an egg and usually, the one that is ‘pulling ahead in the race’ continues while the other one gives up (but not always – sometimes ovulation occurs from both ovaries in one cycle or twice from one ovary – this explains how we get non-identical twins naturally). It depends on which ovary contains the egg that is at the right stage of development at the point in time at the time of ovulation and is nothing to do with a set pattern.

The side we ovulate from does not strictly matter as an egg from one ovary can travel down the Fallopian tube on the other side.

The menstrual cycle lasts about 28 days for most and ovulation usually happens 10 to 16 days before the start of your next period. When you’re ovulating, you are at your most fertile so it is the best time of the month to have sex. Physical signs of ovulation include an increase in vaginal discharge. This changes from white, creamy or non-existent to clear, stretchy and slippery (like egg-white consistency) when you ovulate.

The Fallopian tubes and uterus are lined with little receptor cells that, at the point of ovulation, are sent a chemical signal that ‘switches’ them on and they emit a signal that attracts a similar receptor in the egg and in the sperm to come and meet in the same place, i.e. the Fallopian tube. The Fallopian tubes are not attached to the ovaries and, at the point of ovulation, some very delicate structures called the fimbriae on the end of the Fallopian tube begin to move gently drawing the egg toward the end of the Fallopian tube (like lots of little fingers waving and drawing the egg towards it).

The DNA that makes up the strands for hCG, which is the hormone associated with pregnancy, is only one strand different to the luteinising hormone (LH) which detects ovulation. Both hormones, at a molecular level, are nearly identical. hCG has a beta sub-unit, meaning that it has an extra molecular twist. This means that it is possible for an OPK to detect pregnancy, although this is not always reliable. It is not, however, possible to use an HPT to detect ovulation.

Using a mobile computing app to track menstrual cycles and the fertile window is becoming increasingly popular while trying to conceive and may be suitable for some people. A study looked at various apps that are used to track the menstrual cycle and analysed whether they helped influence chances of conception. The study showed that the use of such apps was associated with increased chances of conception ranging from 12% to 20% per cycle of attempt. 

Alcohol affects fertility by disrupting the delicate balance of the menstrual cycle. Clinical research data suggests that women, who drank socially, 1-5 drinks per week, were at a greater risk of decreased fertility when compared to women who remained abstinent. These findings underscore the importance of remaining abstinent while attempting to conceive.

The National Institute for Health and Clinical Excellence (NICE) looks at the available evidence on the best way of treating or managing a condition and makes recommendations based on evidence. Doctors, nurses and other healthcare professionals in the NHS are expected to follow NICE’s clinical guidelines. Current NICE guidance states:

“Pregnant women and women planning a pregnancy should be advised to avoid drinking alcohol in the first 3 months of pregnancy if possible because it may be associated with an increased risk of miscarriage.”

Research also suggests that alcohol disrupts the hormonal imbalance of the female reproductive system, leading to menstrual irregularities, and even anovulatory cycles (menstrual cycles where ovulation fails to occur). These changes can drastically decrease the chances of becoming pregnant and thus affect fertility. The NHS website provides information on drinking alcohol while pregnant and states that the safest approach is not to drink while pregnant.

It can be hard to stop smoking cigarettes but if you are thinking of trying to conceive, this is one of the best things that you can do. Evidence shows that smoking impacts both male and female fertility. 

According to NICE Guidance on Fertility Problems, for men, there is a link between smoking and poorer semen quality. Stopping smoking will improve your general health. Smoking is also likely to reduce fertility. Breathing in someone else’s cigarette smoke (passive smoking) is also likely to reduce the chances of getting pregnant. 

Research from Edinburgh University has found that a chemical found in cigarette smoke (Cotinine) triggers a reaction which increases a protein in the Fallopian tubes. This protein, called PROKR1 raises the risk of an egg implanting outside the womb, leading to an ectopic pregnancy.

If you smoke, your doctor/GP should offer you help to stop if you wish. The NHS Smoking Helpline can also provide advice and support via phone and the website.

Unfortunately, nothing can guarantee a pregnancy, but if you have a history of abdominal pain which continues after the ectopic pregnancy, you should see your doctor/GP to make sure you do not have a persistent infection that might impact future fertility. Having regular sexual intercourse is a good way to approach future conception.

The EPT is a charity that has the backing of medical specialists and prides itself in providing accurate, research-based medical information. While we understand that many people are interested in the use of alternative and complementary therapies, we do not endorse these on our site. 

We, therefore, remind you that, should you wish to make use of these therapies, you exercise caution and avoid recommending them to users of the EPT forums. Many complementary medicines are powerful and can have harmful side effects if misused. They may also interact with medicines that you may already be taking or intend to take. Please remember that “natural” does not always mean safe – indeed some of the medicines that are prescribed today (including some controlled drugs) are derived from natural products. Many “natural” or “herbal” preparations can interfere with prescribed medicines or even make an existing condition or illness worse.

Buying medicines on the internet is far from safe and you can never be 100% sure that they do what they say they do or contain what they say they do. Unfortunately, there are unscrupulous people who have no issues with making money from people who are trying to conceive or who have suffered a loss, making claims that cannot be substantiated about products and services they aim to supply. Please do be aware of this and seek guidance and or alternative treatment only from appropriately qualified and registered individuals.

Sadly, there are no tests or investigations that can be done to assure you that you will not experience an ectopic pregnancy again. Ectopic pregnancy occurs because of some underlying damage to a Fallopian tube and the cause of this damage may never be established. Assisted reproductive techniques, like IVF treatment where the embryo is placed in the uterus, can also result in an ectopic pregnancy and unfortunately so is not a guaranteed way of ensuring it will never happen again. Doctors would usually want you to wait to try again for three months, after which, your doctor will probably encourage you to try again for 12 months if you are less than 35 or 6 months if you are over 35. Only if you do not conceive within those times would they then consider further tests and investigations. The exception to this might be if the surgeon saw something during the surgical procedure to resolve your ectopic pregnancy that they felt warranted further investigation more quickly.

If you feel that you may have ongoing problems of pelvic infection, you can take a chlamydia test. Chlamydia is usually symptomless and if left untreated, the infection can spread to other parts of your body and lead to long-term health problems, such as pelvic inflammatory disease (PID) and infertility. Testing for and taking antibiotic treatment if required might help to reduce the risk of these problems. 

A tubal patency test might be available if you have been trying to conceive for a year and are not pregnant if you are under the age of 35, or six months if you are over the age of 35. You should visit your health care provider to discuss this.

Hysterosalpingography (HIS-tur-oh-sal-ping-GOG-ru-fee) or HSG test is a procedure to investigate the shape of the uterine cavity and the shape and patency (the state of not being blocked or obstructed) of the Fallopian tubes. The test involves having a speculum examination like a during a smear test and an x-ray of the uterus and the Fallopian tubes. The doctors inject a special radiographic dye into the uterine cavity through the vagina and cervix which shows up on the x-ray. They then watch to see if the dye moves freely through the uterus and Fallopian tubes to look for a block that may be causing fertility problems. Hysterosalpingo Contrast Sonography (HyCoSy) is a similar process using ultrasound. If the Fallopian tubes are open, the special dye will fill the tubes and spill out into the abdominal cavity. If the Fallopian tubes are full or partially blocked the dye will not flow freely and whether the blockage is located at the junction of the Fallopian tube and the uterus (proximal) or whether it is at the end of the Fallopian tube (distal) can also be determined. 

People are able to try to conceive again during their next menstrual cycle after a tubal patency test unless medical professionals suggest a longer wait time. It has been claimed that pregnancy rates are increased in a cycle when a tubal patency test has been performed.

Unfortunately, tubal patency tests cannot provide complete peace of mind. Even if a tubal patency test shows an open Fallopian tube, it does not show whether it will work – only a normally located pregnancy can show that at least one Fallopian tube worked. 

The test is not 100% accurate as the Fallopian tubes can go into spasm during the test and can appear blocked even though this is not the case. This can cause unnecessary anxiety if the Fallopian tube is affected by spasm but in fact is actually working normally. 

The test cannot determine what the internal villi of the Fallopian tube look like.

The tubal patency test can be painful, so analgesics (pain relief) may be administered before and/or after the procedure to reduce pain. Many doctors will also prescribe an antibiotic prior to the procedure to reduce the small risk of an infection. Medical professionals prescribe the antibiotics taking the viewpoint that prevention is better than cure and it is better to prevent an infection in your Fallopian tubes rather than cure it.

There is a 1% chance of getting an infection from a tubal patency test and, of that 1% chance of infection, only 20% of the 1% who get an infection would need hospitalisation. This means that there is a 99.8% chance of not causing damage to a Fallopian tube and a 0.2% chance of damage.

It would be likely that you would know if you got an infection through symptoms like: abnormal vaginal discharge, painful menstrual periods, painful or uncomfortable sexual intercourse, abdominal pain affecting both sides, frequent urination, spotting between periods, pain during ovulation, fever, and/or lower back pain.

Doctors prefer not to use a tubal patency test unless they really need to because it is not a 100% accurate test. For example, if the Fallopian tubes go into spasm during the test they can appear blocked even though this is not the case. The test can also not determine what the internal villi of the Fallopian tube look like. Furthermore, it is an invasive test and there is a small (1%) chance that it can cause infection of the Fallopian tubes hence their preference to only perform the test when it is unquestionably required.

When an ectopic pregnancy is treated, the remaining Fallopian tube is typically examined externally and the doctors would usually have told you if they had seen any problems with it at that time. If you would like peace of mind about this you could ask for a post-operative follow up appointment to ask whether they had looked at the condition of your Fallopian tubes during the operation. You can also request a copy of your medical notes for your operation.

The examination is a pretty good indicator about the condition of your remaining Fallopian tube(s) because it looks at:

The fimbriae – The Fallopian tubes are not attached to the ovaries and, at the point of ovulation, some very delicate structures called the fimbriae begin to move gently creating a slight vacuum to suck the egg toward the end of the Fallopian tube it is nearest to (like lots of little fingers waving and drawing the egg towards it).

• Whether there are any adhesions (scar tissue)
• Whether there is any thickening of the Fallopian tube
• The shape of the Fallopian tube

Selective salpingography is not available in every centre but is well documented as having good success rates. It is normally done under mild sedation with pain relief.

During a tubal patency test, a small diameter flexible catheter is threaded inside the catheter and, with the help of the x-ray machine, can be directed right into the opening of the Fallopian tube. Once this is done, dye can be introduced directly into the Fallopian tube. With this technique, it is possible to demonstrate a normal, patent Fallopian tube whose opening may be in spasm. Fallopian tubes with an obstruction can also be opened by the higher pressures which can be achieved with selective salpingography.

Clomiphene or Clomid is an extremely powerful, oral (taken by mouth), medication that is often prescribed to help those trying to get pregnant if their menstrual (period) cycle is so irregular that they cannot be sure when or if they are ovulating. The Clomid would produce a regular cycle to allow for timed intercourse or intrauterine insemination. The medication works by blocking estrogen receptors in the brain, stimulating them to release Follicle Stimulating Hormone (FSH), and Luteinizing Hormone (LH). These are the naturally occurring ovarian stimulants that prompt ovulation in a normal cycle.

Typically, you will take one to three tablets a day for five days early in your cycle. During this time, some will notice hot flashes, moodiness, or sleep pattern changes but most notice no symptoms at all. Ovulation will typically occur 7-8 days following completion of the Clomid treatment. Because the ovaries are stimulated there may be some bloating, or discomfort with intercourse.

The chance of multiple ovulations is slightly higher with Clomid than with a normal menstrual cycle. The chance of twins resulting from Clomid is 6-8%. There is no increased risk of higher order multiples (triplets, etc).

Rarely hyperstimulation of the ovaries can occur as a result of Clomid use. In this case the ovaries become enlarged with multiple follicles. Other rare side effects include visual changes, reversible hair thinning, dizziness, or hives. People with currently existent large ovarian cysts or liver disease should not use Clomid.

If your Fallopian tubes were removed or both have been deemed completely blocked, it is still possible to get pregnant with IVF because it bypasses the Fallopian tube and the embryos are placed directly into the uterus.

In 2018, the percentage of IVF treatments that resulted in a live birth per cycle started were:

33.0% for women under 35

27.7% for women aged 35-37

22.5% for women aged 38-39

15.0% for women aged 40-42

6% for women aged 43-44

4.0% for women aged over 44

Reference: Human Fertilisation and Embryology Authority, June 2020

The NHS website summarises that, in 2013, the National Institute for Health and Care Excellence (NICE) published guidelines about who should have access to IVF treatment on the NHS in England and Wales. These guidelines were updated in 2017.

According to the guidelines, women aged under 40 should be offered three cycles of IVF treatment on the NHS if they have been trying to get pregnant through regular unprotected intercourse for two years, or have not been able to get pregnant after 12 cycles of artificial insemination (directly inserting sperm into the womb). The guideline also states that if tests show IVF is the only treatment likely to help you get pregnant, you should be referred for IVF straight away. If you turn 40 during treatment, the current cycle will be completed, but further cycles should not be offered.

For women aged 40 to 42, the guidelines also say women should be offered one cycle of IVF on the NHS if they have been trying to get pregnant through regular unprotected intercourse for two years, or have not been able to get pregnant after 12 cycles of artificial insemination; They have never had IVF treatment before; They show no evidence of a shortage of eggs and they have been informed of the additional implications of IVF and pregnancy at this age. Again, if tests show IVF is the only treatment likely to help you get pregnant, you should be referred for IVF straight away.

The reality is somewhat different to this guideline though and NHS trusts across England and Wales offer different levels of service. The provision of IVF treatment varies across the country and often depends on local policies.

Priority is often given to couples who do not already have children and this can sometimes be hard when you do not have a baby but you are told you are not eligible because your partner has a child from a previous relationship. Sometimes people are also advised to lose weight in order to be eligible for IVF as this increases the likelihood of successful treatment.

There can be a number of reasons for this:

As the hormones in our bodies change in the later stages of the menstrual cycle, a special cyst called the corpus luteum cyst stimulates an ovary to produce progesterone. Progesterone has many actions on the body but, along with the other changes in your body, it can leave you feeling bloated, with tender breasts and sometimes feeling headachy and nauseated (sick). These can sometimes be interpreted as the feelings you might get in early pregnancy and can leave you feeling disappointed when a period arrives a few days late.

Sometimes ovulation can occur later in the cycle than day 14. This might especially be the case if you normally have cycles which are longer than 28 days. If you ovulate later in the cycle, the egg may not have implanted for as long as necessary to produce the hCG hormone which is what a home pregnancy test detects.

Sometimes it can take longer than the average 6 to 7 days for the egg to travel along the Fallopian tube and implant. Where this happens, the egg may not have implanted for as long as necessary to produce the hCG hormone which is what a home pregnancy test detects.

The test may be from a faulty batch.

Home pregnancy tests must be read within the time frame specified in the individual instructions on each pack. These times vary a little but any result which appears after 10 minutes cannot be relied upon to be an accurate result. It is not unheard of for people to do a test which is negative, leave it on the bathroom window sill until sometime later, and then when they look at it again a new line has appeared in the test window. This is invariably an evaporation line and not a positive result.

To get an accurate result, it is essential you follow the instructions on the Home Pregnancy Test pack. You should preferably test with the first urine of the day and in urine which has been in your bladder for at least four hours. Finally, you should always read the test result within the time frame clearly stated on the test pack’s instructions.

If the test is done in the surgery using a reagent stick, just like the home pregnancy test you have already done, there is the possibility that the test the doctor is using is not as sensitive as your home pregnancy test.

Sometimes ovulation occurs later in the menstrual cycle than day 14. This might especially be the case if you normally have cycles which are longer than 28 days. If you ovulate later in the cycle, the egg may not have implanted for as long as necessary to produce the hCG hormone which is what a pregnancy test detects.

Sometimes it can take longer than the average 6 to 7 days for the egg to travel along the Fallopian tube and implant. Where this happens, the egg may not have implanted for as long as necessary to produce the hCG hormone which is what a home pregnancy test detects.

The test may be from a faulty batch.