urgent: Methotrexate use when pregnancy cannot be found


I have a failed pregnancy and my clinic is recommending that I take methotrexate even though no etopic pregnancy has been located.

I hesitate to take methotrexate if it is not necessary and am wondering if ladies who have experienced miscarriages/taken methotrexate can give their opinion:

  1. would you take methotrexate if you were in my situation (see facts below)? Why or why not? Would this change if you knew for sure it was intrauterine?
  2. What questions would you ask or tests might you request in order to determine whether this pregnancy is intrauterine or ectopic, and is this determination important? i.e., would another u/s be helpful here now that my levels are >1000 and its 8 days later (total of 8w5d)?
  3. If it is a failed intrauterine pregnancy, is methotrexate ever indicated?
  4. How long did it take your levels of HCG to go back to zero after you took methotrexate? Does anyone know from personal experience that taking methotrexate helped their HCG levels decrease more rapidly than they would have if they had not taken the drug? Does this change if it is IU rather than ectopic?

In hindsight, I am also wondering:

  1. Might an earlier u/s (in the 5th or 6th week) have increased the chance that the doctors locate this pregnancy if it was intrauterine?
  2. Could a pathology lab help determine whether the material passed with my period was, in fact, pregnancy related and therefore indicate that the pregnancy was in fact intrauterine?
  3. Is there anything I can request or do to prevent this from happening again?

Here are the facts:

1st trimester u/s at 7w4d: IVF clinic was unable to locate the embryo that was implanted. The u/s results were reported as inconclusive. The pregnancy was not seen in the uterus or anywhere outside.

Two clinic doctors indicated that I most likely had a failed intrauterine pregnancy that has not fully expelled the placental tissue. However they note that there is a chance (small) that it is an etopic, but they cannot find it. They have ony done one u/s at 7w4d and do not plan to do any additional u/s (8 days have passed since the first u/s).

My hcg levels are low (750–>1030 over a week period and 3 blood draws) and are continuing to rise slightly even though I ended progesterone and finished my period. I swear that the period contained significant pregnancy-related material (grey tissue with vascularization and a kidney bean looking thing (~1.1cm) that was attached to the grey matter by a chord.) The doctor did not want me to bring the material in for pathology to examine it. But I wonder: Could the pathology analysis have answered the question of whether it was IU or not?

I am not having severe cramping, and the bleeding has largely stopped. I feel occasional cramps which are sometimes followed by additional spotting.

Thank you kindly for your thoughts… I have learned a lot from you ladies out there and appreciate hearing your experiences.


Hello. My recent experience has some similarities to yours so I can provide with my decisions, responses, etc.

My beta was rising slowly, so the doctors believed I most likely would miscarry. Last Tuesday I had severe cramping and made them see me the next morning. The checked my uterus and found nothing, and stated I had miscarried. They had me come back Friday just to make sure it was not ectopic (I was at 6 weeks that day).

Come Friday, they found waht they believed to be an ectopic pregnancy in my right tube. I was scheduled to come back on Monday for the shot. I was no longer in pain, so they did not seem worried, but they were adamant about the shot. Unlike you, my numbers were dropping.

In any event, I bled all weekend, with some minor cramping. I expelled a lot of clots. I prayed all weekend it would miscarry on its own.

When I went back in on Monday, they were pretty sure they were giving me the shot. I begged them to recheck and take my blood again. They were not sure if the “mass” in my uterus was an embryo or perhaps just a shadow from my bowel!!?? Since I was not in pain, they took my blood and said that I could wait one more day. My beta was down to 24. I am not yet out of the woods, and I may still need the shot, but am at least thankful that my doctor listened to my concerns.

I guess what I am saying is that it is a decision that only you can make because only you know your body. Often, because people are sue happy, doctors jump right into what will be the “safe” decision. I guess I don’t always blame them.

How many embryos were implanted? If there was more than one, have they checked to see if it was a vanishing twin? I am not trying to give you false hope. We just have to be very careful about taking the methotrexate. When are you scheduled for another ultrasound? I do not believe that pathology reports can indicate the location of the implantation.

I am not sure if this helps or not. I know that this is tough. We spend all of this time, money, effort, etc. trying to have a baby, and now we are just trying to find out how we miscarried. I am sorry. :grouphug:



I agree and appreciate your response: I did a single embryo transfer.

I’m so far along (almost 9w) that I fear my options are limited at this point…


my ectopic ruptured at about 6.5 weeks and my beta the day before was 3300. They could not find anything in my tubes or uterus (except blood in the uterus) via u/s the day the beta was taken. I was given MTX and sent home and told to come back in 5 days for another beta. Didn’t make it. My tube ruptured and I was rushed to the hospital for emergency surgery. MTX did not work for me.

First let me tell you that there is an FDA recall on methotrexate due to glass particles in the packaging or something. Make sure if you do get MTX you ask your doctor about the recall!

My concern for you is that something IS growing inside you. You can’t really detect anything in your uterus until your beta is above 2000 so even if you did have a abnormal pregnancy you wouldn’t be able to detect it with your levels.

This is what I am thinking… your doctors realize that this is not a normal/healthy pregnancy. Something is growing and producing hCG. The embryo probably did start to form at some point but something went wrong. Cells are continuing to divide and hormone is being produced. The fear (I think) is that cells continue to grow and become cancerous. Methotrexate is a anticancer drug (it stops the growth of cells so it is used to stop the growth of a tubal or abnormal pregnancy) so even if you don’t have a tubal or elsewhere ectopic (ectopics can grow outside the uterus and tubes, rare, but it happens) your doctors might be concerned that with how far along you are, letting the cells grow might lead to a cancerous condition.

I totally understand your hesitation on taking MTX, especially if it isn’t called for. I would ask your doctor a few questions.

  1. How long are they comfortable with letting your beta levels rise?
  2. Would a D&C be reasonable alternative to MTX in your case?
  3. Do they suspect a molar pregnancy and is cancer a worry?

As for your hindsight questions:

  1. No an earlier u/s wouldn’t necessarily helped if your beta levels were low. If they were high, then dropped, then you might have seen a sac. And if this was the case, there is definitely left over tissue in there and it needs to come out or the growth needs to be stopped

  2. yes path could tell if what you passed is pregnancy related, but it wouldn’t help your situation. you still have cells growing and they have to be stopped

  3. I would request beta hcg levels every other day or every 3 days until they get to >2000, then get an early u/s. This should be in the 5th week. You won’t see much, just a sac, but knowing that the sac is in your uterus is such a relief. I did this with my first pregnancy (that wasn’t chemical) after my ectopic and that pregnancy resulted in my DS…

Is your fear of MTX the wait in TTC again? I can’t help you with how long it takes for beta to go back to zero since I had a rupture, but 4 weeks to the day after the rupture I got AF. My RE made me wait 6 weeks after my shot (which was really 8 weeks due to my period), so 2 months. It wasn’t that bad.

I am really sorry for your loss. :grouphug: