For eight weeks, the pregnancy seemed normal. I was thirty-six, and thus supposedly at a higher risk for everything, but I’d had no spotting, no unusual pain. I learned that something might be wrong at my first prenatal appointment, even though that, too, started normally. The blood-pressure test and the queries about inheritable disorders went fine. Then the ultrasound took too long; the technician slid into silence. She admitted that she couldn’t find a gestational sac in my uterus: “I’m sure it’s okay. But I’m going to get the doctor to double-check.” She meant to sound reassuring, but I was not reassured. If this woman — who spent her days studying gray screens for early signs of gestation — could not see my pregnancy, what were the chances that anyone else would?
My doctor is so calm that he can appear drowsy, but he walked into the room looking alert. He said he thought my pregnancy might be ectopic. That would mean the fertilized egg had implanted outside my uterus, most likely in one of my fallopian tubes, a location that doomed the pregnancy and endangered my life. He searched the screen for several minutes, but found only a suspicious ring near a fallopian tube. I lay on my back as he explained this, naked below the waist except for a stiff paper blanket, the probe from the transvaginal ultrasound machine still resting inside me. My unease unfurled into a bright flag of dread.
No medical wizardry can relocate a misplaced embryo. Left unchecked, the embryo will expand until it rips open the fallopian tube and triggers a wave of internal bleeding. For most of history, ectopic pregnancy was almost always fatal, and ruptures remain a serious concern today. A woman whose fallopian tube bursts might arrive at the emergency room with two liters of blood pooled in her abdomen; the entire human body contains about five. In the United States, early detection means that fewer than five women die for every 10,000 ectopic pregnancies, but even so, ectopic pregnancy is the leading cause of first-trimester deaths.
On that first afternoon in my doctor’s office, the diagnosis remained uncertain. Although an empty womb on an ultrasound might seem definitive, there was a chance that the gestational sac couldn’t be seen because the pregnancy wasn’t as far along as I thought. That theory rested on the premise that I had forgotten the date of my last period, which seemed unlikely. Still, the doctor ordered blood work to check. The tests would measure fluctuations of the “pregnancy hormone” — human chorionic gonadotropin (hCG) — the same hormone that triggers a positive on over-the-counter pregnancy tests. My hCG would be tested again forty-eight hours later and the two levels compared. In a healthy pregnancy, hCG numbers double every two days or so. A more modest increase would indicate an ectopic pregnancy.
In the interim, I had to be vigilant for signs of rupture. If I suddenly started to bleed, or buckled over with nausea, or grew dizzy from plummeting blood pressure, then I was supposed to go to the emergency room. “You need to tell me if you have any abdominal pain,” my doctor said. “Especially if it’s sharp.” I told him yes, of course I would call a doctor if I had shooting pains in my abdomen. “You’d be surprised,” he said. He asked whether I had any questions, but I’d lost my analytic abilities. My appointment ended, and I went home to wait.
Ectopic pregnancy has terrified and fascinated physicians for centuries. For most of human history, the condition was “a universally fatal accident,” as Samuel Lurie wrote in the European Journal of Obstetrics and Gynecology. Historians credit Abu al-Qasim, a physician who worked in Córdoba during the tenth century, with the first description of an ectopic pregnancy. He recounted the tale of a patient whose fetus died and subsequently emerged in pieces through an oozing abdominal wound. The pregnancy was probably abdominal rather than tubular, which explains how the woman survived and how the fetus reached an advanced gestational age. The abdominal cavity has more space than a fallopian tube, and can sometimes supply enough blood to promote development, but — obviously — it offers no safe exit route.1
1 The most famous case of abdominal ectopic pregnancy occurred in 1582. Surgeons in the French city of Sens autopsied a tailor’s wife, Madame Colombe Chatri, who had died at the age of sixty-eight. They discovered a scaly, calcified fetus so hard that they needed mauls and a drill to break it open. Chatri had carried the so-called lithopedion for twenty-eight years following an ectopic pregnancy and unproductive labor. The “stone-child of Sens” was sold and passed from one wealthy European collector to the next for years, before finally ending up in the Danish Museum of Natural History.
Jean Riolan, a French physician, was among the first to describe a ruptured tubular pregnancy, which he discovered in 1604 when he autopsied a thirty-one-year-old who had died in her second trimester. Before then, doctors had been baffled by the swift and sudden deaths of formerly healthy young women, many of whom had not known that they were pregnant. By the nineteenth century, physicians understood the mechanics of ectopic pregnancy, but they had no reliable way to save their patients. In his 1876 book on extrauterine pregnancy, the American obstetrician John S. Parry wrote that a rupture made a woman feel “as if something had been torn inside her.” Victims became weak, pale, and clammy as their pulse diminished. They fainted, suffered convulsions, and lost themselves to delirium. The lucky died within hours; others lingered for days with pain that made it impossible to stand or lie down straight. A contemporary of Parry’s observed agony “so severe ‘as to be uncontrollable by the most powerful doses of opium.’ ” Experimental procedures — such as starvation, purging and bleeding, injecting strychnine into the gestational sac, and electromagnetic shock — attempted to kill the fetus and spare the woman. But most of these therapies only intensified the misery of dying women.
Treatment options began to improve in 1883, when the British surgeon Robert Lawson Tait operated on a woman with ectopic pregnancy, removing the placenta from her fallopian tube and saving her life. At the time, somewhere between 72 and 99 percent of women with ectopic pregnancies died. Medical advances during the twentieth century — sensitive assays to detect hCG, the invention of ultrasound imaging, and sophisticated surgical techniques — have brought that figure down to the 0.05 percent rate we see today. In recent decades, a drug called methotrexate, which can destroy a misplaced embryo, has allowed one quarter of all patients to forgo surgery entirely. Doctors call treatment with drugs “medical management,” a phrase that encapsulates the modern conviction that we can control — whether through caesarean section or I.V.F. or methotrexate — all the reproductive tics of the body.
Approximately one out of every fifty pregnancies in the United States is ectopic. Risk factors are various: genital-tract infections, smoking, assisted reproductive technologies, and in-utero exposure to diethylstilbestrol, a now banned form of synthetic estrogen that was prescribed to pregnant women between 1940 and 1971 (ironically, to prevent pregnancy complications). Other predictors are maddeningly circular: infertility, a pathological fallopian tube, previous ectopic pregnancies.2
2 Many women will never know why their embryo implanted outside their uterus. In some cases, microscopic scarring probably blocks passage of the fertilized egg. In other cases, the tube’s muscles and cilia — the hairlike structures that usher an egg toward the uterus — may malfunction. But the complete answer likely involves a complex and poorly understood interplay of genomic and hormonal interactions. The problem may originate not in the woman’s organs but in the embryo’s DNA. A few researchers have also raised the possibility that a subset of ectopic pregnancies can’t be blamed on the woman’s reproductive system at all but may instead be caused by damaged sperm.
I had none of the risk factors, but three days after my initial appointment, my doctor called to say that the lab tests confirmed an ectopic pregnancy. I had thought that the news would make me sad, but instead I felt relieved that the diagnosis was no longer in question. If I was not going to have a baby, I wanted the fetus out. The doctor offered three treatment options: surgery to remove the entire fallopian tube (which was bad for my future fertility), surgery to remove the fetus from the tube (risky because the operation might miss some of the fetal tissue or cause scarring), or methotrexate (noninvasive but not always successful). I chose the drug.
When should I come in? “Right now,” he said. I found another professor to cover my afternoon class and drove to the clinic. A nurse showed me to a windowless exam room. When the doctor arrived, I asked him about side effects. Methotrexate is also used for chemotherapy: cancer cells and fetal tissue proliferate quickly, and the drug works by interrupting DNA synthesis. Fortunately, women with ectopic pregnancies receive much lower doses than cancer patients, so they rarely lose their hair or experience nausea. The worst side effect my doctor mentioned was a mouth full of sores.
Although I’d been asked to rush to the office, I had to wait for more than an hour for my shot. Apparently, at five feet four inches tall and 118 pounds, I needed more methotrexate than was stored in the building. I sat alone while a nurse ran across the street to get more at the hospital pharmacy. The serum filled two hypodermic needles, so she brought a second nurse to inject me simultaneously. I stood beside the stainless-steel exam table, pulled my jeans down, and held my shirt up. One of the nurses asked me to lean forward. I felt the needles pierce the skin and the cool surge of liquid flowing into my hip muscle. It hurt less than a flu shot.
I wouldn’t know for a week whether the drug had worked. Doctors judge its efficacy by monitoring hCG levels: a 15 percent decrease between the fourth and seventh days following the shot means that the fetal tissue has stopped growing. Methotrexate works best in women with base hCG levels under 5,000;3 because my pregnancy was further along, my levels were more than six times that.
3 The units here are mIU of hCGß per mL, where one mIU is approximately equal to 1 × 10-6 mg.
If you’re treated with methotrexate, anxiety replaces physical pain. A formerly physical trauma becomes intellectual. Instead of being rushed to surgery, I rushed to take a drug — and then I waited to see whether it would save my life. I was told I was in danger, but it didn’t feel that way. I had no pain to alert me to any physical trouble. It was an unwelcome reminder of the body’s tendency to break, to betray without warning.
I soon entered a disquieting phase of wishing fervently for the death of the fetus inside me, the cells that should have been my first child. I felt like a strange sort of suicide bomber, one with an unpredictable and self-made explosive concealed within my body. I stumbled through work and social obligations, missing a meeting with colleagues and behaving impatiently with students. Like many women who suffer first-trimester pregnancy losses, I hid my condition from my colleagues. You do not tell your boss about your miscarriage or your ectopic pregnancy. You go to work, and you try to act normal.
During that week and the weeks that followed, I braced myself for a black grief. Women frequently mourn the baby they have imagined within themselves. Knowing that the embryo was “nonviable,” and perhaps genetically flawed, doesn’t always help. The absence of cultural traditions to mark pregnancy loss can amplify feelings of grief. We admonish women to conceal their pregnancies until after the first trimester to avoid discomforting friends and family if something goes wrong. When it does — and one in four women miscarries at least once — they are left alone, without the social-support systems that buoy people through other losses. As Sylvia Plath wrote in “Parliament Hill Fields,” a poem about her miscarriage: “Your absence is inconspicuous; / Nobody can tell what I lack.”
The friends I did tell responded with compassion. They sent tulips and Gerbera daisies and encouraged me to see a therapist. The doctor volunteered, although I had not asked, that he was certain in his diagnosis, that this pregnancy would never have produced a child; he wanted to set my mind at ease.
The online support forums I visited suggested that I would suffer months of depression followed by irrational anger. I would make frantic efforts to conceive as soon as physically possible. I would muddle through a depression that my insensate husband could not possibly comprehend. I would resent pregnant women and froth with jealousy at the sight of babies. None of this happened to me. Although babies materialized everywhere — infant twins at the doctor’s office, a caravan of strollers outside the bookstore, a distraught student who confided that his girlfriend was pregnant — my despair burned away quickly.
Instead, I was nearly overcome by anxiety about my health. I’d find my heart fluttering as I sat at my desk or my palms sweating as I fixed a cup of coffee, the telltale signs of a fight-or-flight response. No one talks about these feral emotions — the desperate lust for self-preservation, the relief at the fetus’s demise, the guilt I felt about jeopardizing my health by trying to conceive. Of course, ectopic pregnancy is a peculiar form of loss. It’s hard to grieve for a potential life while worrying about your own.
Still, I found it easier to locate information about what I might expect mentally than what I might undergo physically. This is the luxury of modern medicine in the developed world; dying while pregnant is so uncommon that we can deny the bodily realities altogether.
A friend invited me to a dinner party the day after my methotrexate shots. He said he thought it would be good for me to get out of the house; he didn’t want me “sitting at home being sad.” I wasn’t planning to spend the day sobbing, but I didn’t want to go out either, in part because I didn’t know how my body would react to a chemotherapy drug.
As it turned out, I had reason to be nervous. A nurse called eight days after the methotrexate injections to say they had not worked. Although my hCG levels had fallen, the decrease between days four and seven was only 13.9 percent, maddeningly close to the 15 percent that doctors look for but not quite there. Since my numbers had declined between days one and four, I had already convinced myself that the ordeal was over — the danger, the drugs, the not knowing. The evidence to the contrary infuriated me.
The nurse wanted me to come back to the office for a second round of shots within the hour. I was so angry, so flushed with adrenaline, that I didn’t want to get behind the wheel of a car. I called my husband at work and asked him to take me to the clinic.
I ended up in a nicer exam room this time. Someone had tried to make it feel homey; it had a window, parenting magazines, and a push-board covered with birth announcements and baby photos. The nurses offered to stick me immediately and let me leave, but I insisted on seeing the doctor. I’d glided through the first round of shots with no apparent side effect other than fatigue, but I worried that a second round might be more toxic. I also wanted to know why the decline during the first four days didn’t count in the diagnostic calculations. Didn’t that indicate that the drug was working, albeit slowly? The doctor told me that those days weren’t indicative — sometimes hCG levels even rose before falling sharply.
He went on to say that only a handful of his patients had required a second round of shots, an admission that made me angrier still. I asked what would happen if the methotrexate failed again. I could get a third dose, he said, as long as my tube did not rupture in the interim. “But I’m sure it will work this time,” he said. I laughed out loud. After landing among the 2 percent of pregnant women whose embryos implant in the wrong place, I had lost faith in statistics. “Don’t be that way,” the doctor said. He left me to wait for the nurses and their needles.
What type of life was I endeavoring to end? In the vast majority of ectopic pregnancies, the embryo has no heartbeat. In a smaller number, the heart beats and the fetus appears to develop normally despite its location. Such “normal” development is probably short-lived; the fallopian tube is not equipped to provide blood to a fetus. And, of course, even an otherwise healthy fetus would eventually kill the mother, which is why doctors consider every ectopic pregnancy to be nonviable. Surgeons cannot relocate a fetus to the uterus, and a woman cannot survive if it remains in place.4
4 The medical literature does contain examples of abdominal pregnancies in which mother and child survived surgery to remove a full-term infant. This is so rare, however, and the dangers of blood loss in the abdominal cavity so great, that doctors recommend termination in abdominal cases as well.
My decision to terminate such a pregnancy might seem uncontroversial, but opponents of abortion have sought to restrict the treatment in more than ten states, including Mississippi, where I live. In 2011, abortion opponents there put an initiative on the ballot to “amend the Mississippi Constitution to define the word ‘person’ or ‘persons’ . . . to include every human being from the moment of fertilization, cloning, or the functional equivalent thereof.” The initiative was defeated, but in recent months bills and resolutions with similar language have been introduced in Louisiana, Montana, New Hampshire, South Carolina, Virginia, and Washington.
Personhood laws are in some ways the result of medical progress. Technologies that save women’s lives have been turned against us. Now that the fetus can be seen on an ultrasound, it can be imagined as a baby. Now that nobody dies of ectopic pregnancy, people can pretend that pregnancy isn’t dangerous.
I didn’t know whether my fetus had a heartbeat. Still, at first, I feared a chemical abortion. I worried that the poison would wrench the fetus loose and I would expel the remains, wet and sad and bean-shaped. But it doesn’t work that way. An ectopic pregnancy terminated with methotrexate ends as it begins: in obscurity. If the treatment succeeded, my body would reabsorb the fetal tissue and swallow the cells built from my cells, until the errant body was no longer distinguishable from my own. Any life within me would drift unobtrusively back into unbeing; it would drift back into myself.
I did not need a blood test to know that the second round of shots had worked. On the third day after the injections, I started to cramp, sharp and tight, and then I started to bleed. The discharge flowed deep red, and the thickened lining of my womb shed itself in sticky sheets. I watched the blood fall away in clots for nine days. Then it stopped. A week passed, and then I bled again, bright red and thin, like water washing over a wound.
Lab results confirmed the obvious. My hCG levels had declined 56 percent during the week following the second shot. I was pregnant but not pregnant, without child but capable of triggering a positive result on a home pregnancy test. Although I didn’t need any more methotrexate, there were weeks of follow-up lab work. My hCG number would be monitored until it retreated below 5, the fear being that the fetal tissue might linger or even begin to regrow. I had blood drawn weekly. On good days, the lab would be staffed by a grandmotherly woman who was skilled with a needle. Other phlebotomists left streaky bruises as they fumbled for a vein. I became one of the people whom the women working at the front desk instantly recognized. When I called the office for my test results, the nurse knew my voice.
The tests and their results, which had consumed me during the first few weeks of treatment, became a routine hassle. I taught classes through the end of the semester and visited friends in California. My pregnancy went on failing for ten more weeks, well into summer, the days growing longer and warmer as my hormones grew weaker. My hCG numbers marched downward from their peak: 33,813; 28,715; 24,731; 10,824; 5,195; 1,484; 668; 176; 106; 64; 24; 5. I bled irregularly for the last time during week seven. The flow came lightly but steadily, in rust-colored droplets. I thought about whether I wanted to try to conceive again after my body had recovered, and didn’t know the answer. There’s what the mind wants and what the numbers tell you — and the numbers, stubbornly, don’t lie.