The test is positive, but something feels wrong: a pulling pain on one side, some spotting, perhaps a strange pain in your shoulder. Here you can read how to recognise an ectopic pregnancy, when it starts to cause symptoms, how doctors diagnose it, which treatment fits which findings and how good your chances of another pregnancy are.
Warning signs: go to A&E straight away or call 999 or 112
If you have a positive test or a missed period and severe abdominal pain, pain in the tip of your shoulder, dizziness, fainting, feeling faint or pressure on your bowel. These can be signs of internal bleeding if the fallopian tube ruptures (NICE NG126, NHS 2022). Do not wait for an appointment with your GP or gynaecologist.
What is an ectopic pregnancy?
Normally, the fertilised egg travels through the fallopian tube into the womb in about five days and implants there. In an ectopic pregnancy, it gets stuck in the tube. The medical term is tubal pregnancy. It is the most common form of ectopic pregnancy, meaning a pregnancy outside the cavity of the womb.
The fallopian tube is a thin muscular tube and cannot grow with the pregnancy. An ectopic pregnancy can therefore never be carried to term. Either it ends on its own, or it has to be treated before the tube ruptures.
In a French register study with 1,800 cases, the pregnancies were located as follows (Bouyer 2002):
Normal implantation in the womb
- Ampullawide outer part of the fallopian tube 70%
- Isthmusnarrow part of the fallopian tube near the womb 12%
- Fimbriaefringes at the open end of the fallopian tube 11.1%
- Ovaryon or in the ovary 3.2%
- Corner of the wombinterstitial, in the section of the tube within the wall of the womb 2.4%
- Abdomenbetween the bowel and the lining of the abdomen 1.3%
Most are in the ampulla, the wide outer part of the tube. The closer the pregnancy is to the womb, the thicker the muscle wall around it. Interstitial pregnancies in the corner of the womb therefore often grow unnoticed for longer and bleed more heavily if they rupture (RCOG 2016).
How common is an ectopic pregnancy?
In the UK, it is about 11 in 1,000 pregnancies (RCOG 2016). The US professional society ACOG gives about 2 in 100 reported pregnancies (ACOG 2018). The figures differ because they are counted differently, for example with or without early losses.
After fertility treatment in the US, the rate was 1.6% of pregnancies in 2011, down from 2.0% in 2001 (Perkins 2015). More on this in the section on IVF and frozen embryo transfer.
Early signs and symptoms
At first, an ectopic pregnancy often feels like a normal early pregnancy: your period does not come, the test is positive, your breasts feel tender. Some women have no symptoms at all until the pregnancy is spotted on an ultrasound scan (NHS 2022).
The UK guideline NICE NG126 lists these symptoms:
| Common | Less common |
|---|---|
| Abdominal or pelvic pain | Breast tenderness |
| Missed or late period | Gastrointestinal symptoms such as nausea or diarrhoea |
| Vaginal bleeding, with or without clots | Dizziness, fainting |
| Shoulder tip pain | |
| Urinary symptoms | |
| Passing of tissue | |
| Rectal pressure or pain when opening your bowels |
The bleeding is often darker and thinner than a period, more brownish, like coffee grounds (NHS 2022). It is easily mistaken for implantation bleeding or a late period.
From which week do symptoms appear?
Usually between the 6th and 8th week of pregnancy, counted from the first day of your last period (RCOG 2016). That is about two to four weeks after your missed period. Symptoms can also come earlier or later, and interstitial pregnancies in the corner of the womb are often noticed later. The pregnancy calendar shows which week you are in, for example week 6 and week 7.
Where does an ectopic pregnancy hurt?
Usually in the lower abdomen, often on one side, the side of the affected tube. The pain can be a dull pull, come in cramps or stab suddenly. It can also spread across the whole abdomen.
Pain in the tip of the shoulder, where the shoulder meets the arm, happens when blood leaks from the tube into the abdomen and irritates the diaphragm. The nerves pass the pain on to the shoulder. It is often worse when lying down and is not a muscle pain. Shoulder pain in early pregnancy always needs to be checked straight away (NHS 2022).
What happens if the fallopian tube ruptures?
If the pregnancy keeps growing, the tube can rupture. This is called a tubal rupture. It causes internal bleeding, which can be life-threatening. Typical signs are sudden, severe, sharp abdominal pain, dizziness, fainting, paleness, a fast pulse and shoulder pain (NHS 2022).
In the UK today, about 0.2 in 1,000 women with an ectopic pregnancy die of it (RCOG 2016). Almost always because the bleeding was recognised too late. So the rule is: if you have warning signs, do not wait.
When to go to hospital straight away
A&E or 999 or 112 if you have a positive test or a missed period and
- sudden, severe abdominal pain
- pain in the tip of your shoulder
- dizziness, fainting, paleness or a racing heart
- the feeling that you urgently need the toilet, but nothing comes
See a doctor the same day if you have
- lower abdominal pain on one side or pain that does not go away
- bleeding with pain
- had a previous ectopic pregnancy, tubal surgery, a coil or fertility treatment, as soon as the test is positive
Many hospitals have an early pregnancy unit or a gynaecology emergency service that you can reach around the clock.
Ectopic pregnancy or normal pregnancy?
Without an ultrasound scan, there is no reliable way to tell. Individual symptoms occur in both. These differences help you get a sense of it:
| Normal early pregnancy | Ectopic pregnancy | |
|---|---|---|
| Pain | mild pulling, on both sides or in the middle, comes and goes | often on one side, getting worse, cramping or stabbing |
| Bleeding | none, or brief, light spotting | common, brownish, watery, over several days |
| Shoulder pain | no | possible, warning sign |
| Dizziness, fainting | rare, usually harmless | possible, warning sign |
| hCG in the blood | usually rises by more than 63% in 48 hours | often rises more slowly, stays the same or falls, but can also rise normally |
| Ultrasound | pregnancy sac in the womb | womb empty, possibly a mass next to the womb |
About the hCG levels: in a US study, hCG rose as quickly in 20.8% of women with an ectopic pregnancy as in a viable pregnancy (Silva 2006). So a normal rise does not rule it out. More on this under hCG levels.
Does a pregnancy test show an ectopic pregnancy?
Yes. An ectopic pregnancy also produces the pregnancy hormone hCG, so the test turns positive. It cannot show where the pregnancy is. Sometimes the line is fainter than expected because hCG rises more slowly. But a faint test proves nothing, as explained in the guide to the pregnancy test.
The weeks indicator on digital tests can also be wrong with an ectopic pregnancy (Clearblue 2025). The pregnancy test calculator shows the earliest day you can test.
Causes and risk factors
Usually the tube has changed in a way that moves the fertilised egg along too slowly. But about half of women with an ectopic pregnancy have no known risk factor (ACOG 2018). So you have done nothing wrong.
| Risk factor | What lies behind it |
|---|---|
| Previous ectopic pregnancy | After one ectopic pregnancy, the risk is about 10%, after two or more over 25% (ACOG 2018) |
| Tubal surgery, sterilisation | Scarring and narrowing; if a woman becomes pregnant after sterilisation, the risk is high (ACOG 2018) |
| Pelvic inflammation, chlamydia | Adhesions in the tube, often unnoticed after a chlamydia infection (RCOG 2016) |
| Smoking | The risk rose with the number of cigarettes, to about four times as high at 20 or more a day (Bouyer 2003) |
| Coil (IUD) | It is very reliable contraception; if you still get pregnant, the pregnancy is outside the womb in up to 53 out of 100 cases (ACOG 2018) |
| Fertility treatment | Tubal damage as the reason for treatment, transfer of several embryos (Perkins 2015) |
| Age over 35 | The risk increases with age, markedly from 40 (Bouyer 2003) |
| Endometriosis | Adhesions on the tube and ovary, more on this under endometriosis and fertility |
Sex, exercise or lifting in early pregnancy do not cause an ectopic pregnancy.
Diagnosis: ultrasound and hCG
An ectopic pregnancy is diagnosed with a transvaginal ultrasound scan, often together with hCG levels in the blood (NICE NG126). The doctor looks for a pregnancy sac in the womb and for a mass next to the womb. Sometimes free fluid can also be seen in the abdomen, a sign of bleeding.
Pregnancy of unknown location. If the test is positive but the ultrasound shows nothing either in or next to the womb, this is called a pregnancy of unknown location. It can be a very early viable pregnancy, a miscarriage that is starting or an ectopic pregnancy. hCG is then measured again after 48 hours (NICE NG126):
- Rise of more than 63%: probably a developing pregnancy in the womb. Ultrasound after 7 to 14 days, earlier if hCG is 1,500 IU/l or more. This does not yet rule out an ectopic pregnancy.
- Fall of more than 50%: the pregnancy is probably ending. A urine test is done after 14 days.
- Anything in between: review at the early pregnancy unit within 24 hours.
This calculator shows you the percentage change between two levels:
Calculate doubling time
Your gynecologist or your fertility practice will assess whether your level fits how your pregnancy is progressing.
The calculator does not make a diagnosis. Symptoms count more than any number: NICE advises not waiting for a second level if you are in pain.
If the diagnosis is still unclear, keyhole surgery may be needed, in which the tubes are looked at directly. If the ectopic pregnancy is visible, it is usually treated in the same operation.
Treatment of ectopic pregnancy
There are three options: waiting to see if the pregnancy ends on its own, the medicine methotrexate or an operation. Which one is suitable depends mainly on the hCG level, pain, the size on ultrasound and whether a heartbeat is visible. The UK guideline NICE NG126 sets clear limits for this:
| hCG in IU/l | up to 1,000 | 1,000 to 1,500 | 1,500 to 5,000 | 5,000 or more |
|---|---|---|---|---|
| Waiting | recommended | possible | not recommended | not recommended |
| Methotrexate | recommended | recommended | possible | not recommended |
| Surgery | possible | possible | possible | recommended |
Waiting and methotrexate only without severe pain, without rupture, with a size under 35 mm, without a visible heartbeat and if you can attend all follow-up checks. Otherwise, surgery is done.
-
Waiting
The body breaks down the pregnancy on its own.
- When
- hCG up to 1,000 IU/l, in individual cases up to 1,500, no pain
- What happens
- no medicines, watch for pain and bleeding
- Follow-up
- hCG on days 2, 4 and 7, then weekly until below 20 IU/l
- Hospital
- outpatient
- Next pregnancy
- after two periods
-
Methotrexate
An injection stops the pregnancy cells from growing.
- When
- hCG below 1,500 IU/l, up to 5,000 as a choice, no severe pain
- What happens
- usually one injection into a muscle, sometimes a second
- Follow-up
- hCG on days 4 and 7, then weekly until negative
- Hospital
- outpatient
- Next pregnancy
- after 3 months at the earliest
-
Surgery
Keyhole surgery, usually removing the fallopian tube.
- When
- severe pain, rupture, 35 mm or more, heartbeat or hCG of 5,000 IU/l or more
- What happens
- keyhole surgery through small cuts under general anaesthetic
- Follow-up
- hCG until negative, especially if the tube is kept
- Hospital
- usually one night, recovery about two weeks
- Next pregnancy
- after two periods
Waiting (expectant management)
Many ectopic pregnancies end on their own, and the body breaks down the tissue. Waiting is an option if you have no pain, your circulation is stable, the pregnancy is smaller than 35 mm, no heartbeat is visible and hCG is no more than 1,000 IU/l, in individual cases up to 1,500 IU/l (NICE NG126).
hCG is checked on days 2, 4 and 7. If it falls by at least 15% each time, checks continue weekly until the level is below 20 IU/l. If it rises or stays the same, the decision is reviewed. In a Dutch study of women with low hCG, the ectopic pregnancy resolved without further treatment in 59% after waiting and in 76% after a methotrexate injection; the difference was not statistically certain (van Mello 2013).
Methotrexate
Methotrexate stops the pregnancy cells from growing. It is given as an injection into a muscle, usually once, without anaesthetic and without a hospital stay. NICE recommends it if hCG is below 1,500 IU/l, with no significant pain, no rupture, a size under 35 mm and no visible heartbeat. Between 1,500 and 5,000 IU/l, you can choose between methotrexate and surgery (NICE NG126).
hCG is measured on days 4 and 7 after the injection, then weekly until the test is negative. This often takes several weeks. In the Dutch study, 22% of women needed further injections and 2% still needed surgery (van Mello 2013). In the first few days, abdominal pain gets worse for many women. This is common, but it must be checked by a doctor because it can also be a rupture.
During treatment: no alcohol, no painkillers such as ibuprofen without checking first, no products containing folic acid because they weaken the effect, and little sun. After methotrexate, you should not get pregnant for at least 3 months (RCOG 2016, NHS 2022).
Surgery: keyhole surgery
Surgery is done if there is severe pain, a rupture, a size of 35 mm or more, a visible heartbeat or hCG of 5,000 IU/l or more (NICE NG126). Almost always as keyhole surgery (laparoscopy) through three small cuts. If there is heavy bleeding, an open operation through a cut in the abdomen may be needed.
There are two procedures:
- Salpingectomy: the affected tube is removed. This is the standard if the other tube is healthy (NICE NG126).
- Salpingotomy: the tube is opened, the pregnancy is removed and the tube stays. This makes sense if the other tube is damaged or missing. Up to 1 in 5 women need further treatment afterwards because tissue is left behind (NICE NG126).
In the European ESEP study with 446 women, the other tube was healthy in every case. After three years, 60.7% after salpingotomy and 56.2% after salpingectomy were pregnant again naturally; the difference was not significant. Pregnancy tissue was left behind in 7% after salpingotomy and in under 1% after salpingectomy. Another ectopic pregnancy occurred in 8% after salpingotomy and 5% after salpingectomy (Mol 2014).
How long do you stay in hospital?
After keyhole surgery, usually one night, and sometimes you can go home the same day. Recovery takes about two weeks, after an open operation four to six weeks (NHS 2022). Methotrexate and waiting are outpatient care, with appointments for blood tests.
Rhesus negative: anti-D injection
Since 2026, NICE no longer recommends anti-D prophylaxis for ectopic pregnancy or miscarriage up to and including 11+6 weeks. From 12+0 weeks, rhesus-negative women receive it with medical or surgical treatment (NICE NG126, 2026 update). Other countries partly have different rules. So ask if your blood group is rhesus negative.
Rare forms
In the French register study, just under 7 out of 100 pregnancies were in the corner of the womb, on the ovary or in the abdomen (Bouyer 2002). Other forms did not occur there at all and are even rarer (RCOG 2016):
- Interstitial, in the corner of the womb: where the tube joins the womb. Often found later, risk of heavy bleeding.
- Ovary: rare, usually treated with surgery.
- Abdomen (abdominal pregnancy): very rare, the pregnancy implants between the loops of the bowel or on the lining of the abdomen.
- Cervix: very rare, heavy bleeding possible.
- Caesarean scar: in the scar of a previous caesarean section. Recognised more often as the number of caesareans rises.
- Heterotopic pregnancy: a pregnancy in the womb and one outside it at the same time. Very rare after natural conception, more common after fertility treatment (RCOG 2016).
After an ectopic pregnancy
Physically. hCG has to fall below 20 IU/l, whatever treatment you had. Until then, a pregnancy test stays positive. Your next period usually comes within four to six weeks, often later after methotrexate.
Emotionally. An ectopic pregnancy is a pregnancy loss, often combined with fear, an emergency and an operation. In a London study of women after miscarriage or ectopic pregnancy, 29% had signs of post-traumatic stress one month later and 18% still did nine months later. After ectopic pregnancy alone, it was 21% after nine months (Farren 2020). Ask your hospital for support if anxiety, flashbacks or grief do not ease. Your partner can be affected too.
How things can go on after a loss is also covered in the guide pregnant after miscarriage.
Getting pregnant again after an ectopic pregnancy
How long should you wait?
After surgery or waiting, NHS hospitals advise waiting for at least two periods so your body can recover. After methotrexate, you should wait at least three months because the medicine depletes your folate stores (NHS 2022, RCOG 2016). After that, taking folic acid before your next pregnancy is especially important.
Can you get pregnant with one fallopian tube?
Yes. The remaining tube can also pick up the egg from the ovary on the other side. In the ESEP study, 56 out of 100 women were pregnant again naturally within three years after one tube was removed (Mol 2014). The fertility statistics show how the chances change with age.
Can an ectopic pregnancy happen again?
After one ectopic pregnancy, the risk is about 10 in 100 (ACOG 2018). So the large majority of next pregnancies are in the normal place. An early scan is important: get in touch as soon as you have a positive test, so the location can be checked from about the 6th week (NICE NG126). The due date calculator works out the timing for you.
Ectopic pregnancy and fertility treatment
In IVF, the embryo is placed directly into the womb, but an ectopic pregnancy is still possible. The embryo can move into the tube. In the US in 2011, this affected 1.6% of pregnancies after fertility treatment. After transfer of one embryo, the rate was 1.6%, after three embryos 2.2% and after four or more 2.5% (Perkins 2015).
If both tubes are damaged or removed, IVF is the route to pregnancy, because egg and sperm can no longer meet. A fluid-filled tube (hydrosalpinx) lowers the chances of IVF and is often removed or blocked beforehand. The guide IVF process explains how IVF works, and the IVF calculator works out the chance per attempt. You can find clinics near you in the clinic comparison.
After a frozen embryo transfer, the same applies as after natural conception: the first scan checks where the pregnancy is. More on this under frozen embryo transfer.
Can you prevent an ectopic pregnancy?
Not reliably. You can lower the risk with:
- Not smoking: in studies, the risk rose with the number of cigarettes (Bouyer 2003).
- Condoms and chlamydia tests: get tested for chlamydia regularly, especially if you are under 25. In England, the NHS offers free tests to under-25s.
- An early scan: it does not prevent an ectopic pregnancy, but it finds it before the tube ruptures.
Frequently asked questions
What are the first signs of an ectopic pregnancy?
A missed period, lower abdominal pain, often on one side, and brownish spotting, usually between the 6th and 8th week after your last period (NICE NG126, RCOG 2016). Shoulder tip pain, dizziness or fainting are an emergency.
How often does an ectopic pregnancy happen?
In about 11 in 1,000 pregnancies (RCOG 2016). After a previous ectopic pregnancy, the risk is about 10 in 100 (ACOG 2018).
When do you notice an ectopic pregnancy?
Usually in the 6th to 8th week of pregnancy, that is two to four weeks after the missed period (RCOG 2016). Some women have no symptoms until it is spotted on an ultrasound scan.
Can a pregnancy test detect an ectopic pregnancy?
No. The test is positive because an ectopic pregnancy also produces hCG. Only an ultrasound scan shows where the pregnancy is, often together with two hCG levels taken 48 hours apart (NICE NG126).
Where do you feel pain with an ectopic pregnancy?
In the lower abdomen, often on one side, sometimes across the whole abdomen. Shoulder tip pain happens when blood leaks into the abdomen and irritates the diaphragm (NHS 2022).
How long do you have to stay in hospital with an ectopic pregnancy?
After keyhole surgery, usually one night or just one day. Methotrexate and waiting are outpatient care, with blood tests over several weeks (NHS 2022).
Is it possible to get pregnant after a fallopian tube is removed?
Yes. In the ESEP study, 56 out of 100 women became pregnant naturally within three years after one tube was removed (Mol 2014). If both tubes have been removed, IVF is possible.
Can an ectopic pregnancy resolve on its own?
Yes, many end on their own and the tissue is broken down. But waiting is only safe under medical supervision, with hCG levels on days 2, 4 and 7 (NICE NG126).
Can an embryo survive in the fallopian tube?
No. An ectopic pregnancy cannot be moved into the womb and cannot be carried to term.
Sources
Guidelines and product information
- Ectopic pregnancy and miscarriage: diagnosis and initial management, NICE guideline NG126, National Institute for Health and Care Excellence, 2019, updated 2026
- Diagnosis and Management of Ectopic Pregnancy, Green-top Guideline No. 21, Royal College of Obstetricians and Gynaecologists and Association of Early Pregnancy Units, BJOG 2016;123:e15-e55
- Tubal Ectopic Pregnancy, ACOG Practice Bulletin No. 193, American College of Obstetricians and Gynecologists, Obstet Gynecol 2018;131:e91-e103
- Ectopic pregnancy, NHS, 2022
- Clearblue Multicheck mit Wochenbestimmung, package leaflet 2300687.01, SPD Swiss Precision Diagnostics, 2025
Studies
- Bouyer J, Coste J, Fernandez H, Pouly JL, Job-Spira N: Sites of ectopic pregnancy, a 10 year population-based study of 1800 cases, Hum Reprod 2002;17:3224-3230
- Bouyer J, Coste J, Shojaei T et al.: Risk factors for ectopic pregnancy, a comprehensive analysis based on a large case-control, population-based study in France, Am J Epidemiol 2003;157:185-194
- Mol F, van Mello NM, Strandell A et al.: Salpingotomy versus salpingectomy in women with tubal pregnancy (ESEP study), an open-label, multicentre, randomised controlled trial, Lancet 2014;383:1483-1489
- van Mello NM, Mol F, Verhoeve HR et al.: Methotrexate or expectant management in women with an ectopic pregnancy or pregnancy of unknown location and low serum hCG concentrations, a randomized comparison, Hum Reprod 2013;28:60-67
- Perkins KM, Boulet SL, Kissin DM, Jamieson DJ: Risk of ectopic pregnancy associated with assisted reproductive technology in the United States, 2001-2011, Obstet Gynecol 2015;125:70-78
- Silva C, Sammel MD, Zhou L et al.: Human chorionic gonadotropin profile for women with ectopic pregnancy, Obstet Gynecol 2006;107:605-610
- Farren J, Jalmbrant M, Falconieri N et al.: Posttraumatic stress, anxiety and depression following miscarriage and ectopic pregnancy, a multicenter, prospective, cohort study, Am J Obstet Gynecol 2020;222:367.e1-367.e22
