Is a twin or multiple ectopic pregnancy possible?

By (embryologist), (gynecologist) and (psychologist).
Last Update: 01/25/2022

Twin or multiple ectopic pregnancy is a rather rare type of gestation, in which several embryos, usually two, are gestated outside the uterine cavity.

Early diagnosis is of crucial importance in ectopic pregnancy and, of course, also if it is multiple, since the possible complications derived from the rupture of the fallopian tube may even compromise the patient's life.

What is a multiple ectopic pregnancy?

An ectopic pregnancy or extrauterine pregnancy is a gestation in which the embryo has not implanted in the uterine cavity, but outside of it. Within ectopic pregnancies, the most frequent location is the fallopian tube and, specifically, the ampullary region.

There are certain risk factors, some of them related to the current lifestyle, which may increase the possibility of having an ectopic pregnancy. Among them, we can mention:

On the other hand, a multiple pregnancy is a pregnancy in which more than one embryo is gestated. Its incidence has increased with assisted reproduction techniques, but this type of gestation carries greater risks for the mother and the babies than a single gestation. Therefore, the tendency is to avoid this type of pregnancy to reduce the risk of possible complications.

Thus, a multiple ectopic pregnancy consists of a pregnancy with more than one embryo without them being located inside the uterus. Although it can occur, either naturally or related to assisted reproduction techniques, an ectopic and multiple pregnancy is an infrequent and quite exceptional situation.


Multiple ectopic pregnancy can be of different types, depending on where the embryonic tissue is located. As mentioned above, the most common location of an ectopic pregnancy is the fallopian tubes and, therefore, a multiple ectopic pregnancy can be:

  • Unilateral: when the embryos are in the same tube. In this case, the multiple ectopic pregnancy may be left or right.
  • Bilateral: if the gestational sacs are in both tubes.

However, most reported cases of multiple ectopic pregnancy are monozygotic twins, that is, originating from a single egg and sperm.

In addition, it is possible that an intrauterine pregnancy and an ectopic pregnancy may occur at the same time. This special situation is called heterotopic pregnancy and, although it is also quite rare, its frequency may have increased with assisted reproductive techniques and the transfer of several embryos. This type of gestation occurs in 1/7000 spontaneous pregnancies.

Symptoms of multiple tubal pregnancy

When a multiple or twin ectopic pregnancy occurs, the patient may not notice any symptoms different from those she might have with an intrauterine pregnancy. However, as the number of weeks of gestation increases, it is common for women to see a specialist because they notice symptoms such as the following:

  • Pain in the abdomen.
  • Bleeding.
  • Nausea and vomiting.
  • Dizziness and fainting sensation.

However, it is very important to detect this type of pregnancy early, to avoid possible complications, since it can even endanger the patient's life.

Diagnosis of tubal twin pregnancy

The diagnosis of ectopic pregnancy may be suspected in the presence of a positive pregnancy test result, without the gestational sac being observed in the uterus by ultrasound. However, it is important to take into account the patient's gestational weeks, since the gestational sac will not be visible ultrasonographically until approximately week 5 of pregnancy.

Thus, if there is a suspicion of ectopic pregnancy or in a patient with the aforementioned symptoms, it will be performed:

  • Physical and gynecological examination.
  • Ultrasound
  • Blood test for the quantitative determination of hCG hormone.

In addition, the specialist may also request other analytical determinations, as well as the tests he/she considers necessary to assess the patient's general condition.

Thus, during the ultrasound, it is possible that the extrauterine gestation of several embryos can be observed, which would indicate ectopic and multiple pregnancy. In certain cases, embryos may even exhibit cardiac activity, which could also be detected.

However, if ultrasound is unable to provide a diagnosis, laparoscopy may be necessary.

Treatment of twin or multiple ectopic pregnancy

The treatment of a multiple ectopic pregnancy will depend on the number of weeks of pregnancy, the location, the woman's symptoms, etc. In any case, the specialist must inform the patient of the different possibilities and the possible risks and consequences of each of them.

It is true that some ectopic pregnancies resolve on their own, while others require the use of certain drugs. However, if the resolution of the ectopic and multiple pregnancy is urgent due to the patient's condition, expectant or pharmacological management cannot be performed, and surgery is necessary.

Possible complications and risks

As ectopic and, in these cases, multiple gestation progresses, the affected tube or tubes may rupture. This could result in internal bleeding.

This complication can have important consequences for the woman's health, as it can cause hemorrhagic shock and even endanger the patient's life. Therefore, it is of crucial importance to act before this occurs and to perform surgery urgently.

Whenever possible, multiple ectopic pregnancy should ideally be approached laparoscopically versus laparotomy. Often, a salpingectomy will be performed, that is, the removal of the affected tube or tubes.

However, a salpingotomycould also be performed. This procedure is performed if the tubes are in good condition and consists of removing only the gestational sacs. Thus, salpingotomy would make it possible to maintain the affected tube(s).

Finally, it will be important to monitor the woman's hCG hormone levels to ensure that they are decreasing until they are undetectable. Otherwise, it could mean that there are still embryonic remains in the woman's body, which would require the use of drugs or new intervention.

FAQs from users

Can an ectopic pregnancy occur at the same time as a uterine pregnancy?

By Xinxin Lin MD (gynecologist).

Yes, it is possible and it is what is known as heterotopic pregnancy. It is a rare entity in the general population and usually occurs in 1 in 30,000 pregnancies.

However, any risk factor for an ectopic pregnancy is also a risk factor for a heterotopic pregnancy. The incidence increases when there is a history of pelvic inflammatory disease or assisted reproduction treatments, increasing its incidence to 1 in 100 pregnancies in the latter case.

Is there any benefit to twin ectopic pregnancy?

By Silvia Azaña Gutiérrez B.Sc., M.Sc. (embryologist).

No, a twin ectopic pregnancy is a gestation of several embryos outside the uterus, frequently in the fallopian tube, which can endanger the woman's life.

The main risk occurs if the tube ruptures, as it can lead to hemoperitoneum and hemorrhagic shock and even cause the death of the patient.

Can a twin ectopic pregnancy occur naturally?

By Silvia Azaña Gutiérrez B.Sc., M.Sc. (embryologist).

Yes, twin or multiple ectopic pregnancy can occur spontaneously, especially if the woman has risk factors for ectopic pregnancy such as a history of abdominal surgery, pelvic inflammatory disease (PID), intrauterine device, etc.

If you want to learn more about ectopic pregnancy, you can read the following article: What is ectopic pregnancy - Types, symptoms and diagnosis.

However, if you are interested in learning more about multiple pregnancy and its possible risks, we recommend you to visit this link: Risks of multiple pregnancy for mother and babies

We make a great effort to provide you with the highest quality information.

🙏 Please share this article if you liked it. 💜💜 You help us continue!


Amine BH, Haythem S. Extra-uterine twin pregnancy: case report of spontaneous bilateral tubal ectopic pregnancy. Pan Afr Med J. 2015 Apr 30;20:435. (see)

Arikan DC, Kiran G, Coskun A, Kostu B. Unilateral tubal twin ectopic pregnancy treated with single-dose methotrexate. Arch Gynecol Obstet. 2011 Feb;283(2):397-9. (see)

Betti M, Vergani P, Damiani GR, Pellegrino A, Di Naro E, Trojano G, Pirovano C, Stomati M, Loverro M. Unilateral twin tubal pregnancy: a case report and review of the literature. Acta Biomed. 2018 Oct 8;89(3):423-427. (see)

Dede M, Gezginç K, Yenen M, Ulubay M, Kozan S, Güran S, Başer I. Unilateral tubal ectopic twin pregnancy. Taiwan J Obstet Gynecol. 2008 Jun;47(2):226-8. (see)

Goswami D, Agrawal N, Arora V. Twin tubal pregnancy: A large unruptured ectopic pregnancy. J Obstet Gynaecol Res. 2015 Nov;41(11):1820-2. (see)

Pek JH, Simpson WL Jr, Owen J, Nelson B. Live Twin Ectopic Pregnancy. J Emerg Med. 2020 Aug;59(2):e77-e79. (see)

Revicky V, Krishna A, Al-Taher H. Spontaneous monochorionic monoamniotic twin tubal ectopic pregnancy. J Obstet Gynaecol. 2009 Jul;29(5):447-8. (see)

Rolle CJ, Wai CY, Bawdon R, Santos-Ramos R, Hoffman B. Unilateral twin ectopic pregnancy in a patient with a history of multiple sexually transmitted infections. Infect Dis Obstet Gynecol. 2006;2006:10306. (see)

Samardzic D, Kasales CJ, Patrone SV. Live monochorionic adnexal twin ectopic pregnancy. Ultrasound Q. 2014 Sep;30(3):230-2. (see)

Seak CJ, Goh ZNL, Wong AC, Seak JC, Seak CK. Unilateral live twin tubal ectopic pregnancy presenting at 12 weeks of gestation: A case report. Medicine (Baltimore). 2019 Sep;98(38):e17229. (see)

Sergel MJ, Greenberg DT. Live twin ectopic pregnancy with advanced gestation. J Emerg Med. 2009 Jul;37(1):77-8. (see)

Svirsky R, Maymon R, Vaknin Z, Mendlovic S, Weissman A, Halperin R, Herman A, Pansky M. Twin tubal pregnancy: a rising complication? Fertil Steril. 2010 Oct;94(5):1910.e13-6. (see)

Yamane D, Stella M, Goralnick E. Twin ectopic pregnancy. J Emerg Med. 2015 Jun;48(6):e139-40. (see)

FAQs from users: 'Can an ectopic pregnancy occur at the same time as a uterine pregnancy?', 'Is there any benefit to twin ectopic pregnancy?' and 'Can a twin ectopic pregnancy occur naturally?'.

Read more

Authors and contributors

 Silvia Azaña Gutiérrez
Silvia Azaña Gutiérrez
B.Sc., M.Sc.
Graduate in Health Biology from the University of Alcalá and specialized in Clinical Genetics from the same university. Master in Assisted Reproduction by the University of Valencia in collaboration with IVI clinics. More information about Silvia Azaña Gutiérrez
License: 3435-CV
 Xinxin Lin
Xinxin Lin
Dr. Xinxin Lin has a degree in Medicine from the University of Barcelona and is a specialist in gynecology and assisted reproduction. More information about Xinxin Lin
Colleague number: 48324
Adapted into english by:
 Cristina  Algarra Goosman
Cristina Algarra Goosman
B.Sc., M.Sc.
Graduated in Psychology by the University of Valencia (UV) and specialized in Clinical Psychology by the European University Center and specific training in Infertility: Legal, Medical and Psychosocial Aspects by University of Valencia (UV) and ADEIT.
More information about Cristina Algarra Goosman
Member number: CV16874

Find the latest news on assisted reproduction in our channels.