Friday, November 26, 2010

Woman Underwent Medical Miscarriage 8 Months Ago & Had Continuous Spotting, No BFP Yet: Should She Be Concerned?


Hello, I am a 29 year old female from Pennsylvania. My husband (also 29) and I started trying to conceive last year. We got pregnant on our 2nd month trying, and were very excited. At my first ultrasound, there was only a yolk & gestational sack, which showed growth only until 5w5d. I should have been much further along. I opted for medical management, offered by my doctor, to force the miscarriage. I took a mix of Mifepristone & Misoprostol - 4 pills were inserted vaginally, 24 hours after I'd taken the first pill orally.

The miscarriage began right away, and took days to complete. After 7 days, I went to my doctor for a checkup where she deemed the miscarriage complete with no side effects. I had spotting for months, which my doctor said was normal, and my period resumed in 4 weeks. Since then, we have tried for 8 months to get pregnant, with no luck. We track my cycles through BBT & OPK's, and it ranges now. I used to be regular, now I ovulate anywhere from day 11 to day 18. But I do ovulate every month. My period ranges from day 24 to day 29, depending on when I ovulated. My luteal phase went from 14 days pre-miscarriage to about 11-12 days post miscarriage. Are these cycle changes potentially a bad sign, or can they be normal?

My doctor does not seem concerned at all. She's run blood work, and done an internal ultrasound (last month) and said everything looks fine. She said that a medical miscarriage cannot cause scar tissue or block tubes. Is this true? I find it hard to believe because it was so painful w/so much bleeding. So my major concern is that my miscarriage caused me to become infertile. Is this something you have heard of? Is there a chance of scar tissue if I never had surgery, had no infections, and have never had an infection or any problems before my miscarriage? My husband has had all the male tests run as well, and they have said his tests are perfect.

My doctor will not put me on a fertility drug or run an HSG, as she said it is simply stress causing me to not get pregnant again. Is there anything you think I am misinformed about, or anything you recommend I do different? I am concerned that I took a really scary medication that did damage to me. Thank you so much for your help! J. from Pennsylvania


Hello J. from the U.S.,

In general, a medical induction of miscarriage should not lead to scar tissue formation within the uterine cavity (known as Asherman's syndrome). This syndrome is usually a result of over-scraping of the uterus at the time of a D&C. However, if not all the products from the pregnancy were discharged, as can happen from time to time, then the resultant inflammation caused from the retained tissue can prevent pregnancy. It would be the same mechanism as an IUD. By checking you, I presume that your doc did an ultrasound and the cavity looked completely empty. To be absolutely sure, a hysterosonogram or hysteroscopy can be done. If the cavity is normal, then your current fertility issue is not due to the miscarriage.

The fact that you got pregnant easily before shows that your body does have the ability to get pregnant. We don't consider a woman to have an infertility problem until she has been trying for at least one year without success. At that point, an infertility evaluation should be done. I never never tell my patients that they are not getting pregnant because of "stress." Sure stress can impact the chances of pregnancy, but it is not significant enough to be a birth control device, so not good enough to be the cause of pregnancy failure or infertility. It is a patronizing remark. More than likely, you just haven't been as lucky this go around as you were the first time. Because you got pregnant so easily, you are assuming that you will again. But in fact, the average woman under the age of 30 will take 8-12 months to get pregnant naturally. So you still have to give yourself a chance.

The BBT's and ovulation predictor kits is ONLY to help you predict when ovulation is about to occur. They DO NOT say when ovulation has occurred. There is no way to know that. They also cannot be used to diagnose a short luteal phase, known as luteal phase defect. This has to be done by endometrial biopsy dating. The fact that there is a little variation in your cycles does not indicate irregularity. Cycles can vary +/- 7 days normally.

I understand and sympathize with your concern, but also advise you to keep it in perspective. Give yourself a chance for your body to do what it needs to do without undue pressure on yourself or your husband. Then if it does not happen in a few months (which would make it over a year of trying for you both), then insist on an infertility evaluation. At this point, evaluation and/or treatment might be premature.

Good Luck,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.

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