37 Yr. Old Australian Woman With Complex Hyperplasia With Atypia Does Not Want Hysterectomy: Wants To Conceive

Question:

I am a 37 yr old woman who has been trying to get pregnant since I was 16. I have never fallen pregnant that I know of. I have had a Laparoscopy to see if i have a blockage in my tubes-there was not. Last year I had mid cycle bleeding for a few months & went to doctors who did a LLETZ procedure and found I had complex hyperplasia with atpia. I was told to have a hysterectomy, but declined & said I would like to see if I can get pregnant through a Natropath here in Australia, because she has a 87% success rate of clients falling pregnant.

The findings from my last hysterscopy, dilation & curetteage & polypectomy were, cervix healthy, consistent with previous LLETZ. Uterus bulky 8 week size, cavity 10cms, endometrial polyp and hyperplastic endometrium, both ostia seen, Adenexa NAD.

What does all this mean? Could I still fall pregnant?. Can I die from having complex hyperplasia with atpia? Do I really need to have a hysterectomy or can it be left until after I fall pregnant? I am so confused & very distressed that I may never have children of my own. I have asked my surgeon that performed the lasts LLETZ procedure and all he said was he wants me to have a hysterectomy, I don't want to have one, because I think he is being a little knife happy. What would you suggest? Thank you. D. From Australia

Answer:

Hello D. from Australia,

Complex hyperplasia with atypia is an endometrial diagnosis and not a cervical diagnosis. It is a worrisome diagnosis because of the possibility that it could develop into a uterine cancer. It needs to be treated and in a woman who wants to maintain her fertility potential, is usually treated with depo provera injections for a 6 month period. Rebiopsy is then done to make sure that it is resolved. This diagnosis does NOT require a hysterectomy necessarily. If it is successfully treated with progesterone, that is all that is required. Another possible treatment option is D&C to clear the endometrial tissue. I would not simply ignore it.

At your age, if you want pregnancy and have never been able to achieve it, you should be under the care of an infertility specialist, who is also a gynecologist and should be able to care for both problems. I do not know of any physician in anywhere in the world who can claim an 87% pregnancy rate. If that were indeed true, people would be flocking to see her from all over the world and forsaking us infertility specialists! NO treatment is that good, and such a claim is highly suspicious. I hope you do not waste your time because age is a critical factor for you and your chances are decreasing rapidly.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Comment: Thank you so much for giving me a direct answer. The surgeon I had wouldn't give me a direct answer.You have been very helpful. I have been to the Monash Ivf Clinic but there findings after all the tests were that I have unexplained infertility, which is very frustrating, That is why I thought I would try a natropath. But I still have my fingers crossed that one day I will have a baby. Thank you again.

New Zealander Wonders: Does A Cervical Cone Biopsy (LEEP) Lead To An Incompetent Cervix During Pregnancy?

Question:

Hi Doctor,

I'm a 33 year old woman from New Zealand. I recently had a missed miscarriage and D&C (22nd Nov 2009) , then one month later I had another D&C due to infection and retained product. I also had a D&C at age 17 years and a termination at 29 years. I also had a LETZ at 25 years. The doctor has advised me to wait 6 months before getting pregnant again to help my cervix strengthen. He is also saying that I will most probably have an incompetent cervix due to all surgery and the only thing they can do is monitor me during my pregnancy. Is there anything I can do before my pregnancy to help? Are there any tests to see how strong my cervix is?

Will waiting 6 months strengthen my cervix? Do you know of anyone else who has had this many D&C's and a LETZ and still been able to carry to term?

Thanks you so much! I haven't been able to find answers to my questions and I'm feeling very anxious.

Answer:

Hello J. from New Zealand,

Many women have multiple miscarriages requiring D&C, or have multiple abortions. They are not necessarily at increased risk of incompetent cervix. They are at increased risk of uterine adhesions from the multiple D&C's. The risk of incompetent cervix comes from the LETZ procedure because a portion of the cervix is removed. (Briefly: the LETZ procedure removes the entire abnormal area of your cervix with a hot wire loop. The tissue is then sent to Pathology for diagnosis. Some doctors, myself included, refer to this procedure as LEEP-"Loop electro-surgical excision procedure"). That is NOT to say that you are definitely going to have incompetent cervix, only that SOME women that have had cervical cone biopsies or LETZ/LEEP seem to have an increased incidence of cervical incompetence.

I have been doing LEEP for a long time and have never had this problem with my patients. It is a procedure I excel at and enjoy doing. It probably depends on how deep of a cut the Physician makes. There is no way to predict who will have incompetent cervix or not. In some cases, where the cervix is found to be shortened or there is a previous history of incompetent cervix, the doctor will do a cervical cerclage (put a stitch in the cervix), in advance. I would not recommend that in your case. For now, your Ob doctor just needs to keep an eye on things by doing serial ultrasounds to check the cervical length.

In terms of waiting 6 months. There is no reason to do that. There is no such thing as "strengthening the cervix or waiting for the cervix to strengthen". The cervix will be repaired and ready within 6 weeks.

Good Luck,

Edward J. Ramirez, M.D., F.A.C.O.G.

Follow-Up Reply:

Thank you so much, Dr.Ramirez,

You have made me feel much better, I had been unable to find any info on this (apart from terrible stories from google) and have been worrying myself sick about it. I will pin your email to the wall and remind myself when I get anxious! Again, thank you so much! J.