Serious Post-Partum Accreta, a D&C & Now No Period...Asherman's Syndrome?

Question:

I am a healthy 28 year old who has never had any reproductive issues. I gave birth to a healthy baby in the spring of 2008. She was my third. At birth, I heard the doctor say, "Hmmm, funky placenta." The nurse looked and agreed. I later found out that it was "lobulated", but that was normal.

I went home after 1 day and all was well. Exactly 2 weeks later, when I was laying the baby down in her bassinet after a 3:00 am feeding - something "burst" and it felt like a a bucket of liquid was dumped between my legs. I had stopped the postpartum bleeding a few days earlier, and that had been light without clots the whole time.

All of a sudden it was like a faucet of bright red blood. I ran to the bathroom and was shocked by the sight of the gushing blood. I sat on a pile of towels on the floor and tried to stop the flow. The ambulance came and rushed me to the ER (30 min away). The doctor there decided that I had retained a piece of placenta and a D&C was to be done. No big deal, 30 min. procedure.
I woke up 5.5 hours later with my doctor at my bedside with a very serious look on his face. It turns out that I had accreta and they had to perform a very aggressive D&C. They could not even do a hysterectomy because I had no blood to spare. I lost 4.5 L in the OR alone. He said that he's not sure how the bleeding finally stopped, or how I lived. He had never experienced placenta accreta, nor had any of the docs in the clinic.

Anyway, after a few days in the ICU, I went home and everything has been great.

EXCEPT...it has been 6.5 months since my D&C and I have not had any period - not one drop. I was birth control pills for 3 months and nothing. So, I went off them a few months ago. Nothing. My hormone levels were checked and I had borderline hyperthydroidism, which at my most recent test seems to be correcting itself. My doc thinks this is the reason for my lack of menses.
However, I do not. I am thinking Asherman's Syndrome. He has not examined me at all since the procedure. I feel that a "borderline" hyper-thyroid (w/o symptoms) would not cause a complete stop to my period. It's hard to put in words, but I can feel a kind of crampiness or pressure in my abdomen (not a period kind). Some sexual positions are uncomfortable or painful. And the last time sex was painful, there was a spot of bright red when I wiped. And that was it. So, new blood. It seems to me that would signify something with my cervix...maybe scar tissue?

I am afraid that the hyper-thyroid will mask the true problem. I am not worried about future fertility, but more about my health in general.

What is your opinion?

Answer:

Hello,

You are wise beyond your years, and maybe even smarter than your doctor. It sounds clearly like Asherman's Syndrome. Let me say first, that it is amazing that you are still alive, and still have your uterus at that. What you went through is a very scary event and in many cases, fatal. Whatever your docs did, they did well, and saved your life. Be very appreciative of that.

There are two possibilities for the lack of menstruation. One is Asherman's Syndrome. This is a situation where the aggressive D&C causes scar tissue formation in the uterus. As a result, the uterine lining is unable to form and hence there is nothing to slough at the end of the month (no period). This is how endometrial ablation works to stop bleeding. The only worry I would have in this scenario, is that your cervical os (outlet) is blocked, in which case you could be having some bleeding, but it is staying within the uterus. The reason for this suspicion are the symptoms of cramping and uterine tenderness. Basically, because the uterus can stretch , it will continue to fill and fill and fill. This is called "hematometria". The easiest way to make this diagnosis is with a vaginal ultrasound. To make the diagnosis of Asherman's syndrome, you need to have a procedure called a hysteroscopy. This is where a small scope is passed into the uterine cavity to examine it. If the cervix is blocked, dilating the cervix in preparation for the hysteroscopy will open it up and the blood will be able to be discharged. If you used the birth control pill and didn't bleed, then the uterus has to be highly suspected because the birth control pill works directly on the uterine lining.

The second possibility is that excessive vaginal bleeding postpartum can lead to a pituitary dysfunction, leading to the lack of hormone production. This would result in the loss of menstruation (panhypopituitarism). That is checked for by hormone testing. If the hormones are all normal, then this diagnosis is ruled out.

I hope this answers your questions and gives you some information to take to your doctor. Please make an appointment to see him soon!

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.

Check me out on Facebook and Twitter with me at @montereybayivf

Clomid Protocol Not Working

Question:

Hello!

First of all, thank you for being available to answer questions for all of us. I have taken Clomid twice now. The first month I took it I was on 50mg 5-9 and I ovulated on cd 21 with a progesterone level of 19. I have 33 day cycles. The second cycle I was on 100mg 5-9 and I used my Clear Blue Easy monitor and it never peaked just stayed on high. Then I had my progesterone test and it was only 7. But then my OB gave me 100mg again for the next month. Shouldn't I still be on 50mg if that worked better??

I am also thinking about taking the 50mg days 3-7 instead of 5-9 since it is my last month being able to take it according to my OB. On top of the Clomid, she also gave me Estrace (not sure if that is spelled right) to take days 8-12 and Prochieve to take days 16-28. So if I take the Clomid days 3-7 do I take the other meds on different days?? Also, a little background, I have one child conceived naturally, I am overweight but don't have PCOS and don't have blocked tubes (I was tested for both). If there is any way you can help me with my situation it would be very helpful!

Thanks again!

Answer:

Hello,

Although the Clomid worked the first cycle, I too would have increased it to 100mg to get your cycles more normal and shorter. It is possible that the Clomid at 50mg was barely effective, and worked by luck only. That would explain why the 100mg did not work.

I also do not advocate the method your doctor is using. I am a firm believer in the ultrasound surveillance to evaluate whether or not the medication is working, how many follicles there are and to time ovulation. That is a lot more information that your doctor is getting. I also automatically use progesterone with my Clomid cycles to help implantation and support the pregnancy. Sometimes, Clomid can also cause the uterine lining to be thinned, however, your doctor should be checking this with an ultrasound rather than treating empirically, as I've mentioned before.

Finally, whether you take Clomid on days 3-7 or 5-9 does not make any difference in stimulation.

My protocol is as follows with Clomid:

1. Cycle day 2-5: Baseline ultrasound to rule out residual ovarian cyst, give Clomid calendar and prescription.

2. Stop recreational intercourse on CD #10.

3. Start ultrasound surveillance on CD #11 and continue as frequently as needed to determine when the follicle is appropriate size for ovulation. This also rules out a super-multiple (three or more) pregnancy potential. If there are more than three follicles, we cancel the cycle and prevent pregnancy.

4. When the lead follicle reaches 20-22mms, HCG (Ovidrel) is given to stimulate ovulation.

5. Have intercourse daily, once per day, one ejaculation per day beginning the day after HCG, for four consecutive days.

6. Start progesterone five days after HCG and take daily until the pregnancy test.

7. Do pregnancy test (serum) in two weeks.

I hope this helps. Please discuss your situation with your OB and get a second opinion if necessary.

Edward J. Ramirez, M.D.,FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California, U.S.A.

Check me out on Facebook and Twitter with me at @montereybayivf

Hydrosalpinges and Miscarriages

Question:
I am 34 years old, writing from Australia. I have had one child (3 years old) and two miscarriages. The first miscarriage (embryo stopped growing 6.5 weeks) on Jan. 09, the second Nov. 09 (9.5 weeks). Just before I became pregnant with the most recent one, I found out I had bilateral hydrosalpinges that showed up on the transvaginal ultrasound.

We were considering having surgery to remove the fallopian tubes ( on the advice of an IVF specialist) then start IVF, when suddenly we found out we were pregnant. Unfortunately, at 9.5 weeks I had a miscarriage.

We are awaiting results of tissue testing to determine if chromosomal abnormality exists. We are also booked in for a repeat ultrasound.

1. Does having bilateral hydrosalpinges cause you to miscarry at 10 weeks pregnant? If so, by how much (i.e. what %)? Gyn says they do not make you miscarry but more likely to not allow implantation.

2. Would the preferred option be to clip them, or just remove them and commence IVF even though I have gotten pregnant naturally? Or would the best option be to give it one more go naturally?

Any other advice would be appreciated.

Answer:

Hello,

You present a very interesting scenario because women with hydrosalpinges usually cannot get pregnant. The reason is because the cause of the hydrosalpinges is a tubal infection that caused the damage to the tubes. Not only did it cause the tube to be obstructed, but it even usually leads to damage of the inner lining of the tube that is important for egg and sperm transport. Therefore the recommendation is to proceed with IVF. Your case negates that thinking.

Hydrosalpinges can lead to non-implantation, and by the same mechanism, miscarriage. It is thought that the hydrosalpinx has inflammatory fluid within that migrates back into the uterus. Several studies have found decreased pregnancy rates in IVF when hydrosalpinges are present. That is why it is recommended to clip the tubes or remove them prior to IVF. This inflammatory fluid causes a mild inflammation of the uterine lining causing the lack of implantation. If implantation were to occur, I would expect that the same inflammation could lead to the death of the embryo from a mild amnionitis. That, however, is theoretical.

Because you have shown that you are the exception to the rule, you have two options. You can have a laparoscopy and have the tubes opened (salpingoplasty) or you can have the tubes clipped/removed. If the tubes are opened, you have the opportunity to become pregnant naturally, like you showed that you could. It would allow the fluid to escape into the abdomen, thereby reducing the chances of backflow into the uterus. However, if there is tubal damage within, you are at increased risk of a tubal pregnancy called an ectopic pregnancy. That can be life threatening if it ruptures and you hemorrhage. The second option, which then requires IVF is certainly the safer option, but the more expensive option. You need to discuss these two options with your docs.

If I were counseling you, I would almost be inclined to recommend the former (tubal repair) as long as you were completely aware of the risk of ectopic and willing to take that chance. I would then watch you very closely if you were to become pregnant to rule out the ectopic at the beginning of your pregnancy.

I hope that this answers your questions.

Edward J. Ramirez, M.D.,FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.
Check me out on Facebook and Twitter with me at @montereybayivf

Secondary Amenorrhea...Low Estrogen?

Question:

Hi! I'm writing from the UK and hoping I can finally get some answers!
I had my last depo provera in Dec 2008. This ran out in March, and I had a light menstrual bleed in April but nothing since. It is now November!

My husband and I are wanting to conceive so in July we went to my GP and I was given Noresthisterone, 3 times a day for 10 days. I did NOT get a withdrawal bleed. I had some blood tests done, and I was told by a lucum doc that they were all normal. But in my opinion he didn't look sure, as he kept looking at them.

I have read that if you don't get a withdrawal bleed it could be due to low estrogen. Do you think this could be the case with me? And if it is, what would be the next step? I am desperate for my menstrual cycle to return so we can start to conceive.

Can you give me any advice, or anything that I could ask my doctor about? Many thanks!

Answer:

Hello,

You are correct in that if you do not get a withdrawal bleed after progesterone (Norethindrone), then that indicates that the uterus was not primed i.e. you did not have estrogen aboard to create an adequate uterine lining. Hormone testing would be the first check. Unfortunately, the FSH, LH test needs to be interpreted, not just checked against the laboratories normal and abnormal. A woman cna have an abnormal level but be within the normal limits for the laboratory testing results. For example, the FSH level could be 35, indicating ovarian failure or menopause, yet this is within normal testing limits. The reason this is important, is because if the FSH level is elevated, that indicates that you ovaries have shut down. An example of this occurring at a young age is called premature ovarian failure. In this case, you will be unable to become pregnant naturally, and without using an egg donor. I am not saying that is what you have, but the hormone test is very important to know where you stand.

Most likely, you have an ovarian dysfunction, whereby the ovary is not working correctly so that you are not ovulating and not producing estrogen. This is the most common reason. The FSH and LH levels would be normal and less than 20. In this case, you will need fertility medications to stimulate the ovaries to ovulate so that you can become pregnant.

I would recommend that you see a fertility specialist if you can. He/She will be able to make the diagnosis and recommend an appropriate treatment. A GP cannot do those and does not have the appropriate knowledge base to help you.

Sincerely,

Edward J. Ramirez, M.D.,FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.
Check me out on Facebook and Twitter with me at @montereybayivf

Low Ovarian Reserve & Previous Placenta Accreta

Question:

Hi, I had placenta accreta with my son's delivery in 2007 and lost quite a bit of blood. I did keep my uterus but had to have uterine embolization to stop the bleeding. My doctors alsways said to wait 2 years before trying to conceive, but after seeing numerous doctors recently, I was told I would be risking my life again to consider another pregnancy. I also have a large fibroid about 4 centimeters in my uterus along with a distorted uterus.

The doctors feel the embolization probably caused my ovaries to stop functioning, or even the massive blood loss could have caused it.

We have looked into surrogacy but found out that I have very small ovaries, about 1 centimeter each and low ovarian reserve. The doctor did an ultrasound and said there was blood flow, but feels I am pre menopausal. I went off birth control pills in January and was tested in February. My FSH was 9 and my estradiol was 9. I did 3 days of injections (45) and the doctor only saw one follicle so said to stop treatment. In March, My FSH was 16.75 and E2 was 10. The doctor saw 2 follicles on day 2. The doctor said if I did a full round of IVF the chances would be very low and the quality most likely low. The plan was to do IVF and then have a surrogate. I went to a doctor this week that said I could try knowing the chances are low and to retrieve the eggs, even if there were only 1 or 2.

I am not quite ready to give up, we have also considered egg donor. I am 36 years old. Any suggestions or success rates would be great. Thanks so much!

Answer:

Hello,

I am sorry to hear about your experience. It sounds like you have very low ovarian reserve as demonstated by an elevated FSH level and poor response to stimulation. Certainly, your best option would be donor eggs. That would have a 34 - 63% pregnancy rate per IVF attempt depending on the clinic (our program is 63%). Of course, there is the alternative of trying with your own eggs. Because the stimulation would be low i.e. few eggs retrieved, the chances would go down, but there is still a chance. I have done many older (older than you) patients that have only had one egg produced, one retrieved, one fertilized and one transferred and gotten pregnant and had a baby. So in my opinion, it is more a personal decision on whether to try with your own eggs, al long as you know that the chances are reduced. There is not a specific statistic for your case that I can quote as no one has looked at pregnancy rates based on the number of eggs retrieved. In your age group, I average replacing 3 embryos with a pregnancy rate of 50%. It would probably be less if only one was replaced. European data, where they only transfer 1 embryo, shows pregnancy rates of approximately 33% in your age group. That assumes a higher number of eggs retrieved, fertilized and available to choose from. In any case, I think that if money were not an issue, and you were willing to try with your eggs at least three times (you might even need more), knowing that the chances are significantly reduced, then you should give it a try. If it fails, at least you know that you gave it your best shot, and will be ready to go to donor eggs. I certainly would allow you to have that opportunity in my program.

In terms of your pregnancy risks, you are certainly at risk for a recurrent placenta accreta if you were to become pregnant. However, that can be mitigated by being followed closely and planning for a hysterectomy at the time of cesarean delivery. I would not recommend an attempt at natural delivery in your case. I would also recommend that you consider having the fibroid removed prior to any IVF cycle to maximize the chances that they will not interfere with the IVF cycle or pregnancy. Regarding the surrogacy option. Certainly surrugacy is a good alternative and would eliminate the problems with your uterus, whether you choose to use your eggs or donor eggs. If you go this route, be sure you go with a reputable agency and retain the services of a surrogacy lawyer.

I hope this helps!

Edward J. Ramirez, M.D.,FACOGExecutive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California, U.S.A.

Check me out on Facebook and Twitter with me at @montereybayivf

Nervous First Time IVF Patient - What To Expect On Retrieval & Transfer Days

Oftentimes, first time IVF patients become very worried about how painful the procedure will be. The retrieval should not be painful at all, since it is usually done under some kind of anesthesia. In fact, all the shots that the patient has had to go through prior to retrieval and will continue to do after the transfer are more painful! (The photo above is of a human embryo implanting itself into the endometrium.)

Question:

I'm a little nervous about my upcoming IVF cycle. I'm wondering how much pain I'll be in after the egg retrieval and whether I'll need to take the following day off from work. Also, for the transfer, is there any pain associated with that, and should my husband come with me? Would I need to take the following day off of work with that? Thanks for your expertise.

Answer:

Dear S.,

Unknowns always cause worry. All my patients have gotten through it just fine and I don't have even one patient that regretted the procedure, even if they didn't get pregnant.

It is a difficult procedure, however, because it is regimented, pre-procedure you have to take shots daily and it is emotional. We do the retrieval under anesthesia so you don't feel a thing. Not all clinics do, however, and it does hurt quite a bit if you are not under conscious sedation. After the retrieval you will have pelvic soreness like a strong period. For most patients it is tolerable with Tylenol, Motrin and/or a heating pad. It usually doesn't last more than that day but some patients are sore for a couple of days. The soreness is very tolerable and they usually can go to work the next day without a problem. You will only need to take the day of the retrieval off.

The transfer is a piece of cake! It is like doing a pap smear (which hopefully hasn't hurt you in the past). You should not feel anything. Your husband should be there with you to give you support. After all, he will want to be able to say that he was there when you conceived! I usually recommend my patients to take 3 days off after the transfer in order to lounge around and minimize their activity. Implantation will take 24 hours to 3 days to occur depending on the stage that the transfer occurs. After the 3 days you can go about normal activity, but I recommend light activity, which means no exercise, strenuous activity or sex.

Hope this helps and don't worry, you're in good hands!

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

Check me out on Facebook and Twitter with me at @montereybayivf

To Do Or Not To Do IVF at 42?

Question:

Dear Dr. Ramirez,

I am writing to you from New Hampshire. I am 42, FSH 6, and just completed my first failed IVF cycle using the microdose flare protocol, lupron plus 300 Gonal F and 300 Repronex, stimulated for 11 days. Ten eggs were retrieved, 3 fertilized with ICSI/AH (intracytoplasmic sperm injection/assisted hatching) and 3 were transferred on day 3. Although my RE noted that over 50% of the oocytes were abnormal (likely to be age related with large debris in the perivitelline space), she is now recommending a patch protocol, with the same meds/quantity used in the first cycle. Do you think it would be worth trying another cycle, or should I be realistic and go straight to donor egg or adoption?

Answer:

Hello,

The "age factor" is not an absolute, meaning there are pregnancies in your age group. What you need to decide is how much you want a child with your genetics and how much you want to try and can afford. In your age group the chances of pregnancy are approximately 25% per cycle. So, it means that you may need to try several times before you are successful. This could be up to 6 attempts before you would be successful with your own eggs. On the other hand, the pregnancy rates for donor are 63% in our program. The chances of pregnancy with one attempt are over 50% as well, so with donor eggs, you have a higher chance of becoming pregnant with fewer attempts. The downside is that the baby would not have your genetics. How important is that to you?

Many of my "older patients" will try up to three times, to convince themselves that they have given their best efforts then resort to donor after. I have had many older patients that have only had one egg produced, one retrieved, one fertilized and one transferred and gotten pregnant and had a baby. I cannot comment on your medication protocol since every patient is different and it is up to your RE to decide how you responded to the first cycle and how to "tweek" it.

How to proceed from here is purely a personal choice. In terms of my recommendations, if genetics is not a big concern, then if cost is an issue, go to donor, if it is not, then try at least three times with your own eggs. The good thing is that your ovaries are still responding well to stimulation. Getting a lot of eggs is the key to overcoming the "age" factor!

Good luck and don't lose heart!

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California, U.S.A.

check me out on Facebook and Twitter with me at @montereybayivf