Bleeding After Embryo Transfer

In the course of my volunteering as the Infertility Expert on About.com's AllExperts site, as well as here on my own blog, I have had many questions regarding bleeding right after embryo transfer or in the Luteal phase. What follows is an attempt to answer one of the chief concerns that IVF patients have, namely, "What if I have bleeding after my embryo transfer?" 

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Answer:

The embryo transfer is the most crucial step in the In Vitro Fertilization procedure/process. You can have the best quality embryos, but if they are not placed into the uterus correctly, then pregnancy will not occur. That is why "transfer technique" is so important. There have been studies showing that pregnancy rates can vary by Physicians within the same group, and this is all because of transfer technique. Once the disparities between transfer techniques were corrected and unified, the pregnancy rates became consistent. For this reason, you want to seek out a Physician who has a lot of experience with embryos transfers and comparable good pregnancy rates. If you go to a clinic that has multiple doctors, ask for the pregnancy rates of each Physician or your particular Physician. Although I know that newly trained REI Physicians have to get experience, most don't have a lot of embryo transfer experience from their fellowship. So, if I were paying $10,000 or more for an IVF cycle, I would ask for a more experienced doc to do the transfer. For more details regarding post embryo transfer bleeding, pain and other symptoms, see "What To Expect After Your Embryo Transfer". 

Bleeding, usually bright red blood, with the embryo transfer is an absolute no no. If blood contaminates the endometrial cavity at the time of the transfer, this will kill the embryos and pregnancy will not occur. The catheter must be placed as gently and atraumatically as possible. That is an absolute requirement. The endometrium, which is now in its fullest growth state, thickened from estrogen stimulation, can be easily scraped and cause bleeding.

At our center, we use very soft catheters, very gentle technique, ultrasound guidance and mock embryo transfers preceding the cycle, to accomplish this. The mock embryo transfer or MET is especially important so that the Physician is not learning the curves of your canal at the time of transfer but has worked it out prior. You should have the same Physician who did the MET doing your transfer. This is especially important in patients whom we consider to have a "tortuous" canal, making it more difficult to insert the catheter with care. In this type of patient I will sometimes do the MET two to three times to become well acquainted with their canal.

You should not worry if brown blood or discharge occurs at the time of transfer, it will usually manifest within the first day or so after the transfer, but not into the mid-luteal phase or later. That type of bleeding would be from a different source.

There are situations, however, when bleeding can occur but not be ominous. Sometimes a woman's cervix will bleed easily from being scraped by the speculum or irrigation or wiping. This external bleeding will not affect the endometrial cavity as long as the transfer catheter is not exposed to the blood. For example, I do not let the catheter get exposed until the introducer is well into the cervical canal, near the internal cervical os (entrance to the endometrial cavity), to begin advancing the catheter.

Bleeding that occurs later in the luteal phase, days after the transfer, is very common if vaginal progesterone is used. This has been shown in various studies using Crinone, for example. In my patients, because I use both vaginal and injectable progesterone, it is almost 90%, but the bleeding tends to occur near the time of the pregnancy test or soon thereafter. This is probably caused by some erosion occuring on the external cervix. The exact cause, however, is not clearly understood. It is usually light spotting and can be anywhere from red to brown. Red is newer blood and brown is old blood. In general I tell my patients not to worry about this. The only bleeding that I would worry about is bleeding that is red and heavy like a period. This is not good, and should not occur if the hormones progesterone and/or estrogen have not been discontinued. Some patients will experience slight spotting 3-5 days after embryo transfer and refer to this as "implantation bleeding." Whether or not this is caused by implantation is not known. Implantation should not cause bleeding. However, again, if it is not bright red blood that is heavy like a period, it should not cause worry.

I certainly hope this information will help those of you who have either queried me or who have Googled for some reassurance in this regard.

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

http://www.montereybayivf.com/

Endometriosis and Conception

Question:

Hello, I am 20 (almost 21) years old. I was diagnosed with endometriosis in September of 2007. I had a laparoscopy done, there was too much to be removed. My doctor at the time said that the endometriosis had not affected my reproductive organs, yet, thankfully. From 10/07 to 1/08 I took Yaz birth control to help maintain my disease, it didn't help. So, 03/2008 I started Lupron Depot, every month for six months. My last shot was Sept. 2008, my first cycle was December 2008 which was only 2 days of dark spotting. March was my next cycle and it was very painful and back to normal like my disease is still there just as before the shot. This month (April 2009) I have had my "third" menstrual cycle and it was horrific. My fiance almost took me to the hospital I was in so much pain. I don't to back to my ob/gyn until June. I have called with concerns but they said to wait it out until June.

My biggest concern is being able to get pregnant now. I have accepted that this is the way I have to live with this disease, painfully. Now I am focusing on having a child. I want a baby more than anything but I can't seem to conceive. I am not on birth control or any type of contraceptive, and never have been except the four months before the Lupron. I am so scared that I will not be able to have a baby, and we are trying. I have not resorted to a fertility doctor because I want to try and let it happen naturally first. But, I do not want to wait too long because I know women with endometriosis are encouraged to have children asap.

My question to you is, could my endometriosis have spread during the birth control or Lupron and gone to my ovaries? Should I have another laparoscopy to see if it has spread or if the injections even helped? Would my disease harm my pregnancy if I ever do get pregnant? Is the Lupron out of my system (it's been 8 months)? And lastly, any suggestions on trying to concieve with my disease and also just dealing with my disease in general, especially with that one day a month when I first start my period that is just so painful words can't describe?

Sorry for so many questions but with me being so young, people kind of don't want to help you get pregnant and tell you to just wait or that I am too young to be trying to get pregnant so young. But I feel like its something that I need and want and so does my fiance. We own our own home and financially and mentally feel that we can do this. Now its just making it happen!

Thanks for you time and help.

Answer:

Hello....let me answer your questions one at a time, since there were so many of them.

1.Birth control pills are not a good treatment for endometriosis because they contain estrogen, which feeds the endometriosis. The progesterone component helps a little, but it would have been my last choice. Lupron is the treatment of choice followed by Depo Provera. So, it is very possible, and likely, that the endometriosis has worsened over time. That is in its nature to do.

2. Another laparoscopy would be indicated, but that depends on the stage of endometriosis that was found to begin with. If you had stage III or stage IV, then the laparoscopy does nothing to help your cause (i.e. getting pregnant). In that case, I would go directly to IVF to achieve pregnancy. If you had a lower stage, then repeat laparoscopy with treatment might help you to become pregnant.

3. Endometriosis will not harm the pregnancy. In fact, pregnancy is a great treatment for endometriosis and that is why we recommend getting pregnant as soon as possible. Unfortunately, getting pregnant is not easy with endometriosis. This disease, whether it is on the ovaries or tubes or not, can prevent pregnancy no matter where it is located because it causes the pelvis to be inflamed. That inflammation kills the egg upon ovulation. Therefore, the entire pelvis tends to be a hostile environment.

4. The Lupron is out of your system by now.

5. As I mentioned above, your treatment would depend on the stage of endometriosis that you have, but the bottom line is that you should try to get pregnant as soon as possible. You certainly have options. You could have a repeat laparoscopy, with treatment of the endometriosis surgically, followed by another course of Lupron Depot for 3-6 months, then aggressively try for pregnancy (possibly IUI's ) or you could proceed directly to IVF. Based on the fact that your doctor said he could not get all the endometriosis out in the first laparoscopy, I would presume that you had stage III or IV endo. In that case, the treatment of choice would be IVF. This is the only treatment that can bypass the endometriosis and get you pregnant. The pregnancy will then help your symptoms, because you won't have periods and, it may even CURE the endometriosis (pregnancy is a great treatment for endometriosis). This latter option is what I would recommend for you.

It sounds like you are NOT seeing the right physician. You should not have to wait so long. I would recommend that you see a fertility specialist so that you can become pregnant as soon as possible. The problem with endo is that it worsens with time. You don't want to end up having a hysterectomy, and not be able to get pregnant, because the pain is too severe and you waited too long!

I have had quite a few patients with the same problem that you have. They opted for IVF and got pregnant. Afterwards, they ended up having a child or children naturally as well, all because the endometriosis they were afflicted with had been resolved by their first pregnancy.

I hope this helps.

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California, U.S.A.

www.montereybayivf.com

Polycystic Ovarian Disease In Young Woman

I have had many, many questions regarding Polycystic Ovarian Syndrome or Polycystic Ovarian Disease. As an infertility specialist, I see women every week that suffer from either the syndrome or the disease. If not treated, it can lead to serious health problems such as diabetes and heart disease. It can also cause infertility. PCOS or PCOD is common and affects as many as 1 in 15 women. Often the symptoms will begin in a woman's teen years, like the following questioner from Texas.

Question:

Hi Dr. Ramirez,

I am a 19 year old black female in Texas looking for answers. I started having periods at 12, but I have never had a normal, monthly cycle. I generally skip 3-6 months, after which I have a period lasting anywhere from 2 weeks to 3 months. At first, because I am hirsute and I was overweight, it was thought that I had polycystic ovarian syndrome, but I have been tested numerous times for such and I don't have that. During my long periods it was thought that I had uterine fibroids, for which I was also tested negative more than once.

I've lost 35 lbs. but I still have the same issue. Now I have a "bloodless period", with a brownish or clear fluid. I have been to 4 different ob/gyn's, non with a conclusive answer. The reason I post this in the infertility section is because I don't believe I am fertile, but I want to know what is causing my infertility so maybe I can go and get help to resolve the issue.

Thank you so much!

Answer:

You have PCOD. The is NO specific test for this disorder. It is a clinical diagnosis, which means that it is based on the signs and symptoms. If you have hirsutism, increased weight and very irregular periods, that is enough to make the diagnosis. PCOD has a wide variety of presentations. Some will have an FSH/LH imbalance on blood testing, but not all. Some will have irregular periods, but not all. Some will have increased hair growth, but not all. Some will have elevated insulin levels, but not all. The point is, your doctors are wrong. You have PCOD.

Therefore, you should be on the birth control pill to control your cycles. The problem with PCOD is that the ovary is dysfunctional and not processing FSH and LH correctly. Because of the dysfunction, it does not lead to ovulation and estrogen and progesterone are not produced. Instead, the precursors, the chemicals that usually are made into estrogen and progesterone, proceed to making testosterone, a male hormone. That leads to the increased hair growth, hair loss, obesity etc. By using the birth control pill, the ovaries are shut down, so that no testosterone is formed, and the estrogen and progesterone replace the hormone that you are not producing. The best pill for this purpose is Yasmin because the progesterone type, Drospirenone, blocks the testosterone receptors as well.

There are fertility issues with PCOD patients because they are not ovulating, which means, they are not giving off an egg each cycle. Those patients need to use fertility medication to get the ovaries to ovulate. Once ovulation is resumed, they have a normal chance of getting pregnant.

I hope this clarifies things for you. You might want to see a Reproductive Endocrinologist because this kind of doctor specializes in women's hormonal disorders and understands PCOD.

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 http://www.facebook.com/ejramirez and Twitter with me at @montereybayivf

Ovarian Cysts

Question:

I am writing from Melbourne, Australia.

After two months of erratic menstruation, I was referred for an ultrasound which found the following: "The uterus is of normal contour with a normal endometrial echo. Both ovaries were visualised with a large dominant follicle on the left measuring 3.9cm in diameter. There is no septation or other change to indicate it is a pathological cyst. Follicle development is also present on the right ovary with the largest follicle measuring 1.6cm in diameter. There is no free pelvic fluid or other change."

My doctor has advised I wait and book for another ultrasound in 3 months time.

Should I follow this advice or seek a second opinion from a different doctor?

Answer:

Hello,

I don't think you need to wait three months. You should have an ultrasound done within the first 7 days of your next period to see if the cyst is still there. If it is, I would recommend a one month treatment with the birth control pill then another repeat ultrasound. If it is still there after that, then it is probably not a physiological cyst and needs to be removed by laparoscopy.

Sincerely,

Edward J. Ramirez, M.D.,FACOG

Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.

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