37 Year Old TTC With Past History Of Hyperplasia & Endometriosis Is Desperate To Conceive

QUESTION:

Ok, I went to the Gyno in Dec of 2009 because I wasn't getting my period. He sent me for an ultrasound Jan. 2010 and the lining of my uterus was thickened so he did a biopsy which led to my first D&C which was April. I was diagnosed with hyperplasia of the uterus and he said I was producing too much estrogen so he put me on Depo provera.

I got my first shot April 19. 2010 and he told me if I didn't go on the depo shot I would definitely get cancer. I had my second shot July and then I had another D&C September and everything came out good, hardly any tissue. After the D&C the Gyno said he wanted me to stay on the depo till I go through menopause ughh!! I've had three more shots, one in Oct.. one in Dec. and my last shot was March 21, 2011. I want to have a child and in late July I will be 38. My gyno said I could go off the depo shot, so I asked him what if it takes me a year to get pregnant? He said, "You're not allowed to take that long you'll get cancer of the uterus for sure."

I think I need a second opinion & I'm hoping my withdrawal from the depo isn't so horrible. One thing I think you should know is I was diagnosed in my mid 20's with endometriosis and my gyno (back then different doctor) said I didn't have a lot of tissue he also never told me I couldn't conceive, he just said after you have children just get a hysterectomy. I was put on different forms of BC (birth control) over the years and my last form of BC was the NUVA ring. I always had bad cramps w/ my periods so he had me wear the ring continuously. I would wear it for three weeks and take it out and put in a new ring right away to avoid periods, when I was doing that I had break through bleeding all the time & that's where I think all the excess tissue came from with the hyperplasia. I've been on the depo shot for a year and three months then I'm due for my next shot which I don't want.

I'm writing from South Jersey. I only want to have one child! Please tell me what you think. Thank you for all your time. :)

ANSWER:

Hello A. from the U.S.,

First, I don't think you need to worry about the hyperplasia at this point. You have been adequately treated for it. You just need to make sure that you have regular cycles because not shedding the lining at least every three months is what can lead to hyperplasia, and if left untreated the simple hyperplasia can turn into atypical hyperplasia (precancerous) which can then turn into cancer.

I think that pregnancy is a good idea for it and you need to pursue it aggressively! Your age is the number one issue at this point, in terms of getting pregnant. A second issue with getting pregnant is the history of endometriosis. Depo Provera is certainly a good treatment for this disease but endo can recur and can impede pregnancy. Considering your age, I wonder if there are other factors as well since you have never gotten pregnant to date. My recommendation, in general, to patients at 37 years old or older is to strongly consider IVF (in vitro fertilization). Other than age, you don't have an absolute indication for this, unless something else is found wrong, but the chances of pregnancy are so much higher with IVF than any other treatment at your age.

For example, your natural chance of pregnancy is approximately 3% per month or 5% per month with IUI. On the other hand, with IVF it is 69% per month in our clinic, and at least 50% across the country. That is a significant difference. The problem with age is that the majority of eggs that you still have will be of poor quality so the only way to increase your chances to find an egg with good quality is through IVF. You can certainly try with more natural methods but with each month that you fail, your chances are decreasing (it's like chasing your tail).

I would strongly recommend that you go to a good IVF clinic and have a consultation. I know that there are some excellent ones in New Jersey.

Follow-Up Question:

One more question, being on the depo shot for this time period (one year & 3 months) I'm afraid as to how long it will take to get out of my system. Reading posts by women who've been on it much longer than I (like 7-12 yrs.) say it can take 6-18 months to start a normal period & ovulate again. Any suggestions on how to rid the depo from my system when I'm actually due for my next shot? I've read lots of water and excercise.

Thanks again after this no more questions I'm sure you're busier than ever.:) A. from New Jersey.

Follow-Up Answer:

Hello Again,

I don't have any solutions to how to speed up the return of your natural cycles. The Depo can linger for a while but I have never seen it take more than 2-3 months. If you want to start trying for pregnancy sooner, you could undergo ovulation induction and that will get your ovaries to stimulate and ovulate.

You are very welcome to ask your questions and thank you for your patience in waiting for my reply.

Good Luck,

Dr. 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: Dr. Ramirez was very helpful to me I really appreciated his input. Thanks again!!

Canadian Is Nine Weeks Pregnant, Has Enlarged Yolk Sac And No Fetal Pole: Is There A Problem?

Question:

Hi Dr Ramirez,

I was prescribed Clomid this cycle and am now pregnant. I am currently 9 weeks along. I went for an ultrasound at 8 weeks, 1 day pregnant and my measurements indicated that I was 8 weeks, 6 days pregnant. There was no fetal pole found. The yolk sac is measuring 8.6 mm. I am doing HCG/progesterone testing every other day -- so far all levels are within range. I am going for a follow up ultrasound at 10 weeks pregnant. Is the enlarged yolk sac a bad sign, even though my measurements and bloodwork are good?

Thanks, E. from Canada.

Answer:

Hello E. from Canada,

Assuming that your dates are correct, the yolk sac size is not a problem but the fact that there was no fetal pole or fetal heart motion at 8 weeks is bad. Usually by 6.5 weeks gestational age, a fetal pole and heart beat can be detected. This is seen for sure by 8 weeks. An empty gestational sac is called a "blighted ovum" and basically means that the sac developed but the fetus did not. You should not have to wait until 10 weeks gestational age to make the diagnosis. Your doctor should make that diagnosis already and recommend treatment.

If you wait too long, then a D&C (surgery) would be required to clear the uterus. At an earlier stage it can be done using medication alone. I should not be the one to be the bearer of bad news so I am sorry that this answer is not reassuring. You need to talk with your doctor right away and don't let them put you off or avoid the issue, like they seem to be doing.

Take care and good luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com

Young UK Woman Trying To Conceive Has Irregular Cycles, Prior D&C: What Could Be The Problem?

Question:

Good evening, Dr. Ramirez. Thank you for taking the time to read this email.

I am concerned about my periods. Nearly two years ago, I made the difficult choice to have an abortion. Not wishing to go through that again, I chose to have the Depo shot for six months after. However, due to weight gain, I stopped taking it. That was over a year ago.

For the last year, my periods have been coming every two months, but the last one I had scared me. Instead of being red, as was the normal, the blood was brown in most areas and black in others. It lasted seven days, but did not increase in flow, if anything it slowed and thinned towards the end.

I went to see my local doctor, and she told me that I would not get help because I am under 30. My partner and I have been having unprotected sex in the hope for a baby, but to no avail. I cant even work out when I am ovulating.The women in my family have been known to suffer from Polycystic ovaries, especially my sister who is close to me in the gene pool. Is it possible to develop this? I'm so worried and depressed all the time. Please can you help and advise me? I am writing to you from chilly England.

Regards, K. from the United Kingdom.

Answer:

Hello K. from the U.K.,

I can't give you specific advice because I don't have enough information. Certainly if your cycles are irregular, something is going on with the ovaries. There are several levels that have to be checked to find where the problem is. Polycystic ovarian syndrome, or PCO, is an ovarian disorder where the ovaries dysfunction and don't ovulate. That certainly is a possible cause, and probably the most common cause of irregular cycles. Again, without testing it is difficult to know. PCO can be latent for a period of time and then for unknown circumstances, like weight gain, can manifest itself!

In terms of your bleeding, the brown and black blood are nothing to be concerned about. That is old blood that has made its way out of the uterine cavity. It started out red but sat in the cavity for some period of time before making its way out. One concern that I might have, since you are interested in fertility, and because of the bleeding change, is if any damage was done within the uterine cavity from the abortion. Sometimes if the D&C is done too vigorously, scar tissue can form within and prevent the blood from flowing out easily. A procedure called a hysteroscopy would need to be done to evaluate for this.

Regardless of your age, if you have not been able to achieve a pregnancy after one year of trying, you fall into the category of infertility and should see an infertility specialist. They would not only evaluate your for your menstrual irregularity and try to remedy this, but will also evaluate the uterine cavity. So go tell your unhelpful gynecologist that you want to be referred to an infertility specialist!

Good Luck and a very Merry Christmas over there in chilly England!

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Monterey, California, U.S.A.

Comment: Helpful, polite and understanding. Everything you want when you need help!

Prior D&C And Infertility: Woman From Barbados Needs A Thorough Infertility Evaluation

Question:

Good Morning All.....My name is D. and I'm from Barbados in the West Indies. Just to give you a bit of background info on myself and hopefully you can make suggestions for me.

I've read the testimonials on the site and I was very touched and moved by the numbers of persons who were able to receive some type of positive assistance regardless of how small of how large.

In 2005 I had an abortion which resulted in me having to have a D&C and I've not been able to get pregnant since. I say not since 2005 because I remember at some point in 2008 having a very faint positive on a pregnancy test but to this day I cant be sure because the next day I did the test again and it was negative ....so I don't know if it was a false positive if it was a true positive or what it was.

In 2007 I saw a fertility specialist and had some tests done. I specifically had the test done where they run the dye through the tubes to see if they are opened and both tubes were opened. At the end of of various consultations the specialist told me that she couldn't find anything wrong and that only thing she could think of was that I had some scar tissue in the cervix area which was blocking the sperm from entering the cervix and travelling on to meet the egg....she said she arrive at that because it was difficult for her to pass the tube to eject the dye through the cervix. She said the only way I would be able to get pregnant is by having and IUI. Now I'm not being forward or anything and I know I'm not a doctor, but the blocked cervix theory is not sitting well with me and it doesn't seem logical at all.

I spoke to two other specialists and they too do not agree with the assessment. I have a regular 26day cycle EVERY month without fail and testing ovulation sticks shows me a surge around day 10-11 every month. The only thing is that my period has gone over the years form 5 days to perhaps 3 at times with clotting and dark blood or brown blood at time.....other that that it is like clockwork every month.. It doesn't make sense that blood and clots would be able to pass through the cervix and sperm cannot pass through the same opening.

I'm of Christian Faith and I've put the entire situation in God's hands but I think can also prepare my body for when he decides to bless me. I keep thinking that perhaps herbs or something can help I don't know what to do really. I've been married now for 1 and a 1/2 years and we've been trying since 2008 but nothing. I was thinking about the Fertility Cleanse and wonder if you think that would be a good first step, if not I welcome any thoughts you may have Thank you so much for your time and please have a blessed day.

Answer:

Hello D. from the West Indies,

Thank you for your kind comments. Now, what your doctor is referring to when she talks about "scar tissue in the cervix" is probably cervical stenosis. Many women who have never had children can have a small narrow cervix. We call that stenosis. You are correct in that the blood can pass through this, so sperm should as well. Cervical stenosis is NOT a reason for infertility, but IUI will definitely help this issue.

A D&C, dilation and curettage, can lead to scar tissue formation within the uterus which is called "Asherman's Syndrome". The only way to clearly identify this is to undergo a procedure called a hysteroscopy. This is where a small scope is passed into the uterus to look inside the cavity. Scar tissue can be readily seen and if present, can be removed at the time. But this is a difficult problem because often the scar tissue will return and several hysteroscopies with removal of the scar tissue may be needed.

There are other possible causes of infertility that you may not have had checked. For instance, have you had a laparoscopy? It is a surgical procedure whereby a scope is passed into the abdomen via the umbilicus in order to examine the pelvis. The pelvis is important because this is where the egg needs to pass through after ovulation (leaving the ovary) in order to get to the tube. Abnormalities such as endometriosis or pelvic adhesions can prevent the egg from getting to the tube. In addition, has your husband had a semen analysis done? Have you had a end of cycle endometrial biopsy to check to see that the uterine lining (endometrium) is forming correctly? These are just some examples of fertility testing. Lastly, you have not mentioned your age. Advanced age (over 35 yo) can play a role in egg abnormalities.

If you have had all this testing and still nothing has been found, then you would be categorized as an "unexplained infertility". This just means that we have not found a cause, and the most likely reason is because we don't have the technology to find the cause. Many of these patients have to resort to IVF (In Vitro Fertilization) in order to achieve pregnancy because there might be a sperm-egg fertilization problem (which you cannot test for). If your doctor is a fertility specialist, then she should be able to map out a treatment plan for you. Before resorting to alternative treatments that may not work, please go over some of the suggestions I made with your doctor.

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: I was kind of skeptical in looking for a response.Like most online Q&A I expected a vague response at best and I expected the doctor to be as short as possible considering he wasnt being paid but I was pleasantly surprised with Dr Ramirez...he was great and I got more info from him than I did with my own doctor... Thank you so much Dr Ramirez and may God bless you as you seek to help others :)

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.

American In The UK Taking Clomid & Has Thin Uterine Lining: Needs A Specialist

Question:

Hi Dr. Ramirez,

I will try to keep this as concise as possible. I am very healthy, slim and 29 years old, and have never had issues with my periods. My husband (29 years also) and I conceived on our first try last year, but unfortunately had a missed M/C at 12 wks (fetus stopped growing at 8 wks). Tests confirmed non-recurring genetic abnormality. After the D&C I had only spotting, until 5 days after when I had a very heavy bleed with large clots lasting only one day. Then I got my first period 6 weeks later. The 3 subsequent cycles were 42-45 days.

Pelvic ultrasound revealed PCOS, hormone levels were all normal, including thyroid. Lining on this ultrasound was only 5.5 on day 40, just before I started my period. I have just completed one round of 50 mg Clomid unmonitored due to travel, and BBT shows clear ovulation on day 18 with 12 day luteal phase. This cycle I have had my first follicle tracking on day 11 which showed dominant follicle at 15 mm, but lining of only 4 mm. My questions are:

1. Could the thin lining be due to problems from the D&C?

2. My gyn prescribed Progesterone pessaries for the second half of this cycle to help thicken the lining- is this the appropriate treatment?

3. When should I consider seeing a fertility specialist?

Thank you for your time- I am writing from London. M.

Answer:

Hello M. from the U.K.,

A thin lining could certainly be due to an over-vigorous D&C, leading to scarring in the uterus. This is called Asherman's syndrome. A procedure called hysteroscopy can be done to evaluate the uterus cavity for this. However, that being said, it is not very common to develop this with D&Cs. The more common possibility is a thin lining due to the use of Clomid.

Clomid is an estrogen receptor blocker and so blocks estrogen receptors at the endometrium (uterine lining). For that reason, many patients have to use extra estrogen given vaginally in order to overcome the blockage from the Clomid, or they use a different medication such as Femara or injectables.

Progesterone is NOT the hormone that thickens the uterine lining. Endometrial thickening and priming is dependent on ESTROGEN in the first half of the cycle. The fact that your doc told you the wrong info makes me skeptical that he/she clearly understands the physiology of this treatment. So, I think you should go see a fertility specialist instead. Without proper estrogen priming, the uterine lining will not be ready for implantation. The progesterone, which is given after ovulation, is to convert the endometrial lining to develop the "pinopodes" that are necessary for implantation. (See diagram up above, the "pinopodes" are small finger-like protrusions in the endometrium) Without the proper priming, the pinopodes will not develop.

Good Luck and keep trying, you should succeed with the right treatment path,

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 Dr. Ramirez! I am very grateful to have your opinion, which confirmed to me that I need to see a specialist. As an American living abroad, it can be daunting to find the same quality of health care that we take for granted in the US. Again, I really appreciate your help.

Husband In Oman Concerned With Wife's First Miscarriage: Should She Have A D&C? When Should We TTC Again?

Question:

Good Day! My wife is 25, we have been trying to conceive from last three years. She got pregnant as well last march, we have gone for the checkup at 6th week and could see the heartbeat at 90bpm and was asked to have a follow up after two weeks. When we were for checkup we found it as a missed carriage (sp. miscarriage) due to no cardiac activity and eventually we have to go for the D&C procedure.

Now my concern is that, how far and the success rate /time to get pregnant after a D&C procedure? Since we have been trying so hard to get one and finally got disappointed, we are very eager to get the next soon...Please reply me, K. from Oman.

Answer:

Hello K. from Oman,

The good news is that your wife got pregnant! That tells you that your body can do all the steps necessary to achieve pregnancy naturally. That is a big step because most people with infertility don't know what is going wrong. This also means that she should be able to get pregnant again.

My recommendation is NOT to do a D & C, wait up to four weeks to see if your wife will miscarry naturally and if she doesn't ask for a "medical miscarriage". This is where we use a combination of medications to induce the miscarriage. There is always the danger that an over-vigorous D&C could lead to scar tissue formation called "Asherman's syndrome." Of course, if a "medical miscarriage" is not available where you are, then the only option is a D & C.

Once the miscarriage occurs or D & C, then your doctor should follow the blood pregnancy hormone levels until they go down to "0". At that point, it will take 4-6 weeks for your wife to have another period. Once she has this, you can begin trying for pregnancy again. There is no need to wait any longer than the start of your wife's period, which an indication that her ovaries have begun functioning again.

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.

German Woman Suffers Multiple Miscarriages Over Two Year Period - Proceed To Clomid Superovulation?

Question:

I´m 31 years old and writing from Germany. I have no children and have suffered four miscarriages. My husband and I have been TTC for 2.5 years now. After using the implanon hormone implant for birth control, I had it removed in 09/07 to begin TTC. In 11/07 I fell pregnant only to miscarry at about 5w3d. My hormone levels showed an hcg level of less than six. I was told to wait three months and try again, that I would have better luck. In March of 08 I fell pregnant a second time. At my first appt. at 8w5d it was discovered that there was a large sac with no fetal pole. I began to miscarry at 11 weeks and had an emergency D&C because I was losing so much blood. I asked that the tissue be analysed, but was told it was not done for a second loss and that this was in all likelyhood caused by a chromosomal problem. I was told to wait three months before trying to conceive again. Exactly 28 days after the D&C I got my period. I fell pregnant the next cycle, but did not realize it until I started miscarrying. My doctor did not do a blood test, only looked at an ultra sound, shrugged her shoulders and said I wasn't pregnant anymore, if I had ever been. She suggested that I could go for genetic counseling if it would make me feel better.

My husband and I went for genetic counseling, had kareotypes done, both of which came back normal, were tested for various thrombophilic conditions and immune disorders plus thyroid. My results came back as normal for everything but Leiden Factor V. I carry one copy of the gene. I was told by the geneticist that it would be good to start heparin at 8weeks in my next pregnancy and sent on my way.

In December of 08 I fell pregnant a fourth time, was given 100mg of aspirin to take starting at 4w5d. At 5w1d I began to bleed, but the ob/gyn felt that my lining still looked good, gave me progesterone supplements to take and told me to come back in five days for another ultrasound. On my return visit she could not find a sac in the uterus, and was unsure if she wasn´t seeing a sac in müllerin duct. I was told to stop the progesterone immediately and go to the hospital immediately should I have any sharp pains. Otherwise I was to report to the hospital in another five days for a beta draw. After stopping the progesterone I miscarried the next day. Three days later my hcg levels were drawn at the hospital and found to be 144, so I was required to come back every 48 hours for another draw to be sure that they were indeed falling. My levels fell nicely and I was sent home to wait three months before ttc again.We have been trying for a year now, and have not been able to get pregnant.

I have charted, used the clear blue fertility monitor and opk's to no avail. After six months I went to see an RE hoping that he would be able to give me some answers about my miscarriages, but he offered no ideas as to why, only said that my miscarriages were not a result of the Leiden Factor V. He did some bloodwork at CD13 to check my hormone levels, which he said looked very good, did a SA for my husband and a penetration test and said he saw no reason for us not to be pregnant. He suggested a doing a lap but made no further recommendations.

My regular ob/gyn was not in favor of the lap and suggested that I try a bit longer, and that if I wanted to we could try clomid and progesterone to get a stronger ovulation.I am unsure and very confused as what my next course of action should be testing and treatment wise, and if I really have a chance at having a biological child. I would appreciate any thoughts you might have on this subject. Thank you very much for your time.

Answer:

Hello L. from Germany,

Recurrent miscarriages are a difficult problem. The most common reason is because of a spontaneous chromosomal abnormality. That means it occurred when the egg was dividing, and not because you are carrying something. Hematologic disorders, such as Factor V, have been shown to increase the risk of miscarriage. Since you underwent evaluation and that was the only abnormality found, that is good because most patients with recurrent miscarriage due to spontaneous abnormalities will eventually be successful.

You mentioned that you were 31 years old, which is a good thing. Age plays a significant role in the risks of spontaneous anomalies and increases the risk of miscarriage with increasing age, especially after 35 years old. I call this the "Age related egg factor." Most patients that have recurrent miscarriages are because of age related spontaneous genetic defects. In your case, although there may still be "abnormal" or "weakened" eggs within your ovary, your chances of spontaneous defects are low. That means that your chances for success are high.

It sounds like your RE was addressing the issue of your infertility and not the recurrent miscarriage problem. Laparoscopy would be indicated to evaluate for infertility only. I don't think it is indicated at this point as well, but I wonder why you have not gotten pregnant after 1 year of trying. Something has changed and an evaluation is definitely warranted. I would go back to doing a full basic infertility evaluation and not make any assumptions, despite having gotten pregnant in the past. A hysteroscopy would be warranted to evaluate the uterine cavity because of your history of D&C. Therefore, you might also want to consider laparoscopy to complete an infertility evaluation, but not for evaluation of recurrent miscarriages.

If you don't want to do an evaluation but want to proceed with trying for pregnancy, then it is a little shot in the dark. Certainly doing Clomid "superovulation" is an option. This is where the fertility drug Clomid is used to increase the number of eggs that you ovulate per month. This can be paired with either timed intercourse or IUI. I might suggest the latter, IUI (Intra Uterine Insemination) for a higher pregnancy rate between these two. You might want to use low dose aspirin (81mg)per day and heparin (2000 units/twice per day) and medrol 16 mg per day starting from the beginning of the cycle, as well as, supplemental progesterone (vaginal or injectable) and estrogen.

The other option would be to proceed with IVF (in vitro fertilization). In this case, embryonic genetic testing, called PGS (preimplantation genetic screening) can be done to determine which are the normal embryos so that only these would be transferred. If you decided to pursue this option, I would recommend that you choose a clinic that has experience doing this and can do testing at the blastocyst stage (trophectoderm testing), rather than an earlier stage where they take one of the cells, and test with CGH (comparative genomic hybridization) .

I hope this gives you some information to consider.

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.

IVF Patient's Early BetaHCG Levels Show Drop In Estrogen

Question:

On January 12th, I discovered I was pregnant following IVF. My HCG numbers have been excellent. However, on January 21st I learned that my estrogen levels had dropped to 259 (from 400 on Jan 15). My progesterone and HCG continued to do well (HCG 569 on Jan 15, 3616 on Jan 21st). My Doctor has indicated that I should plan a D&C imminently as the pregnancy is unlikely to be viable.

Would you share this view? How significant is an estrogen drop? Thank you.

Answer:

Thank you for your question.

In the early pregnancy, less than 6 weeks gestational age, estrogen is derived almost completely from the ovary. Placental estrogen production has not started. Based on your first BHCG, I estimated that you are less than 6 weeks gestational age (assuming your BHCG was drawn at 8-10 weeks post transfer). If that is the case, and you are not taking exogenous estrogen (from another source), then the drop is concerning because it is an essential hormone of pregnancy.

Your doctor might want to consider adding estrogen in some form. Estrogen alone is not sufficient to diagnose an impending miscarriage. If all three hormones are dropping, then that would be significant. I would continue to follow the BHCG levels, which is the most sensitive to make that diagnosis.

In such an early pregnancy, a D&C is generally not required. Good luck and hang in there!

Sincerely,

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Estrogen Supplement For Thin Lining

Question:

Hello, I am from Canada and I have been seeing a fertility specialist since January 2009. My husband and I have been TTC for 1.5 years and experienced a miscarriage in September 2008, when I had a D&C. My lining has never been above 4.5 mm and is normally about 2-3mm thick. I have been put on 8 mg Estrace daily for the past 2.5 weeks. Ultrasound today showed no change in thickness, and suppression of the follicle size. What is your experience with thin lining and pregnancy success Is there anything else that you would suggest for me to do to thicken my lining?

Answer:

Did you use the Estrace orally or vaginally? If you have not tried it vaginally, that is a more efficient delivery method for the endometrial lining. Orally is the worst. The second best would be estrogen patches.

If you are using them vaginally and your lining is still not developing, that is a problem. It should be getting to a minimal width of 9 mms. Did you have a hysteroscopy to make sure you didn't have scar tissue after the D&C? That could be a cause of a thin lining that doesn't respond to estrogen. Most people will form an adequate lining with estrogen supplementation, so you would be a rare entity. If the hysteroscopy shows evidence of scar tissue then you must proceed to have that removed prior to starting any infertility treatments. It is difficult to do, so you must find a competent specialist to do it who will then schedule an operative hysteroscopy as an outpatient surgical procedure.

I have seen in the literature, reports of people trying nitroglycerine tabs vaginally, Levitra and Viagra to increase blood flow to the uterus and thereby try to increase the lining. They have not worked universally.

Sincerely,

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

D and C or not for miscarriage.

Question:

I wrote to you several months back and took your advice on seeing a fertility specialist since I was approaching and now am 41 years of age (as of late July 2009). In mid-July I went through the pre-testing treatment, including the estrodiol day 3 levels and hsg to check for fallopian tube blockage. My estrodial was 9.6, which was ok, and my tubes were not blocked, per my doctor's review of the testing results. Well, found out that I did get pregnant just after the hsg test, and today at 8 weeks pregnant found out by ultrasound that there is no fetal heartbeat/viable pregnancy. Not sure what to do. It looks like the development stopped around week 6, and at 8 weeks my body has not registered the loss. Should I go for a DNC in a week or so or wait for a natural miscarriage. I would like to do what is best for trying to conceive as soon as possible again. Does a DNC cause extra recovery period than a natural miscarriage? I had a DNC about 3 years ago and it took me about 6 cycles to conceive at the age of 38 (which I had a beautiful girl). Now at 41 there seems to be less time, so any advice would be very appreciated. My ob/gyn told me to come to her office in a week to discuss my options - especially if I have not naturally started to miscarry in a week. Should I head back to the fertility specialist after this time and start treatment? Ultimately my question is whether a DNC has a longer recovery than a natural miscarriage? Thanks, Kim

Answer:

Hello Kim from the U.S.,
　
At this point you have three options:
　
1. Await natural miscarriage.
PROS: It is the most natural method.
CONS: It could take up to 4 weeks, it will be painful and lots of bleeding, it is unpredictable, and you may still need a D&C if all the tissue does not pass.
　
2. Medical induction of miscarriage (vaginal tablets)
PROS: Onset of miscarriage is within 24 hours, easy to use medication
CONS: Just like natural miscarriages except no waiting.
　
3. D&C (Dilation and Curettage)
PROS: Over quickly, scheduled procedure, done under anesthesia so you won't feel anything
CONS: Surgical procedure with surgical risks (infection, perforation, bleeding, anesthesia)
　
With all miscarriages, it will take time for the ovaries to reset so that you can get pregnant. This will take 6-8 weeks. Because of the inflammation caused by the D&C, you need to wait at least 6 weeks.
　
Because of your age, you are at increased risk of miscarriages due to spontaneous chromosomal abnormalities, and, yes, you time is running short. You might want to consider a more aggressive treatment method such as IVF, rather than the natural methods you are using now. IVf increases your chances of a successful pregnancy better than any other method. Otherwise, be prepared for more miscarriages before you are finally successful. Your infertility specialist should have explained exactly what your chances for pregnancy are with each method. If not, then ask.
　
I hope this helps,
　
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
　
Monterey, California, U.S.A.

for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on facebook and twitter with me at @montereybayivf.