Inadequate Luteal Phase Support In IVF Cycle Can Cause Bleeding & Failure

Hello Dr. Edward,

Thank you in advance for your answer! I'm from Paraguay. I just went through my second IVF-ICSI and both times I started bleeding 7-8 days after day 3 transfer, just when implantation should be occurring. Do I have an implantation problem? Are there any tests I should do? What should be done to prevent this early bleeding? I'll appreciate your expert opinion on this!

Here are the details of the case:

He: 38, had testicular cancer 6 years ago (unilateral orchiectomy and radiotherapy), very low count, morphology and motility. Now healthy, treated autoinmune hypothyroidism, BMI 26.

She: 34, no known fertility concerns, healthy, BMI 27.

Went directly for IVF-ICSI due to male factor.1st IVF/ICSI: 12 eggs, 6 fertilized, 3 transfered (day 3, 2x 8 cell + 1x 7 cell, fair quality), none to freeze. Long agonist protocol: suppressed with BCP + Lupron, stimulated with Menopur + Puregon, triggered with HCG, after ER Dostinex (8 days), anti-inflammatories and antibiotics (3 days), luteal support with Prometrium. Early bleeding 8dp3dt: BFN.2nd IVF/ICSI: 14 eggs, 8 fertilized, 3 transferred (day 3, 1x 9 cell + 1x 8 cell + 1x 7 cell, good quality), 4 frozen. Same protocol, added Estrace and more Prometrium for luteal support. Early bleeding 7dp3dt: BFN. Thank you!

Answer:

Hello E. from Paraguay,

Thanks for the information. You don't mention how much Prometrium you used in your cycles but I think that may be the problem. I think you may have inadequate luteal phase support i.e not enough progesterone. Certainly prometrium should be adequate to cover the luteal phase, and many studies have shown that vaginal progesterone only is adequate, but the dosage has to be adequate as well. I think the minimum used should be 100mg three times per day. In my practice, because I don't want patients to not get pregnant or lose a pregnancy because of inadequate progesterone, I use both injectable progesterone 50mg per day and vaginal progesterone (I use Endometrin) 100 mg per day. That is what I would recommend for you. You should not be having bleeding that soon after embryo transfer.

Protocols and technique are what distinguishes IVF centers and their respective pregnancy rates. So, that is what you need to carefully evaluate.

Good Luck,

Dr. 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.

South African Husband Concerned: Is Wife's Abnormal Bleeding Caused By Cystourethrocele?

Question:

Good day, I am writing from South Africa. My spouse has recently been having blood discharge and discomfort after intercourse. After consulting a local gynae, he advised that her bladder muscles seem to have collapsed pushing the bladder more into her vagina. He has recommended constructive surgery by insertion of some sutures.

Could you please advise what causes this (she works long period as a scrub sister in theatre), possible treatments? Also, please advise what effects having intercourse would have before the surgery is performed. Thanks. J.

Answer:

Hello J. from South Africa,

I understand the problem that your wife's gynecologist identified. It is called a cystourethrocele. It is a condition whereby the upper vagina becomes weakened and the bladder sags into the vagina. It is usually a result of childbearing, which causes the muscles to stretch out, and they never return to their normal tensile strength. The upper vagina supports the base of the bladder.

However, although this may be an identified problem, I am not sure that this is the reason for the post-coital/intercourse bleeding. Cystoceles don't usually bleed, unless over vigorous intercourse causes the vaginal skin to tear, which is hard to do. The other possibility is if your wife is menopausal, the vaginal tissues can become thinned and brittle and intercourse can cause an abrasion, leading to some bleeding. In any case, an evaluation needs to be done to identify the cause of the post-coital bleeding. The most common source of bleeding is from the cervix or uterine cavity. Disorders such as cervical polyps, endocervical polyps, cervical lesions/cancer, endometrial lesions/cancer, can cause post-coital bleeding. I would not assume that it is from the cystocele if these things have not been evaluated.

Cystoceles are repaired by opening the vaginal layer, pushing the bladder up and bringing the muscle back together to hold the bladder up, then closing the vaginal skin. The formal name for it is anterior vaginal repair or anterior colporrhaphy. If there is bladder leakage, called stress urinary incontinence, this procedure can also be combined with a bladder neck suspension to lift the bladder neck with sutures on either side.

Please have your wife evaluated further for some of the possible disorders I named above if she hasn't been already before proceeding further.

I hope this answers your question,

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.

44 Year Old with High FSH "Can I Get Pregnant?"

Question:
Hi,
　
I just turned 44 (today!). My periods were pretty regular up until 16 months ago when they suddenly stopped. I've had one period in 16 months, and have had my FSH levels tested twice in the past twelve months. The first time they tested, it was 112. The second time, it had dropped to 86. Estrogen levels were "normal," but they didn't give me a figure. Both doctors who have tested me said that I'm in full menopause, though I've had no other symptoms other than the missed periods.
　
I've recently started seriously dating someone. He's been tested for all STDs (and is fine, as am I), and we had unprotected sex yesterday. And suddenly, this morning, my period seems to have started!
　
I assumed because of the FSH levels and the missed periods that I cannot get pregnant, but was hoping to confirm this--is it possible to get pregnant given the FSH levels and missed periods?
　
Thanks in advance for any help you can provide!

~beth (in Baltimore)
　
Answer:
Hello Beth from the U.S.,
　
Happy Birthday! Based on the FSH levels, you are in menopause, and by the way, congratulations on the new relationship. I can't explain the bleeding but that is definitely abnormal. I doubt that it is due to pregnancy, but cannot be sure without any further testing. I recommend that you get checked. In addition, considering how young you are to be in menopause, you might want to consider starting on some form of hormone replacement therapy. The lack of estrogen production will be detrimental to your body in many ways, including vaginal lubrication. Despite all the negative press releases about hormone replacement, recent studies are showing benefit if the woman starts at the time or near the time of menopause. That is why I recommend it. I use a low-dose birth control pill in my young woman because the menopausal formulations are not made for the estrogen requirements of the younger woman's higher metabolism. That should take care of any more abnormal bleeding episodes and make your cycles regular again. More than likely, the bleeding was a last hurrah from your uterus. We call it dysfunctional bleeding, but it still needs an evaluation.

Good Luck,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.blogger.com/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