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!!

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.

Stage 2 Endometriosis Patient: Life & Fertility After Lupron?

Question:

Hi. My name is B. I am 26 and I live in Mississippi. I was diagnosed with Stage 2 Endo in June of 2009. Within 4 months of the lap (performed in June) I was already experiencing high levels of pain during urination, bowel movements and intercourse. My doctor had previously recommended Lupron, but I had declined so I went on continuous birth control. I still had high amounts of pain on a regular basis. I decided to do the treatment after the pain returned so quickly.

While on the shots, I didn't experience nearly as many hot flashes as I had expected and I only gained about 12 -15 lbs. I had my last shot about 27 days ago (3.75mg) and I want to know what I can expect.

When should I start having a cycle again? Also, I have had some mild-moderate pain during the last 3 months of my treatment and occasionally what felt like menstrual cramps. My doctor said he thought it was probably scar tissue.

Any thoughts on the pain I experienced during the second half of my treatment? Any thoughts on my statistical time frame for the possibility of having a family vs. infertility. My boyfriend is very cynical and doesn't believe my best chance at a family is within the next two years. How adamant should I be about going for it considering my circumstances? Thank you!

Answer:

Hello B. from Mississippi, let me answer your questions in sequence:

1. In general, the normal cycle will resume within 3 months of the last month of Lupron injections. That means, give yourself three months after the one month from the injection.

2. I can't explain the pain that you had in the last 3 months of treatment. Scar tissue is a possibility but the symptom is so nonspecific that I can't give a more definite answer.

3. In general, I advise patients to begin trying for pregnancy immediately after completing a Lupron treatment because there is a 6 month window before the endometriosis will return and inhibit fertility. If you are not in the position to try for pregnancy right away, then you should follow the Lupron with some type of prophylactic treatment to prevent the immediate return of the endometriosis. I recommend Depo provera but if you don't want to take this, then a low estrogen dose, high progesterone birth control pill is second best. Do not use a high dose estrogen pill (30mcg or greater) because the estrogen feeds the endometriosis. Again, Depo provera is my preference.

4. Lastly, I hope you don't mind this piece of advice: You should never insist on having a child with a partner. It needs to be a mutually acceptable proposition. Having a child is a life-changing event. You want your situation to be stable before then.

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.

Twitter with me at @montereybayivf and follow me on Facebook at http://bit.ly/9Iw9oV

Off Depo Provera But Still No Period, What's Wrong?

Question:

Hello, I am 30 years old and was on the Depo-Provera shot for 3 years during which time I did not have a single period. I had my last shot in January 2008 and still have not had a period. My husband and I would like to start a family in the next 2-3 years and I am getting increasingly worried that this will not be possible. I am also suffering from very bad vaginal dryness (could this be related?)

I am currently doing some voluntary work in Argentina now and it is difficult to see an English speaking doctor. Is there something I can do to help my self in the short-term or should I consider returning home to seek medical advice?

Answer:

Hello T. from Argentina,

I am surprised that you can't find an English speaking doctor in Argentina. Maybe you should look for a Reproductive specialist specifically as most of them do speak English. If you still can't find one, then you should return to the U.S. for consultation.

Certainly, something is not working correctly which is preventing the ovary from ovulating, hence no periods. This is not due to the Depo Provera, since it does not last this long. It can delay periods for 1-3 months but not usually longer. There is something else going on and you need to undergo evaluation. The vaginal dryness is because you are probably not producing estrogen, which occurs with ovulation, and the vaginal gland is estrogen dependent. You don't want this to go on much longer because the vagina will actually begin to shrink and intercourse will be difficult and painful.

In order to get pregnant, depending on the cause of the problem, you need a treatment that will get you ovulating again. There are various options, but it depends on the cause. In the meantime, you might want to consider going on the birth control pill in order to get you cycling again (it overrides the ovaries so is not correcting the problem), which will give you estrogen. Many parts of your body require estrogen. You should be able to get this from a non-English speaking doctor while you plan to return to the U.S. for consultation.

Thank you for writing and good luck!

Sincerely,

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

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