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!

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

Patient Has Only One Tube, One Ovary & A History Of Ectopic Pregnancy: What Are Her Chances Of Conceiving?

Question:

Thank you for taking the time to answer my question. I am a 27 year old female with a history of endometriosis. I had my left ovary removed two years ago due to a cyst. My Dr found endometriosis that had pulled my bowels up to my uterus and did a laparotomy a few months later to correct this. I was then put on 10 months of Lupron injections to try and keep the endo from growing so fast and got pregnant two months after coming off of them. However, that resulted in an ectopic when I was only about 3 or 4 weeks along. My tube ruptured and he had to remove it. He also found more endo that he was able to remove. So I now I'm left with a right ovary and a left tube. It's been 5 months since my ectopic and I have yet to get pregnant again.

I've switched to a high-risk OB/GYN. He did an HSG and my tube looked good. He also put me on 50mg of Clomid days 3-7. I had two ultrasounds to show that I had indeed ovulated and then he started me on progesterone suppositories (my progesterone in my first pregnancy was 7). It has been over a month since my last cycle, but all of my pregnancy tests have come back negative, so I believe the progesterone has delayed my period. My question is, do you think there is a chance of me conceiving again. My Dr told me to be saving for IVF (which my husband and I cannot afford right now). I would like to have 3 or 4 kids, but I don't know if that's possible now. I'm devastated over this and I would appreciate any advice you can give me.

Thank you. K. from the U.S.

Answer:

Hello Kasey from the U.S.,

Normally, it is possible to get pregnant when you only have one tube and one ovary that are opposite from each other. In fact, in nature, the egg ovulated from one ovary, say the right side, does not necessarily go into the right tube. This is a misunderstanding. The Fallopian tubes actually hang 2 cms (1 inch) down below the ovary and the egg can be ovulated from any part of the ovary. In reality, the egg is expelled from the ovary with all the fluid that surrounds it in the follicle. That fluid rushes out taking the egg with it. It then falls into a space called the culdesac located behind the uterus, where the ends of the fallopian tubes hang. Then by simple fluid motion (think of a spec of dust in a small puddle of water), the egg either contacts one tube or the other. It does not always find a tube. So in this way, it can contact either the right tube or the left tube and in your case, it can contact the opposite tube.

I think you might have another problems, however. Maybe two major problems. One is that you have endometriosis. That is a pelvic disease whereby the endometriotic implants cause an inflammation in the pelvis. This inflammation can attack and destroy the egg before it has a chance to be picked up by the tube. The second issue is that you have have multiple pelvic surgeries. Surgery tends to cause scar tissue in the pelvis and culdesac. Scar tissue (adhesions) are like spider webs in the pelvis and can block the egg and tube from getting together. There is a third problem as well, but not one that will prevent you from getting pregnant, but one that could be devastating, and that is that you have a history of ectopic pregnancy. Ectopics occur when the egg gets caught in tube, and is usually the result of scar tissue within the tube. This is most often from a previous infection that got into the tube and caused formation of the scar tissue from inflammation. It does not necessarily need to be bad enough to block the tube so the tubes would be open on HSG, as in your case. It could mean that there is scar tissue in the remaining tube, that could either prevent the egg and sperm from getting together i.e. damage the structure within the tube so that it is not functional, or lead to another ectopic.

With all of this going on, IVF is in fact the best treatment for you. Try to find a center that may help you with a financial plan (we have many) that fits your budget, even if it is far away. Your Ob/Gyn can monitor you for the IVF clinic if it is too far for you to visit.

I hope this helps,

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.

36 Yr. Old Irish TTC'r With Low AMH & Scar Tissue From Cystectomy Needs IVF

Question:

Hello,

I have a number of queries.

I am a 36 year old female from Dublin, Ireland who has been TTC for 2.5 years. After one year of trying myself and my partner were referred to a fertility clinic. At that time, ultrasound and MRI showed that I had a 4.5 cm dermoid cyst on my left ovary and I was referred for a csytectomy in April 2009. My surgeon chose to do a laparotomy saying that there would be less likelihood of the cyst rupturing during surgery and having to clean up the pelvis so I went with his advice, while I was open he took the cyst on the left ovary but also took what he thought was another cyst on the right ovary as it was hemorrhagic. The histology report showed that the cyst from the right ovary was actually my corpus luteum for that month.

After the recovery period for the surgery my partner and I began to try and conceive naturally with no luck. At this stage (December 2009) we were frustrated with the first fertility clinic we went to so we changed clinics and in February of this year I had an AMH test and pelvic sonogram in preparation for IVF. The AMH results show that I have low ovarian reserve (0.5). The left ovary had no follicles on it at ultrasound and the right one only had four or five. I do know from past ultrasounds that I have been ovulating from my right ovary every month since the surgery (and probably before that since I always had pain on this side every month).

I was also diagnosed with uterine polyps at the sonogram which I am going to have removed via hysteroscopy and d and c prior to starting a cycle of IVF in April.

My questions are these:

- could the removal of the corpus luteum on the right ovary and the cyst on the left have damaged my ovarian reserve?

- do you have any suggestions for maximising my chances of success with IVF given my low ovarian reserve? Would you recommend DHEA?

- since the surgery I have had consistent pain where I perceive my right ovary to be and menstrual like cramping at odd times of the month - could this be related to the surgery. I have asked doctors about it and since they can't see anything wrong with an ultrasound they tell me not to worry about it.

I am very concerned about the effect that the surgery had on my fertility as well as the fact that my surgeon nor the first fertility clinic I was with did not warn me of any risk associated with the surgery.

Thank-you for your time

ANSWER:

Hello N. from Ireland,

The previous surgery would not have had an effect on your ovarian reserve. However, the type of surgery you had (exploratory laparotomy with cystectomy) could have altered and worsened your fertility. Unless a lot of the ovary was removed, however, it should not have affected your ovarian reserve.

In reality, low ovarian reserve is just a description of how you will stimulate with the fertility drugs. AMH (anti-mullerian hormone) is only a test that gives us a measurement of ovarian reserve but it is not an indicator of your fertility. Keep in mind that you only need ONE good embryo to get pregnant. In fact, I did IVF on a patient this month who ended up only having one embryo to transfer, because of low ovarian reserve/low response, and today her pregnancy test is positive!

You are still young so your chances are still good. I would go with a high stimulation protocol (not the flare protocol), then you can only hope for the best. I don't advocate DHEA (which is dehydroepiandrosterone, an endogenous hormone i.e. made in the human body, and secreted by the adrenal gland). Make sure the IVF clinic you go to has a good and high pregnancy rate. You don't want to waste time on one that doesn't.

In terms of your pain, it is possible that you have scar tissue that formed around the ovary as a result of the surgery. Scar tissue cannot be seen by ultrasound. You would need a laparoscopy to see it.If worst comes to worst, you could always come to the US, although I know that is a very expensive proposition. I've had patients from as far away as Serbia on the European side and China on the Asian side.

Follow-Up Question:

Hi Edward,

Thanks for your response, particularly about the impact of low AMH on fertility. I have a couple of follow-up questions:

- how could the type of surgery (laparotomy) I had have adversely affected my fertility?

- what is a decent pregnancy rate for a fertility clinic?

- would you advise a laparoscopy to check for scar tissue prior to the IVF or should I just go forward with my cycle?

Thanks, N.

Follow-Up Answer:

Hello Again,

Whenever surgery is performed abdominally, especially an open surgery and one around the reproductive organs, scar tissue formation can be induced. This will interfere with the passage of the egg from the ovary to the tubes.

In your age group, we are hitting a 68% pregnancy rate per attempt with IVF. I know that in general in the U.S., pregnancy rates are 50-60% per IVF transfer. I don't know what they are in Europe, but you might want to use that as a guide. We break that down into age groups and the statistics I gave you are based on your age, and not across all ages.

I do not recommend laparoscopy to check for scar tissue formation prior to IVF. Only do this surgery if you are dead set on trying to get pregnant naturally. IVF will bypass the pelvis completely, and is the ideal treatment for severe pelvic scar tissue/adhesions, so the surgery is not required.

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.

South African Had Surgery for Stage 4 Endometriosis - Now What?

Question:

Hi, doc, I'm 30yrs old and recently had laparascopic surgery. I was diagnosed with stage iv endometriosis, most of it was removed. My fiance also has fertility issues. He was diagnosed with anti sperm antibodies. We are desperate to conceive and will meet our doctor next week to discuss our options. I would love your opinion on this matter?

Thank you, Regards from South Africa.

Answer:

Dear M. from South Africa,

Stage IV endometriosis is the worst stage that you can have. This has definitely been shown to impair fertility via natural means. The problem is that the endometriosis has now impaired the pelvis and this is the path that the egg must take in order to reach the tube. Both the scar tissue formed from the endometriosis and surgery, and the inflammation caused by the endometriosis will interfere with the egg.

Most women with stage III or IV will not get pregnant naturally and will need to go directly to IVF. To these women I first recommend trying naturally after surgery for a 6 month period. You can either try on your own or with IUI, it doesn't really make that much of a difference. Most RE's would treat with Lupron or Letrozole after the laparoscopy for three months to remove any residual endometriosis prior to starting with a treatment.

Since your problem is combined with your partner's problem, then you have two major strikes against you. That would definitely make me strongly recommend IVF as the treatment of choice. That is not to say that you could not get pregnant without IVF. I have had a patient with stage four endometriosis that became pregnant spontaneously. However, the statistical chances of pregnancy is 1% or less.

Thank you for your question and good luck!

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Can Scar Tissue Affect Fertility?

Question:
I have never been pregnant or on birth control pills or had surgery but I have scar tissue so bad they can't see my reproductive system. Will I ever be able to conceive? Is this fixable?

Answer:
Hello Sarah from Canada,
　
I am not sure how your diagnosis was made without having had surgery. Scar tissue is usually only diagnosed by a surgery called a laparoscopy.

But, assuming you have scar tissue, and it is bad, this could be caused from a previous pelvic infection, called PID, due to bacteria that ascends through the vagina, cervix and uterus, or it could be caused from a disease called endometriosis that causes severe inflammation of the pelvis. In either case, severe scar tissue is caused in the pelvis and obstructs the egg's ability to reach the Fallopian tube.

In some cases of pelvic scar tissue (adhesions), surgery can be performed to try to reduce the scar tissue, but this doesn't always work because scar tissue can form as a result of the surgery as well. The best option would be to do IVF (In Vitro Fertilization) whereby the eggs are removed directly from the ovaries and the pelvis is bypassed completely. The chances of pregnancy are age dependent but are very good and can be as high as 63% per attempt.

You don't need to worry about never getting pregnant. The technology has advanced quite a bit and we can get almost anyone pregnant. The only consideration is what has to be done to get you pregnant, and what you are willing to do to get pregnant.

Sincerely,

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

Monterey, California, U.S.A.

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