QuestionHi, I'm Suzanne from Iowa. I have a slightly extensive gyn history. First, i am currently 43 y/o. I had da vinci myomectomy in 2008. I had 19 cm of fibroids on just the right side of my uterus. After the da Vinci, my periods changed dramatically. I went from a 7 day fairly medium/heavy cycle to a 3 day light cycle. My periods have always been heavy since I started having them at age 13.
After being unable to conceive, I had an HSG done that showed extensive adhesions and only the left tube open. I saw a fertility specialist and he did laparoscopy and hysteroscopy in 2009 to help open my uterus. After surgery, he told my husband and I that the adhesions were too bad to fix and that we should consider surrogacy.
This past October 2010, I found out I was pregnant! It was a joyful surprise. Unfortunately, at 9 weeks, the heartbeat stopped and I had to undergo a d&c for a missed abortion. At the time of my d&c, my ob/gyn did a hysteroscopy as well and said all the adhesions were gone. So, back to the fertility specialist, who redid my HSG and said sure enough, my uterine cavity is nearly completely normal. My right tube is still blocked, most likely from my initial surgery.
SO, now they started me on clomid 100mg on cycle days 3-7. I had CD14 u/s that showed 4 follicles, 2 on each side, measuring 18-22mm. My endometrial lining was thin, however, at 5mm. They still did IUI and only placed me on progesterone suppositories only because I questioned the thinness. Now, I've been put on 5mg of Femara.
I guess I'm wondering what are the chances that my endometrial lining will be thicker on femara? Should we be doing anything different to increase the lining? Noone ever said anything about the lining being too thin in October with the 1st pregnancy. I read about viagra suppositories helping and even baby aspirin. I am feeling lost with this clinic, I don't feel like they care very much. Unfortunately, it's the only fertility clinic
available.
Thank you for your opinion!
AnswerHello Suzanne from the U.S.,
The fact that you were able to become pregnant shows that you certainly have the potential to become pregnant again. That means that your body did everything it needed to do (9 steps) to achieve the pregnancy. However, your age is a significant factor, and was probably the reason for the miscarriage. The "age factor" occurs because a woman is born with all the eggs she has for her life and they degrade in quality with time. It is possible that the Depo provera preserved some of this quality (I for one believe that in may because the ovaries remain dormant), but no one knows for sure. If you continue to attempt "natural" treatment methods, you need to be prepared to have additional miscarriages.
In terms of your uterine lining, Clomid has been shown to decrease or thin the endometrial lining because it is an estrogen receptor blocker. Femara works by a similar mechanism but does not seem to have the same problem. It, however, does not seem to work as well as Clomid in terms of recruiting follicles (eggs). The better solution if you are going to follow this "natural" treatment track is to use injectable medications such as Follistim, Gonal-f, Menopur or Repronex, which will recruit follicles but not affect the uterine lining. Or another option would be to add estrogen supplementation (not progesterone) to increase the uterine lining. You would use either estrogen patches or vaginal suppositories. The amount used would be less than a birth control pill so hopefully it will not cause the erythema nodosum. As you have read, including what is contained in my blog, low dose aspirin, low dose heparin, viagra and estrogen supplements have been used to increase the uterine lining.
My worry is that based on your age, you are running out of fertility time. Most infertility clinics that do IVF do not see many pregnancies after the age of 43 without using donor eggs. I worry that if you want to have a child with your genetics, time is critical. For this reason, I would NOT recommend wasting time on a natural treatment method that only gives you a 0.5% chance of pregnancy per month of trying. At least with IVF, you would have a 40% chance of pregnancy, and higher chance of delivery.
Good Luck,
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 twitter with me at @montereybayivf and facebook @montereybayivf
