QuestionHello again, I sent you a question back in January (see below for my history and previous question)and wanted to follow up with you again as I am still having LP bleeding issues. Since I last wrote you I have been seeing an RE. She rechecked blood work which all came back fine. Completed a Clomid Challenge (last month), which also came back fine. During this same month (last month) she did a Sonohystogram and found nothing abnormal. This particular month I did not have any irregular LP bleeding at all. The perplexing part is that in the last year of trying to conceive, the only two months that I have not experienced this irregular bleeding have been the months of the HSG and Sonohystogram. This leads me to believe my problem is not hormonal as my RE suspects. She had wanted to proceed with injectables and an IUI believing that this is some kind of ovulatory disfunction that would be corrected with the right injectable medications and IUI. Also, after doing the Clomid Challenge last month, I am on Letrozole this month. I had hoped this would fix the problem if it was hormonal, but I am experiencing my normal irregular bleeding again this month.
I am desperate for a second opinion. What could be causing the problem when the only solution thus far has been when dye and saline are injected into the Uterus? Thank you so much for you time!
HISTORY & PREVIOUS QUESTION:
I am 30 years old and have been trying to conceive for 8 cycles. Here's my story. Until last summer I had been on bcp for 12+ years. About eight years ago I started having bleeding (more than spotting, less than my normal period) about half way through my cycle. Dr. at the time tried several different bcp, nothing helped. Had a DNC, came back fine. Decided to get off the pill and see if that helped. It did. No LP bleeding for 8 months. Being off the pill caused moderate acne, so I got back on the pill at month 8 after deciding the bleeding wasn't a health issue and I'd rather deal with that than the acne. Stayed on the pill for the next 7 years or so until last summer when my husband and I decided we were ready to start a family. LP bleeding continued throughout this time.
I expected the bleeding during the LP to subside within a cycle or two after getting of the pill just like it had done a few years back. To my surprise, it actually got worse. A little heavier and lasted up until my period started. For six cycles it was pretty much exactly the same....within a day or two after ovulation, the bleeding would start. Heavier at first and then trail off to light bleeding that would continue until my period started. Everything checked out at my Gyno's office. CD3 blood work came back fine..FSH was at the very top of normal, but still within normal. Prog. level was at 15. Two sono's showed everything was normal. Colp came back normal.
The last two cycles have been a bit different. The first one I used vaginal antibiotics b/c of suspicion I might have had a bacterial infection. It did shorten the bleeding, which started the same....right after ovulation or at ovulation and continued for 7 days instead of 12 or up to my period. I also experienced this a year earlier. Antibiotic cream which shortened the bleeding for one month and then back to normal. I'm not sure if this information is entirely related b/c my Dr. feels that if an infection was causing the bleeding then it would be at various times of my cycle, and wouldn't always start at the same time (right after O). Last month I had an HSG which came back fine. Strangely enough, that month I didn't experience the bleeding after O. Only just the slightest amount of spotting. Nothing like the previous months. A bit more spotting came a few days before my period. But this was still a huge improvement.
This current cycle, I'm back to the same old bleeding after O. My concern is two part. One, a health concern that this could be something more serious. Two, could this kind of bleeding keep us from getting pregnant and if so, what needs to be done.
Thanks in advance for you help, it is much appreciated!
AnswerHi Again,
I do think that your bleeding is hormonal as evidenced by a negative hysteroscopy and HSG. It could be that you need more progesterone supplementation or that the lining is not forming correctly. Have you had an end cycle endometrial biopsy for dating and endometrial development (b-Integrin)? If not, you might want to have that done. If it is abnormal, it would mean that the progesterone level is inadequate.
There is not health concern other than the fact that it is a nuisance. From a fertility point of view, if all hormones are in place and working correctly, there should not be break through bleeding, as this could disturb implantation. Your RE needs to figure this one out. It may be a simple as increasing the dosage of the progesterone.
Sincerely,
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.
