Ask the MA Consultant
Archives from September 2007 – June 2008


Prologue

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SU
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Table of Contents

1. Miscarriage causes
2. Incompetent cervix, Labor induction
3. Predicting incompetent cervix in the MA patient
4. UU and placing a cerclage
5. Bicollis: septate cervix versus true duplication
6. When in the cycle to have a laparoscopy/hysteroscopy
7. MA complications and the type of physician to see
8. Post-resection pregnancy monitoring in the septate uterus
9. Leaving lower septum segment intact; Resection techniques
10. Distinguishing between SU and BU using Doppler ultrasound
11. Diagnosing and resecting a vascular septum
12. Monitoring septum resection
13. UU and L-shaped cervix: cerclage?
14. Small cervix—is it a MA?
15. Treating endometriosis
16. When to measure cervical length in pregnancy?

17. Length of septum: absolute vs. relative measurement
18. Monitoring for incompetent cervix
19. Can HSG fail to show a septum?
20. Transabdominal versus transcervical resection
21. “Regrowth” of septum, effect of pregnancy on septum
22. C-section techniques for MA, Resection during birth?
23. Infertility questions

24. Late ovulation
25. Polycystic ovarian syndrome (PCOS)
26. Incompetent cervix guidelines
27. Ectopic pregnancy
28. Use of Clomid
29. Balloon catheters and progesterone following resection of SU

 


1. Sept. 6, 2007 — Miscarriage causes

    
“How can I tell if my miscarriages are cause by my MA, or from
something else?"

Only by having a complete diagnostic work-up. The diagnostic work-up,
begins by obtaining a complete Medical History, Although in Medicine
nothing is 100%. Most losses that are caused by MAs occur in the
late first trimester, middle trimester or end as a premature birth.
(there are also other causes for late losses as well such as:
infection, incompetent cervical os, thrombophilias, polyhydramnios,
uterine fibroids, etc.). Earlier losses are more frequently related
to genetic, immunological, or other causes.

So, when is a diagnostic work-up indicated? When any woman has
repeated pregnancy losses, or an "atypical" miscarriage (a woman that
has had a normal ultrasound at 8 weeks gestation has more than 90%
chance to have a baby, so if she suffers a loss in spite of an normal
ultrasound, should further investigation prior to the next conception
should be considered. It should not be written off as just "bad
luck"), any late loss or premature birth also should be followed up
with a complete work-up.

So, why do Drs say "we have to wait till three pregnancies are lost
before we investigate?" This is based on retrospective studies that
have shown, that if a woman has lost three consecutive pregnancies,
if she were to conceive again, she most likely will experience
another loss. However as explained above, there are situations that
should be followed by further testing instead of waiting for another
miscarriage to occur.


2. Sept. 14, 2007 — Incompetent cervix, Labor induction


There are two answers to share today and more to come next week:

" I'm pregnant and I am afraid of an incompetent cervix.... What
should I do"?

The first comment regarding this question, is that the answer is
different depending whether the patient is planning to conceive or
she is already pregnant, since the question implies she is pregnant
I'll answered it as such.

Assuming she is in the very early part of the gestation and the
suspicion of IC is based on previous pregnancy loss (premature labor
and/or premature ruptured membranes), history of MA, or previous
surgical procedures performed in the cervix, one has two options, 1)
Assume there is a strong possibility of IC. After having an
ultrasound that suggests the pregnancy is "normal," insert the
cervical cerclage (there are different types, for different
situations of the same diagnosis) at about 12 weeks gestations (most
of the genetically, but not all, abnormal pregnancies, are apparent
before 12 weeks gestation). 2)- The second option is to measure the
length of the cervix early and to monitor its length at frequent
intervals. In this situation, the patient must be seen every 1 - 2
weeks because this is the only way one can detect early cervical
changes. These patients need lots of support from the doctor. In
this case, it is also important to be sure there are no bacteria in
the urine and the vagina.


"Is it safe to induce labor with MA"?

If a patient has had an open reconstructive procedure (Tomkin's,
Jones or a unification), then the safest delivery will be via a
Cesarean section. In all other situations, normal obstetrical
protocols will govern the decision.


3. Sept. 21, 2007 — predicting incompetent cervix in the MA patient

The Question:
I want to know which MA patients are at risk for
incompetent cervix/pre-term labor, and why. I had a small septum
(1.5 cm) removed and stage 2 endo. I am now pregnant and my RE does
not feel I need to see a MFM doc, but I am worried. What diagnoses
tend to have IC?


The Answer:
Some women with US (uterine Septum) have do have IC (Incompetent
Cervical os). This is probably a result of the reproductive organs
not having completed their maturation process or it can be a
consequence of resection (at the time of the septum reduction) of a
wide endocervical septum.

As a rule ANY patient that has undergone a septum reduction, should
be followed more closely than in a regular pregnancy (visit with the
doctor at one or two week intervals). The cervix should be measured
at the time of the first ultrasound (at about 6 weeks). The
frequency of measurement of the cervix will be determined by the
initial findings of the ultrasound. Frequent measurements are
particularly important, If the patient had a previous late loss or
premature birth. Fortunately most patients who have a successful
resection surgery will go on to have a good pregnancy outcome.


4. Sept. 28, 2007 — UU and placing a cerclage

The Question:
I have a question - to cerclage or not to cerclage, with a UU? What
are the pro's and cons, and what are the deciding factors?

The Answer:
With the CORRECT diagnosis of UU, the decision to perform a cerclage
will be based on whether there has been a previous late loss or a
premature birth that has no other explanation other than the MA.
Otherwise, a careful monitoring of the condition of the cervix will
be in order.

Cervical cerclage carries certain risks such as: accidental puncture
of the membranes, bleeding and/or infection. These are minimized by
how well the procedure is performed. On the other hand, the benefit
of the cerclage is that it will prolong the duration of the pregnancy
in patients that had experienced a late loss or a previous premature
birth attributed to IC.


5. Oct. 5, 2007 — Bicollis: septate cervix versus true duplication

The Question:
Is septate bicollis an accepted diagnostic term? Some doctors use
this to indicate that there are two cervices. Others say that it is
actually one cervix that is divided in half by a septum. Which is
correct? Can you clarify what this means?

The Answer:
To further clarify the confusion that exists when referring to the
terms of the various forms of MA, please let me first review with you
the normal events that occur in the development of the internal
female genital organs.

Between the 6th and the 12 week of intrauterine life, there are two
sets of tubes (Müllerian ducts) inside the primitive abdominal
cavity. In response to a genetic message, they begin to move toward
the midline, ending up in contact with each other, except for the
upper parts, which will become the two Fallopian tubes. The [segment
of tubes that fused] will develop into the uterus, the cervix and the
upper half of the vagina. Failure of the Müllerian ducts to unite
(fuse) will create various forms of MA.

If the failure to fuse involves the upper part, but stops above the
internal os—the internal opening of the cervix—it is called
bicornuate uterus (BU). This anomaly usually has one cervix
(unicollis). If the failure of fusion goes beyond the internal os
(i.e. involving the cervix) then there will be two separate hemiuteri
(didelphys), this more frequently is associated with failure of
fusion of the cervix as well (bicollis), in this case both
endocervical canals are surrounded by a muscular layer rather than be
separated only by a fibrous layer, as in the case of a septum.

Total failure of fusion, will also be associated by separation of the
upper half of the vagina. In these last cases frequently one of the
sides, does not develop (hypoplastic horn) or is non-functional
(rudimentary horn), and these may or may not communicate with the
other half. In these cases, they are frequently associated with renal
anomalies as well.

Some cases of double cervix are also occasionally associated with
obstruction of one of the hemivaginas.

In regards to the important aspects of the true double cervix: one is
that they are patent and will allow the menstrual flow in the proper
direction and second that they should not be surgically treated,
because the cervix most likely will be rendered incompetent (IC).

Once normal fusion is completed, the wall that separates the
Müllerian ducts then begins to disappear, forming the uterine cavity,
the endocervical canal and the upper half of the vagina (single
vagina).

Failure of the wall to disappear will create septation. This can be
partial (uterus subseptus), or complete septation, involving the
uterus, the endocervical canal and the upper vagina.


6. Oct. 10, 2007 — When in cycle to have lap/HSC?

The Question:
Can you tell us at what point in a woman's cycle it is
best to have a lap/hyst surgery for a septum resection and why?

The Answer:
In general, a Lap/hyst. For a septum resection, is best performed in
the first half of the cycle. During this time visualization is better
and there is a lesser risk of interfering with an early pregnancy.


7. Oct. 12, 2007 — MA pregnancy complications and type of physician to see

The Question:
What are the problems associated with MAs and what kind of Dr. should
I see?

The Answer:
MAs are known to be associated with above average reproductive
problems, such as mal presentation, recurrent spontaneous abortion
(M/C), late abortions and premature birth, and more rarely, the baby
can experience compression congenital anomalies. Uterine septum (US),
carries the most risk, because of this and the relative ease of
correcting US, Drs. should discuss the patient's options during a
preconception consult.

When there is a suspicion of MA, who should I consult? The correct
answer is a Reproductive Surgeon. A RE (Reproductive
endocrinologist). The newer generation of REs, usually don't have
more experience than a regular OB-Gyn. This is due to the fact that
the curriculum for the Fellowship is more focused on research and
academia rather than clinical study.

A Reproductive Surgeon deals with problems like MAs on a regular
basis and has more experience and skill in making the correct
diagnosis and resolving the problem. To further support this, there
is a reported 5% of patients who have a "residual septum" when
resection is performed by an experienced Reproductive Surgeon. Based
on what we all see and read today, the incidence of residual septum
is much higher than previously thought. Perhaps this is a reflection
of the results of surgeries that are not always perform by
experienced surgeons.

Reproductive Surgeons usually hold Certification on Advanced
Laparoscopy/Hysteroscopy and are members of The American Reproductive
Surgery Society and other Gyn. Surgical associations.


8. Oct. 19, 2007 — Post-resection pregnancy monitoring in the septate uterus

The Question:
What potential pregnancy complications should a patient who has a
resected septate uterus be aware of? What type and frequency of
monitoring would you recommend?

The Answer:
Most patients who have had a successful transcervical uterine septum
reduction will do well in their pregnancies. However, is prudent to be
monitor more these patients frequently than other patients. Potential
issues to watch for are: Incompetent cervical os (infrequent), and deep
placentation at the site of the resection (placenta accreta) (very rare).

Patients who had an open Metroplasty (Jones, Tomkins) will also have
the concern of uterine rupture (rare).


9. Nov. 13, 2007 — Leaving lower septum segment intact, Resection techniques

The Question:
"Are there any situations in which the lower 1/3 of a septum
should be left intact while the upper portion is resected?" & "what
are the best techniques for resection"

The Answer:
In a previous answer I did explain what causes the septum to be
created
and its clinical consequences. I suggest this be shown
again as part of this answer if possible.

With a correct diagnosis of a complete SU, we gain nothing by leaving
the cervical part of the septum and data in the medical literature
does not show an increase in the incidence of IC. Removing the septum
of the cervix facilitates the resection of the rest of the uterine
septum. It also probably allows the cervix (and the internal
cervical os) to reform along with the rest of the uterus so that it
is closer in form to a normal uterus.

In cases of true duplication of the cervix, the separation of the
external cervical openings tends to be quite wide. In this
situation, there is nothing to be gain by attempting the resection
and IC could be a complication. Therefore, having a correct diagnosis
is the most important factor in making the decision on whether to
resect the septum or not.

Regarding which instrument (technique) is better for the resection of
the US: The correct answer is the one that the surgeon has more
experience with, and which has given the best and most consistent
results for him or her. Regardless of which technique or instrument
is used, it is important to ensure that the septum us transected in
the middle. This allows a symmetrical separation (one half moves
forward and becomes part of the anterior wall of the uterus, and the
other half moves backwards and becomes part of the posterior wall of
the uterus). The resection should be carried to the fundus but
without reaching the myometrium (the muscular wall of the uterus).

In my professional life, I have used every available resection technique.
The one that has worked best for my patients is performed
under fluoroscopy (X rays) control. This technique can be performed
in a few minutes and does not have the risk of fluid overloading that
sometimes happens during Hysteroscopy resection. It also allows me
to see if I have resected all of the septum. Since I can see the
results at the end of the procedure there is no chance of leaving
a "residual septum" behind, nor do I really need to perform a HSG
post-op. The technique also eliminates the need to prescribe Lupron
or estrogen post resection.
This technique, like others requires practice for the surgeon to
achieve a degree of comfort with the procedure.


10. November 28, 2007 — Distinguishing between SU and BU using Doppler US

MA consultant: I reviewed the HSG film of
Jenh33341.

This is an ideal situation for an Ultrasound with Doppler. If there
is a vascular pattern between both horns, the diagnosis is likely to
be a Septum (SU), conversely, if there is no vascular pattern
(silent) the diagnosis most likely is
BU.

If a BU is diagnosed prior to the surgery, Laparoscopy will not be
necessary, saving the patient expense and eliminating the need for
anesthesia. If the Dx. is a SU and the Dr. is not comfortable
performing a resection, the patient should be referred to a
specialist (reproductive surgeon) in order to avoid the need for a
second Laparoscopy and use of anesthesia.


11. Nov. 30, 2007 — Diagnosing and resecting a vascular septum

The Question:
Can MRI help determine the vascularity of a septum? Should a
vascular septum be left intact?


The Answer:
Yes an MRI and a Doppler ultrasound are capable of determining the
vascularity of the septum. However, this information is of no great
value. A Dr who is concerned about a vascular septum bleeding during
a resection procedure, can use techniques to prevent bleeding. In my
own experience I have not seen much difference whether the septum is
vascular or not.

If the reason not to resect a vascular septum is because one feels it
will be a good "ground" to support a pregnancy, experience has shown
this is not accurate. When I was in training we did research on
septums that were removed (Jones procedure, and hysterectomies with
incidental septums) and found no difference in the vascularity of
the septum when compared to that of the wall of the uterus. The most
likely explanation is that the vascularity of the septum "falls"
behind with respect to the rest of the uterus as the pregnancy
progresses and for that reason pregnancies are lost late (2nd-3rd
trimester).


12. Dec. 13, 2007 — Monitoring septum resection

The Question:
I met my RE yesterday. He told me he can resect the septum with
hysteroscopy under ultrasound monitor. He thinks it is better to have
the procedure monitored under ultrasound than under laparascopy. In
your opinion, is this an effective and appropriate method?

Thank you.


The Answer:
With an established diagnosis of septated uterus the resection can be
monitored with ultrasound, fluoroscopy and/or a laparoscopy. This
depends on the surgeon's preference based on his/her experience and
preferred technique. However, if the diagnosis hasn't be settled,
laparoscopy is a must.


13. Dec. 31, 2007 — UU and L-shaped cervix: cerclage?

The Question:
I am 30 years old, I have a right UU, 1 ovary & tube, 1 kidney, & a
wonky cervix. I was also diagnosed with severe endometriosis, which
was lasered & excised a year ago in a 2nd lap. I'm now 8wks pg with
a singleton after IVF. My cervix was initially L-shaped &
inaccessible by hysteroscope, but was straightened during the
subsequent lap/hyst. It has been described as unusually small when
visualised vaginally. My medical records note that dilators from 2-
7mm were used. Given this cervical interference plus 2 IVF
transfers, in your opinion would I be considered a candidate for a
preventative cerclage? Are there any other considerations that
should be made for me during pregnancy?

The Answer:
If this is your first pregnancy, you have two options, one: the
cervix should be measured via U/Sound and used as a baseline, and
then followed at intervals to be sure it remains the same length.
If it appears that the cervix is becoming shorter, then a cerclage
could be considered.

The second option: will be to proceed with a cerclage, this will be
important in particular if you have had a previous loss of a
pregnancy. Your doctor will also know if it is technically possible
to perform a cerclage in you cervix due to its appearance and
location.


14. Jan. 4, 2008 — Small cervix: is it a MA?

The Question:
One of our group members was told by her Dr that she has a small
cervix. Is it possible to have a "small cervix" without any other
manifestation of a mullerian anomaly? If so, can you explain the
process involved in the embryologic development of a small cervix? Is
it more likely that there is a cervical duplication or vaginal septum
that has been overlooked than actually having a small cervix?

The Answer:
The answer is yes to all possibilities. My question is, how did they
make the diagnosis of a small cervix? (by an exam or ultrasound?).
There is always the possibility of having a small cervix even in
absence a other anomalies, in fact there are women born without cervix
(cervical agenesis) an otherwise a normal uterus. So let’s first find
out how the diagnosis was made.

Jan. 6: Moderator: Here are some more thoughts from the list consultant (I sent the
original message to him--hope that was ok. I thought it would be
useful for the list to learn more about this situation)

Re: " The small cervix "

The new information opens three possibilities:
1) That the cervix is STENOTIC (narrow endocervical canal), this can
develop as a consequence of previous surgery involving the cervix
(cervical conization, a LEEP procedure, trauma with consequent
formation of scar tissue, Cesarean Section, etc) and of unknown
cause. A stenotic cervix if significant, will be associated with a
scant menstrual flow and significant pain at the time of the menses
(Dysmenorrhea).
2) A septum extending into the cervix.
3) a SHORT cervical body.

In case of (1) or (2), I'd approach it as follows (since attempts to
prove the cervix in the office have been unsuccessful), I would bring
the patient to the operating room and under anesthesia, I would
attempt to pass a micro dilator under Ultrasound guidance (this to
avoid the risk of creating a false passage), once I reach the uterine
cavity the I gradually and gentle dilate the cervix, then I perform a
hysteroscopy to rule out the presence of a septum, if a septum was
present, I would then resect it. Finally I will advance a balloon
catheter and leave it for few days to prevent re-closing.

If the final diagnosis is a SHORT cervix, I would just recommend
close monitoring during pregnancy.


15. Jan. 8, 2008 — Treating endometriosis

There was a question posted by Marie Herschel that I would like to
answer. She has advanced endometriosis (IV) and has had two surgeries
without good results results, she also has a SU.

The Answer:
Although the etiology of endometriosis is still elusive, in cases
where there is an intrauterine anomaly such as MA, fibroids, cervical
and vaginal obstruction, where the menstrual flow can not exit or is
partially blocked, there will be retrograde menstrual flow in to the
abdominal cavity with the consequent implantation of endometrial
cells on the surface of the peritoneum. These cells will grow in
response to the hormones of the cycle, like the normally situated
endometrial cells, and at the time of menses they will shed blood and
create the inflammatory reaction which, along with other factors,
causes pain and scarring.

The fact that the septum has not been removed is most likely the
reason why the treatment for the endometriosis has had poor results.
In my experience with this type of endometriosis after the
obstruction has been corrected and the endometriosis treated, it does
not recur or takes a long time to do so.

With respect to the best forms of treatment for endometriosis, the
answer is all of them, if properly performed. Treatment is also
based on the location of the particular implant, if the wall of an
organ (bladder, bowel or are around the ureter) is involved, they need
to be resected. Other locations respond well to other techniques. In
short, any surgeon who performs endometriosis operations should be
familiar with all available techniques and be able to apply the one
that is best suited to each case.


16. Feb. 7, 2008 — When to measure cervical length in pregnancy?

The Question:
During pregnancy, when should the first cervical length
measurement be taken?

The Answer:
Most studies indicate that it should be taken between 14-16 weeks.


17. Feb. 21, 2008 — Length of septum: absolute vs. relative measurement

FYI:
One of our list members recently sent a HSG film to our consultant
for review. In his response, he noted that the actual measurement of
the septum is less important than the proportion of its length. For
example, it is more important to know if a septum is 1/3 the length of
the uterus than to know the exact measurement. Many of us have said
that a septum that measures over 1.3 cm should be resected but that may
not actually be accurate in all situations. This is an important
distinction!

18. Mar. 30, 2008 — Monitoring for incompetent cervix

The Question:
Are MAs associated with incompetent cervix and should
women with MAs be monitored for IC during pregnancy?

The Answer:
IC can exist in association with MAs, in particular with BU, but also
can be present in the absence of a MA. All women with MAs should be
monitored for IC during pregnancy.


19. April 15, 2008 — Can HSG fail to show a septum?

The Question:
Can a HSG fail to show a septum?

The Answer:
If the x ray is not properly oriented (does not show the
full length of the cavity) it will not show the septum. On the other
hand, if the film shows the whole uterus there is no way to miss it.


20. April 22, 2008 — Transabdominal versus transcervical resection

The Question:
My Dr. said that I have an extremely large uterine
septum that may not be able to be resected via lap/hyst and that
bleeding may be a problem. Is this correct? Under what circumstances
is an abdominal metroplasty called for? Is it required for cases
involving a very large septum?

The Answer:
Most septums (including the long ones) can be resected
transcervically. Perhaps some cases involving very broad septums or
when there are fibroids involving the septum, one might consider a
trans-abdominal resection. The problem with resecting the long ones is
that it takes significant amount of time to complete the procedure and
there is the possibility of large amount of fluid absorption with
consequent fluid and electrolyte imbalance. This is why resection under
fluoroscopy control is better in that we don't need to use much fluid
and it is much faster.


21. April 23, 2008 — “Regrowth” of septum, effect of pregnancy on septum

Comment from the MA consultant:
Recently there have been a lot of
questions about whether a septum can grow back or not. The answer is
no, it can not grow back when it is been resected well. However, it can
re-attach under certain circumstances.

When the septum is not resected in the MID LINE then the retraction
will not be symmetrical, leaving one large segment that can not retract
into the uterine wall and therefore it can attach again to the opposite
side of the septum. This also can occur in cases of a long septum,
even when properly resected, when Pregnancy does not happen soon after
resection. I have always felt the pregnancy is the final factor in
completing the disappearance of the septum, and for that reason I would
not recommend resection of a complete septum if pregnancy is not
planned in the near future.


22. May 4, 2008 — C-section techniques for MA, Resection during birth?

The Question:

Does the presence of a MA (in this case BU/SU combo) change the way
that a c-section is performed? Are there any special risks that should
be considered?

Is it possible to see a uterine septum during the c-section and should
if so, should the septum be resected then?

The Answer:
It all will depend on what the surgeon encounters at the time of the
C/Section. Yes, you can both feel and see a septum at the time of a
C/S. I personally, have never resected a septum at the time of a C/S.
I feel that it might not be the right time to do so for two reasons 1)
because the wall of the uterus is overdistended and the septum may not
retract properly in to the wall 2) the uterus is quite vascular and
there will be the risk of causing significant bleeding.


23. May 6, 2008 — Infertility questions

The questions recently posted re: infertility treatments are very
important and merit a "complex" answer. One most first keep in mind
that Infertility and its treatment (in particular, ovulation
dysfunction) is not an exact science and therefore it is subject to
variation of opinion. Having said that, I'll answer based on what I
have (based on my experience) seen through the years of dealing with
this problem (ovulation dysfunction).

First let me review the normal events of the menstrual cycle: In a
practical manner, the cycle is divided in two more or less equal
parts by the actual ovulation. In the first half (proliferative)
maturation of an oocyte (egg) occurs. Although many eggs respond to
the call, normally only one will continue all the way, whereas the
rest are left "behind." The oocyte matures inside of a cyst
(follicular cyst). The cells of the wall of the cyst secrete
Estradiol (E2), and the estrogen prepares the uterus (stimulates the
growth of the endometrium, cervical mucus production, etc). All this
is mediated by the pituitary gonadotropins (FSH and LH). The second
function of estrogen is via feedback: to maintain the hypothalamus-
pituitary information about what is going on in the ovaries.

When the estrogen level reaches a "critical level" that triggers
the "LH" surge, the consequences of this surge are 1) completion of
the first miotic (genetic) maturation, which largely determines the
quality of the egg. 2) causes the release (ovulation) of the egg,
usually between 36 and 48 hrs from the arrival of the surge. 3)
Reforms the collapsed cyst and this becomes a Corpus Luteum cyst,
responsible for the continued secretion of estrogen and now of
progesterone.

Progesterone is responsible for making everything built by estrogen
become functional and by opposing to estrogen, it "balances" the
cycle. This second half of the cycle is referred as the "luteal
phase".

In the event, that conception occurs, after the implantation, the
early gestation will secrete Human Chorionic Gonadotropin (HCG), and
this hormone (the one that results in a positive pregnancy test) will
continue stimulating the corpus luteum to continue functioning during
at least the first 2 months of gestation. If there is no pregnancy,
then in absence of HCG, the CL. begins to decrease its production of
progesterone and estrogen, and the endometrium without support begins
to shed and a new cycle begins.


24. May 7, 2008 — Late ovulation

Regarding "late ovulation"...

First as a rule, when compared with "normal cycles," cycles with late
ovulation tend to have lower rates of conception, a longer period to
conceive, above average rates for early miscarriage. Therefore,
addressing the issue makes sense.

As I noted before, during the first half of the cycle egg maturation
is the main event. It depends on FSH, which in turn is released by
the pituitary gland after receiving a signal from the hypothalamus.
Once the follicle becomes mature, the LH surge triggers ovulation and
ends the first half of the cycle.

Late ovulation will occur under two situations: when there is a delay
in the maturation of the egg (the most common) and is due to low FSH
or an abnormal FSH/LH ratio, or a less common, out of sync or suboptimal LH surge.

So how do we make the diagnosis? I normally obtain a thyroid function
test and a prolactin level. Other tests ordered will depend on the
particulars of the overall clinical presentation. If the are
abnormalities, that's were the treatment should begin. If the results
are normal, I will do an ultrasound around day 12 or 13 of the cycle.
In this study I look for the size of the dominant egg (maturity) and
the thickness and appearance of the endometrium (function). If the
egg maturation appears to be lagging, then the treatment is aimed to
increase more release of FSH. There is more than one way to do this,
but the first method attempted usually is Clomid (dose depending on
individual bases and the level of stimulation desired). If the
follicle appears mature in the ultrasound, a single injection of HCG
along with progesterone support will be the way to go. Since 2/3 of
the patients who conceive with fertility treatment (regardless of
what level of treatment), do so within 4 cycles, one should give a
fair chance to the treatment (assuming there is good response) and if
there is no conception after 4 cycles, then one most reassess the
treatment a make new recommendations


25. May 10, 2008 — Polycystic ovarian syndrome (PCOS)

Once Insulin becomes elevated it causes several changes and
symptoms. These vary in their degree from patient to patient. First,
the patients begin to gain weight. Most of it locates in the middle
of the body (abdomen) and it is referred as central obesity, this
also includes the intra abdominal organs (visceral obesity). The skin
becomes darker in areas such as the base of the neck, armpits,
groin, and around the waist line (acanthosis nigricans).

At the level of the ovary, it directly stimulates the production of
androgens which compromise egg maturation and overwhelm the
conversion of androgens into estrogen causing the androgens to
release into the bloodstream. Insulin, also by direct effect in the
liver, reduces the production of sex-binding globulin so not only do
the androgens become elevated in the circulation but their "free"
portion becomes elevated as well. This will manifest in increased
oiliness of the skin and acne and darker and thicker (hirsutism) in
the midline of the body (upper lip, chin, between the breasts and
from the umbilicus down). The effect on the ovaries leads to longer
cycles (oligomenorrhea) and eventually to their disappearance (
secondary) amenorrhea and of course with this, a drop in the potential
for conceiving.

In the very early stages of the disease some patients can conceive
spontaneously or with standard IO, however these pregnancies tend to
experience several complications. First, they have about two to three
fold miscarriage rates, there is also evidence that babies exposed to
maternal hyperinsulinemia during the time their central nervous
system is developing (the first trimester) will be more likely to
develop the same problem and even diabetes at very early age. There
is also a higher chance for gestational diabetes, macrosomia (large
babies), and toxemia.

Finally, the main concern is that, patients with this disorder will
become diabetic at much earlier age than the general population.
Because of this, the condition, when clinically suspected, merits a
proper diagnosis and correct treatment. One should never think that
once the patient conceives the problem ends, but rather, attention to
this condition should continue.


26. June 6, 2008 — Incompetent cervix guidelines

IC is one thing everyone talks about but we don't have a way of
making an absolute diagnosis. This is why we see a lack of agreement
as to when and how we should act when we think a patient has IC.
Having said that, the following comments are a summary of what we use
as a guideline when dealing with this issue.

We know that early in its development, the wall of the cervix is very
similar to the wall of the uterus, namely a muscle. With time,
fibrous tissue appears in the wall of the cervix and eventually
becomes the most important component of the cervix. This tissue is
probably what makes the cervix resistant (competent) to funneling and
dilating.

If this is so, then failure in the change on the composition of the
cervix will be the basis for a diagnosis of IC. This also might be
the reason why we see a higher incidence of IC in association with
MA's when compared to women with a normal uterus.(over 20%). This is
the reason why patients with MA (in particular SU and even after
complete resection) should still be followed closely because they
have the added risk of IC.

It is true IC can be caused by trauma to the cervix (at childbirth) or
due to cervical surgery (cervical conization), so patients with this
history should also be closely monitored. It is also true that in
cases of preterm delivery, one most look for other causes and suspect
IC only when no other cause has been found.

So, what do we do if there is the possibility of IC?: If there is a
strong possibility for IC, the early we act the better, the reason
for this, is that to place a cerclage when the cervix is closed and
long has better results. An optimal time will be at the completion
of the first trimester (12 to 14 weeks), otherwise we should follow
the patient very closely to be able to detect any early change in the
cervix.

I hope this helps to understand better this condition.


27. June 11, 2008 — Ectopic pregnancy

As a rule ectopic pregnancy can be caused by any thing that that
interferes with the migration of the early embryo through the
Fallopian tube. These could be anomalies of the Fallopian tube
(Congenital, post infection and/or post surgery), and due to an
abnormal (out of balance) cycle. A diagnosis can not always be made,
but if the tubes look normal, I would check the cycle quality
throughout.

Follow-up Question:
Starlyn, Please thank the list consultant for this response. Can you
ask to clarify what he/she means by an "abnormal (out of balance)
cycle".

The Answer:
The Fallopian tubes are not just a simple conduit but rather they are
quite sophisticated organs. They are important in allowing the egg to
go in to the tubal lumen, the sperm in a different direction,
allowing the process of fertilization to occur, providing them with
their nutrition and finally with their transport towards the uterus
in a properly timely manner.

All of this depends on the condition of the tubes (anatomical,
sequelae post infection, etc) and the hormonal background of the
patient (the estrogen and progesterone levels and the estrogen-
progesterone ratio). The cycle for no having a better term, is out
of "balance" when the hormone levels are inappropriate and/or the
estrogen-progesterone ratio is abnormal.


28. June 16, 2008 — Use of Clomid

The Question:
I'm wondering what the difference between taking clomid CD3-7 and 5-9
are? 1st cycle I took it 5-9, 2nd Cd3-7 Does one seem to produce better
results, higher risk of multiples?

The Answer:
Probably very little difference. Those of us that prefer day 3-7 feel
this is better because it keeps the the length of the cycle to within
28-30 days and we feel that starting the clomid earlier helpts maintain
the level of FSH higher and longer (a desired response).

Regarding the risk of "multiple pregnancies", this is not influenced by
the days one takes the clomid, but rather on whether the dose of clomid
is appropriate for the desired level of the treatment and whether the
patient is properly MONITORED or not.


29. June 24, 2008 — Balloon catheters & progesterone following resection of SU

The Question:
Can you please comment about the use of balloon catheters and
progesterone post-resection?

The Answer:
Whether or not to place a catheter following a resection of a septum
really depends on the surgeon's preference. The reason a balloon
catheter is used is that it keeps the uterine cavity distended and
prevents adhesions from forming and helps the septum to retract better.

I personally, keep the balloon in place only for the duration of the
anesthesia. I have never found any gain by leaving the catheter any
longer, and on top of it, it is quite uncomfortable and runs the risk
of causing an infection. Regarding the use of progesterone, it makes
sense if the patient is taking estrogen post resection, adding cyclic
progesterone will "balance" the effect of the estrogen in the
endometrium. Because of the technique that I use to resect the septum,
I don't need to use hormone replacement.





Last updated on June 26, 2008, by LAA
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