Dear Curious, You are very insightful. Before we had pregnancy tests that detected the hormone hCG, doctors would give women progesterone and if they didn't have a menstrual period it was a sign that they might be pregnant. So checking a pregnancy test is a good starting place. If you are not pregnant, don't worry that happens some time. If you are trying to get pregnant and have to take the progestin every month then you probably still have a hormone imbalance that is preventing ovulation. Your doctor can do some tests to make sure that you have a correct diagnosis and then most likely he/she will prescribe something like letrozole, tamoxifen, clomid or another medication to help you start cycling (ovulating) on your own. Good luck! View Thread
The 0.025 mg patch should not be too much to interfere with your normal cycle. However, clearly something has changed. The patch may have nothing to do with the change in your cycles but you need to get evaluated by your gynecologist or reproductive endocrinologist to find out why you are no longer cycling. The cause of the arrest in your cycles will determine the best course of action. Until you start cycling again, the probability that you will get pregnant is very low. Good luck!View Thread
Dear Anxious & Confused, You are raising more than one issue that is worthy of discussion. First, it is important to know whether you truly had an ectopic pregnancy or was it a nonviable pregnancy of undetermined location. Years ago we used to diagnose an ectopic pregnancy by doing laparoscopy in seeing the pregnancy in the fallopian tube. Today, patients may be treated with methotrexate if we do not find the pregnancy in the uterine cavity and the hCG level does not fall. Some of these pregnancies are not ectopic pregnancies. The pregnancy might be in the uterus and we miss it with the D&C. If you have an ectopic pregnancy then you may have tubal disease and it may be important to evaluate your tubes with an HSG. Second, it is important to understand some basic principles about ovulation (i.e. releasing eggs). If you are not having regular predictable spontaneous menstrual periods without Provera then you are probably not ovulating, at least not on a regular basis. Your ovaries make estrogen during the first half of your menstrual cycle and they make estrogen and progesterone during the second half of your menstrual cycle (after you ovulate). If you are stuck in the first half of your menstrual cycle, i.e. not ovulating, then a menstrual period can be induced by simulating the second half of your menstrual cycle. This involves giving you the hormone that your ovaries are not making (Provera). It would be helpful for you to see your gynecologist again and talk about hormonal reasons that you might not be cycling and medications that may help you begin having regular predictable cycles again. The best news is that you are only 31 years old. As fertility specialists, we can correct many fertility problems but we can't (yet) make women younger. Good luck! View Thread
Having a tubal reversal is a big decision & I commend you for seeking advice first. If I were you I would seek the counsel of a reproductive endocrinologist or gynecologist that can help you assess your ovarian reserve & fertility potential. Our fertility potential changes silently over time. Second, I would investigate both tubal reversal and IVF as independent options. There are pros and cons to each. Tubal reversal allows you to conceive naturally. However, it is surgery and there is a recovery time. There is also the issue of having an increased risk of ectopic pregnancy and the possible need for reproductive assistance anyway. Also once you conceive you have the issue of contraception again. IVF has become much more successful in recent years & it does overcome some of the downsides of tubal reversal. The downside IVF is that your starting over if you don't get pregnant and use although oocytes that were retrieved. My advice would be to seek both personal and professional counsel. Good luck!View Thread
What you are describing is not that rare. There are two potential approaches:
#1 You can undergo an extensive evaluation and plan treatment that addresses all of the potential issues that are identified.
#2 You can make some assumptions about the most likely cause of your problem and initiate therapy without a complete evaluation. This would require you to have a trusting relationship with a healthcare provider who understand your situation.
What you are describing is most consistent with what the World Health Organization calls a type II ovulation disorder. Many doctors and patients refer to it as Polycystic Ovarian Syndrome. A more informative way of describing it may be functional female hyperandrogenism resulting in estrogenic ovulatory dysfunction. This is a fancy way of saying that you have a hormone imbalance involving testosterone and estrogen. Approximately 5% of the adult female population has some symptoms of this disorder making it the most common endocrine problem that women have. Normally women's ovaries secrete estrogen for approximately 2 weeks followed by estrogen progesterone for approximately 2 weeks. Women with this problem often get stuck in the first half of their menstrual cycles and secrete estrogen continuously. Estrogen is a hormone that causes the uterine lining to grow. Over a period of approximately 10 years this unopposed growth can lead to the development of uterine cancer , which you describe. This is often a fairly treatable cancer using high-dose progesterone under the care of a gynecologic oncologist if a woman wants to conceive.
In the absence of cancer, this progesterone-deficiency disorder can be treated with birth control pills, other progestins or ovulation induction to help your body naturally produce progesterone. This latter therapy would increase the chances that you would be able to conceive. There are a number of relatively inexpensive oral medications that can be used to try to induce ovulation if this diagnosis is correct.
Three medications that are commonly used for this purpose are clomiphene citrate, tamoxifen and letrozole. I would recommend that you develop a relationship with a healthcare provider that understand your personal circumstances and is willing to work with you within your resources.
The dose of estrogen that you are on should not prevent you from getting pregnant. However if you are not having regular predictable cycles with a positive ovulation predictor test at the right time, you may have a problem with ovulation that needs to be treated. I am currently treating a patient of mine with estrogen patches while I am also giving her ovulation induction medications to increase her chances of getting pregnant because she does not make estrogen on her own. You should see a gynecologist or a reproductive endocrinologist to help you evaluate your cycles, ovarian reserve, other endocrine factors, etc. Good luck!View Thread
I was almost afraid to respond to this question. However, it's a fun topic to ponder even though it might be opening a can of worms. The simple answer is no. However, experts from a variety of fields could organize an entire medical conference to discuss this question.
Identical twins provide a natural experiment to give us some insights into this question. Identical twins share the same DNA but develop into completely unique individuals. Why? One reason is that we do not express all of our genes. Some genes are turned on and some are turned off. This process is dynamic and appears to start shortly after fertilization and continues through our adult lives. In a sense, our environment influences expression of our genes. This is called epigenetics. Some environmental exposures increase our risk of developing cancer and others may lower our risk of developing heart disease.
This is an exciting area of research because it may be possible in the not-too-distant future to individually tailor medical therapies to individuals based on their known genetic code. For couples who contemplate using eggs from donors, it may also be reassuring to know that the maternal environment may influence the development of their unborn children.
I'm not sure what sparked this question, but it certainly gives us an opportunity to discuss some interesting ideas. Looking forward to see what follows.View Thread
I typically tell patients to wait about 4 weeks after surgery because of the swelling (edema and inflammatory process) that is involved in healing and could theoretically increase your risk of an ectopic. However, I did do a tubal reversal once in early-November and the patient didn't take my advice and had a positive pregnancy test on Thanksgiving. Good luck!View Thread
I delayed responding because I wanted to consult with an infectious disease specialist at Duke first. What I have learned is that it is difficult to know how to accurately counsel you about when it is safe to have unprotected sex. Most of the avaialable data reports levels of immunity after the 3rd dose of the vaccine. One option would be to have your husband's immunity checked by asking his doctor to try to estimate his current level immunity by ordering an antibody test to hepatitis B. Alternatively, you can just wait until he gets his 3rd dose of the vaccine and use the estimates of immunity that currently exist. Here is a package insert to Merck's vaccine if you want to read in more detail. http://www.merck.com/product/usa/pi_circulars/r/recombivax_hb/recombivax_pi.pdf Good luck.View Thread
Yvette, It is hard to give you accurate statistics because the rate of decline in fertility varies a lot from woman to woman and we lost the ability to observe your fertility potential when you had your tubes tied. You are at a higher risk of miscarriage now than when you were younger and you are at a higher risk of an ectopic than before you had your tubes ligated. However, your ovarian reserve sounds like it is hanging in there. If you're OK with a little risk and are in the hands of a health care provider that you trust, I think that I would remain hopeful at this point. If you want to maximize your chances of success and have the resources, I would probably try on your own or with some gentle ovulation induction for 3-6 months and then jump to IVF if that doesn't work and you are getting frustrated. IVF can maximize your fertility without significantly increasing your risk of multiples. If you have the resources, IVF centers are increasingly acquiring the ability to examine the genetics of blastocysts (day 5-6 embryos), which allows couples to transfer embryos that are chromosomally normal (46xx or 46xy). This is expensive but it almost eliminates the effects of age on fertility following an embryo transfer based on data presented recently at the American Society for Reproductive Medicine meeting in San Diego. Good luck.View Thread