You are currently browsing the Dr Licciardi blog archives for July, 2006.

Uterine Scar Tissue After a D and C

This week I dealt with 2 patients who had a previous D and C, and both had potential issues. The first had a simple D and C for a first trimester miscarriage. Uterine scarring in this case is very rare. While most people having an infertility workup should have a hysterogram to look for scarring, we generally are not concerned about scarring after one or more early uncomplicated D and Cs. On ultrasound I observed an area of the uterus that looked as if it may be scarred so I performed another hysterogram. To my surprise, a scar was present and I removed it via hysteroscopy. Hopefully all will be well. Unfortunately, despite our best efforts, scarring may reoccur in a small percentage of patients.
The second woman needed a D and C later in the pregnancy. At 19 weeks the fetus was diagnosed with Down’s Syndrome, and she underwent a D and C. Now a D and C performed in the second trimester is much more risky. The odds of scarring are much higher. After a second trimester D and I have all my patients get another hysterogram. In this case, her uterus looked fine and she will try again without the need for a hysteroscopy.

References:

  • March CM. Management of Asherman’s syndrome. Reprod Biomed Online. 2011 Jul; 23(1):63-76.
  • Tuuli MG, Shanks A, Bernhard L, Odibo AO, Macones GA, Cahill A. Uterine synechiae and pregnancy complications. Obstet Gynecol. 2012 Apr; 119(4):810-4.
  • Cooper JM, Houck RM, Rigberg HS. The incidence of intrauterine abnormalities found at hysteroscopy in patients undergoing elective hysteroscopic sterilization. J Reprod Med. 1983 Oct; 28(10):659-61.

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PCO: Pretty Cute Ovaries?

OK, now that I got some of that cyst stuff out of the way we can move on to

PCO, which stands for “Poly Cystic Ovaries”. Describing this entity to a patient is a killer because of the terrible name. The typical first questions are “I have cysts? What kind of cysts? Do I need surgery? Are they cancer?” And it goes on and on. The cysts in this case are nothing more than small follicular cysts, which we all now know are normal. They are tiny, but visible on ultrasound, fluid filled cysts that have an egg inside each one. The difference here is that there are more than we usually see. Normal is less than 12.

Many women have polycystic ovaries. Some such women have regular periods and have no trouble with reproduction. Some have periods that are a little longer than usual, say 35-42 days, but still get pregnant easily. Others have periods that are even further apart, maybe 60-90 days, which does make it difficult to get pregnant. On top of these irregularities, some women with PCO also have one or more of the following: obesity, excessive hair growth, diabetes, and elevated cholesterol levels. When one person has a few of the characteristics, not only do they have polycystic ovaries, we say they have “Polycystic Ovarian Syndrome”. The traits of this syndrome vary considerably from woman to woman. Some have very striking features of all of the signs; some have just 2 subtle signs.

A big part of the syndrome is Hyperandrogenemia, which means excess androgens in the blood stream. Androgens are testosterone and other similar hormones. Normal women have androgens, in fact they are important for normal ovarian function. It’s when there is an excess of the androgens that people develop the abnormal hair growth.

It’s really hard to tell a patient she has “a syndrome”. Some doctors even call it polycystic ovarian “disease”. I don’t like to use either word. Again we have an entity with a name that just make matters worse for the patient. If we called PCO Pretty Cute Ovaries we would be doing a great service to the patient’s sense of well being. More to come.

References:

  • Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod 2004;19:41-7 (also Fertil Steril 2004;81:19-25)
  • Legro RS, Barnhart HX, Schlaff WD, Carr BR, Diamond MP, Carson SA, Steinkampf MP, Coutifaris C, McGovern PG, Cataldo NA, Gosman GG, Nestler JE, Giudice LC, Leppert PC, Myers ER; Cooperative Multicenter Reproductive Network. Clomiphene, metformin, or both for infertility in the polycystic ovary syndrome. N Engl J Med 2007; 356(6):551-66.
  • Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Consensus on infertility treatment related to polycystic ovary syndrome. Hum Reprod 2008;23:462-77 (also in Fertil Steril 2008;89:505-22.)
  • Azziz R, Carmina E, Dewailly D, Diamanti-Kandarakis E, Escobar-Morreale HF, Futterweit W, Janssen OE, Legro RS, Norman RJ, Taylor AE, Witchel SF; Task Force on the Phenotype of the Polycystic Ovary Syndrome of The Androgen Excess and PCOS Society. The Androgen Excess and PCOS Society criteria for the polycystic ovary syndrome: the complete task force report. Fertil Steril 2009; 91:456-88.
  • Goldzieher JW, Axelrod LR. Clinical and biochemical features of polycystic ovarian disease. Fertil Steril 1963; 14:631-53.

The doctor said I can’t start because I have a cyst.

These are usually just “leftovers”. The normal cysts of ovulation dissolve away just before the period. An ultrasound on day 2 or day 3 usually shows no cysts. There may be small follicles (normal follicular cysts) but nothing over about 10 mm. However, sometimes the scan shows larger cysts. They can be black looking on the scan, these are filled with clear fluid. Sometimes they are grey in appearance, these are filled with blood. Whether or not you start is related to your estrogen level and the philosophy of your doctor.
If the cyst is producing estrogen (can’t tell by looking, need to wait for blood results), the cycle can’t start. Taking fertility drugs will do nothing more than make the big cyst bigger. If the estrogen is low, starting would be fine. An exception would be if the doctor is concerned about the consistency of the cyst and wants to follow the cyst over 1-2 months to be sure it shouldn’t be removed.
Some doctors don’t like starting the drugs even if the estrogen is low. They will tell you to wait a month. I don’t have a problem with that, it’s their call.
Cysts are much more common in women doing “back to back” cycles. The drugs cause multiple follicles to grow, and there may not be enough time for them to all dissolve before the period.

References:

  • Penzias AS, Jones EE, Seifer DB, Grifo JA, Thatcher SS, DeCherney AH. Baseline ovarian cysts do not affect clinical response to controlled ovarian hyperstimulation for in vitro fertilization. Fertil Steril. 1992 May; 57(5):1017-21.
  • Qublan HS, Amarin Z, Tahat YA, Smadi AZ, Kilani M. Ovarian cyst formation following GnRH agonist administration in IVF cycles: incidence and impact. Hum Reprod. 2006 Mar; 21(3):640-4.
  • Keltz MD, Jones EE, Duleba AJ, Polcz T, Kennedy K, Olive DL. Baseline cyst formation after luteal phase gonadotropin-releasing hormone agonist administration is linked to poor in vitro fertilization outcome. Fertil Steril. 1995 Sep; 64(3):568-72.
  • Hornstein MD, Barbieri RL, Ravnikar VA, McShane PM. The effects of baseline ovarian cysts on the clinical response to controlled ovarian hyperstimulation in an in vitro fertilization program. Fertil Steril. 1989 Sep; 52(3):437-40.