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So Your Uterus is Bicornuate? Check Again, and Again

This is an issue I have been dealing with since the start of my practice. It’s the identical story over and over again. I came across the same thing 2 times this month. The issue is far from trivial because the proper diagnosis will change the method of treatment. Delayed diagnosis (sometimes for years) will delay and sometimes prevent pregnancy.
OK, what’s a bicornuate uterus? A bicornuate uters is an abnormality in the way the uterus is shaped. It does not develop; some women are born with them. Uterine and/or vaginal abnormalities that are present from birth are lumped into a category of Mullerian Abnormalities. There are many different varieties, and all are rare.
In a girl embryo, the uterus starts as 2 tubes that merge together to form a larger hollow structure. If the 2 tubes do not completely come together, a bicornuate uterus develops. It is a uterus with 2 horns , one going out to the left and one going out to the right.
This is a very general description. There are tons of variations. Some bicornuate uteri have larger horns and are not connected in the middle, and others are mostly connected in the middle with just a small amount sticking out as horns.
Here’s the rub. I have seen many patients who were told they have bicornuate uteri but their real diagnosis was a septum. This mistake has happened even if the patient had a HSG, 3-d ultrasound, 3-d sonohysterogram, MRI or even hysteroscopy.

So what? It’s a big what. The uterus with the septum is smooth over the top. The bicornuate dips at the top, sometimes considerably. Next time we will talk about what the difference can mean to a woman who is infertile or having miscarriages. I’ll try to get some pictures to make it easier.
Dr. Licciardi

References:

  • The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, mullerian anomalies and intrauterine adhesions. Fertil Steril 1988; 49:944-55.
  • Jones HW, Jr. Mullerian anomalies. Hum Reprod 1998; 13:789-91.
  • Troiano RN, McCarthy SM. Mullerian duct anomalies: imaging and clinical issues. Radiology 2004; 233(1):19-34.

Sperm Deficient Females Can Be Quite Fertile

This is a phenomenon that I have observed since I started practicing. Basically these are women who are not exposed to sperm ie: single and or lesbians. When I consult with such women I go through all the possible treatment options, but say, “It may just be that you are sperm deficient, and with just a whiff you could be on your way.” I like saying this because it usually invokes a little smile.

As we have discussed, women who have not become pregnant after 6-12 months of trying have low fertility rates going forward. Not getting pregnant means there is a problem that will stick with you until you get help. If a woman has not yet tried, her fertility may be quite high, and one of the most important points here is this is especially true in older women. If a 43 year-old woman has been trying with her sperm-filled husband for a year, I would be eager to treat her. However I would need to tell her it’s going to be a rough road that may not get her to pregnancy.

I am much more optimistic with a 43 year-old sperm-deficient woman. Here I go through the options and say, “Listen, I don’t know about your journey. We need to forget about your age and get you some sperm. If you not pregnant after a while, then we’ll start worrying”.

Now I still need to check the FSH, but even if it’s borderline I don’t worry much. It is also true that some of these women want to go straight to IVF. This is never a bad idea, but a few months of insemination may be all they need. So this entry is not meant to delay anyone’s treatment. If you are thinking about getting pregnant, try as soon as you can. Waiting is always a big mistake.

Your best chances of getting pregnant come from calling a qualified specialist. Taking that step is an easy phone call. Waiting is rolling the dice.

Microdose or Microflare or Flare Lupron

We talked about Lupron preventing the pituitary from producing FSH and LH. Well, there is a little more to the story. When Lupron is first given, maybe for the first 2-3 days, it actually causes a burst in the production in FSH and LH. Any FSH of LH that has been produced in the cells of the pituitary gland gets released. However, that’s it. Once the FSH and LH are squeezed out, no more gets made and there is no more to stimulate the ovaries. We call this few day burst a “flare”. Sometimes we take advantage of this flare in our stimulation protocols.

If FSH stimulates the ovaries, maybe if we can get the body to pump out extra FSH, as the Lupron does, we can improve the response to the drugs, especially in women who do not respond well to the standard drug protocols.

Microdose and Microflare are the same things. The Lupron dose is very low, 1/50th of the standard day 21 dose. Because of the low dose it needs to be given twice a day. This gets enough Lupron on board to give a little flare and there is enough lupron around to prevent premature ovulation. This was the protocol we used in poor responders before Antagon was invented. I still think it’s an excellent protocol for poor responders and occasionally use it. I like the Antagon better because it’s a lot easier for the patients and nurses (fewer injections). Many times oral contraceptives are used in the month prior to the Lupron start.

Flare. This is a mega flare. It uses full strength lupron starting on day 2, usually along with the FSH, to really take advantage of the body’s FSH. Overall, this protocol is not great; I haven’t had much luck with it. However, some clinics are very comfortable using it regularly. It’s all about personal preference and personal experience.

Sometimes this flare effect is a bad thing, particularly in women who take daily Lupron starting day 21. The burst of FSH and LH can be enough to stimulate the ovary to make a cyst that remains present on day 3. Here we need to keep women on the Lupron until the cyst shrinks, which could be 5-10 days.

Thanks for tuning in, and please read disclaimer 5/17/06.
Dr. Licciardi

References:

  • Schmidt DW, Bremner T, Orris JJ, Maier DB, Benadiva CA, Nulsen JC. A randomized prospective study of microdose leuprolide versus ganirelix in in vitro fertilization cycles for poor responders. Fertil Steril. 2005 May; 83(5):1568-71.
  • DiLuigi AJ, Engmann L, Schmidt DW, Benadiva CA, Nulsen JC.  A randomized trial of microdose leuprolide acetate protocol versus luteal phase ganirelix protocol in predicted poor responders. Fertil Steril. 2011 Jun 30; 95(8):2531-3.