Womens Health

Considering Pregnancy: What You Need to Know

DES history and abnormal Pap

No menses coming off BC pills

What to look for checking BBT

How long before conceiving after laparoscopic ovarian surgery?

Average time to menses after stopping pill

Does cervical mucous color indicate ovulation?

Prolapsed uterus but want to become pregnant

Ruptured uterus in last pregnancy

Possible Asherman's Syndrome - uterine scarring after D&C

Is IVF with lesbian partner possible?

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DES history and abnormal Pap

I am 29 years old and my mother took DES while she was pregnant with me. I am planning on starting a family soon. In 1996, I had a abnormal PAP. My doctor did a colposcopy (sp?) and found everything was normal. Now, for the second time I have another abnormal PAP with atypical glandular cells. The doctor mentioned something about immature metaplasia (columnar cells/inside the cervix). She wants me to wait three months and redo the PAP to see if the cells have returned to normal. My question is..because we will be trying to conceive soon, should I request to redo the PAP sooner(or have a colposcopy). Would it be wise to get this resolved before we try to conceive? Also, what impact does DES have on this situation?

Since your first abnormal Pap "went away" fairly quickly, your doctor is on the right track to just wait for the next Pap. Wanting to get pregnant soon complicates things and I agree that you might want to get this resolved.

The history of DES both lessens and worsens concerns. On the one hand we worry about cancerous changes because of the DES and on the other hand, the glandular changes of DES will lead to more "atypical glandular cells of unknown significance". Since you want to get pregnant soon and have this resolved, I would favor an office endocervical currettage at the time of a colposcopy. That way if there is any cancerous or dysplasia changes up in the endocervical canal you can get that diagnosed and treated.

You should get this resolved before conceiving. The options would be:

  1. Wait 3 months and talk to Gyn MD and have a endocervical currettage to "resolve" at time of a colposcopy.
  2. Talk Gyn into doing that now.
  3. Get Pap in 3 months and see what it shows.


No menses coming off BC pills

The last day of my first period was the same time I stopped taking birth control because I'm trying to get pregnant. Today it's been 36days since my last period. I've taken two tests, but they were both negative. Is it possible that tests were taken too soon. (taken 6 days ago)? I've been on the pill and then got off and I never remember there being a huge lapse in between periods after I got off the pill, maybe just a week later than usual. I have no symptoms of pregnancy. ie, sore breasts or nausea.

History-- I've been on the pill on and off for about 8yrs. I had a urinary tract infection 3wks ago and took Augmentin to clear it up. Can you please tell me if I could be pregnant? If I'm not, then that means I can't ovulate until after I start my next period right? What could be holding it up?

Ovulation can be delayed after coming off pills even though that's not what happened to you before. There's no way of telling if you are pregnant or have had delayed ovulation except by pregnancy symptoms or periodic pregnancy tests. Usually if women have not had a period (or become pregnant) for 3 months, it's time to induce a period with progestins. Sometimes that's enough to get you ovulating. If it doesn't, then you may need a work-up for anovulation at that time.

I still have not started my period. I was wondering can I still ovulate even if i haven't had my period??

You will ovulate 2 weeks before your period but in general, no period means no ovulation except possibly within the last two weeks.

Also, there has been a few times this last month where I experienced a very thick milky discharge when having sex, and a lot of it. Can you tell me what this may be??

I don't know.

I've been keeping my BBT and it does the usual up and down thing.

That's consistent with no ovulation.

When should I go see a doctor?

Go ahead and make an appointment for about 3 or 4 weeks from now. If no menses by then, the doctor will probably start you with a progestin withdrawal.


What to look for checking BBT

What is the most reliable way to tell when you are ovulating?

For us, a serum progesterone about day 24 of your cycle that is over 2.5. For you, an ovulation predictor kit in which you check your urine daily around time of expected ovulation for LH.

When checking your BBT what exactly are you looking for?

An elevation in the temperature of about 0.4-0.6 degrees F in the second half of the menstrual cycle over the baseline temp of the first half of the cycle. Usually the rise is preceded by a slight dip in temperature which is actually when you ovulate.

When are you most fertile?

14 days prior to your expected menstrual period.

Is it true that sperm can live for up to three days once inside the uterus?

They can live up to 7 days in the crypts of the cervix glands and periodically shower the uterus and tubes. I think inside the uterus they only last about 2 days, but 3 days wouldn't surprise me.


How long before conceiving after laparoscopic ovarian surgery?

I am 16 days post laparoscopy for adhesions and an ovarian dermoid cyst. I have been advised by my RE to wait 6wks after surgery before trying to conceive. He said the ovary needed time to heal. Can you explain why? Also unfortunately I found out to wait until we had already tried. If pregnant, what could be the consequences of not waiting the 6 weeks?

Should be ok. Main reason to wait is that ovary is in state of shock due to surgery and won't ovulate so chances are less of getting pregnant. Also, recommendation for no sex is so that there is no chance of infection introduced to the healing ovary. Assuming you didn't get infection ( would be evident by 3-7 days after surgery with fever and increased pain) then there shouldn't be a problem.

You can resume sexual relations within 2 weeks but it's best to use additional protection to just let the tissues heal.


Average time to menses after stopping pill

I also took 3 pills out of a new pack of pills, however my problem is the opposite! Three days after I stopped taking the pill I started a menses! My problem is I have had some rather large clots and I am worried!

In your case, there was more endometrium present either because your own estrogens were higher on the 3 days of the pill and they built up some endometrium. If the large clots don't slow down to spotting only by seven days, you should call your doctor to see if you shouldn't go ahead and restart the pills over one more cycle. Next time it would be better to stop the pills at the end of a cycle.

The first day of my last period was Aug.3 (monday), at that time I was taking the blue pills (B.C.P) that following Sunday I took my last pill, which was the first (white)pill of a new pack. The next day, I decided to stop take taking the pill to try for a baby. It's now been 44 days since my last period. Is it because I started one pill out of my new pack? What's the average delay of a period after getting off the pill?

The one pill shouldn't delay menses. Average time to menses after pills is about 6 weeks.


Does cervical mucous color indicate ovulation?

Can you please tell me whether the appearance of egg white cervical mucus always indicates ovulation.

Color is not that reliable. Most cervical mucous is often clear color. By egg-white, you mean clear like white (albumin) part of egg BEFORE it's cooked. The stretchability of the mucus is a pretty good sign though. At ovulation you can usually stretch the mucus about 6 inches or more. These signs are good but not perfect.


Prolapsed uterus but want to become pregnant

I would like any information from you on becoming pregnant with a prolapsed uterus. I would like to have a third child. I have two already, yet after my second one, my prolapse became worse. I was told it would be fine to conceive, carry and deliver with the prolapse. I was wondering if anyone has been through this.

Here are a couple of articles that refer to uterine prolapse and subsequent pregnancy. Both cases resulted in successful outcomes.



Successful pregnancies and vaginal deliveries after sacrospinous uterosacral fixation in five of nineteen patients.

Kovac SR, Cruikshank SH

Department of Obstetrics and Gynecology, St. John's Mercy Hospital, St. Louis, Missouri.

OBJECTIVE: We sought to determine whether sacrospinous uterosacral ligament fixation restores the uterus to its normal anatomic position, preserving uterine function and allowing future childbearing.
STUDY DESIGN: This study was undertaken at two separate medical centers. Women with symptomatic uterovaginal prolapse who desired either uterine preservation or future childbearing were included.
RESULTS: We successfully performed sacrospinous fixation of the uterosacral ligaments in 19 patients. Five patients have since been delivered vaginally (for a total of six deliveries). Normal anatomic restoration was accomplished in all but one patient.
CONCLUSIONS: Sacrospinous uterosacral ligament fixation is an acceptable surgical means to care for symptomatic uterovaginal prolapse in women desiring uterine preservation or future childbearing. To our knowledge, this is the first report of successful pregnancies and vaginal deliveries after sacrospinous uterosacral fixation.



J Reprod Med 1984 Aug;29(8):631-633

Uterine prolapse complicating pregnancy. A case report.

Hill PS

A patient developed uterine prolapse during pregnancy. Conservative management consisted of bed rest and use of a pessary. A viable infant was delivered at 30 weeks' gestation following premature rupture of the membranes. A review of the literature suggests that maintaining conservative treatment of these patients throughout pregnancy can result in uneventful, normal, spontaneous delivery.



Ruptured uterus in last pregnancy

Last year, my uterus ruptured during labor and I lost my baby girl. I was 39 weeks and my doctor scheduled me for a foley bulb induction of labor because I had a previous C-section in 1994 with my son due to the fact that I was 2 and a half weeks late and was induced but only went to 4 cm.

Overnight I passed the foley bulb and was at 4cm at 9am. They then started the pitocin and I was at 8cm at 3pm 10 cm at 4pm and pushing. I had an constant epidural and was doing well pushing. My husband and mom saw the baby's head and all of a sudden I was in tremendous pain and was screaming and throwing up green bile the nurse felt it was a contraction and started moving me all around and unfortunately I had no doctor there. Finally the decision was made after 45 minutes of screaming to catheterize me and do a C-section. when they went to catheterize me they found out that not only had my uterus ruptured but also my bladder. Unfortunately they were unable to save our little girl and were almost unable to save me. The baby had gone straight thru my uterus and bladder and into my abdomen.

I am now with new doctors and they have done a ultrasound and MRI to see the condition of my uterus and determine whether or not I will be able to carry another child. The MRI showed signs of a thin wall so they are doing a laparoscopy and hysteroscopy tomorrow to get a better look and give us hopefully good news. Uterine ruptures are rare so I have not been able to find any information on them and future pregnancy. I want to make a completely informed decision of whether or not to get pregnant again. There's nothing in this world that my husband and I want more than to be able to have another child but we can't take a risk of another baby's life or my own. Please if you have any information at all about this or know where I can find some, let me know.

You are correct that uterine rupture is rare and that pregnancy after repair of a uterine rupture is even rarer. I couldn't find anything written about that and have never had a patient in that situation.

While you certainly would be high risk for repeat uterine rupture, the thinness of the scar can be followed with ultrasound throughout pregnancy. We don't so that routinely because it isn't common but in your case it could be done. I've enclosed an abstract about following uterine scars with ultrasound.


Tohoku J Exp Med 1997 Sep;183(1):55-65

Ultrasonographic evaluation of lower uterine segment to predict the integrity and quality of cesarean scar during pregnancy: a prospective study.

Qureshi B, Inafuku K, Oshima K, Masamoto H, Kanazawa K

Department of Obstetrics and Gynecology, School of Medicine, University of the Ryukyus, Okinawa, Japan.

A prospective randomized study was conducted to measure the serial thickness of the lower uterine segment (LUS) by transvaginal ultrasonography in a control group of 80 women having no history of uterine surgery and in a study group of 43 women having a history of previous cesarean section (C/S). In the study group, more than 2 mm of thickness of the LUS was considered as good healing and less than 2 mm of thickness as poor healing. After serial sonographic examination, the women with good healing were given trial for labor unless an obstetrical indication for C/S existed. The appearance of the LUS during surgery was compared with antenatal ultrasonographic assessment by direct inspection. Twenty two (79%) of 28 women with a well healed scar had trial labor with the result that 46% had a successful vaginal birth without any uterine rupture of dehiscence. Eight women with poor healing all had elective C/S. Seven women with a 2 mm LUS thickness were individually categorized for delivery mode. Two of those women delivered vaginally. The LUS was found to be thin to translucent in these later two groups. Two mm or less as a criterion for poor healing had the sensitivity and specificity of 86.7% and 100% respectively. The positive predictive value was 100% and the negative predictive value was 86.7%. Ultrasonographic evaluation is effective in predicting the quality of a uterine scar and in differentiating the risk group of probable uterine rupture from the non risk group.



Here is another abstract that notes 8 cases of uterine rupture that were repaired and subsequently had pregnancies and were delivered by Cesarean section.

Int J Gynaecol Obstet 1996 Jan;52(1):37-42

Pregnancy following rupture of the pregnant uterus.

Soltan MH, Khashoggi T, Adelusi B

Department of Obstetrics and Gynaecology, King Khalid University Hospital, Riyadh, Daudi Arabia.

OBJECTIVE: To review the cases of ruptured uterus at King Khalid University Hospital (KKUH) over the 11 years of the hospital's existence(1984-1994), to analyze the causative factors of uterine rupture with a view to its prevention, and to highlight the management approach in relation to maintaining the patients' future fertility.
METHODS: Case notes were reviewed for all patients with ruptured uterus at KKUH over a period of 11 years from January 1984 to December 1994. Relevant data relating to the clinical features, characteristics of labor, operative procedures, and maternal and perinatal outcome were assessed.
RESULTS: There were 11 cases of ruptured uterus, six of which occurred in patients with previous cesarean scars. Two patients were primigravidas, one of whom ruptured her uterus following a road traffic accident. In one patient with six previous preterm labors, rupture resulted from non-removal of cervical cerclage during labor. The rupture occurred in the fundus in one case, and in the lower segment in the remaining 10. Fetal heart abnormalities were observed in all cases in which the uterus ruptured during labor. Abdominal hysterectomy was performed in three cases, two of which were total and the third subtotal. The remaining eight patients had suture repair, all of whom became pregnant later and were delivered by cesarean section.
CONCLUSION: Even though rupture of the uterus was a rare complication of pregnancy at KKUH, it occurrence should be suspected when there are sudden fetal heart abnormalities during labor, or unexplained postpartum shock. Suture repair should be considered whenever possible in order to preserve the patients' reproductive potential.



Possible Asherman's Syndrome - uterine scarring after D&C

I am 26 years old. I had one normal pregnancy with an emergency C-section. I went on the pill again for 2 1/2 years. Stopped the pill and got my period 4 months later. I had two normal periods and then got pregnant. Seven weeks into the pregnancy, I started to miscarry (the hormones were not increasing). I had a D & C on the advice of my doctor. Its two months later and I still haven't had my period. Pregnancy test is negative. I've been placed on .625 mg Premarin® for 25 days, followed by Provera® for 10 days. I was told that if I didn't have my period I have to have another D&C. Is this normal?

I must say I'm in a panic. I got off the birth control to have another child. He told me he thought I might have Asherman's Syndrome. Can you elaborate a little; what does it mean?

Based on the fact that it took you 4 months after your first pregnancy to ovulate and have a period, I don't think its unusual for you to have gone 2 months after this pregnancy without a period. In fact, anovulation rather than Asherman's Syndrome would be the most likely diagnosis.

Asherman's syndrome is the formation of intrauterine adhesions. These adhesions can obliterate the endometrial cavity. The most frequent cause of Asherman's is curettage associated with pregnancy - either after a term delivery or a miscarriage. For certain types of miscarriages, the incidence of Asherman's syndrome is as high as 30%.

What kind of success do people have with hormones? Or do you usually have to have surgery? I feel like I'm too young to be going through this. Please shed some light on this.

There is some controversy in the literature about the use of hormone therapy to diagnose suspected Asherman's. Most women with the syndrome will have a withdrawal bleed following the regimen your doctor gave you so it's relevance as a test in this situation is not certain but it should give you a withdrawal bleed and won't hurt you. Hysteroscopy is the surgery needed to diagnose Asherman's Syndrome. I don't think you would need that yet.

After you take this sequential estrogen/progestin regimen, if you have a period, I would probably wait and do nothing for the next two months to see if you start menses on your own. Your doctor could check serum progesterone levels every couple of weeks to see if you ovulate. If you ovulate (serum progesterone above 2.5 ng/ml) and still don't have a period, then Asherman's is a real consideration and you may need to have the hysteroscopy. If your serum progesterone never rises, then you are not ovulating and the doctor may want to investigate that and treat rather than going first to hysteroscopy.

Remember that the odds are that you will start your menses on you own and that you don't have an "Asherman's" problem. Your doctor may suggest avoiding pregnancy (use other contraception) until this is straightened out just so you and he won't get doubly confused when you don't have a period.


Is IVF with lesbian partner possible?

My lesbian partner and I are wondering how we would go about the process of taking my egg, and fertilizing it with a sperm donor, and then inseminating the fertilized egg into my partner. She will then go through the pregnancy from there. Question is...is this possible? What information could you give us on this complicated issue i.e. complications, pricing, suggestions?, etc.

You need to make an appointment to see a reproductive endocrinologist who performs advanced reproductive technology techniques such as invitro fertilization.

Basically they induce you to ovulate with medications (usually so there is more than one egg). At the time just before ovulation, they use a needle through the vagina to aspirate the eggs from the ovary and then mix them with the sperm sample in the laboratory. Then after about 48 hours, one or more fertilized eggs are placed back into your partner's uterus which has to be exactly in phase with yours (controlled my medications they will give you. This success rate is about 30% to get pregnant each cycle they do. Cost per cycle ranges from $5000-$10000 plus the cost of the semen samples which are about $600 if obtained from commercial labs.

You may run into some RE's who won't take you in a program because of objections to your life style, but I would imagine about 90% would be pleased to have you in the program because, presuming you don't have infertility, your odds of conceiving are quite high (maybe more than 30% per cycle) and there is substantial competition to have high pregnancy rates to quote others.

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