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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:
- Wait 3 months and talk to Gyn MD and have a endocervical currettage to "resolve" at time of a colposcopy.
- Talk Gyn into doing that now.
- Get Pap in 3 months and see what it shows.
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.
You will ovulate 2 weeks before your period but in general, no period means no ovulation except possibly within the last two weeks.
I don't know.
That's consistent with no ovulation.
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.
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.
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.
14 days prior to your expected menstrual period.
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.
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.
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 one pill shouldn't delay menses. Average time to menses after pills is about 6 weeks.
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.
Here are a couple of articles that refer to uterine prolapse and subsequent pregnancy. Both cases resulted in successful outcomes.
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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.
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J Reprod Med 1984 Aug;29(8):631-633
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.
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.
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Tohoku J Exp Med 1997 Sep;183(1):55-65
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.
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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
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.
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%.
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.
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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