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Heavy bleeding after ectopic pregnancy. Taking medicine. Is this a sign for bad fertility?

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Dr. Aarti Abraham

OBGYN

Practicing since :1998

Answered : 6009 Questions

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Posted on Mon, 11 Feb 2013 in Infertility Problem
Question: I ovulated regularly on CD 13 for six months in a row (monitored with ultrasound). The only known fertility issue was low AMH. But I had an ectopic pregnancy. Since the ectopic, I seem to have ovulated on CD 16/17 for the first three full cycles after the miscarriage (according to ovulation predictor kits) and my cycles have been a few days longer. I also stopped spotting before my period. Could this be the new normal? What could have caused this change? Is this new, later ovulation pattern a good sign or a bad sign for my fertility? (The only other difference in my lifestyle is that I've been taking extra vitamin D and extra folic acid to help my body get back to normal after the methotrexate and surgery.)
doctor
Answered by Dr. Aarti Abraham 2 hours later
Hello XXXXXXX
Thanks for trusting us with your health query.

The ovulation pattern per cycle normally varies by a few days from woman to woman. Also, after surgery, stress and obviously a pregnancy ( albeit, ectopic ), it is normal for the period pattern to vary slightly.

I would not read much into the change in ovulation by 3 days or so. It is not at all an indicator of either deteriorating or improving fertility. The pre menstrual spotting has stopped, which is a good sign, as it indicates regularity in periods.

This might be the new normal, or the pattern might again vary by a few days, which is not significant, as I mentioned.

Of concern is your unexplained infertility ( though a low AMH is a contributory factor, so I would not term it unexplained ) . A low AMH indicates poor ovarian reserve - decreased capacity to produce eggs ( follicles ) in proper number, and proper quality. In fact, it could be one reason for your ectopic pregnancy, as oocyte quality is also affected by a low AMH, leading to abnormal implantations such as seen in ectopic pregnancies, miscarriage, and obviously infertility.

I would suggest continuing folic acid and vitamin D, and consulting a good Infertility practitioner, who would help you with further investigations and treatment.

After an ectopic pregnancy and surgery, the status of your fallopian tubes becomes an additional factor which might contribute to infertility.

At 34, you should go in for ovulation induction and IUI / IVF as deemed necessary by your reports.

Take care, and feel free to ask for further clarifications.
A newer molecule, DHEA , has been recently highlighted to have a positive role in women with low AMH.
Please discuss with your doctor regarding DHEA supplementation also.



Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Aarti Abraham 13 hours later
Thanks, Dr. Abraham!

I'm glad to know this recent change in my cycle doesn't indicate any particular change in fertility. I remembered that when my cycles shorted from 28-days to 26-days, my Ob-Gyn sent me to get my AMH checked for failing ovarian reserves. So I was very nervous when it changed again...

I think I might have misunderstood the specialist I saw to get my AMH checked. She seemed to think that as long as my FSH, LH, Estradiol, and antral follicle count stayed in a reasonable place (7.7, 7.7, 61, and 10-14), the AMH probably wouldn't affect my egg quality. She also did some 'empirical therapy/testing' and she seemed extremely enthusiastic that a 50mg round of Clomid produced three mature follicles and estrogen of 1100. She said that estrogen was unusual high for a single Clomid dose? I can see why that might seem like a good thing for a fertility doctor--since her prescription is working even more effectively than expected--but I wasn't sure what that said about the health of my ovaries. Wouldn't it be better to have a more typical reaction? Do you think that she was right to be encouraging? Or could I have misunderstood her (it was a very quick appointment...)?

Her clinic said that with everything that had happened I could call them back to arrange IUI or IVF when my body had recovered from the surgery. But they were going to let me pick which to try. Of IUI, IVF, and natural cycling, which would you suggest to a patient after an ectopic? I had the first ectopic during the Clomid round. So now I'm nervous that this whole thing happened because we started messing around with my body. I heard that artificially elevated hormone levels can make the chances of another ectopic higher. But, obviously, there was already some sort of problem--we were trying timed intercourse for six months before that with no luck. And I don't have much time left... So really I don't want to have to take another three or four months off for a second ectopic.

Would it be okay to start taking the DHEA you mentioned like I would any other vitamin--since I'm obviously having trouble with my ovarian reserves? Or is it something that requires hormone testing first, like the Clomid?

I wish that the specialists were as good at explaining what is going on as a GP... We really do want to have a baby. But we don't entirely understand what is going on with my body (so it's hard to pick between the choices the specialist is offering us).
doctor
Answered by Dr. Aarti Abraham 4 hours later
Hi again XXXXXXX
The FSH, LH, Estradiol and AFC ( antral follicle count ) are all fine, so I would like to know just how low is your AMH.
Also, she is right in pronouncing that a good response to clomiphene does mean that the ovarian reserve is not as low as the AMH indicates. You did not misunderstand that. Three good follicles and a good estrogen level indicate that the ovaries responded well to clomiphene.
It makes sense to wait for atleast a couple of months after any kind of pregnancy ( including ectopic ) to try again.
With one ectopic, chances of another one are quite high.
I would also like to know if your tubal assessment was done - either in the form of a laparoscopy or HSG ( hysterosalpingography ).
If the tubal anatomy is disturbed on laparoscopy, it is best to go in for IVF , as IUI or natural cycling would have high likelihood of repeat ectopic.
So, I would suggest a tubal testing, preferably hystero-laparoscopy for you, followed by IUI/IVF as indicated.
You should not go for more than one or two cycles of natural cycling, as you have already lost time.
Take the DHEA on prescription, and never on your own.
I hope I have been clear enough.
Am open to further discussion.
All the best, and take care.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Aarti Abraham 36 minutes later
Apparently an HSG showed no problems before the ectopic. In fact, they could find nothing wrong at all--nice cervical mucus, nice tripartite lining, ect.--except a shockingly low AMH level of 0.4 (at a lab where "normal" is 1.0 or above and 0.3 is "extremely low"). The doctor said it was the AMH level of a 44 year old woman and she would have thought it was a mistake except that my cycles were indeed getting shorter. She said that probably indicated that there were fewer eggs developing each month?

So it sounds like I should go back to the clinic as soon as possible, ask them to check my levels to start DHEA, ask if they can do an HSG to check on the tube that was affected by the ectopic, and then either do an IUI cycle or go to IVF depending on how my fallopian tubes look.

Thank you so much to the explanations and the advice! I would have kept dragging my feet because I wasn't sure how to proceed and my first experience with fertility drugs was so unpleasant.
doctor
Answered by Dr. Aarti Abraham 6 hours later
Hi XXXXXXX
Well , to put it frankly, an HSG is not as sensitive as a laparoscopy to evaluate tubal damage.
Starting DHEA and taking folic acid and vitamin D is a good idea, but proceeding for IUI or IVF on the basis of an HSG is not a good idea according to me.
I would advise a laparoscopy if the cost factor is not a constraint, as it would provide you indisputable, objective evidence of the tubal status, and also help your Specialist guide you better.
And thank you for the appreciation. I know how stressful infertility can be, I would urge you to reduce stress levels by indulging in yoga/meditation etc.
Really wish you all the best !
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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