Asherman's? Ob/Gyn recommendation

Hi,


I'm new here. At 11 weeks I had my first ultrasound and found out the baby stopped growing, in fact it wasn't even visible even though the placenta was large. I had a bad feeling about this as my pregnancy symptoms suddenly diminished. Still, I was shocked. I decided to wait to miscarry instead of having a d&c. I waited 3 weeks and the pain was intense, I didn't go to hospital or anything. My gyn/ob saw me the next day and again a few days later and said there were still some 'products of conception' left and I'd need to have a d&c anyway. After the d&c my periods have been very light. Before they were at least a week long. I'm very worried I could have Asherman's (intrauterine adhesions). It has been 5 months since the d&c and only 3 months since we've been ttc but the scant periods (3 days) are very unusual for me. Is there anyone who has been diagnosed and treated for Asherman's and who could recommend a good gyn/ob in Sydney?

Sky, I wish I could help you, my sister was diagnosed with Asherman's after the birth of her second baby. She lives in Perth so I cannot recommend the gyno/ob that she saw.

Are you concerned that the d&c may have caused Asherman's?? From my understanding, and I have discussed this with quite a few obs/specialists in the past 18 months, it usually takes multiple d&c's to cause Ashermans, it would be extremely unlikey to get it from one. My sister was very unlucky, she got it after two d&cs (she haemoraged after both of her labours and required a d&c) and I've been told that is also very rare, it usually takes much more than 2 procedures.

Thanks, Willow. From what I've read it is possible to get it after only one procedure-all it takes is for them to go too deep. I also heard it was more common than people think and underdiagnosed. I haven't been diagnosed but the symptoms I've been having sound like it. I'm thinking of joining an Asherman's support group to find a good gyn/ob. Sorry to hear about your sister. It's still possible to have children if you get treated for it by an experienced specialist.

http://www.integramed.com/inmdweb/co.../ashermans.jsp
http://www.infertilitynetworkuk.com/...d=80&Itemid=80
http://www.ashermans.org/

Sky
I can't help with the ob/gyn in sydney as I'm up in Newcastle. But i went to the local hospital gyn clinic. Why don't you ask your GP for the name of a good Gyn /Ob as they refer patients to them all the time or do what I did and go to the local hospital Gyn clinic (they are free or medicare funded).
I have recently been diagnosed with Ashermans. I haven't had a period since I had my m/c and d&c last Sept. I am still waiting for my historoscopy to see how bad the ashermans is (went on a 3 month waiting list last january and its now May)

I wish I could be more help. :doh:
Chris

Wow, I can't believe you can get it after one d&c - I was terrified of this after my m/c when I was told I'd have to have a d&c but was assured by the gynae team that they take it very easy and kind of under do it rather than over do it for this reason. Every ob/gynae specialist I've spoken to about it has assured me that it is very, very rare to get it from one d&c.

I'm sorry you're both going through this, it's just awful. My sister was advised not to have any more children because her risk of a massive haemorage following another birth was huge and would put her life at risk. So in her case (and with her history of haemorage) it was more about what would happen after the delivery as opposed to actually being able to fall prg and carry another baby to term.

I'm not sure that she sought a second opinion and have often thought she should have, but I guess if she was desperate for a 3rd she would have.

I'm sure there was a BB member I spoke to last year who flew over from NZ to see a specialist in this area in Sydney. I'm going to search through some posts and see if I can find the posts.

I'll get back to you soon...

***ETA: Found her!! It's Milly B, I used to talk to her in the clomid/met forums. She saw someone at the Royal Women's in Sydney who is apparently an expert in the area of Asherman's - here's her post

https://www.bellybelly.com.au/forums...ad.php?t=17360

I really hope this helps Sky!

I am a member of the AS support group. Yes, you can get it after one d&c.... the most common is from a postpartum d&c for retained tissue, or following a late loss or termination. However, you can also get them from an early d&c, or any kind of uterine surgery. You can also have adhesions from infection, although surgery/instrumentation of some kind is almost always the cause.
It's a bit too complex to go into here, but I want to say that although it can definitely happen if the doctor is too aggressive, some women simply scar very easily and we don't know why.
We have one of the world's top experts here in Sydney. I encourage anyone who has been diagnosed, or even suspects it, to look at the site under Yahoo health groups. The group is fantastic & there is a wealth of information available on the site, or by posting to members.

Thanks for posting Castle, I hope the girls see it.

Castle,

Do you know if one of the symptoms of Asherman's is to have short cycles ie. to get your period sooner than you're supposed to? My cycles got short after the d&c but they are progressively getting longer each time which I'm taking as a good sign. The bleeding is still light though.

I saw the specialist and he wanted to do a hysteropscopy. I was expecting him to tell me what the different possibilities are for my symptoms. Surely it can be hormonal too. The u/s showed I had a large dominant follicle. He wasn't interested in that. He did say that my body was probably still adjusting from the pregnancy and d&c. Maybe the d&c was a bit too deep but I'm gradually building up the endometrium again. He was nice but I felt a little pressured to not talk too much because he saw about 4 people in the half hour I was waiting.

Chris, how did your hysterocopy go? In Sydney you wouldn't have to wait that long for the procedure. I just saw the dr yesterday and he was booking me in for next wednesday.

sky

Sky

I am still waiting to have it done. I rang the hospital last week to find out what was going on only to find out that the Gyn has gone on holidays and will be back mid July so I made an appointment to see him when he comes back as my "pain cycle" is really getting to me.:cry:

Wow that was fast..... Wouldn't it depend on if your private of public???

Cheers
Chris

Hmm, I guess it would but I'm a little confused because when I rang the specialist to find out if he was the one doing the hysteroscopy he said that normally he shouldn't say this, but he will be. I said I was happy to pay out of pocket for a private fee to ensure he was going to be the dr but he said it was ok. I decided not to have it done next week. I guess I'm feeling positive because my period came a bit early again but for the first time there was some normal looking blood. I would like to get a second opinion on what else could be causing these symptoms and if they've all been ruled out before getting a hysteroscopy. There's something else too. It might make me unpopular for saying it, but the specialist is involved in studies for which they are actively recruiting subjects (I even heard an ad on the radio) and I don't want to undergo an invasive procedure to make up numbers for a study. Even if I do have A and did require a hysteroscopy, I'd like to be treated as an individual and my health needs given top priority- the first intervention is the most critical for correcting adhesions.

Have you had hormonal tests to rule out other possible causes of your absence of periods? Not just estrogen, progesterone FSH and prolactin, but also thyroid and cortisol. Also, a pelvic ultrasound is useful as it can reveal if you're ovulating and how thick your endometrium is (however it cannot detect adhesions).

Best wishes
sky

Sky,
I don't know your whole story. However, I want to clarify what you said about the hysteroscopy. There are diagnostic hysts and operative hysts. A diagnostic hyst, which is almost certainly what you would have, is an in-office procedure & a tiny camera is inserted through the cervix so that the doctor can have a good view of the uterine cavity. No anaesthetic is required although a nurofen is a good idea! In an operative hyst, the same thing happens but it takes place in theatre, under a general anaesthetic, and the doctor uses the scope to guide surgery. Sometimes if there is scarring at or near the cervix (eg if you aren't having AF), then an in-office hyst isn't possible & it HAS to be done in theatre--too painful otherwise!
I would not hesitate to have the diagnostic hyst. It can only give you answers. And coming off your cycle is the best possible timing. None of this means you will have to schedule surgery.
Have to go, but please post again!

Sky, it's a good sign that your latest AF is looking better. You are right to be concerned. The scanty periods are a typical sign of AS. The "classic" is a woman who's ovulating, but doesn't have periods. However, this is only when the scarring is so bad that the entire uterus is adhered, or if the scarring blocks the cervix. Women with more minor cases often aren't told that it's AS. They are just told "residual scarring" or "minor adhesions" or "a few synechiae".

The short cycles aren't related to AS. It's common after ANY pregnancy, no matter how it ends, for your cycles to be slightly different. The scanty periods (shorter flow, less flow overall) ARE a possible sign of AS.

Please consider having the hysteroscopy. A diagnostic hyst will only give you information. It's the gold standard for this sort of diagnosis. It will show either a normal cavity, OR scarring in the uterus, OR a cavity which can't be entered because of scarring at or near the cervix. If you have a normal result, you can then proceed to blood tests & hormone levels. Just be aware that these are not necessarily definitive. For instance, I have normal progesterone levels. I don't respond to them at the cellular level (even though I make enough progesterone, my body acts like I don't). A skilled doctor, especially if a reproductive endocrinologist, is the best possible person to go over these issues with you. That's why I would recommend seeing him anyway. Can you tell me who the specialist is?

I hope you don't have AS and it is just a change in your cycles.

I wanted to share my story... I had a hysteroscopy & curette 10 weeks after my daughter was stillborn in Sept 2004 for retained placenta products.I was bleeding for over 9 weeks post birth including a large bleed one night at about 4 weeks after her birth.

During the curette I haemorrhaged in OT - requiirng me to stay overnight and all the next day but I had very scant bleeding, 3.5 weeks later my Af was 1 day , scant bleeding and shorter cycles ~24 days so it continued for next 3 months.I had like 1-2 day of very light bleeding ... I hardly needed a pad a liner would do. I was so cared I had AS. I googled everything. Previously I had regular cycles and 4-5 days of AF with very heavy days (but unexplained infertility as well). It was a complete change.

My OBG (who did the curette) ignored my concerns and just referred me to IVF for my unexplained infertility. The FS said AS was very rare but 'okay' lets do sonohysterogram anyway to check my tubes etc too and it came back I didn't have AS.

All my cycles after the curette were very scant bleeding. No answers were given why it happened or was like this but on IVF my first lining u/s was just on the range. Even on IVF hormones my AF was not much and cycles in between.

It wasn't till a year after my curette that I conceived by IVF - for other reasons not related to light AF. Haven't had AF yet either since 11 months after my sons were born. So I don't know yet.

I just wanted to give you hope that it might not be AS. I asked my GP, OBG & FS and all told me it was rare and unlikely.

Trish, the diagnostic standard for AS is a hysteroscopy--NOT an SHG. The SHG gives good information about your lining, but not about adhesions. I am not saying that you have AS, just that that would not normally be considered the way to diagnose it. An SHG or an HSG (another type of x-ray) are both useful tools but they do not give the information that a hysteroscopy does.

It can be normal after any curette to have lighter AF. Elective curettes are done for women with heavy bleeding problems just for that reason. That is why no doctor will jump in and say "you have AS" without further investigation.

AS is uncommon, but everything we know about it indicates that it is underdiagnosed. Many women are happy to end up with light AF and if they are having only 1 or 2 children there may never be any investigation done...it is usually not an issue unless a) the woman has no AF and is in pain, or b) she is trying to conceive. With a mild case, a woman may be able to conceive, but there are other issues at delivery. Sadly, many women are referred on to IVF or told that children will never be an option, rather than having the underlying problem addressed.

Of course some women have fertility issues and need an IVF referral anyway. Often they know about that before the AS diagnosis.

Thanks Castle for explaining that, sorry, I didn't mean to say that the SHG was used diagnostically just to say whether or not I had AS but the FS was refering me for SHG also to check tubes/patency etc, as well, as I had 12 yrs unexplained fertility.I knew I was ovulating normally.

But a FS then told me after it - I didn't have AS. If I had the IVF cycle wouldn't have proceeded. I understood other investigations/procedures could follow depending on the SHG results. The SHG showed I had fluid in my tubes/damaged tube but not sure why ? not necessarily the cause of 12yrs inferility.The curette wasn't the cause of my infertility nor tube damage.The very light AF was a new problem. Just to clarify.

I then trusted his opinion that a hysteroscopy or that other tests were not required about my lack of AF and we proceeded to IVF.I did actually have a laproscopy after the SHG to clip my damaged tube. It was always in the back of my mind the IVF wouldn't work because of my strange AF/lining.

Syke, sorry, I also wanted to say I am so sorry you lost your precious baby. Also, three months TTC might just be your body readjusting after your pregnancy hormones and it is still a normal time frame of TTC.

Sorry if there was any confusion. I really only wanted to say that lighter AF after a curette doesn't mean you have AS just to reassure you and encourage you - it isn't always the case but of course you should speak to your OBG if you are worried and not rely on internet advice.

I had been so worried sick about AS, from my AF symptoms, the fact that I had haemorrhaged during the curette performed via hysteroscopy (possibly from the OBG scraping very deeply and that because he couldn't see to stop the bleeding he told me the next day he almost did a hysterectomy) and from googling and on forums telling me it might be. I was glad I didn't and I hope you conceive again very soon.

Please let us know how you go.

Trish, you are such a sweetie! thanks for clarifying everything you said. How lucky you were that your OB took the idea of AS seriously. Many women with AS have said that their doctors were almost unaware of it...usually they did not self diagnose....it was often after following up a 2nd opinion, or after seeing an RE, that AS was even mentioned.
Sky, Trish is right that it can take your body several months to settle after a m/c, and that 3 months is still a normal time frame for ttc. However, I personally would still be inclined to have the hysteroscopy for the information it can give.

I agree with you Castle, a hysteroscopy would be best at any time if you continue to have real concerns.

Sky, No one likes to feel like they are unknowingly part of an experimental study but often they can help other women in similar situations. As long as they disclose this upfront. I would also want my specialist doing the procedure and not someone I didn't know.

Castle ... I found only found out about AS from Dr Google ;) and maybe from reading about on forums ... not sure what came first though ... fog brain and it being 2 yrs ago now . The Dr was very surprised I mentioned it. The FS was very surprised how much I knew about IVF and everything ... thanks to Belly Belly I was very well inofrmed (:clap:).

Castle , I believe my original OBG was reluctant to offer me another hysteroscopy or any investigations apart from cd21 progesterone - I had IVF on my agenda anyway so he just referred me ...said because of my age - no point mucking around = go straight to IVF and give me $$$ as you walk out the door.See you later.He was very nice and all but quickly said off you go ...your age ra ra.

I think also because of what happened the last time he did HS and he maybe didn't want to have to confirm anything he might have caused.

Sky, I wish you the best of luck for normal AF ... or a BFP instead. I asked my GP and she did do thyroid function tests and few others but said mostly it was one of those things. There are 2 types of Thyroids tests too but she said all these things are just rare. Like premature menopause ... I worried about everything :rolleyes:.

I hope your specialist has more time for you next time and you don't feel so pressured not to have as much as time as you want. Noone needs that when we pay a lot of money to see them and we have genuine concerns about TTC another baby ... this matters more than the money.

Chris, I hope you get your Hysteroscopy quickly and you also get some positive answers and on the road to specialist treatment. How frustrating waiting must be when you must be worried.

Willow -I know when I had to have the hysteroscopy the OBG ran through the complications (even though I was a registered nurse) I almost fell off the chair . They make it sound so scary.

Castle,

Thanks for clarifying the difference between a diagnostic hyst and an operative one. The dr made it sound like he'd also operate which is what made me uneasy. He basically said he'd just have a look and then clip away any adhesions he saw. Is this standard procedure? He made it sound like it was this really casual thing, I mean we're talking about my fertility here. Either it's a serious concern and he better be willing to give me the treatment I need, or he thinks there's probably nothing wrong with me, but will have a look if it means he can have another participant in his study. Calling him didn't reassure me because at the end of the call it was clear he mixed me up with another patient who was on some treatment. I'm really upset because I thought I'd get better care than this. I need to know if it's normal to 'clip away' during a diagnostic hyst. The dr was going overseas for a couple of weeks straight after the appointment he wanted to book me in for which is another reason I thought it wouldn't be a good idea. What if I got an infection? What if new adhesions formed? When I asked him if I might need to have a balloon inserted etc. as I've read he said "no, no!" but how would he know unless he thinks I don't have AS?

sky

Trish,

You sound like me, googling everything. I also found out about AS that way when I was trying to self diagnose. I worry about POF too!!

I wanted to reply to your post but it's late now- will write tomorrow.

sky

Sky, I would be getting a second opinion ... i just saw you posted ... Google was my best friend and still is.

Sky, in a diagnostic hyst, if there are only a very few filmy adhesions that can be broken up with the scope itself, the doctor will go ahead & do it. If there are more, or if the problems are near the cervix, they will take a quick look & then book you for theatre: either an operative hyst, or a lap/hyst depending on what the issues are. It's also possible you'd be sent for an SHG or an HSG, 2 different radiology tests.
Who is the doctor??
The renowned AS doctor in Sydney does not use balloons, as a matter of policy, because he thinks they increase the potential for infection.
As far as infection, even if it's just a diagnostic hyst, you will be often prescribed a short (3-5 day) round of antibiotics, because a body cavity is entered. This depends on the doctor & on your own history. It would be something to ask for if you are concerned, & I should think you'd get a scrip without hesitation.
If new adhesions form, they form within the first few months, but it would not be something to worry about over a matter of weeks. Also, the "main man" works with someone very good, who would care for his patients while he's gone. You would not be left to go back to your GP.
Does that help? :)
If you really have heaps more questions, I'd suggest joining the AS group, which you can do before a diagnosis, and posting questions there.

Trish,

Thanks for sharing your story and reassuring me that I may not necessarily have AS (maybe just AS phobia!). You certainly have been through a lot. I'm so sorry about your still birth- I can't imagine the pain you went through, and having to cope with the bad curette experience and the fear of having AS right after. I'm so glad to hear that after all that you have two children. It gives me hope to hear success stories like yours and others. Your FS would have been able to see if you had AS during the laparoscopy procedure. Hearing all the procedures you underwent makes me think I'm overreacting about the hysteroscopy, and that I should try to trust the specialist. I'm nearing 40 and don't have a lot of time to wait and see if I conceive (not that it took long the first time). I also want to avoid the possibility of another mc which could result if I did have AS and conceived.

I'll keep you posted on what happens.

All the best,

sky

Castle, thanks again for your explanations. It helps me to hear other people's experiences to understand what's going on. The dr didn't explain much at all to me. And I'm the type of person that wants to know EVERYTHING! I'm seeing Prof Vancaillie, the reknowned AS dr I think you are referring to. I'm wondering if you are the same person from the AS support group I contacted a few weeks ago. At first I thought it would be best to wait for a diagnosis before joining the group but now I see there are tons of questions I have even at this stage. I'll see you there soon.

sky

thanks Sky - I can understand your anxiousness I was 38 when I lost my daughter. I just left it late to go the IVF path -after we knew we could get pregnant. I wanted to try. Didn't have the encouragement to try before.BB and another friend helped me there ... to give it go I had so much to gain.

Yes, I think that is what worried me the most - not having another chance because of some 'rare' syndrome.

It was a different FS OB/G - Dr Gayer - she is fantastic and I would recommend her highly - though she was associated with the IVF clinic and it was actually half way during my first IVF cycle ... before I started the IVF hormone injections. I was fitted in urgently after they decided hydrosalphinx (fluid in damaged tube could) hinder embryo implanting (get washed out).I refused to cancel the cycle ... another month later was too long to wait.IYKWIM.

The POF had be so scared too because I knew if was a possibility too given my age. Though they can also work with this.

Re - a Hysteroscopy - I also knew it could be done without a GA (but I wouldn't ~ the SHG was bad enough).I agree with Castle - join a group or lurk and read others stories.The hysteroscopy might just be worth it.That at very least you will have some idea or good news but finding the best specialist is the key.

Again, if you don't have AS - and if you are over 35 I wouldn't wait more than 6 months TTC before a referal to FS (not necesarily for IVF) as a few ladies were discussing in another thread. Ask you DR for referal for both you and your DH. There are a few options open to you not just IVF.

I hope you don't need it though and you are soon announcing a BFP.Goodluck.

Sky, definitely don't wait before joining the group. Lots of women join pre-diagnosis. You'll find the members have a wealth of info on other gynae issues as well.
I agree with Trish, you should be getting on this asap if you're over 35.
Yes, Dr V is the specialist. You did not get in touch with me. Someone else is the support person for Sydney--I assume that's where you are. I'll see you there soon! BTW, Dr V does only hysteroscopic surgery. He would refer you to a FS if you needed help conceiving.

Sky
I joined the As group and have found out alot of info. I am now going to go and see Dr V also. I hope I get good news and will be able to TTC soon. My gyn up here did not give me to option to have my AS fixed. He didn't even ask did I want another baby.

The ladies have been very informative and just reading other peoples posts you get answers to your questions.

I am still waiting to see my Gyn up here he is on hols till mid July. I don't know when i will be able to get my hystoscopy done.

Cheers
Chris

Thanks everyone for all your support and advice.

Trish, Dr V said he didn't think I had any problems conceiving given it took 3 months the first time. We only started seriously thinking about having a family around last July because we wanted to have some financial security and we both were studying until not long ago. I'll keep Dr G's name in mind if I ever do need to see a good FS but for now it's not a concern. We've only been ttc for about 3 months after the d&c but have postponed it until after I sort out what's happening with my AF, in case the underlying cause for it can interfere with a future pregnancy or my ability to conceive. A hysteroscopy is not a particularly risky or invasive procedure compared to others. My biggest worry with the hyst is uterine perforation but that is a risk with almost any invasive gyn prodecure. I plan to have the hyst in July after my next AF. I hope I'll have some good news to report back.

Castle, yes I'll make sure to get some ABs before the hyst. I was given sporahexal and another one too before the d&c as well. I've just joined the AS group and look forward to finding out more about AS.

Chris, I hope you have your hyst soon. Who will be performing it? Good luck.

sky

Sky, put the uterine perf out of your mind with all the other one-in-a-million things that people simply cannot spend time worrying about.
If the doctor cannot avoid a perf when he's using a camera and should therefore know exactly where everything is....
It's much more of a risk with the d & c, especially if it's a "blind" d & c done without hysteroscopic guidance. But that is behind you now.
With a doctor who is a super-specialist in this area, you should feel very confident that risk of a perforation is virtually nil!