Vaginal Birth After Myomectomy -- Uterine Rupture Risks

My latest thing is trying to evaluate the risks of a vaginal birth now that I've had an incision all the way through my uterine wall. I have been advised to have a scheduled c-section by my surgeon. I've researched this topic before, and I even avoided the surgery for a long time because I knew that they would say I would have to have a c-section.

It looks like the risks are:

* up to 9% (4-9%) chance of a uterine rupture total (including
ruptures that occur prior to active labor, i.e. rupture at 28-34
weeks)

If the uterus was to rupture there is a:

* 1 in 3,300 births chance of the baby dying, and a
* 1 in 5,000 risk of hysterectomy
Is vaginal birth after cesarean risky?


Additionally:

"The risk of uterine rupture is 1 in 500 even with planned repeat
cesarean versus 1 in 10,000 with an unscarred uterus."
CIMS Alarmed by Highest US Cesarean Rate Ever

"women having planned cesareans for a subsequent birth were three
times as likely to have hysterectomies as women planning VBACs: 1 in
220 versus 1 in 625."
Is vaginal birth after cesarean risky?

"For women being induced without use of prostaglandin, the odds went
up only slightly, but when labor induction included prostaglandin,
they soared to 1 in 900 for hysterectomy and 1 in 770 for infant
death."


This in contrast to the rupture rates among VBACs with a transverse
incision:

”1 in 625 with a planned repeat cesarean,
1 in 192 with starting labor on their own,
1 in 130 with an induction of labor but without using prostaglandin
to soften the cervix first,
1 in 41 with labor inductions that included prostaglandin.”
Is vaginal birth after cesarean risky?

and

"cord prolapse, or antepartum hemorrhage) in any women giving birth,
is approximately 2.7%, or up to 30 times as high as the risk of
uterine rupture with planned vaginal birth after cesarean"
[Note that they are referring to VBAC after low transverse section
data)

So, if 9 women will have uterine rupture does that mean that the
other 91 women shouldn't be allowed to do a trial of labor?

I was looking in A guide to effective care in pregnancy and childbirth 3rd Edition (Enkin, Keirse, Neilson, Crowther, Duley, Hodnett and Hofmeyr, Oxford University Press) and found these interesting quotes:

"Maternal mortality and serious morbidity are fortunately very rare, and for this reason estimates of their frequency are imprecise. A large meta-analysis showed maternal mortality of 2.8 per 10,000 for women undergoing trials of labor, and 2.4 per 10,000 for women having an elective cesarean. Uterine dehiscence (asymptomatic separations of the uterine scar) or ruptures occur in less than 2% of trials of labor, the same proportion as is seen among women who have routine repeat cesareans. Most of these are asymptomatic and of no clinical importance."

"The rate of maternal death associated with cesarean section (approximately 4 per 10,000 births) is four times that associated with all types of vaginal birth (1 per 10,000 births). The maternal death rate associated with elective repeat cesarean section (around 2 per 10,000 births), although lower than that associated with cesarean sections overall, is still twice the rate associated with all vaginal deliveries, and nearly four times the mortality rate associated with normal vaginal birth (0.5 per 10,000 births)."

"...the probability of requiring an emergency cesarean section for acute other conditions (fetal distress, cord prolapse, or antepartum hemorrhage) in any women giving birth, is approximately 2.7%, or up to 30 times as high as the risk of uterine rupture with planned vaginal birth after cesarean"[Note that they are referring to VBAC after low transverse section data)

"Hospitals whose capabilities are so limited that they cannot deal promptly with problems associated with a planned vaginal birth after cesarean are also incapable of dealing appropriately with other obstetrical emergencies."

It is strange how the ob/gyn field reacts towards childbirth and its complications, even though it is a natural process. When you contrast what I've learned through my experience with fibroids, that many women who have finished having children are advised to have hysterectomy for these benign tumors though they can be safely excised via abdominal or laparoscopic surgery. In contrast, a doctor specializing in the colon, when presented with a patient with a polyp in the colon, does not proceed to remove the colon, s/he would remove the polyp alone. And then I was looking for stats on complication rates after other surgeries and saw this, perhaps not the best comparison but still:


"The Duke analysis found that the mortality rates for heart failure patients was 11.7 percent, compared to 6.6 percent for coronary artery disease patients and 6.2 percent for patients without heart disease. In terms of readmission rates after surgery, heart failure patients had a 20 percent rate, compared to 14.2 percent for coronary artery disease patients and 11 percent for patients with out heart disease."
from: Heart failure patients at increased risk during non-cardiac surgery


So the death rate from having non-heart related surgeries on patients with heart disease is really high. Much higher than the risks associated with childbirth, and much higher than the risks of uterine rupture. It just boggles the mind how different these specialties are when they approach patient care.

"Early findings suggest that a the greatest influence on a woman's decision to attempt a VBAC trial of labor is her personal philosophy of birth (normal life event vs potential disaster) and the attitude of her healthcare provider surrounding VBAC trial of labor. The final findings will be presented at the 2004 ACNM Annual Meeting in New Orleans, Louisiana."Vaginal Birth After Cesarean (ACNM 48th Meeting)

While uterine rupture is slightly more likely with planned vaginal birth (5 per 1,000 versus 2 per 1,000 for a repeat cesarean), newborn outcomes do not differ. With appropriate care, 7 out of 10 women or more laboring after a cesarean will birth vaginally.
CIMS Alarmed by Highest US Cesarean Rate Ever

"Leaving aside that cesareans impose other risks that balance out the risk of uterine rupture during a VBAC, commentators on the Washington State data deemed the 1 in 3,300 chance of losing the baby during a spontaneous VBAC labor was sufficient to mandate planned repeat cesarean. The odds of amniocentesis precipitating a miscarriage fall somewhere between 1 in 200 and 1 in 400, more than ten times the risk of the baby dying from a VBAC-related uterine rupture. Yet obstetricians aren’t lobbying for an end to amniocentesis on the grounds that it is too hazardous."Is vaginal birth after cesarean risky?


"Even the way in which the Washington study data was presented was biased against VBAC. The article stated that spontaneous VBAC labor increased the risk of rupture 3.3-fold compared with repeat cesarean, a statistic quoted in media articles. This sounds alarming, but the absolute difference was four women per thousand, a miniscule number when you consider that two-thirds of women experiencing uterine rupture will suffer nothing worse than the cesarean they would have had in any case had they not decided on a VBAC."
Is vaginal birth after cesarean risky?


Increased risks are associated with:

• Gestational age of at least 42 weeks also raised the risk for a negative outcome.
  Results of the National Study of Vaginal Birth After Cesarean in Birth Centers (scroll down a bit)
  
  
• “Awaiting spontaneous labor beyond 40 weeks of gestation decreases the likelihood of successful VBAC but does not increase the risk of uterine rupture”
  Practice Guidelines: ACOG Releases Guidelines for Vaginal Birth After Cesarean Delivery
  
  
• “Approximately 50% of uterine ruptures that occur may be catastrophic, with significant rates of morbidity and mortality to both the fetus and mother.”
  Uterine Rupture and Vaginal Birth After Cesarean Section: An Historical Enigma
  
  
• “One study showed that women who had a previous vaginal delivery prior to attempting a trial of labor had a rupture
  rate that was one fifth the rate of women who did not have a previous vaginal delivery.”
  Uterine Rupture and Vaginal Birth After Cesarean Section: An Historical Enigma
  
  
• “Prior classical uterine incision is associated with a rate of uterine rupture of up to 12%.”
  Minimizing Obstetrical Risk: Vaginal Birth After Cesarean Section
  
  
• “Interdelivery interval: If the prior delivery was less than 18 months, there was a 3-fold increased incidence of uterine rupture compared with women having a longer interdelivery interval” and
  “Maternal age: Women over 30 years of age were 3 times more likely to experience a uterine rupture than those under 30 years”
  “Number of prior cesarean births: Women with 2 or more prior cesareans had a 3-fold increase in the incidence of uterine rupture (1.7%) compared with women with only 1 prior cesarean (0.6%).[9]”
  “Single-layer vs double-layer uterine closure: The 1-layer closure technique is associated with a 4-fold increase in the incidence of uterine rupture (3.1%) compared with prior 2-layer uterine closure (0.5%).”

Vaginal Birth After Cesarean (ACNM 48th Meeting)


"Pain at the scar does not reliably indicate uterine rupture. Caesareans for this reason often find intact scars.
Changes in contraction strength do not reliably indicate rupture, so routine intrauterine pressure catheters have little value.
Manual exploration of the scar results in both false positives and false negatives. False positives lead to unnecessary surgery. Wound openings without other symptoms probably need no repair anyway. The exploration (which is painful) may introduce infection and could potentially convert a wound opening into a rupture."http://www.bambi-bangkok.org/magazine/2000/b2_aug00.htm

"The majority of dehiscences after lower segment transverse incisions are 'silent', 'incomplete', or incidentally discovered at the time of repeat cesarean section. The potential dangers of uterine rupture are related to the rapid 'explosive' rupture, which is most likely, to be seen in women who have a classical midline scar. Rupture of the scar after a classical cesarean section is not only more serious than rupture of a lower segment scar, it is also more likely to occur. Rupture may occur suddenly during the course of pregnancy, prior to labor, and before a repeat cesarean section can be scheduled. A review of the literature at a time when classical cesarean section was still common, showed a 2.2% rate of uterine rupture with previous classical cesarean sections and a rate of 0.5% with previous lower segment cesarean sections. That is, the scar of the classical operation was more than four times more likely to rupture in a subsequent pregnancy than that of the lower segment incision.

Unfortunately, even in the older literature, there are very few data on the risk of uterine rupture of a vertical scar in the lower segment. One 1966 study reported an incidence of rupture of 2.2% in classical incision scars, 1.3% in vertical incision lower segment scars, and 0.7% in transverse incision lower segment scars. The distinction between the risk of rupture of vertical and transverse lower segment scars may be related to extension of the vertical incision from the lower segment into the upper segment of the uterus.

The uncertain denominators in the reported series make it difficult to quantify the risk of rupture with a previous classical or vertical incision lower segment scar. It is clear, however, that the risk that rupture may occur, that it may occur prior to the onset of labor, and that it may have serious sequelae, are considerably greater with such scars than with transverse incision lower segment scars. It would seem reasonable that women who have had a hysterotomy, a vertical uterine incision, or an 'inverted T incision, be treated in subsequent pregnancies in the same manner as women who have had a classical cesarean section, and that trial of labor, if permitted at all, should be carried out with great caution, and with acute awareness of the increased risks that are likely to exist."
Labor and birth after previous cesarean, 4.4 Type of previous incision in the uterus

The length of time from your c-section to your current due date is another issue. If less than 12 to 24 months will have passed since your c-section, your health-care provider will question whether there has been sufficient time for healing. Is the scar site strong enough to go through labor without separating? The highest risk for uterine rupture during labor is during the first year after a cesarean delivery. The risk of uterine rupture decreases over the following years. Other factors, such as surgical technique, suture material used, or infection may be involved as well. This issue is controversial and is being studied.
Midwife Elizabeth Stein on Vaginal Birth After Cesarean

“A woman's risk of uterine rupture increases with:

• Each additional uterine surgical scar. While a uterine rupture occurs in up to 8 per 1,000 women with one scar, up to 37 per 1,000 women with two scars develop a rupture.
  
• The use of medication to start (induce) labor. Use of misoprostol (Cytotec) or oxytocin (Pitocin) to induce labor has been linked to increased risk of uterine rupture during VBAC. In a recent study, uterine rupture occurred in:
  * 24.5 per 1,000 women who were induced with misoprostol.
  * 7.7 per 1,000 women who were induced with oxytocin.
  * 5.2 per 1,000 women who had a spontaneous labor.
  * 1.6 per 1,000 women who had a repeat cesarean without labor.
  However, careful use of oxytocin to aid (augment) a slow labor has rarely been linked to uterine rupture.4, 3
  
• Any uterine scar tissue that reaches above the lower, thinner part of the uterus. About 40 to 90 per 1,000 women with a vertical incision develop a rupture.

”
Rupture of the uterine scar and VBAC


“The type and location of the previous uterine incision helps to determine the risk of uterine rupture. The incidence of uterine rupture is 0.2% to 1.5% in a woman who attempts labour after a transverse lower-uterine-segment incision 14,16,18,27,45 and 1% to 1.6% after a vertical incision in the lower uterine segment. 46-49 The risk is 4% to 9% with a classical or “T” incision; and for this reason, a TOL after Caesarean is contraindicated in these situations.16,19,30 Shimonovitz et al. found the risk of uterine rupture after 0, 1, 2, and 3 VBAC deliveries to be 1.6%, 0.3%, 0.2%, and 0.35%, respectively, indicating that the risk of uterine rupture decreases after the first successful VBAC.”
SOGC Guidelines for Vaginal Birth After Previous Caesarian Birth

“Four studies have examined the relationship between the interdelivery interval and the rate of successful VBAC and uterine rupture.102-105 Esposito et al. examined 23 cases of uterine rupture and compared them to 127 controls.102 There was an increased risk of uterine rupture with a short interpregnancy interval (<6 months between pregnancies; <15 months between deliveries) compared to controls (17.4% vs. 4.7%, P=0.05).102 Shipp et al. reviewed 311 women who underwent a TOL after Caesarean less than 18 months after their Caesarean section and compared them to 2098 women who underwent a TOL after Caesarean after more than 18 months.103 The shorter interval was associated with a 3-fold increase in the risk of uterine rupture (2.25% vs. 1.05%: OR, 3.0; 95% CI, 1.2–7.2).103 Huang et al. reviewed 1185 women undergoing a TOL after Caesarean and noted no difference in the success of vaginal delivery in those with a shorter interval of <19 months (79% vs. 85.5%, P=0.12), but they did note a significant difference in successful
VBAC in women who underwent medical induction compared to spontaneous labour (14.3% vs. 86.1%, P<0.01).104 Their study noted no difference in the rate of uterine rupture.104 In 2002, Bujold et al. reported an observational study of 1527 women undergoing a planned TOL after Caesarean at different intervals from the index Caesarean delivery.105 The rates of uterine rupture were as follows: <12 months, 4.8%; 13 to 24 months, 2.7%; 25 to 36 months, 0.9%; and >36 months, 0.9%.105 After adjustment for such confounders as number of layers in the uterine closure, induction, oxytocin, and epidural use, the odds ratio for uterine rupture in a woman <24 months from her last delivery was 2.65 (95% CI, 1.08–6.46).105”
SOGC Guidelines for Vaginal Birth After Previous Caesarian Birth

Here's one more article about VBAC:
Predicting Cesarean Section and Uterine Rupture among Women Attempting Vaginal Birth after Prior Cesarean Section

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1201366/

Fibroids, Painful Pregnancy and Birth Trauma

Being diagnosed with fibroids is scary enough, but when you are in the middle of trying to start a family or add new babies to your family it can be traumatic to be dealing with the unknowns, things that we see members here worry about week in and week out. Questions like, "was my miscarriage related to my fibroids?", "do I really need to have surgery" (oftentimes the first major medical experience we have in our lives), and "will I be able to have children with fibroids or after a myomectomy?" Additionally, there are complictions that arise during pregnancies such as extreme pain from fibroid degeneration, massive fibroid growth, etc. that can also be painful and confusing.

Regardless of if you conceive with your tumors in place or if you have had a myomectomy, childbirth might not be a straight shot vaginal delivery for many women with fibroids (and since 1 in 4 women in the US deliver via c-section today anyway, it isn't a given for anyone really).

I've personally found the whole experience to be a bit frustrating and disappointing and I'm still trying to conceive my first child. Now that I've had my fibroid out and I've been told I need to deliver all future pregnancies via c-section I find that frustration is building once again and I needed more info. I started researching more about the topic of c-section delivery and traumatic birth experiences (as well as uterine rupture risks -- which I will post separately about). I was also prompted in part by a online friend sharing her story of a traumatic pregnancy with degenerating fibroids -- she can't be the only one who has been left feeling deeply upset by her painful pregnancy with fibroids.

Below are a range of sites of organizations, research and counselors
focused on treating and understanding traumatic birth and postpartum
depression.

Traumatic Birth Experience

Victorious Birth - Cesarian and Traumatic Birth Support

Postpartum Depression and Maternal Birth Trauma

Depression After Delivery, Inc.

Birthing and the development of trauma symptoms: Incidence and contributing factors (Kreedy)
(there are links to the full study at the bottom of the page)

Birth Crisis Network (UK)
(Scroll down to the bottom of the page to links to more info)

Counseling for Reproductive Health and Healing - Deborah Issokson, Psy.D.
(She's in the Boston area, but does speaking engagements)

AF arrived last night so I got to use my fertility monitor this morning. I know the first cycle it is just gathering data to compare to in future cycles but I have to say that the first day you use it is it a bit of a downer. I guess I don't have to POAS again until next week. I wonder how it will interpret my fertility, especially in contrast to my charting.

Do you know that I'm so much better since I felt all emotional and sick on Tuesday and then had to deal with my SIL's delivery. I feel like my ghost pregnancy, the one that you can't help but think about after that 9 months is defined when you get pregnant, the one that has been hanging over me -- it's over. I completed it and now I can go on. I metaphorically delivered my ghost baby up the other day. Does that make sense?

A woman who did a home birth, unattended post myo

I get the sense that it was a smaller fibroid that was removed but since the going protocol is for a c-section post most myos this was a brave direction to go when she was turned away by the birthing center.

Birthing Issues

The Prenatal That Wasn't

Perfect Prenatal -- read her letter and research into the actual risks of rupture post myo.

Dropped!

Gardening -- where she talks about the legalities and her comfort with her decision

Are they going to induce you??? -- scroll down a little to see what she says

Perfect Birth -- the home birth story

To a woman wanting to try the natural route with a large fibroid...

I tried the natural route and had some success with acupuncture and chinese medicine. But, when I did finally get pregnant my fibroid doubled in size. You think you are uncomfortable now, just wait as 80% of fibroids will grow during pregnancy.

I really think you should have it out, as scary as that might seem. After they get larger than 4cm they have a hard time getting rid of them through alternative therapy, though I'm sure there are exceptions. It is only because you are already uncomfortable that I'm telling you to have a myo, not every woman with fibroids has ones large enough, or positioned in way that set them out on a bad footing for pregnancy and yours sounds like mine.

I had mine removed in November and it was the size of a grapefruit (ack!) It is a big relief to have the fibroid out of there. Just the psychological stress of managing this fibroid that was going to keep doing its thing was a big burden. When I thought about getting pregnant with it in place again I just about had a panic attack, it was really uncomfortable and mine didn't have any degeneration.

I wish they would give out MRIs more easily as I think if I had seen how it was really positioned I might have had the surgery sooner. My fibroid was located right up against, but not engaging with, the endometrium. I don't regret waiting though since my miscarriage experience helped prepare me mentally for the surgery.

Here are some quotes from Johanna Skilling's book Fibroids about how fibroids can contribute to infertility:

"If a fibroid causes a miscarriage it's more likely to happen in the first or second trimester; in fact, fibroids can cause miscarriage so early on, you migh not even realize you are pregnant. Later in pregnancy, fibroids tend to cause pain or preterm contractions rather than miscarriage"

"How can fibroids cause miscarriage?...either by distorting the uterine cavity or by altering the blood flow that would normally be needed to nourish the growing fetus."

"Fibroids can release chemicals called prostaglandins, the hormone that triggers pain...Prostaglandins can also induce contractions of smooth-muscle tissue"

"...the cells of a fibroid divide faster than the "normal" cells in your body...This rapid cell division can trigger a response from your immune system--sending the body's natural defenses to try to deal with the perceived invader. This reaction is bad news for another "alien" in your body -- your fertilized egg."

My SIL went into labor yesterday evening and our little 2 1/2 yo nephew spent the night at our house. I went to bed late and after reading him 5 books, one of them twice, turning the light off and singing to him, we both fell asleep in our bed. My partner was upstairs finishing some work and came down later. Little Alex is a hogger, he totally hogs the bed. My partner and I were both laying on the edges of the bed and Alex just rolled around between us, grabbing at pillows, kicking the covers --- all while he was sound asleep. At 2am he started shouting in his sleep and with that I was wide awake. I got up and watched TV and the movie Little Women and knitting until 6:30 am when I went back to bed in our spare room. I had about 3 1/2 hours of sleep last night.

On the plus side, Alex did really well on his first night away from his parents, he gave me a hug and a kiss when he left after telling his dad that he wanted me to come too. I finished up the baby cardigan and booties that I was making for his little sister and sent those off with him as well (he helped me wrap the package, you could totally tell as I let him stick stickers on it and draw on the paper with crayons and the folds were all lumpy).

The baby is named Camille (ka-Mee is the French pronounciation they
are using) and she came out this morning without complication
weighing in at 7 lbs 6oz, a good pound less than her brother.

We'll see them later tonight at the hospital. I will probably cry as
Sunday was my EDD for my failed pg. I would probably cry anyway and I just need to let it out. I already cried today. I'm just feeling so emotional. They are dropping babies around us like they are going out of style or something like that.

I'm going to start posting links to some of the postings I've found on other blogs by women who have had fibroids and myos and pregnancies, etc. It's amazing how many people there are.

Enough Already: I'm Never Right About A Damn Thing...

So Close: Natural Schmatural -- scroll down to Rachel's reply post.

Dirty Words

LaLa Blog-o-Rino

memage

Almost Faemist

Nancy's Blogger

The Road to Sleeplessness

Menstrual Irregularities

Here's a page which illustrates/explains different types of menstrual irregularities:

http://www.femalehealthmadesimple.com/FileTwelveFinal.html

"Any woman of childbearing age who has missed more than two consecutive periods -- but was not pregnant -- needs to investigate it and possibly have her period induced. Preventing the development of hyperplasia is the reason."
From: Endometrial Hyperplasia, WebMD

"Excessive estrogen stimulation can lead to significant increases in uterine lining thickness. The tissue becomes hyperplastic or atypically hyperplastic . It may become cancerous."

(and)

"Inadequate ovulation may cause excessive, irregular, or frequent menses recurring less than every 3 weeks. Inadequate ovulation leads to an excess of estrogen, which stimulates growth of the menstrual lining, and a decreased level of progesterone - which normally would be present in levels that would adequately thin the menstrual lining and prevent excess or irregular bleeding."
From: Dr Decker, Heavy Menstrual Cycles Management Options

"We like to see a lining of at least 8mm in thickness when measured by ultrasound at the time of maximal thickness during the cycle (see above ultrasound images of an 11.5 mm lining). There is some ongoing debate as to "how thin is too thin", as well as to "how thick is too thick". In general, 8-13 mm is good, less than 6 is potentially a problem, and greater than 15 or so could possibly reduce chances for a successful pregnancy."
From: Uterine problems causing infertility or miscarriage

About My Retained Tissue Experience

(to a woman dx with retained POC)

I had retained tissue for certain after my d&c, it was due to my uterus being wrapped around my fibroid so the RE had a hard time reaching all of the tissue on the far side of the fibroid. My doc left the clinic a week after my procedure and I had to have a different RE pick up my care. She said that we could do a repeat d&c but the risk was that they might overdo the scraping; methotrexate which would require taking a break for a few months (and it isn't like that's not a pretty hardcore drug on its own -- it affects all the tissues in your body), or wait it out.

Since my beta was dropping she and we decided to wait it out. It took forever and I was having cycle weirdness and finally my body got fed up and did some really crazy things like not letting me sleep for more than 3 hours for over two weeks and then when AF arrived I was hemorrhaging, losing at least 2 pints of blood in 2 days. And then the bleeding continued on and off for another month up until my repeat d&c. I even asked the RE about all the bleeding I was having and she didn't have anything to offer me. I did see my acupunturist during this time and he was a huge help with symptoms like feeling like I was full of cold water, and feeling like I was drinking 3 triple espressos a day.

The only thing that caused any changes though during that time though was that I went to a health spa with a friend at the end of October. The first day of classes I took Feldenkrais, trancendental meditation, qi gong and walked a labrinth. That evening, 3 months after my first d&c, I passed a large chunk of tissue. There had to be something to all that meditational-like movement practices that caused things to shift. Still there was more left, and it was due to the fibroid preventing my uterus from contracting it out properly on it own, so I still had to have the surgery.

Oh, and to just make things feel freakier, I think the retained tissue continues to grow inside of you, though slowly dying off at the same time. Hence you get a larger mass of tissue with slowly lowering beta levels.

Your doc might consider using a hysteroscope while doing the repeat d&c to better see what they are doing though this requires a visit to the OR under general anesthesia for certain. I used cytotec to dialate my cervix for the repeat d&c.

If you do in fact have retained tissue take care of it sooner rather than later to save your body a lot of struggle and your heart a lot of pain. You want to end this physical connection to the miscarriage as soon as possible.

Hope this helps.

Progesterone Affects During Luteal Phase and Into Pregnancy

I've been researching the affects of progesterone in our bodies, particularly focusing on the affects during the luteal phase. Here is a compilation of the things I've read it does (note that some of the pages I’ve linked to are long, to find the references on the individual pages use your browser’s search function (CONTROL+F in Windows/IE), to locate key words. I suggest starting first with “progesterone” and then going for specifics such as “endometrium”)

Affects of Progesterone During Luteal Phase

• Maintains endometrial lining during luteal phase, and into pregnancy in the presence of a fertilized egg (blocks collagenase from breaking down endometrium(PDF))


• Changes endometrial lining surface to be more receptive of the fertilized egg; causes the surface to have a more mucus like coating; causes glycogen bubbles to occur in endometrium which provide energy for the fertilized egg


• Promotes the endometrial glands to become enlarged, undergo maximum secretory activity and its blood vessels become coiled and enlarged.


• Prevents the woman’s body from rejecting the fertilized egg, stops rejection of fetal (foreign) DNA


• Reduces certain types of prostaglandin production to reduce uterine contractions making the uterus more hospitable to the fertilized egg/embryo (“progesterone block”)


• Affects blood sugar levels


• Affects zinc and copper levels (1),(2)


• Stimulates growth of breast tissue


• Facilitates thyroid function


• Raises body temperature about .5 degrees Centigrade (0.9 degrees F.)


• Causes relaxation of smooth muscle cells throughout the body (1), (2)


• Facilitates egg transport through the fallopian tube

Another list of functions of progesterone

So, over the past couple of years I noted that a couple times a year I was in a lot of pain around ovulation. At first I thought it was my fibroid causing it, actually it was partially due to this pain that my fibroid was diagnosed. It it focalized on the right side and if I press on the area it feels worse. In the past I've noted that ibuprofen wouldn't help the pain at all.

When I had u/s to check it out after the fact and always they have seen that I have ovulated on the opposite side (which was opposite from my fibroid as well) and that there was some fluid in my cul de sac consistent with ovulation, but nothing else.

Last night I was in so much pain that I couldn't sleep and I finally broke down and took some percocet I had left over from my surgery in November. I fell asleep around 3am. This morning I still have dull pain, but it is a lot less intense then last night. I put a call into the REs office for advisement, it seems like I should at least ask since it was painful enough to keep me up.

Part of me wonders if it was an ovarian cyst rupturing and not just a regular follicle. I didn't have such a great ovulation last cycle -- hardly any EWCM, and dry generally -- I wonder if I didn't actually ovulate or else just had a cyst. Still, the u/s when I've had this pain before showed just a single ruptured follicle on the other side.

The moon and cycles

I'm trying to help a perimenopausal friend of mine eek out a few more cycles of fertility so she has a chance to have a kid. I was just reading some info about Lunaception and pulled up the lunar calendar and saw that my cycle is already synched up with the full moon. Coincidence or by design?

My friend is just 42 and she just got back blood results showing her body is menopausal. It's sad because I'm not sure exactly how it was that she waited so long but the window to have children may already be closed.

Fibroid Research Study

I sent my blood sample in to this study last summer; my sister and I are both doing it. If you know any sisters with fibroids please tell them about the study.

What: The Center for Uterine Fibroids is currently enrolling families in the "Finding Genes for Fibroids" study. This is a clinical research study, aimed at identifying the causes of uterine fibroids. This study has been reviewed and approved by the Human Research Committee at Brigham and Women's Hospital.

Why: We hope that information gained from the study will provide future generations of women with non-surgical treatment options. This is not a treatment study. We hope that your generous efforts will make a meaningful difference in the future treatment of fibroids.

Who: In order to be eligible for this study, your family must have at least two women who are full sisters and have uterine fibroids. Sisters with a past history of uterine fibroids are also eligible. The sisters may be you and your sister, your mother and her sister, two cousins who are sisters, or any other sisters in your family. Once your family meets this minimum requirement, we encourage other family members with or without fibroids to participate. This includes men. The more family members who take part, the more powerful our data will be.

How: You can participate from anywhere in the world; all study procedures are completed through the mail at no cost to you or your family. The study involves filling out a consent form and a survey and sending us a small one-time blood sample. The consent form discusses the risks and benefits of the study. We ask you to read and sign the consent form and fill out a medical records release form. We request only medical records having to do with fibroid diagnosis and treatment. The survey can take from 15 to 45 minutes to complete, depending upon your medical history. Once these forms are sent back, we send all participants a blood sample kit. The kit contains directions about how to get your blood sample drawn and reimbursement procedures. Once this sample is returned to us, your participation in the study is complete.

I had Qi Gong practice last night and my instructor explained how to use the five elements. It was very interesting to learn how each organ system is associated with colors and elements and I think this will really help me out with my meditation. Here's a great page that explains the basics of the Five Elements.

Then this morning I had my acupuncture appointment. Some things had markedly improved from my treatment last week but I had some other things that needed adjusting and he totally knew what to do. I had swollen glands in my neck from my cold that were bothering me and now they feel clear and normal. From the moment he put in the first few needles I felt my body start shifting my energy around, it felt like I was going from disorganized to synchronized in a matter of minutes. Now I feel warm, smooth and even more happy. I have a faint headache just behind my eyes though, I bet something is still kinked up somewhere.

I'm doing both Qi Gong and acupuncture to try to regain health, rebalance after all of the health problems from last year and also to try to get my body to be stronger and less flimsy in general. Meditation is more sporadic but I do it with a friend of mine when we get it together. Improved health is going to take a lot of ongoing practice but I'm hopeful that I'll get balance someday.

Epididymitis

Any infection of the reproductive organs has the capability to interfere with fertility, though it looks like this infection doesn't usually lead to lasting fertility problems when it is treated but there is a chance of obstruction or antisperm antibodies.

"Unilateral or bilateral obstruction of the genital tract (either congenital or acquired), epididymitis and varicocele are also sometimes associated with an autoimmune response against spermatozoa."
from: Antisperm Antibodies

Here are some links about epididymitis, and fertility for your reference:

What is Epididymitis and how is it treated?

Epididymitis And Orchitis

Orchitis and epididymitis

bacterial epididymitis

If your partner has this infection currently or he did previously I would suggest that after treatment by a doctor (probably with antibiotics), if you are TTC he should have another S/A to make sure everything is working properly.

Treatment for a Bloody Nose

My cold has freaked out my nose and I've had several bloody noses today. I had these a lot when I was a kid, but not for years. Luckily I know what to do, now here's the real trick (and I haven't seen this written down elsewhere)... when you have a bloody nose don't tip your head back as it makes the blood run down your throat and that gives you a stomachache. What you need to do is take a piece of absorbant paper and fold it up and place it under your upper lip, on top of your gums right below your nose. There are blood vessels here that go up to your nose and the paper will dry them out and reduce the flow of blood to the nose. Your bloody nose will stop within 15 seconds. Really, it works. Now stopping the reason you are prone to bloody noses is another thing -- vitamin C and vitamin K will help with that some though, plus iron if you are anemic.

You must have heard about all the babies that got conceived during WWII when the husbands were on leave. Evidently enough interest and excitement can cause our bodies to break with the standard cycle. Even if you have regular cycles your ovaries are constantly recruiting new eggs into the maturity cycle so with proper motivation (husband back in town) there is a chance that things might be able to happen regardless of where you are in your cycle (except maybe during your period, it seems less likely).

Fertility Enhancing Diets

I just posted some general tips here but note that while these tips work for both men and women, but there are some additional supplements that each gender should have such as selenium for men and iron for women:

Diet Tips
Dietary changes will depend on your individual constitution but generally these are good things to do and will help with your general health as well as your reproductive health -- I've read a lot of books over the past couple years about hormone balance, fertility, stress, fibroids, and alternative medicine:

Increase consumption of leafy greens -- these help your body with hormone balance and production and contain calcium, magnesium, phosphorus and vitamin d plus folic acid all of which are excellent for your fertility and the combination of them is easier for your body to digest.

Cut out simple sugars -- don't eat sweets and cut back on simple carbs as well as these foods are just empty calories and lack nutritional value. Too much sugar can affect your immune system and increase stress on your adrenals and all cells throughout your body. Have a piece of fruit instead. My acupuncturist has told me that even fruit juices contain too much sugar unless diluted.

Increase dietary fiber -- this helps to get rid of excess estrogen which takes a burden off of your liver.

Increase healthy fats in your diet -- more unsaturated fats and less saturated and hydrogenated fats.

Increase anti-oxidents -- Vitamin E and Vitamin C both help to fix cellular damage and heal tissues.

Cut out caffeine -- another adrenal stressor and can impede fertility.

Cut back on dairy -- we're not baby cows and the calcium in cow milk isn't easily absorbed without magnesium (and Vit D but they add that in). This is more controversial, my doctor told me that I would need a lot of calcium if I got pg but my acupuncturist says that the milk causes pelvic congestion and I got pregnant after following his directions and not after following my MDs so I've made up my mind. I just have a little dairy when I'm craving it.

Eat organic, whole foods as much as possible -- Processed foods and regular animal products are full of additives and chemicals which interfere with the endocrine system.

Here are some books you might want to refer to for more information about fertility/diet/hormonal and reproductive health:

Healing with Whole Foods

The Infertility Cure The author hosts fertility retreats and has a website with some recipes on it.

Healing Fibroids

Thyroid Power

Encyclopedia of Nutritional Supplements

Inconceivable -- I haven't read it but it is supposed to be hardcore into diet and lifestyle changes. The author has a website with some recipes on it: http://www.fertileheart.com/foods/p.fd.soups.html

About Ovulation

The ovaries are full of thousands of eggs held in hormonal stasis in their "primordial follicle" which is a androgen dominant environment. This is the pool from which follicles are constantly being recruited into the maturation process which can take 3 months from early maturation up until the time of ovulation. Maturation of the egg/follicle requires changing the environment within the follicle from androgen dominant to estrogen dominant.

Not all eggs that start the maturation process are developed all the way that you might see them on an u/s prior to ovulation, these ones were lucky and their development synched up with the hormonal cycle perfectly so they could mature up to the point of ovulation.

Ovulation itself is a series of hormonal events the LH, a little progesterone to ripen the follicle, a drop in estrogen are some of these changes. Hormonal imbalances can interfere with this process, as evidenced by women with PCOS whose follicles don't properly mature.

So, if there are imbalances that are interfering with hormones on subtle levels it can throw off the follicular development and you might end up with an functional ovarian cyst, a partially ruptured follicle, no ovulation, or maybe delayed ovulation. If ovulation doesn't happen normally then there's a good chance that even if you release the egg then the follicle isn't going to change over as well into the corpus luteum, the structure that produces the progesterone which causes a lot of changes in our bodies that make it receptive to accept a tiny embryo (I have a lot of information about progesterone but that will have to be a different post if you are interested)

Here are some links about ovulation, you also might check out The Infertility Cure by Randine Lewis which has an interesting chinese medicine explanation of ovulation through the cycle phases that I enjoyed.

http://www.merck.com/mrkshared/mmanual/figures/234fig4.jsp

http://www.merck.com/mrkshared/mmanual/section18/chapter234/234a.jsp

http://www.emedicine.com/med/topic1340.htm

Advice to someone trying to build their iron stores before surgery...

I've been working on building my blood over the past months, I had some bleeding problems related to my miscarriage that have left me anemic once again.

Here's a totally wacky suggestion but since I was just up in the Andes you should know that your body will produce more red blood cells at higher altitudes. You could plan on spending the next month up at a higher elevation.

I don't have it in front of me but the book Healing with Whole Foods (Pitchford) had suggestions for what to take for anemia. You might check it out at a book shop if you have time; I love this book as it provides information on how to correct illness and various conditions through diet. B6, B12, Magnesium, Vitamin C and of course Iron work together to bolster blood development. There was some other theory about transmutation or something where one other nutrient turns into iron into the body but I don't remember what it was you have to read the book.

There are also blood building herbs you can take, from what I recall these are yellowdock, nettles, and dong quai but I wouldn't use them on my own -- better to work with an herbalist, naturopath or chinese medical specialist than dabble. Also, since surgery is so close at most you might be able to use them for a couple of weeks.

If you are still bleeding in the meantime Potassium is supposed to help control bleeding so make sure you are getting enough in your diet. Also, things like garlic and onions are blood thinners so you will want to be careful of that.

I just wanted to show you this quote that I just found which explains from a chinese medicine perspective why just eating iron rich foods might not help treat anemia:

"Of course, knowing that a patient suffers from a specific type of anemia may influence the treatment strategy as a whole, i.e., if a patient suffers from iron deficiency anemia, iron rich foods and possibly iron supplements should be consumed. However, even in such a scenario, if the patient suffers from the spleen and stomach vacuity weakness pattern of blood vacuity, iron supplementation plays only a secondary role; the fortification of the spleen and stomach are primary. As long as foods are not absorbed correctly, no iron supplement will be of any help. This explains why certain iron deficiency anemia patients fail to improve even though they are on megadoses of iron." (from A Clarification of Andrew Gaeddert’s Article Key Blood-Building Strategies)

I've been eating lots of iron rich foods, even more so since I've been back from vacation and I'm still ailing -- pale gums, pettichae (little red spots on my breasts that are associated with anemia in Western medicine). When I went to see my acupuncturist yesterday he said I had blood stagnation and qi depletion and already after one treatment I'm feeling a bit better though we still have a ways to go. He's going to treat me with herbs after this period (which started today) is finished. Hopefully I'm not going to be hemorrhaging again, so far so good.

Anemia & Iron Rich Foods

Here are some links to pages with information about iron rich foods and some others about anemia generally. B vitamins are also important in healty blood production so make sure you eat a balanced diet with enough B vitamins.

Rules about iron include - take it with vitamin C, don't overcook foods (steaming is best), antacids, calcium (dairy products) and caffeine all block absorption so definately don't take at the same time. Iron from red meat and liver (heme iron) is more easily absorbed than from plant sources (non-heme) though taking non-heme foods at the same time as heme foods can improve iron absorption.

Here's a great link about iron absorption

Also, since some of the iron supplements are hard on people's stomachs I though I would share what I'm taking which hasn't caused me any difficulty (although if you are severely anemic this probably isn't strong enough) -- Nutrition Now Chewable Iron (25 mg of elemental iron per tab -- though they recently changed their formulation to ferric pyrophosphate and I don't recommend it anymore. Others I've met online have had good luck with Slow FE or Floradix.

"Which forms of supplemental iron are best?
All iron supplements are not the same. Ferrous iron (e.g. ferrous sulfate) is much better absorbed than ferric iron (e.g. ferric citrate).13 14 The most common form of iron supplement is ferrous sulfate, but it is known to produce intestinal side effects (such as constipation, nausea, and bloating) in many users. Some forms of ferrous sulfate are enteric-coated to delay tablet dissolving and prevent some side effects,16 but enteric-coated iron may not absorb as well as iron from standard supplements. Other forms of iron supplements, such as ferrous fumarate, ferrous gluconate, heme iron concentrate, and iron glycine amino acid chelate are readily absorbed and less likely to cause intestinal side effects."
From: Vitacost's Iron Information page


What foods contain high amounts of iron?

Eat Iron-Rich Foods

Iron: Vegan Society

Menorrhagia Diet

Iron

How much iron do certain foods contain?

Iron deficiency anemia in pregnancy: a short account

Iron Deficiency Anemia

Iron Balance - explains iron intake, losses and affects of iron
deficiency in women

Anemia and Fatigue

Iron Deficiency

and kind of unrelated but interesting information:

Workshop on Maintaining Iron Balance in Women Blood Donors of Child-Bearing Age

Since I got pg last spring I've noticed some changes in my cycle. Some of the changes are hard to know if they are sticking around since I had retained tissue until my surgery and second d&c in November and my body is still healing from the surgery. Still, there are some things like fibrocystic breasts that I've not experienced since before my BFP.

Here's what I've noticed:

BEFORE AF is heavy but fluctuates between flooding, clotting, heavy flow and medium flow and lasts at least 7 days Goes directly from period (AF for Aunt Flo) into lots of cervical fluid (CF) Copious fertile quality CF for 5 days before ovulation Full, sore breasts during luteal phase (LP) Really moody during LP Pimples on chin during LP Nightsweats during LP Half day of spot before AF arrives

AFTER AF is really heavy and fluctuates between straight blood (bright red), little to no clotting, heavy flow and medium flow and lasts at least 6 days Slow start on CF after AF, definately drier CM for 5 days before ovulation, mostly creamy and not really wet Pimples on chin around ovulation Scant EWCF for a day or two at most Full breasts in the LP, they don't hurt Tired during LP Faint pimples on chin during LP Nightsweats during LP and throughout the cycle Several days of spot before AF arrives

I'm going to be working with my acupuncturist again starting this week, hopefully that helps out a lot. I've been trying to address my post-surgery depletion with my diet as well but I may have to meet with my naturopath if I think I need more help on that end of things. It's so wacky to have things be so different even though my diet and lifestyle isn't that different.

Pregnancy and infant loss in the news

I just wanted to make note of an observation I had while watching the news today. Both the case of the murder-kidnapping of that fetus as well as a big arson case in Maryland have suspects who are dealing with pregnancy and infant loss. It sort of points out to me the great anger, grief and confusion that losing babies causes; and the lack of something to help people cope with their loss.

The suspect in the arson lost a baby at the beginning of the year and said something to authorities that the person who lit the fires likely had suffered a great loss. If it is true he did this and the two instances are related I can only imagine how hard the past year has been for him -- not excusing the actions though.

And the murder-kidnapping suspect, going from murder to parading the infant around the next day. The fact that her family didn't know it wasn't hers, that she had a pg loss and then was able to convince them that it must have been a mistake...while what she did was awful and macabre, it is just an extreme action paralling the extreme confusion and grief that pregnancy loss can do. It's almost like the very bad and black thoughts overtook her.

It seems we need to do more to help support people experiencing pregnancy and infant loss -- yeah there are crazy people out there, but if there was a better understanding of what people go through when they experience this kind of loss maybe there will be less anger, hurt and depression and more healing.

Perhaps I'm rambling, I just needed to get that out.

Working on fertility and fibroid prevention post myo

I had acupuncture treatment for most of the year up until my surgery and I expect to start treatment again in the new year. Through my weekly appointments I learned a lot about symptoms and sensations and was amazed as my acupuncturist was able to move things around -- such as getting rid of a sore throat in seconds, dissipating heat and pain in my abdomen within minutes, adding heat to my lower back that lasted for days when I was feeling cold and watery with some hormonal disturbance related to my miscarriage.

I needed a break from medical care for a little while, with having retained tissue from my miscarriage I was so out of whack and I was starting to feel like a perennial patient -- like it was more normal to be unhealthy than healthy so I needed some time to just be me. Anyway, I've been noticing little symptoms of hormonal imbalance over the past couple weeks so I know that my body isn't "normal" yet. My basel temp has been a little high, I have pain associated with my gall bladder channel, I have light night sweats, vaginal dryness, acne, low back pain and my body is telling me not to eat sugar right now. I feel so bad that my body is struggling still but I'll continue to take care of myself and in January after I return from vacation I'll go see my acupuncturist again.

I just bought The Infertility Cure by Randine Lewis, a fertility expert who specializes in acupuncture and Chinese Medicine. It is so interesting to read, adding to my own experience with acupuncture treatment. Reading it I see more examples of symptoms of imbalance in my body, some of them part of the pattern of imbalance I have had over the course of my treatment (liver, kidney and spleen Qi stagnation and Yang Qi stagnation). While these things will interfere with conception when I'm ready to try to concieve again, they also are part of the pattern of imbalance that contributed to my fibroid formation. It only increases my resolve to make changes and adjustments to try to be as healthy as possible to try to counteract the pattern to try to prevent future fibroids from forming. I've already made changes since my fibroid was discovered, I'll just have to keep working equally as hard moving forward.

I went to dance class today.

My doc said after 6 weeks I could return to normal activity; my six weeks were up yesterday. My body started complaining a couple days ago about wanting some exercise, I started getting achy -- amazing that it took that long. I ran down the block and back with my dog -- I can move again.

So this morning I knew from the aches and pains that I still needed more movement, to help get my energy flowing again. I went to a beginning modern dance class -- I've been studying modern dance since I was 5 so this wasn't something far-fetched. Anyway, as part of the warm-up we do some abdominal work, not sit-ups but lots of moving and stretching and small crunches and contractions. I got through that, taking a break for parts of it. Then we did footwork, brushes, tendus, degagés, passés (for those of you who have studied ballet or modern).

After about a half hour my fascia had enough stretching and was complaining so I stopped; my legs and arms and back were fine though perhaps a little weak. I've been kinda tired since, though I was run down before then as well -- I think it is my anemia from all my bleeding. I remembered how someone asked if they could do yoga a couple weeks ago, and how interesting it was to finally be the one getting to move again myself. My advice is take it slow, stretch a lot, listen to your body and stop if you need to. I'm going to keep up the exercise over the next few weeks and when I return from vacation I'll try to hit dance class again and I bet I'll be that much stronger.

You think you have a plan...

When I was younger I thought I would start having children when I was 28 but then that year my partner had his vasectomy reversal. We thought we would wait until I was 30 or so before we'd start trying, then 2000 rolled around and his S/A wasn't good. We stopped using protection and nothing happened, but we weren't ready for it then anyway. Then there was 31, and 32, we'd be ready by then. Well I can't say I really felt ready when we started TTC in 2002, and only later did we find out that my body wasn't really ready yet either -- at the same time I was diagnosed with my fibroid I was told I had bacterial vaginosis. A few weeks later my naturopath told me that not only was I anemic but that I really needed to do something about it. This all in spite of regular cycles -- well at least my pituitary and ovaries still work. Then 2003 was all about research into fibroids and hormones -- and not having surgery and crying after a lot of doctor's appointments. 2004, it started out hopeless, then gradually things started to change. We had treatment planned and then we even got pg on our own -- what a surprise. This second half of the year has been about letting go, grieving, healing, changing, transformation, and recovery.

I'm 34 now and I'll be 35 in six months time. I wonder where 2005 will take me, but I'm sure that I can't possibly predict.

Six Weeks -- Feeling Pretty Fine

I haven't had my laptop so I haven't been able to upload any photos in a week. I'll have some soon of my healing belly. I don't think you can see much change on the outside but I can definately feel the difference on the inside. I'm a lot less sore now and I have more energy.

My cramps were awful last week, I thought I was going to die and I had spotting which isn't normal for me. My period came last week, over a week late, and it wasn't normal. I had more hemorrhaging for several days and felt very light-headed. It doesn't even take that much blood loss for me to feel this way. I was anemic to start with, something I've been working on since my surgery by taking iron supplements. I think my uterus might have had a hard time contracting properly and maybe it was still adjusting to all the recent changes.

I looks like things are getting back into order though, all biological signs are A-OK now. My incision is still sensitive but I don't have to wear the granny knickers anymore and I can comfortably sleep on my belly at night. Wednesday morning my body told me it was time to exercise again. I've been aching for the first time since my surgery, the kind of aches you get when you don't exercise for a while. I've been trying to pick it up and do more physical activity including a little jogging down the street and push-ups.

We babysat my 26 month old nephew at the beginning of the week and the kid had us running around for hours. My partner says that he's not sure he wants one now, that his life will be certainly over if he has to do that every night. I don't think he is serious, he would love a baby if we had one and be awesome about it. I told him we can get an au pair, though I don't know that we really would do that. We'll figure it out when the time comes.

My partner also noticed the other day that for the first time in a couple years there is this lightness to my person, some weight being lifted. I think it is from the fibroid mostly. It was a big psychological burden on me to know that I wasn't well and that I had to manage a condition that may or may not affect my fertility. My partner said that now I know I can get pregnant and now that the fibroid is gone things are looking a lot easier. Let's hope so.

It will be another 8 weeks or so until we're able to start trying to conceive. I'll be away on vacation for part of that time and then I'm going to try to take some art classes in the new year to help keep my mind off of it all.

Why we have bleeding problems... Links/References

At the beginning of the year I posted some links about dysfunctional uterine bleeding (DUB) and one list member (on the fibroid group) asked if I would look into why women tend to have flooding first thing in the morning. Most of you probably know this phenomena whether or not you have DUB -- its when you are sound asleep and suddenly awaken because a big gush of blood is coming out all at once and you run to the bathroom if you can though sometimes you wake up too late and the sheets, your underwear and your nightclothes all need washing.

I wish I had a hematologist to confer with but doctors tend to keep to themselves or just don't overlap with my software oriented social network. I've got a few references here some mechanical and some physiological to causes for bleeding. Since excess estrogen/low progesterone is one theory of part of the cause of fibroids it is interesting to see that the same conditions also set the stage for bleeding problems. Also, I couldn't find references to early morning menstrual bleeding but there was a reference to there being early morning changes in the blood which might be related, at least in action.

"Most very heavy menstrual bleeding does not mean that a woman is shedding substantially more endometrium. The endometrial slough is determined by the size of the uterus and the hormonally induced endometrial thickness. The uterus has large blood vessels that come through the myometrium to feed and supply the endometrium. Really heavy bleeding occurs when the uterine muscle cannot do its job of contracting around these vessels. This is important because after the endometrium is passed out, the basilis layer may be very thin, which could expose the raw muscle surface. This means that the large
vessels can pump blood directly into the uterine cavity if the muscle cannot contract well."
http://www.centerforendo.com/news/adenomyosis/adenomyosis.htm

"what frequently happens when excessive amounts of estrogen are secreted. Parts of the endometrium outgrow their blood supply and are discarded but not simultaneously. While the one part recovers another part is discarded and the bleeding continue for prolonged periods. In the illustrations the bleeding might decrease while the one area heals before the the other area starts bleeding."

"Fibroids usually cause excessive cyclic bleeding. The amount of blood loss is increased and /or the duration of the bleeding is increased. The mechanism is probably due to enlargement of the womb, thus increasing the surface area of the endometrium."
http://www.femalehealthmadesimple.com/FileTwelveFinal.html

"The plasminogen (fibrinolytic) system (Figure 1 ) comprises an inactive proenzyme, plasminogen, that can be converted to the active enzyme, plasmin, that degrades fibrin and that activates matrix metalloproteinases (MMPs), which in turn degrade extracellular matrix(ECM)"
"There is a clear correlation between the circadian variation in the time of onset of myocardial infarction, with the highest incidence at about 8 a.m., and the circadian rhythm of plasma PAI-1 activity, which is also highest early in the morning."
http://www.asheducationbook.org/cgi/content/full/2001/1/1

"PGE2 --> vasodilation; PGF2a --> vasoconstriction; progesterone is necessary to increase ararchidonic acid, the precursor to PGF2a. With decreased progesterone there is a decreased PGF2a/PGE2 ratio. Since vasoconstriction is promoted by PGF2a, which is less abundant due to the decrease in progesterone, vasodilation results thereby promoting AUB [Abnormal Uterine Bleeding]"
http://www.unmc.edu/Olson/PowerPoint/36 (no longer available)

4+ Weeks Post Myo

Another report on how I'm recovering -- hopefully this helps people who are considering the procedure.

I retured to work part-time one week ago. I got tired and sore by the afternoon and was sure to go home. During the rest of the week I noticed that day by day I had more stamina and less pain -- it seems that the pain picks up if my body needs a rest. I was able to work almost a full day on Friday without any problem and then my uterus where I had the incision started aching so I headed home. In contrast, my first shopping trip 8 days post-op I felt lightheaded and really tired after a couple hours out of the house. My second shopping trip 18 days post op I was out for a few hours on my own and got really tired and flushed feeling -- that's when you know you need to head home.

Saturday I took it easy, just doing light housework and cooking plus lots of knitting. Yesterday I went shopping for several hours and it was only after I tried on a bunch of different pants (after having been out for some time) that I started feeling achy. I handed over the items I was going to purchase to my partner to carry and then went home. I was feeling a little tired but I wanted to get a tree for Christmas so I drove out to do that and just had the staff carry and load it for me in to the car. I took a rest when I got home and finished stringing popcorn for the tree and then after making dinner I decorated the tree and vacuumed downstairs (I had my partner bring the vacuum downstairs for me).

Every day I'm feeling more and more myself. The pain from the adhesions behind my incision in my skin seem to be breaking up a little bit and I think my skin might be adapting/growing to that situation as well. I still haven't had my period but hopefully this week. When I had my d&c for my miscarriage in July it took 50 days to get my period, I think my body tends to take it slowly and get everything back in alignment before it continues.

I had sex once so far and it wasn't bad at all -- we did it spooning, on our sides which takes all pressure off of my belly. The only reason we've only had the one go is because our sleep schedules are different so I'm tired when he's just getting interested (sound familiar anyone?).

I'm all stuck together

I try to be good and take care of myself during my recouperation from surgery and !@#$ it seems like my skin has healed by bonding itself to my fascia. A couple people have told me this will go away, another one says that she is still dealing with this leftover from surgery. I'm so upset about it because there is this pulling sensation when I move. I need to be able to move without pain, I'm a dancer. Why didn't anyone tell me this was a possiblity? I'm so bothered by it I want to hurt myself.

I'm going to have to try some serious deep tissue massage to see if we can clear it out and it is going to be painful. It's going to stay painful unless I do it though. Argh!

14+ days post op

So I had my post-op visit yesterday morning and everything was good, she said I looked great. She said removing my retained POC was very difficult because of the fibroid and that there was no way for my uterus to expel the tissue on its own based on how the fibroid was positioned filling the interior of the uterus. So my prospects for a normal vaginal delivery were probably slim to none since my uterus couldn't contract well, or at least I would have had a complicated delivery. I was sooooo uncomfortable when I was pg with the rapid fibroid growth and the pregnancy having to grow off to the side because that was the only way my uterus would move, next time should be a lot better.

My doc also said that my uterus will be enlarged for a while, shrinking back some but that it would never be the size of a normal unpregnant uterus since the fibroid made the muscle wall have to grow larger. Maybe I'll be extra fertile now though, the interior of my uterus will be one vast space with lots of room for an embryo to settle in.

She said I could remove the steri strips in the shower or bath, I just pulled them off carefully when they were dry, the adhesive was already starting to go. Uncovering the incision though made it burn more, I think this is partly due to my nerves regrowing right now --
they have to cut through some in the skin there and they may or may
not grow back completely. I had to take the 600mg ibuprofen and after an hour that wasn't helping so I took a percocet and it really helped take the edge off the pain. My father said he had that same burning sensation as he healed from his triple by-pass a few years ago. The incision looks great and I don't think that it will show that much at all in a few months.



She agreed that starting trying to conceive (TTC) again in February
sounded like a good idea and that we should try for a few months on
our own before going back for any more fertility consultations. After having way too much medical attention over the past 6 months (due mostly to the pregnancy/miscarriage) and way, way too many blood draws for my liking, now I'm in a holding pattern and it feels so strange to be told that I'm healthy and back on my own. Not that I liked being not well but you do sort of get adapted to fitting in the medical care when things go wrong. Yeah to be healthy again though!

Oh and I guess it was around 11 days post op that I started to feel
more myself and I've been less fatigued and able to do more around
the house, tidying up, cooking, light cleaning, etc.

Recap of my pre- and post-surgical treatment

The day before my surgery I did go for acupuncture. I like my acupuncturist and my body responds well to his treatment. He said that my nervous system was a bit overactive -- but that was to be expected.

I've been taking the arnica since the day of surgery, at least 2 times a day now. I took the phosphorus C the night before, and started on Traumogen (vitamins to aid healing from Thorne) the night before as well. I had no nausea from the anaesthesia, and I only threw up twice, once from the PCA meds and once from the percocet. I've been taking iron with C and Traumogen every day since my operation 2-3 times a day.

I did have some bruising around the incision as I was healing, but that's gone away now, as has most of the swelling. I hope this doesn't freak you out but I've been taking photos of my incision as I'm healing and thought you might be interested.



On day 3 you can see that my belly is very round. Two days later a lot of that swelling has gone away and the bruising showed up. The colors got pretty bright and multicolored by day 7, as bruises often do. By yesterday the bruising is gone and the swelling is mostly just above the incision.

Oh, I've been also doing some Qi Gong breathing, deep breathings to fill my lungs -- at least once a day. And you want to make sure that you stay connected to your uterus after you are out of surgery and think about sending it healing energy -- I guess some people disassociate from their wounded parts sometimes and it interferes with healing. Read this article about Qi Gong and surgery, I found it very interesting.

Medical Qigong Therapy & Surgery

Post op, stay away from cookies, candy -- simple carbs. I found that my body didn't want them anyway. Drink cranberry/pomegranate/grape juices to help prevent a bladder infection.

I also did guided imagery with the help of a CD my fibroid sister Deborah sent me in a care package. I told people about my surgery and asked them to pray for me and send healing thoughts. I also tolds people when and where I would be treated, and when to expect me home with my phone number so people could call. I felt very supported and warm for the days before and after my surgery.

You can get through this too.

Fibroids and pregnancy

Welcome to the club. I've met some women here who have successfully carried babies to term with fibroids in place, with some fibroid growth. I've also heard women report that they have had excrutiating pain from degenerating fibroids and the babies were fine but the pregnancy was rough on the mother. There are also a lot of women who have had miscarriages, which may or many not have to do with their fibroids -- myself included.

Doctors don't really know which fibroids will cause problems and which ones won't -- at least not beyond just normal clinical experience, the studies just haven't been done yet on a lot of topics. Some tiny fibroids can become really large during pregnancy. Large fibroids might experience some growth but not cause too many problems, or vice versas. I learned of one woman recently who had her fibroid removed during a c-section to deliver her baby -- the fibroids and the baby weighed the same. What you want to find out is where is/are the fibroid/s, what type are they (submucosal, intramural, subserosal)

The Babycenter.com fibroid message board has lots of posts from women who are trying to conceive with fibroids in place or post myomectomy (surgery to remove fibroids), as well as women having to deal with fibroids during their pregnancies.

Just because you have fibroids doesn't mean that you can't conceive and carry a healthy child to term, but it can make the journey a little less smooth.

I've posted a bunch of interesting articles about fibroids and fertility in the Links area of the NUFF uterinefibroids message group. Do check them out (subscription required).

Go out to the bookstore and buy: What Your Doctor May Not Tell You About Uterine Fibroids, and Sex, Lies and the Truth About Uterine Fibroids.

Oh, and I would seek the assistance of an RE (reproductive endocrinologist) if you have a diagnosis of uterine fibroids. They are more knowledgeable about hormone imbalances and specialize in fertility issues -- they are ob/gyns with advanced training -- and if you haven't had any luck with well-timed intercourse after a year the you should go for a consult anyway. They might try to push you for surgery and fertility drugs but it is up to you what you want to have done.

What happens when you are having a myo

I'm on bed rest one week and two days post abdominal myo and I'm feeling great. Tired but healing quickly. Since you were curious about the before and after...

Pre-op consult -- they take your blood pressure, weight, check your blood to make sure you aren't anemic and get your blood type if they don't have it on record. You meet with your doc and ask last minute questions and sign a few forms. Sometime you will get to meet with the anesthesiologist at this time but I didn't. They give you instructions on when to stop eating and drinking prior to surgery.

Day of surgery -- check in 2 hours beforehand. I brought knitting to keep my hands busy and mind calm. The hospital seems to make you keep signing forms that say the same thing (whatever). My surgery was delayed by more than an hour so we went home for an hour and I did some last minute housecleaning.

When it is your turn they take you into an area with a gurney and give you a hospital gown to change into. My partner was allowed to be with me until they were ready to take me into the operating room (my doc said -- be sure to ask yours ahead of time about this). They hook you up to an IV and the anesthesiologist asks you questions about your previous experiences with anaesthesia. You have the option of asking for an epidural with sedation if you prefer, it is up to you and the anesthesiologist. I did the general and it was fine. They take your bag and you say goodbye and then they wheel you in to a freezing cold room. They hook you up to a blood pressure cuff and the oxygen monitor (little finger cuff) and then put a blanket over you. The anesthesiologist puts a mask on your face and tells you to breathe in oxygen and the next thing you know you are waking up in recovery.

They keep taking your blood pressure alot post-op and you are groggy and have a hard time opening your eyes. You are hooked up to a PCA, where you are able to dose yourself with painkillers as needed -- don't hold back because staying on top of the pain at first will help you a lot. After about an hour they wheel you to your room. They put some pressure stocking on your legs and some cuffs that compress/decompress automatically to help prevent blood clots. My wound was covered with a bandage so I couldn't see the incision -- thankfully. I had a catheter in for not even a full day, but know that the first pee can be really difficult. The nurse gave me warm water to run over my vagina while on the toilet and that helped get things moving. I recommend drinking unsweetened grape or cranberry juice for a week afterwards to help ward off a urinary tract infection -- it helps prevent bacteria from adhering to the lining of your bladder, etc.

They will have you up and walking less than a day after surgery, take it slow and roll onto your side slightly, then drop your legs off the bed and use those side muscles to lift you up. The first few times you get up will be very awkward and painful. Stay on top of the pain meds and breathe a lot and you will do fine. The pain isn't excruciating, I ranked the worst at 5 on a scale of 1-10 but it was mostly around 3-4.

And then do as I've been advised from other post myo gals -- take it easy and don't push yourself. Even though my incision looks great I can't see my uterus and it has a lot more healing to do than my skin.

Extreme Makeover: Uterus Edition

"We converted this cramped two bedroom bungalow into a special open floor layout and removed some earlier renovations which were gettingin the way…"

So, I'm home from the hospital as of yesterday afternoon and I'm well on my way to a full recovery. I'm really tired still and reading is kind of hard, I just start falling asleep so I'm going to make this post and then you'll probably hear more from me later in the week.

My entire surgical team was comprised of women. From the two REs and the anesthesiologist to the nursing team – how very cool to know that competent women were working hard to help heal me. I wore my purple fuzzy socks of courage and even got compliments on them from the nurses. I opted for the general anesthesia and other than a sore throat on Saturday it was totally fine.

It took as long to remove the remaining tissue from my miscarriage as it did to remove my fibroid, but already my bleeding has slowed. I had been bleeding for the 4 weeks prior to my surgery and was a little anemic as a result. They didn't need to give me a transfusion and they commented on how little blood was lost – I went for an acupuncture treatment the day before and that can help lessen blood loss. One of the REs said she was a firm believer in acupuncture and wasn't surprised that it would help out.

The fibroid made it impossible to use the hysteroscope to view the retained tissue but they believe they got it all out of there. My fibroid was described as being the size of a grapefruit, and was removed via a single incision about 3 or so inches long. It was growing right up against the endometrium, but it was not engaged withthe endometrium – what a blessing. So, while they had to cut all the way through the muscle wall to get it out there was no disturbance of the interior of my uterus so I've got the most surface area possible to help catch fertilized eggs.

Over the course of the two procedures my bladder was manipulated and traumatized quite a bit. Between that and the catheter the most difficult part so far has been trying to urinate; I have to sit for along time and try to relax and let got of any part I can think of. I also had blood tinged urine but the doctors said it was as a resultof the trauma. I'm drinking cranberry juice and lots of water and am under strict orders to urinate every 2 hours. They weren't sure if my bladder was enlarged from the fibroid or now, or if I'm just one of those women who can't empty her bladder completely (it happens they say) but we sure as heck don't want me to have a bladder infection so I'm going to stay on top of it.

My incision on my swollen belly is a good 5 inches long, I imagine that it will decrease over time. The gum, the walking, the sleeping mask, ear plugs, robe, slippers, granny knickers and my own pads all came in handy. The doctors and nursing staff were amazed at how well prepared I was for the hospital – I gave the fibroid ladies all the credit. They are truly the best group of women on the web.

My myomectomy scar - Day 3


Oh, and the baby making department… my RE said that the way the fibroid was positioned that she didn't think that I would have beenable to carry to term even if we didn't have a blighted ovum and that she expected that I would have continued having miscarriages. She thinks we have a great chance now and said we could try as soon as two months from now, though I think we will wait until February is over.

My partner is exhausted; I think the emotional stress of the weekend has gotten to him. He held me in the hallway last night and hugged me and said he felt so relieved that it was all done now. Poor guy; he was nice and helped watch over me the first hours after my surgery on Friday, massaging my feet and making sure they got me situated into a good room.

So, I'm feeling all right and my abs aren't too sore – they didn't clamp me, just pushed and pulled them a bit. Other than the incision site being sore and my uterus as well in the two spots they worked the rest of my body feels fine – I'm just incredible tired.

I can't believe that I'm through with the worst of it and now I've just got to heal. No regrets on my part for delaying the surgery, I know it was the right thing for me. Thank you for your prayers on Friday – I felt like I was in a warm cloud, so relaxed and comforted the entire time.

[See also: Preparing for surgery posts]

"We can rebuild her. We have the technology.
We have the capability to make the world's first Bionic uterus.
This uterus will be that womb. Better than she was before.
Better . . . stronger . . . more fertile."

Fibroid leaving on a metal tray (sung to the tune of Leaving on an Airplane)

So my bag is packed, I'm ready to go
I'm sitting here, making another post
Already I'm looking forward to the change
So cut me and dissect me
Tell me that how much better I'll be
Help me get back on the fertility road

My fibroid is leaving on a metal tray
Don't expect to see it ever again
Oh 'Roid its time to go.

So, anyway... Friday is my big day, I've got gum and granny knickers, a maternity belt, arnice pellets, purple socks of courage etc., etc. -- all courtesy of the generous sharing of info by the fibroid ladies on the NUFF group. I'm feeling pretty relaxed and this will all be over and I'll be on my way to recovery within the next 24 hours.

I don't need to take phosphosoda or any laxative so that is good. And my doc thinks the d&C and myo should only take 2 hours. My RE will be assisted by another RE, a fellow, so I'm in good hands. I check in at the hospital at 1:30 tomorrow and the surgery is scheduled for 3:30.

Please send good thoughts and prayers if you can tomorrow.

Definitions of (girlie) bleeding

In the time I've hung out online with women trying to get pregnant I've had the chance to learn more of the nuances of spotting. I've heard women say that if there is any blood contained in your cervical fluid they they considered it spotting. At the end of your period though it it more residual flow, I have that too. This type of spotting tend to be brownish.

[added in this article link 2/4/06]
Menstrual Mysteries -- more info about determining problems with your menses based on quantity.

Spotting is bleeding outside of your period. I've had spotting this month and it just continued as red coloration to my cervical fluid, this is dysfunctional uterine bleeding related to my miscarriage.

Spotting also is the first sign of an impending period for many women. I'm pretty sure that this is light pinkish, with maybe a little brown as the blood oxidizes.

Heavy menstrual flow is when you need to use more than one pad an hour, though I consider this really heavy, medically referred to as Menorrhagia. Because your body is bleeding so much the chemicals that are supposed to keep the flow fluid can't work as well and you do get some coagulation -- the clots, or liver-like lumps. I find that when I have clotting I tend to get really nauseous kinda intense cramping feelings -- I think this might be the clot passing through the cervix -- when I miscarried there was a similarity to the sensation though the miscarriage was more painful in my opinion.

My previous period was unusual, again it seemed to be related to my body trying to get rid of retained tissue from my miscarriage. I had bleeding for 3-4 days that was bright red and had no clots. On toilet tissue it looked like I was dabbing at a wound, it was plain blood and without the mucus component of a normal menstrual flow. I consider this abnormal for me, though women with fibroids contacting the endometrium might experience this as a frequent event.

"Women lose between 20 and 80 cc's (1-2 ounces) of blood during a normal period." (hah! right)
http://www.fwhc.org/health/moon.htm

This page includes diagrams and links to more information about normal/abnormal menstrual bleeding and includes a reference to fibroids (scroll down the page)
MENSTRUAL ABNORMALITIES

I found a lot of mention of the fact that doctors often underestimate women's blood flows and that there is a pictorial chart (see link below) that women used in one study that was a clearer indictator of blood loss. I'm sure many of us have experienced this underestimate by docs -- perhaps if those of us with heavy periods would catch the blood that pours out of us when we go to the toilet and bring it to the doctor's office they might be able to see what we go through.

The Medical Algorithms Project has a copy of the The Pictorial Blood Loss Assessment Chart (PBAC), an excel spreadsheet that helps calculate blood loss
http://www.medal.org/

So if you have the fibroid out, can you deliver the old-fashioned way?

In all that I've read the horizontal vs. vertical incision hasn't been an issue of health for the most part, it is aesthetic (someone please correct me if I'm wrong about this). It would be great if your doc could do a bikini incision, and maybe to do the ovarian surgery laparoscopically but doctors have to make that call. Since you have been experiencing serious bleeding problems it is pretty certain that your fibroid has contact with the endometrium and your incision will go the full thickness of the uterine wall.

Since I've been researching the possibilities of vaginal delivery post myo I thought I would share some of the other information I've collected related to pregnancy post myo....

With incisions into the uterine wall (especially those that go the full thickness) there is a greater risk of uterine rupture during pregnancy it seems, even if you don't go through labor, but it is a very RARE event. I will add the exception in cases of laparoscopic removal of fibroids because they often don't suture the uterus as well through that procedure -- though this is likely dependant on the size, type and position of the fibroids being removed as well as the skill of the surgeon. You should ask your doctor to try to preserve as much of the myometrium (muscular wall of the uterus) outside of the endometrium as possible and also to make sure that they are going to stitch up the uterus wall in more than one layer -- to help retain integrity of the wall and to reduce the risk of adhesions as well.

"The chance of postoperative uterine rupture increases with pregnancy; the rate reported is five percent."
http://www.uterine-fibroid-treatment.com/html/myomectomy.php3
(note this is across all types of myos - lap and abdominal)

Discuss rupture risk with myomectomy patients - Uterine Rupture in
Pregnancy
http://www.findarticles.com/p/articles/mi_m0CYD/is_20_37/ai_93531937

Pregnancy outcome and deliveries following laparoscopic myomectomy
http://humrep.oupjournals.org/cgi/content/abstract/15/4/869

Other risks in pregnancy post myo include placenta acreta and of course growth of new fibroids (boo hiss!):

"Placenta accreta is a disorder in which all or part of the placental villi are in direct contact with the myometrium and are anchored to the muscle fibers rather than to decidual cells. It is attributed to lack of decidua beneath the placenta, which allows placental villi to invade the uterine wall. Risk factors include old cesarean section scars, fibroids, prior myomectomy, and uterine malformations. Clinically, placenta accreta presents as a failure of the placenta to separate spontaneously from the uterus after the birth of the child."
From: http://www.neonatology.org/syllabus/placenta.html (scroll down for reference)

Many women undergoing laparotomy (abdominal myo surgery) will be advised against attempting labor and will be steered towards c-section due to a greater change of uterine rupture at the scar site. Here are some quotes and links you might find informative, related to VBAC (vaginal birth after cesarian, being a close cousin to delivery post myo) and pregnancy delivery post- myo.

"The type of uterine incision made at the previous cesarean section is important in evaluating suitability for a VBAC. The scar visible on the skin does not necessarily predict what type of uterine incision might be found underneath. Where in the uterus the incision was made affects its strength and integrity after healing. The upper part of the uterus is composed of a different type of tissue than the lower uterine segment and cervix. The fundus, together with the upper three-quarters of the uterus, is composed of a thick, muscular tissue that does not heal with a very durable scar, while the lower uterine segment is composed of a fibroelastic tissue that heals quite well and is more flexible and elastic when stretched after healing. Virtually any scar is weaker than the surrounding native tissue (like the old episiotomy scar that springs open during the most gentle birth). Usually the forces of labor will dilate a ripe cervix but labor will open the path of least resistance, which in a few cases will be the previous uterine incision. In addition, any incision that extends into the muscular portion of the uterus is much more vulnerable to disruption in a subsequent pregnancy and labor because of the poorer integrity of scars in the muscle. A low transverse, or low cervical, incision is the preferred uterine incision in any VBAC"
from: A VBAC Primer: Technical Issues for Midwives
http://www.midwiferytoday.com/articles/vbacprimer.asp

"Among the 21 pregnancies which resulted in live births, 8 (38%) were delivered by Caesarean Section (one case because of fetal distress, two cases because of delay in progress of labour, three cases because the uterine incision involved the whole thickness of the uterine wall, and two cases due to patient request), and the remaining 13 (62%) had vaginal delivery. There were no instances of premature labour (<37 weeks), preterm rupture of membranes, placental abruption, intrauterine growth retardation, scar rupture or post-partum haemorrhage."
from: Myomectomy: a retrospective study to examine reproductive performance before and after surgery
T.C. Li1, R. Mortimer and I.D. Cooke
http://humrep.oupjournals.org/cgi/content/full/14/7/1735

Doppler Sonographic Evaluation of the Vascularity of the Myomectomy
Authors: Alfonso Rossetti M.D., Ornella Sizzi M.D., Giuseppe Florio M.D., Giulietta Tancredi M.D., Pierluigi Paparella M.D., Salvatore Mancuso M.D.
http://www.thetrocar.net/view.asp?ID=2
(Talks in more detail about how the uterus heals and why there is a risk of rupture sometimes)

UTERINE RUPTURE AND VBAC
http://hometown.aol.com/melissaem1/myhomepage/baby.html
(VBAC stands for vaginal birth after caesarean)