Hysterosalpingogram (HSG)

An HSG is a hysterosalpingogram, an x-ray of the interior space of the uterus and fallopian tubes using a contrast dye. It can be used to look for uterine abnormalities and adhesions, determine how much infringement fibroids are making into the interior of the uterus (to some degree), and identify if your tubes are open (referred to by docs as "patent"). Some docs do it standard a few months after a myomectomy, mine did not. The dye does have what my RE referred to as a "voodoo effect", where there is some slight increase in pregnancies after the procedure, speculated to be caused by the dye perhaps causing the little hairs (cilia) in the tubes to function better.

It can be done by your doctor in a radiology facility or by a radiologist -- mine was done by my RE and she was a lot more comfortable with the procedure than the radiologist I could tell.

They insert a catheter to insert the contrast dye through your cervix; a good cough evidently will open up the cervix so it is less painful. The dye feels like pressure going in, and it can cause a drop in blood pressure. It's generally uncomfortable and causes some cramping. My RE tried to manipulate my uterus for the xray shots using the special speculum and I found that to be very uncomfortable with my 6-7cm (at the time) fibroid.

Here is an link detailing Guidelines for the Performance of HSG - it advises taking 1000 mg of NSAIDs prior to the procedure.

Rarely it can cause infection, and some people are allergic to the contrast medium. Some docs give antibiotics preventatively ahead of time, they also might have you take a heavy dose of Tylenol an hour beforehand.

Here are some links to sites showing images from HSGs:

HSG Link 1

HSG Link 2
HSG Link 3

I should go pick up my x-ray film from the University of Washington Radiology Department, where I brought it when I consulted about UAE a couple years ago. I'd like to scan it and and post it here so you can see what my distorted uterus looked like.

Pelvic Adhesions

Adhesions are really common after pelvic surgery but they don't necessarily have to cause you problems or impact your fertility. Some doctors will perform an HSG (hysterosalpingogram) a few months after a myo for women wanting to try to conceive but mine thought we should just see what happened for a few cycle on our own. We were able to conceive and have implantation in my uterus so no problems there for me.

Adhesions & Pelvic Pain
What Women Need To Know About Prevention and Treatment

Pelvic Adhesions

Pelvic Adhesions - Their Role in Infertility and How to Prevent Them
PDF brochure from RESOLVE

Reduction of Adhesions

Asherman's Syndrome

Pelvic Abnormalities: Pelvic Adhesions (photos)

International Adhesions Society
(they are also conducting a survey of patients regarding informed
consent forms with regards to mention of adhesions)

Adhesion Related Disorders

Chronic Pelvic Pain
(includes some info about how to minimize adhesion formation)

Pelvic Adhesions
(fairly clinical and scientific information about adhesion formation and prevention in a Powerpoint presentation)

Pelvic Pain Needing Treatment

Wound Healing and Scarring - Sutures

Prospective clinical trial of SprayGel as a barrier to adhesion formation: an interim analysis.
(there are other media that can be used to prevent adhesion formation as well, if you are interested continue searching on these terms:
"pelvic adhesions barrier agents")

To someone who is wondering whether or not to have a myo

Lots of women get pg with fibroids in place, it is an elective procedure however so in part you get to decide when it is right for you. Some considerations I've noted about when it is a good time to have fibroid surgery:

• you feel like you have exhausted all other possible treatment options
  
• you are feeling pain and discomfort, even some of the time. This can include back pain, pelvic pain, leg pain, etc.
  
• you are having bleeding problems (really heavy periods, or periods that don't seem to stop -- this can lead to problems with anemia which can impair fertility and put you at risk for other health problems such as clotting)
  
• you have had trouble conceiving or have had miscarriage/s
  
• you are wanting to try hormonal fertility treatments and your fibroids are already a good size
  
• you are having difficulty urinating or are having to pee all the time or you are developing urinary tract infections
  
• you can't stand the thought of having fibroids inside of you and want to get rid of them
  
• you fibroids are compromising the interior space of the uterus
  

Since you are already dealing with TTC with one tube I can see that it doesn't feel like a straight shot decision for you at all. There is a risk of adhesions after any abdominal surgery, but whether or not these will cause problems is another question.

The surgery is a big deal in that it can be quite invasive and most of us haven't had that much physical trauma before. It is also one that you will recover from quickly. An abdominal myo is very similar to a c-section and loads of women have those operations every day.

Have you read What Your Doctor May Not Tell You About Fibroids yet? It is a super book that really helped me to feel empowered about my body and my fibroids. It describes in detail about the various procedure options and includes info about fertility success rates post-op.

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/

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.

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.

Watch a myomectomy surgery or UFE procedure online

You know you are obsessed with learning about all the procedures when you watch videos of medical procedures for their entirety. I liked these webcast and if any of you are interested in seeing what happens during a myomectomy or UFE and you can deal with watching surgery, I encourage you to check it out.

Replay of: Abdominal Myomectomy-
A Treatment for the Removal of Fibroids
http://www.or-live.com/lich/1190/

Dr West's site has some video clips of myo surgery as well (there is
a link in the blue box to see images and clips)
http://www.manhattanfibroidassociates.com/

Here's the link to the Thomas Jefferson University Hospital doing an
embolization producedure (UAE/UFE)
http://www.or-live.com/jeffersonhospital/1140/

What should I do?

So I still have retained POC (products of conception) from my miscarriage in July. It is likely that my fibroid has contributed to this situation by not allowing my uterus to contract as well as it might (8x10cm intramural fibroid, uterus wrapped around fibroid). My RE wants to go in with a hysteroscope to aid in the removal of the 2x3cm piece of tissue in my endometrium -- the fibroid doesn't allow for a very clear image of what is there.

She mentioned that while I'm under she could remove my fibroid as well. It isn't the largest fibroid that she's operated on, but it isn't small either. She thinks that if I have the surgery done now I should be all right to travel to Ecuador for Christmas -- about 6 weeks post-op -- to go on a birding tour.

My fibroid hasn't shrunk at all since August, though it is smaller than the largest measurement right before my d&c of 9x11x11cm or so. On the day I got my BFP it measured 6.5x7 -- so it is now twice as large and I'm feeling it everyday.

Tthis RE does surgery twice a week only and I like her, she's been practicing since 1983 and does on average one myo a month -- but she's regularly doing reproductive surgeries. I'm feeling pretty good about her and she said that she would consider my desire for a vaginal birth as she did the surgery.

If you were going to be put under right now for another procedure would you opt to have your large fibroid removed as well?

Abdominals not cut, Myo not panacea for fertility problems

ARE THE ABDOMINAL MUSCLES CUT DURING MYO?

I was worried about my abdominal muscles being damaged during myo (which have yet to undergo) and I asked the surgeon about it. She told me that they do not cut the abdominal muscles, instead they just push them to the sides, and I imagine they brace them there.

They do cut through some connective tissue and the abdominal fascia, a membrane that holds your internal organs together, but they stitch the fascia closed at the end of the procedure (I'm not sure if they reconnect the connective tissue -- I haven't seen mention of that anywhere) What Your Doctor May Not Tell You About Fibroids includes a detailed description of the procedure that you may with to refer to.

MYO TO IMPROVE FERTILITY

The ability of myomectomy to improve fertility is not definative at this point in time (this is confirmed in What Your Doctor May Not Tell You About Fibroids by Dr Michael Brody, an ob/gyn and former RAND medical researcher). There have been annectodal stories of success by patients and doctors but current research has had flaws that limit its usefulness in determining the appropriateness of this procedure to treat infertility, especially if other factors exist that may be contributing to the infertility (male factor, blocked tubes, endocrine issues, etc.) This is partly why I have been reluctant to undergo this procedure for my largely asymptomatic fibroid, we have a known male factor.

Gynecologic Myomectomy
"Myomectomy is also performed frequently in patients with infertility with the presence of fibroids (Vercillini, 1998). Studies supporting myomectomy as a fertility-enhancing procedure are uncontrolled and do not use life-table analysis; nonetheless, a number of authors recommend offering myomectomy to women who are infertile after other causes of infertility have been eliminated (Hutchins, 1995;
Nachtigal, 1989; Verkauf, 1996).

Several papers suggest that patients with fibroids who are undergoing assisted reproductive technology procedures may have lower success rates compared to patients without fibroids. Stovall et al (1998) noted decreased fertility rates in patients with any myomas undergoing in vitro fertilization or zygote intrafallopian transfer. Eldar-Geva and coworkers (1998) noted decreased success in patients with intramural and submucosal myomas but not in those with subserosal myomas. Ramzy et al (1998) noted no change in fertility, but this study specifically excluded anyone with large, submucous, or intramural myomas that distorted the endometrial cavity. Importantly, note that no randomized studies document that removal of these myomas
improves success rates."


TABLE 1 - ACOG CRITERIA FOR MYOMECTOMY IN INFERTILITY PATIENTS
Procedure:
Myomectomy* (68.29) (CPT Codes 56309 [laparoscopy with removal of leiomyomata], 58140 [abdominal approach], or 58145 [vaginal approach]

Indication:
Leiomyomata (218.0-218.9) in infertility patients (628.3), asa probable factor in failure to conceive or in recurrent pregnancy loss
(646.3)

Confirmation of Indication:
In the presence of failure to conceive or recurrent pregnancy loss:
1. Presence of leiomyomata of sufficient size or specific location to be a probable factor
2. No more likely explanation exists for failure to conceive or recurrent pregnancy loss

Actions Prior to Procedure:
1. Evaluate other causes of male and female infertility or recurrent pregnancy loss
2. Evaluate the endometrial cavity and fallopian tubes, e.g. hysterosalpingogram
3. Document discussion that complexity of disease process may require hysterectomy

My Reasons for Not Wanting a Myo

Here are my reasons for not wanting a myomectomy:

1. major abdominal surgery
2. risk of adhesions
3. length of recovery period
4. fact that with multiple factors there isn't a documented increase
in fertility
5. they would require me to deliver by c-section if I did get pregnant post myo
6. that I'm largely asymptomatic except for slightly heavier periods and some pelvic pain for a few days prior to ovulation and at the start of my period

We don't even know if we want to do any assisted reproductive therapy anyway, we went to the reproductive endocrinologists (RE) to get their opinion on our situation (my partner had a vasectomy reversal and has an issue with sperm morphology -- morphology refers to shape of the sperm). It was just kind of intense having the head of reproductive endocrinology at a leading university tell you that he consulted with all of the other REs and they've decided they don't want to be my friend.

I've always wanted to go the natural way -- I was never on birth control pills, don't eat junk food really, stay fit. I don't like it when the medical establishment says (in its Terminator voice) "you are infertile. we will cut you open and remove that fibroid. take these drugs and we will harvest your eggs and MAKE you pregnant."

Now I don't know how the rest of you feel but I'm not feeling like I want to go out on a limb with any procedure since I would feel worse if I didn't feel like my care providers were on my side. I guess I will continue doing my watch and wait routine and in the meantime at least take advantage of the MRI order from the RE so I can learn more about what's inside of me. Maybe God or the Universe will intervene in the meantime.

Sheesh!

So, I've been keeping you apprised of my situation. I just got off the phone with the RE (RE#2) and here's what he told me...

...that they won't do fertility treatments on me unless I have my fibroid treated

...that if I have the embolization they won't accept me as a fertility patient

...that they recommend myomectomy

...that he no longer authorized the MRI

They won't do fertility treatments if I have the embo because they are worried about the uterine wall being weak (weaker than a uterus that has had multiple fibroids removed -- aka. myomectomy!?) and the possibility of multiple births being so much higher with fertility treatments. They are also a little concerned about not the liability but their stats, that somehow I might compromise their success rates.

Heck, no one knows why I haven't been able to get pregnant, it could be any of the following that I've been able to deduce...

* sperm morphology
* low progesterone (I started using natural progesterone cream)
* anemia/low ferritin (being treated)
* fibroid (though I've never even been kinda sorta pregnant)

I don't even know what to think know. It seems like my options are a) leave it up to God, or b) do the embo and then leave it up to God, or c) do the embo and do fertility treatments if needed, elsewhere.

We're not interested in adoption.

Maybe I should just go save the dying children in 3rd world nations and give up on this mother thing.

I cancelled the myo

I posted yesterday about being depressed about my upcoming abdominal myomectomy. Thank you to all who replied. I went back and looked at Carla's book, and reflected on the other information I have obtained over the past year. I also thought about how the surgery was making me feel, right now at this point in my life.

I wasn't going shopping for new fall clothes because I knew I wouldn't be able to wear them for some time. I couldn't sign up for a printmaking class I wanted to take because I was going to be recouperating. I couldn't audition for a modern dance company this month, even though I'm dancing the best I have in my life. There were so many other things too that the surgery was going to prevent my participating in.

Then I thought about the fact that a myomectomy won't definately improve my fertility and that with male factor infertility (MFI) we hadn't even tried any less invasive procedures first.

I talked with my partner last night and we agreed that I'm not ready for the surgery right now. The prospect of surgery, when I'm not feeling ill and don't expect to for some time, was akin to torturing myself. I would have cried for days prior to surgery, up until the time they put me under and then when I awoke I would cry again, for the discomfort, the impacts (albeit hopefully short-term) and for not knowing that the surgery fixed anything. I know myself and how I react to things, I'm not making this up.

I have decided to shift my plan back into the wait and see strategy that has worked fine for me to date. We'll continue to look into treatment options that will deal with the MFI; I'm figuring that if surgeons are so quick to operate on me for a fibroid that I should at least have the option of trying ART (assisted reproductive technologies) first.

Here is an interesting article that I found (after I decided):
http://www.obgyn.net/displayarticle.asp?page=/infertility/articles/myomectomy_infert

There is also this study, but it is $19 for 1 days access:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Retrieve&list_uids=10402378&dopt=Abstract

Wish me luck. I may decide to go ahead with the myomectomy but for right now I'm not in the right place to move forward with that option.

Myo next week, feeling depressed

My surgery is scheduled for next Thursday October 9th and I'm feeling depressed about it. I need to have the surgery due to fertility issues -- we're likely going to have to do IVF (although I pray that we don't). I'm 33 and my 6cm fibroid is just going to continue to grow, even if my naturopathic treatment helped slow it down.

I don't have the bleeding that many of you are experiencing; my heart goes out to all of you with debilitating symptoms. I feel periodic discomfort and then there is the infertility. Otherwise I'm completely healthy and I think that's why the prospect of having the surgery is so sad for me. I just don't want to feel bad, and right now it is the surgery that is going to cause me more short-term pain.

When I compare that to the prospect of not having children I think it is a reasonable trade off to have the surgery. But still, how did the rest of you get through the last few days of anticipation prior to your surgeries?