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.