Dear Professor Winston,

I am wondering about the validity of the so called Hidden C test which tests menstrual blood for chlamydia and other infections? I have suffered an ectopic pregnancy in 2013 (natural conception after 9 months trying). This was diagnosed with ultrasound and treated with methotrexate. I subsequently had a HSG (X Ray) which showed blocked right tube (ectopic side) and open left tube. But it took three goes of injecting the dye before the radiologist was able to see the left side (she needed to give it a higher pressure injection before the left showed up). I then had a laparoscopy which showed damage to the fimbriae of both tubes but, as the dye passed through them, my consultant did not see the need to remove or clip them. Subsequent ultrasounds during IVF have also failed to show any fluid or hydrosalpinges. The laparoscopy also showed minimal endometriosis and I do suffer from very painful periods every month. I proceeded to IVF and had a good response (10 blastocysts). We transferred one and unfortunately it failed. I then had a FET (frozen embryo transfer; 1 blastocyst) which also failed. Then I had an endometrial scratch and the next FET worked (2 blastocysts) but unfortunately I had a MMC (missed miscarriage) of twins at 7 weeks. We plan to try again soon with another FET cycle (1 blastocyst) but I am worried that I may have some sort of hidden infection which may be behind all this. I had genital warts treated when I was in my 20s and all the other STD tests came back negative at the time and repeatedly ever since. I am especially concerned as chlamydia is supposedly hard to diagnose and can remain silent for years. The centre offering this test recommends a course of antibiotics to suppress the infection during an IVF cycle if a patient is found to be positive. Do you have any insight on this? I am concerned that this could be the cause of our bad luck but need to be realistic too as I do not want to waste years of my life and thousands of pounds on pointless treatment either. I am 35, normal weight, normal AMH, all other bloods are normal and my husband’s test have come back normal too. I am so very grateful for all the work you are doing to help clarify the muddy waters of IVF and infertility. Yours, S.

Reply…

Dear S,

There is very little evidence that infection of the sort you describe affects the outcome of treatment. I have always been suspicious about chlamydia infection having serious negative effects on the chance of pregnancy. Research we did over thirty years ago did not prove this. But I guess it does little harm to have antibiotics if the clinic is recommending this. One thing that occurs to me is are you sure that the outline of your uterus on x-ray is normal? This is important because just occasionally if you have had some damage in the past the uterine cavity should be assessed to make certain. So I would ask your consultant to look personally at the X-rays. We may be able to look at a scanned copy if really necessary.

I think I would keep trying as you are with IVF. I agree with your consultant; I would be very much against clipping your tubes or removing them even though your risk of an ectopic is a bit higher than average. But you must probably also have some chance of a naturally conceived pregnancy too with a somewhat patent tube (though, of course, I haven’t seen your laparoscopy personally).

By the way, I have to say, we used to cover embryo transfer in IVF patients like yourself with antibiotics routinely and pretty well all our transfers had this treatment. A piece of magic, merely, but I think it can do no harm and it adds nothing to the expense.

Good luck,
Robert Winston

Follow up…

Dear Professor Winston,

Thank you so much for your reply. My uterine cavity was reported to be normal on the HSG I had in July 2013. However I hope you do not mind that I have enclosed pictures from it for you to review if you have some time spare? I have had an evacuation of retained products of conception (ERPC) since the HSG in Sept 2014.

I guess I am concerned at the sheer amount of antibiotics recommended by the clinic (a combination of amoxicillin and doxycycline over 25 days prior to commencing treatment) however, anecdotally as I have not seen any official statistics, they have success with it in patients who have repeated IVF failures. I also note that doxycycline is often used long term as an antimalarial medication so this has reassured me too.

Again thank you for giving me renewed hope in the IVF process and I do hope that we will be successful in the future. It can be hard to maintain the hope after a few set backs but I am very grateful to have a good clinic and great husband and we support each other. I am also lucky to have found your website and thankful again for all that you have done to support infertility research.

Wishing you and all your team a very happy Christmas,

S

Reply….

Dear S,

Thank you for sending the scanned copies of your x-rays.

Actually, I am not fully certain that the x-rays you have sent me are normal. They are poorly exposed and moreover not well centred on the pelvis – no reproductive expert should be that interested in your spine or hips. Also, they didn’t get you to move around much between photos so all the pictures are taken at the same angle and plane. What I have done is simply to try to manipulate the contrast and to enlarge the area they should have focussed on in detail.

All the x-rays show basically the same features. In X-ray 1 which i enclose computer enhanced you can see a tiny irregularities depicted and arrowed at ‘a’. The main body of the uterus seems constricted at b and the left cornu (arrowed at ‘c) has not filled properly and doesn’t fill well in any of the photographs. In x-ray 2, these features remain the same, with the addition of a small area marked at ‘c’ which looks irregular in the lower part of the uterus.

I am not saying these x-rays (and I have looked at all of them using image enhancement) are definitely abnormal but they are suspicious. Moreover, they are unquestionably poorly taken – frankly, the radiographer has not done a great job. If you compare my images with just one of your X-rays you will see that the picture of the uterus is so small that it is very hard to make much comment on those original films.

As to the antibiotics, I am sure they will do no harm but I cannot believe that they are really needed.

Sorry to say all this – but another HSG at this stage, properly taken, is in my view indicated. But having said all that, I don’t see an absolute barrier to your conceiving successfully.

Best wishes
Robert Winston

X-ray 1
xray1

X-ray 2
xray2

Original X-ray 1
original xray

Further follow-up…

Dear Professor Winston,

I cannot thank you enough for reviewing my images. I will request another HSG when I see my fertility doctor in the new year. Could I ask what it is you would suspect from those images?

I did have an ultrasound done very recently which suggested adenomyosis.

I also have a very long history of very painful periods. The significance of this was that when I suffered the ectopic I thought the pains and bleeding I had with that was my normal period pain. I went on for another four weeks not realising I was pregnant before the ectopic was diagnosed.

Thank you again so much for taking the time to reply to me. I am truly humbled at your interest in my case.

Kind regards,

S

Reply….

Dear S,

I did not know you had painful periods but my appraisal of the HSG certainly fits well with that diagnosis as the indentations on the x-ray would be very compatible with adenomyosis. The definitive investigation would be an MRI scan rather than ultrasound, but MRI is expensive of course. People with adenomyosis do not usually get ectopics, but ectopic pregnancy is sufficiently common for both diagnoses to co-exist.

Best wishes
Robert Winston

 

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