Hello Prof Winston,

I am 36 yrs old and my husband is 42. We have a 8 yr old and a 6 yr old who were conceived naturally within 6 months.

We have been trying to conceive number 3 for 3 yrs. A laparoscopy not long time ago showed mild endometriosis which was removed. My tubes were patent and my womb looked normal. My right ovary had a PCOS appearance and diathermy was performed on it. I had caesareans with my children – placenta previa with the first and the second baby was transverse. I tried 4 months of injectables and had a good response but no success. We moved to IVF in Feb 2016. My amh is 10.5, FSH 7.8, LH 4.4, prolactin 181 on cd3. I got 7 eggs, 6 fertilised normally. 2 EEVA high predictors were transferred on day 3-bfn. 2 of the other embryos made it to blastocyst (4bb,3bb) and they were transferred in May and again a bfn. I have just undergone another cycle where 12 eggs were retrieved, 10 fertilised and on day 5 a 5ab 50% hatched blastocyst was transferred. A further 5ab blastocyst and 3 others of good grades were frozen. The one thing i feel is significant is my short luteal phase and more importantly the fact that from around 6dpo (natural cycles, injectables cycles, IVF cycles and fet cycle) I get menstrual cramping. It is very strong and I think the contractions of my uterus are preventing implantation. My doctors have increased my luteal support but nothing stops the cramping from occurring. Is there any advice you can give me about medication to prevent the cramping or any idea as to why it is happening? I don’t think I had this cramping before my laparoscopy and I certainly didn’t have the pain I now have on right ovary nearly every day. I feel like I am wasting good embryos.

Thank you.

D.

Dear D.

But you don’t tell me about the most important of all the investigations?  What about the hysterosalpingogram?  I do understand that you say your ‘womb looks normal’ and it may do from the outside.  Yet the cavity of the uterus is critically important and the best way of outlining that is with a dye which shows up on x-ray, carefully and slowly introduced.  This is better than hysteroscopy and much more informative than another commonly done test HyCoSy.

Why am I suspicious of a problem in your uterus in your case?  You have a history of placenta praevia, a Caesarean section, and then an abnormal lie of the baby (transverse) followed it seems by yet another caesarean section.

To my mind it seems deeply worrying to go through IVF when there is a strong possibility of scar tissue after two operative deliveries and some probable anomaly in the uterus possibly causing placenta prevue, and then scar tissue after surgery possibly further impairing your fertility.  You say you feel you are wasting good embryos?  I must tell you that in my time doing fertility treatments over very many years I have seen an immense number of women having embryos transferred into an abnormal uterine cavity.

May be I am wrong, but if you have not had a really detailed HSG done  yet that must be a priority – and if you have you might like to send me the digital photos to educate me.

My best wishes

Robert Winston

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