Dr. Sameer Kumar
Obstetrics and Gynecology
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hello doctor,
I am on a 13-day cycle. My endometrium has shrunk to 7.7 which was 7.9 on 11th day. I am on Ecosprin 75 mg, Progynova 2 mg twice a day, Estrogen cutaneous cream. I was on Viagra vaginal insert for five days from day two. Now it has stopped. So, my question is why is my endometrium shrinking to 7.7 from 7.9? So my RE said will take a call after two days TVS. So, can you tell me what is going on?
Hello,
Welcome to icliniq.com.
A change of endometrial thickness from 7.9 to 7.7 mm is minimal and can be due to measuring bias. However, an ET of more than 7 and less than 8.5 mm by mid-cycle is an acceptable thickness for implantation. The medications that you are on are fine and should be continued. There is nothing wrong unless you develop irregular shedding or spots which can justify the loss of endometrial thickness otherwise the likely cause is USG measurement bias. Advise is to get a TVS repeated.
Patient's Query
Thank you doctor,
Following the previous messages.
Today is my 16 CD, I got a transvaginal ultrasound done and endometrial has decreased to 6.5 mm from 7.9 and my embryo transfer canceled and the doctor has put me on antibiotics Doxycycline and Progesterone tablet for 10 days and asked me to come back on my first day of menses.
So, my question is why is my endometrium lining decreasing inspire of supplements and is it due to infection or autoimmune disease as my ANA is positive, though I met endocrinologist he said is mildly positive and nothing to do with pregnancy. So, I want to know what is going with decreasing endometrial lining or is it because I am 41 years old, female.
I do not have a history of uterus surgery or DNC or any pathology. Pap smear which I did two years back showed inflammatory epithelial and no malignancy so was on antibiotics that time. Just wondering why did my lining reduce.
Hello,
Welcome back to icliniq.com.
The only acceptable and proven reason for the decrease in thickness of the endometrium is deficiency or inadequacy of estrogen. At 41, when AMH and estrogen levels are already low, it is likely that the twice a day Progynova 2 mg dosage is inadequate for maintenance of thickness during this cycle. There are no definite reasons or other supplements which can successfully confirm the endometrial thickness during each cycle. If a woman has persistently thin endometrium despite adequate amounts of estrogen, then the chance for pregnancy is reduced.
However, in your case, Progynova 2 mg may be increased to thrice a day in the next IVF cycle to improve and maintain endometrial thickness.It is likely with growing age and each cycle the natural estrogen are constantly decreasing, hence requirement would have increased.
Patient's Query
Hi doctor,
Thank you for the reply.
This is my second-time trial for embryo transfer got canceled again due to a thin endometrial lining of 6.9 mm and had one big cyst of 2.6 cm and a residual cyst from the previous cycle. So both the cysts started to grow simultaneously with the estrogen gel application which was twice this time, and oral Progynova 2mg once a day. I had pain and bloating, so eventually, the cycle got canceled again. I do not know what is going on.
I have ANA positive 3+, so my fertility doctor sent me to rheumatologists. Got my ANA profile done, and he said I have three antibodies positive. He said since I do not have any symptoms and he has put me on HCQ 200 mg once at night. But I heard from my friends that this HCQ 200 mg causes retinal damage, so I am worried, actually. And I do not know what is going on with my embryo transfer and thin lining and cysts and all; the best part is instead of endometrial growth with estrogen supplements, my cyst is growing to the size of 2.6 cm, so doctor please guide me.
Hello,
Welcome back to icliniq.com.
ANA (antinuclear antibodies) positivity indicates thrombotic predisposition and hence uterine arterial insufficiency which can further be confirmed with an endometrial receptivity assay. The doctor has rightly increased tablet Sildenafil or Viagra vaginal inserts till day 11 and continued on capsule Ecosprin. The low AMH (Anti-Mullerian hormone) is not encouraging though, but one can give a break for a month and try again in the second month.
Regards.
Patient's Query
Hi doctor,
Thank you for the reply.
I have a few doubts.
What about the ovarian cyst?
Why did my ovary get active when it is supposed to be quiet during Progynova supplements and estrogen gel application?
So my endocrinologist said to wait for three months by taking HCQ 200 medication, and my fertility specialist said she would put me on Lupron to reduce the ovary activities she said my endometrium is not responding due to ovary cyst spontaneous enlargement, so what is your opinion on this?
Why does my ovary get active and painful during the supplements?
Did my cyst have an effect on the endometrial lining being thin? What is your opinion?
What about the HCQ 200 side effects on the retina? Is it safe?
I am very curious, doctor; please do reply.
Hello,
Welcome back to icliniq.com.
I am not sure about HCQ 200 tablets' side effects on the retina, and it is not recommended if you are planning for pregnancy. Secondly, ovarian cyst is actually underdeveloped follicles from the previous cycle that did not rupture, and yes, they cannot be allowed to be carried to another cycle with estrogen supplementation. Ideally, FSH (follicle-stimulating hormone) levels and lh surge should be monitored as well every 3rd day to increase the accuracy of monitoring during a cycle. Now, ideally, a gap should be given anyhow to allow follicles to reduce naturally, and hence Lupin injection is advised for a three-month gap from menses so that new follicles do not get recruited naturally in the next three cycles (the aim is to arrest follicular recruitment in view of low ovarian reserve). The endometrial receptivity assay would be mandatory.
The presence of a cyst indicates that there was no natural progesterone production, which occurs after follicular rupture, from the corpus luteum, which causes secretory chances in the endometrial lining, thereby increasing the thickness of the lining.
Patient's Query
Hi doctor,
Thank you for the reply.
What is the alternative for HCQ 200 tablet during or when planning pregnancy for my ANA positive?
Hi,
Welcome back to icliniq.com.
As your doctor has planned on Lupron injection. Anyhow a gap of three months for HCQ 200 tablet treatment would be taken care of. ANA test would have to be repeated.
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Obstetrics and Gynecology
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