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 32. I have PCOS for past seven years. Now planning to conceive with Gonadotropin injection and timed intercourse. But my day two blood work shows FSH 4.7, LH 11.2 and prolactin 9. Due to high LH will I get ovulation and if so, how will be the chances of having a healthy pregnancy? Two years back, I got pregnant with Gonadotropin injection but had many complications and pregnancy went on till 35 weeks, then fluid leak and baby passed meconium and was alive only for 15 days, later died at NICU. Three months ago, was pregnant again with Gonadotropin injection but no heartbeat for five weeks, five days. Had missed abortion.
Hello,
Welcome to icliniq.com.
The LH levels are more than 10 as expected in PCOD, ideally should be less than 7, but still on the lower side. You can continue with the protocol and ideally LH surge occurs at 20 and usually the follicle is matter at 18 mm size. So, pertaining to your query that whether you shall ovulate or not depends on the follow up of LH surge with LH kit from day 10 of your cycle daily to check for positive result. Once positive test is achieved, the follicular scan be done to check for size of follicle and if more than 18 mm, it is mature, then hCG injection can be offered for ovulation.
Patient's Query
Thank you doctor,
But I am in a confusion whether to terminate this cycle and continue with reducing the LH and FSH levels before going for ovulation induction? Or to continue with the cycle and try pregnancy. But my fear is that will I miscarry after conception due to this high LH levels and PCOS. Also, the health of the baby produced like this? Do you have any occurrence of positive outcomes for patients with high LH and PCOS having successful pregnancies? Whenever I ovulated with Gonadotropin injection I got pregnant in the first cycle itself. Now took two injections on day 2 and day 4 and tomorrow day 6 and asked to do a scan on day 8. The doctor said if the cycle does not work we will go for reducing the levels. My worry is about pregnancy if the ovulations went on well this time. I know both the hardship of carrying a complicated pregnancy and a miscarriage.
Hello,
Welcome back to icliniq.com.
As you are already a known case of PCOD, hence LH levels are definitely not going to be normal or <7 as in normal women on day 2. The fact that you have been offered and ovulation induction cycle are because of the fact that you have PCOD, where anovulation has always been the biggest concern, hence stimulators drugs like Letrozole and Gonadotrophin have been used. The quality and maturity of the egg is dependent on FSH levels and not LH levels. FSH levels are normal on day 2 and shall grow with Lupine hCG which shall help in follicular growth improving its quality and maturity with the ongoing cycle. The aim of ovulation induction and timed intercourse is to allow conception. However, further maintenance of pregnancy, or miscarriage due to missed abortion or anembryonic gestation, these are attributed to sperm quality.
The first conception was fruitful but you had preterm rupture of membranes, probably secondary to chronic vaginal infections (we do not know as you have not mentioned, but a common cause) which caused preterm labor. This cannot be attributed to LH or FSH levels as you were PCOD even then. So go ahead with the cycle and preferably if possible opt for IUI cycle rather than timed intercourse which shall improve your chances of conception with quality sperms. You should continue as you have already started it and if this cycle fails then from next cycle you should opt for controlling your PCOD first before opting for conception.
Patient's Query
Hi doctor,
As you said I went on with the ovulation induction cycle and now I am happily pregnant for 12 weeks. During my first pregnancy I was diagnosed with incompetent cervix during my anomaly scan 19 weeks and I was rushed to the hospital for a emergency cercalage where there were bulging of membranes. After that having a strict bed rest I reached till 35.2 weeks. At that time my low BP was 90 mm/Hg. So my stitch was removed and waited. After when fluid leaked out it was stained with meconium and spontaneously vaginal delivery occurred. Attaching the reports for that below. But could not save the baby due to infection. Now I am consulting another doctor for this pregnancy. So, she suggested me to do a shirodhkar cercalage at 15 weeks. My question is if everything is well till end, how safe will be going for a normal delivery and will this shirodhkar can be removed at the end?
Hello,
Wlcome back to icliniq.com.
Firstly congratulations on your conception.
Secondly, as your previous history suggests cervical incompetency and emergency cerclage at 20 weeks is mandatory that you opt for elective cervical cerclage Shirodhkar or McDonald cervical stitch) between 15-17 weeks of gestation to prevent preterm spontaneous miscarriage. The aim remains to allow pregnancy to continue till term. i.e., 37 weeks as normal pregnancy and then after 37 weeks the cerclage can be removed and depending on obstetrical indications, you may be offered a vaginal delivery.
It would be best if you repeat your cervical length transvaginally before cerclage. If the length is less than 2.5 cm or 25 mm, then cerclage is indicated anyhow, else the cerclage would be prophylactic cervical cerclage in view of previous history of cervical incompetency.
Patient's Query
Thank you for your reply Doctor,
For this pregnancy, 12 weeks scan abdominally says cervix 3.4 cm, OS closed, and no funnelling. As a preventative measure, consulting doctor given appointment for shirodhkar cercalage after two weeks. In my first case, I don't know what type of cercalage it wait. But removed easily at the clinic without any anasthesia. But this time it is shirodhkar cercalage and will it's removal is painless and easier as pervious one?
PS :Current doc is more interested in C-sections. What to do if she is restricting the possiblity of a vaginal birth? My doc is not so explanatory as you are. At times she laughs at my questions. Thats why I am asking here.
Hello,
Welcome back to icliniq.com.
Shirodhkar stich is given in cases where earlier McDonald stich has failed and you are right when you say that shirodhkar is a permanent cerclage and placed 1 cm below internal os after anterior and posterior colpotomy. So, the cerclage knot would go inside the abdomen and you would be left only with the chance of elective c-section. However at 3.4 cm cervical length, still you can opt for MACDONALD STICH now between 14-17 weeks gestation. This can be easily removed at 37 weeks and vaginal delivery can be attempted. Because the previous stitch was an emergency cerclage and there was already incompetency which had set in, so if it lasted for 35 weeks even, it has done its job. My suggestion shall be to opt for Macdonald cervical cerclage again which is done per vaginally and just 1.5 cm below shirodhkar stitch, but it can be easily accessed per vaginally and removed during labour pain. Prophylactin macdonald stitch has compared rated to shirodhkar stitch when done in early gestation between 14-17 weeks. I feel you must discuss it out with your gynaecologist again and opt for MACDONALD CERCLAGE. If she insists on shirodhkar, then you have a choice of seeking a second opinion before opting for the procedure. I hope i have answered your query in detail, Wishing you safe pregnancy, Regards
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Obstetrics and Gynecology
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