Dr. Sameer Kumar
Obstetrics and Gynecology
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Patient's Query
Hello doctor,
I am 41 years old and trying to conceive for 13 months. My AMH is 4.3 and FSH is 8.2. Thyroid and uterus are all normal. I was put on IVF short protocol before six months and managed to get only one egg and IUI failed. I fell pregnant naturally after three months but had a miscarriage at 6.5 weeks. Period came normally after 28 days of D and C.
I then started DHEA on the next cd1 and continued with Cd10 and pregnacare. On cd10 I started Inositol and folate supplement. I have been testing for LH surge since this cd7 and no positive yet. I have on and off right side dull ache similar to ovulation time. I am now cd19 with no surge but spotted yesterday and now have some red bleeding. I am confused if this is my period or ovulatory connected and or related to DHEA. I know I should have tested my DHEA level prior. I will keep testing for surge but I suspect this is a very early period. I am taking supplements to improve my egg quality prior to IVF next year. Please advise.
Hello,
Welcome to icliniq.com.
If there has been no LH (luteinizing hormone) surge positivity in the kit and you have spotted, it simply means that this is irregular shedding where the endometrium has grown till mid-cycle and is unsupported in the absence of progesterone which is released post ovulation by corpus luteum. So ovulation is pending naturally and this is endometrium breaking and bleeding in the absence of progesterone which marks the start of the secretory phase of menstrual cycle.
Patient's Query
Thank you doctor,
I still have the right side dull ache and have more than spotting but it is not like a proper period. Can I still ovulate or is it too late this cycle? Why has this irregular bleeding occurred? The ache, blood and date make me suspect a rupture of a follicle. Is this possible? I had this pain for more than a few days. Is this just an early period? Is it worth getting an internal scan? I was concerned whether DHEA had impacted me in this way. Please advise.
Hello,
Welcome back to icliniq.com.
As you are on your cd19 with no LH surge, it is likely that you may not have ovulated yet. However, the confirmation can be achieved only by a transvaginal ultrasound which if delineates a collapsed follicle then it shall confirm a rupture and release of an ovum with some fluid in the pouch of Douglas on ultrasound.
You have to understand that menses are always a progesterone withdrawal response in the second phase of the cycle and hence in the absence of ovulation (without LH surge) is not termed as menses. The bleed in the shedding of the endometrium are mostly darkish brown in color and not actually bright red as in menstrual flow.
Ultrasound shall also tell you about the endometrial thickness, which if is more than 8mm, and the presence of blood in utero indicates proliferative endometrium which has not been stabilized by progesterone yet (in the absence of ovulation as corpus luteum secretes progesterone after follicle rupture). So in short, you can continue testing for LH surge for three more days and if still no surge and the bleeding increases, then you can consider this as a failed cycle.
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Obstetrics and Gynecology
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