Kim (not her real name) got married early and easily had her first child at age 23. After happily breast-feeding her baby girl for a year, she and her husband used condoms for a year to delay conceiving a second child. Then they stopped all contraception and went about their lives experiencing the joys of being parents to their daughter, not really wanting to have another right away, but not fighting it either. Despite having sex about twice a week, no pregnancy occurred. By age 27, three years later, with still no second pregnancy yet, Kim started being proactive.
By her account "Well, I knew that I could get pregnant, because it happened so easily the first time. My friends got me into tracking my temperature and I soon found some websites to help me. I made a lot of friends online who were going through the same thing. Only they didn't even have their first child, so I felt guilty if I started to stress too much. Over time, however, it started to get very stressful. My period was regular. My temperatures were going up. My mucus was excellent and I certainly could tell every month that I was ovulating. My husband started getting a little weird about my obsession once I started doing the ovulation kits and demanded that we do the baby dance whenever the test told us. I would try and stay in bed not moving for an hour afterwards. I kept thinking, it wasn't this difficult before. Each month, the kits said I was ovulating and then came the long wait and then the devastation when my flow started."
Kim showed me pages and pages of careful temperature charts. She had the classic biphasic pattern, with positive LH testing at the expected times. She and her husband diligently got together during the right times. There was nothing wrong, other than for the fact that she was now 30. Had gone from age 24-27 without contraception, just casually having sex every few days. She then went from age 27 to age 30, faithfully enduring months and months of charting, testing, hoping, waiting and crying.
She continued "I refused to consider anything other than getting pregnant naturally seeing that's how I got pregnant the first time. I kept telling myself to wait patiently, even though every month from the time of ovulation, I would become a nervous wreck. I had nausea, breast sensitivity, headaches and I thought I was pregnant almost every month. I would get cramping and spotting some times, which someone told me was implantation bleeding. But then either my period would come or if I was even one day late, I'd do a test and get a big disappointment. One day at a childrens' party, I was talking to the mom of one of my daughter's friends who was pregnant again with twins. She told me she had seen you, so I finally took it as a sign to come in and get your advice"
Kim and I spent over an hour in talking in my office going over her situation in detail. I performed an ultrasound, which showed a normal uterus and normal ovaries. Afterwards, here was the plan. First we got her husband to come in for a semen analysis. The count was 195 M/cc with 60% motility. This was well above average. We then had several options at this point. We could do empiric treatment with fertility drugs and IUI (intrauterine insemination) or we could do an HSG to check the tubes and uterine cavity. Even though Kim did not have painful periods and was unlikely to have developed tubal blockage after she had demonstrated with her first pregnancy that at least one tube was open way back then. I explained to her that it was even possible that she already had blockage in one tube back then, but could have conceived from the other side. Unlikely, but possible.
Well, this was not the case. The HSG results showed that both her tubes were clean and easily let the dye flow through. However, there was a very interesting finding inside her uterus. There was a small lesion about the size of a small grape. This was so subtle that I could not see it on her plain ultrasound during her first visit. I explained to her that this most likely represented a fibroid or a polyp. A fibroid is more rubbery and a polyp is fleshy, but they both acted the same way to prevent pregnancy, sort of how a copper wire IUD does. Kim had no infertility coverage from her husband's insurance and had paid out of pocket to see me for the consultation and for the tests. I told her that in actuality, a uterine lesion was no longer a pure infertility problem. Although the chance of it being cancerous was very very small, it was reasonable to have it removed. I called her regular OB/Gyn and we arranged for her to get it removed by her, so it would be covered under Kim's insurance plan. It was a simple 20-minute outpatient surgery called an operative hysteroscopy. A small fiber-optic instrument was inserted into the cervix and the polyp was safely removed with a tiny electrified cutting wire. There was no surgical incision nor scarring. It wound up totally covered by her insurance as a legitimate gynecological procedure. The microscopic report on the polyp came back as totally non-cancerous.
After the surgery, Kim came in with her husband to discuss their options. Their daughter was now 7 and they felt that it was already too big an age gap for the next child and totally unlike how they felt before, they now wished to proceed with aggressive fertility treatment to hurry and conceive. I explained to them that we had found a real problem and that we had eliminated it. Therefore, they should give consideration to being conservative in their choice of options. We made a deal that they should try on their own for six months and if they were still not pregnant by then, we could do fertility treatment.
Two months later, Kim called us in tears to say that she had missed her period and that her urine pregnancy test was positive!! She went on to have another girl. And two years later, she had a boy. Both were conceived 100% naturally after removing the offending lesion.
KEY POINTS TO CONSIDER:
- Uterine lesions can cause abnormal bleeding and cramping. Even small ones can cause infertility, by interfering with implantation.
- If a real problem is found and eliminated, it's often worth it to try on your own for six months to a year.
- If you have been trying to conceive for more than one year, give strong consideration to getting a semen analysis and an HSG.