Mail fra Dr. Davis (USA- New Jersey)

Endelig ;) fått mail fra Dr. D, og den var jo ganske oppløftende. Jeg vet han har en god statistikk, og det hele virker jo ganske optimistisk slik han skriver det. Ikke så ille dyrt heller, men jeg må sjekke litt rundt hva som skjer ved eventuelle komplikasjoner etc. Synes også det er postivivt at han tenker jeg kan få 17p-sprøytene. Det er vel sikkert fordi jeg føler at dette er siste sjangs, og at nå må "alt" gjøres. Og iom at det ikke er særlige bivirkninger av de sprøytene, så tenker jeg litt ; "hvorfor ikke??".

Min e-post på slutten (samme e-post til alle legene).

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Hello esmeralda,



I will try to address your questions and concerns and, if you have additional questions, please feel to send another email.
An arcuate uterus is a very mild form of a bicornuate uterus but is generally much more like a normal uterus in function. It should not interfere with either getting pregnant or staying pregnant.


Your weight should not be too much of an issue. Obviously, a BMI of 35 is much better than 43. I looks like you must have lost at least 20 kilos! I have done the TAC for many women weighing in excess of 100 Kg. 70 or 80 would be better for your overall health and the pregnancy in general, but it doesn't affect the TAC surgery much.


Most infections, of the type you describe, result from the cervix having already opened. In other words, the infection was caused by the incompetent cervix. If your cervix were strong and closed, the vaginal infection should not have caused a problem.


There is no evidence that bedrest makes any difference. I am not sure I quite agree with his explanation, but I do agree that being at strict bedrest would not have made much of a difference.


Given that you have a congenitally short cervix, and that they could only ge the TVC up about 1 cm, ther is likely very little chance that a TVC will work.


Your chances of success with a TAC should be very good. The uterine anomaly will not affect the chances for success. One of the more common factors that we find in women requiring the TAC is abnormalities of either the uterus or the cervix. Even with these conditions, success rates are 95-97%!!


Experience is diccicult to judge. There are some who might be very good after 10 cases and other who will never be good at it no matter how many they do. They best way to judge is to look at success rates. How many is enough? Hard to say. I currently do about two per week. I am on track to do close to 100 this year alone.


Given your short cervix and how early your cervix changes, I think that pre-prenancy would be a good choice. Having it done pre-pregnancy will not interfere with IVF at all. They should be able to do any and all procedures with the TAC in situ.


The TAC can be done as soon as your normal mense resume. Or, if your cycles are irregular, about six weeks after the loss. You can go through IVF as soon as the cycle after the one in which the TAC is placed.


Yes, I have many patients from around the world. I have arrangements with one of my hopitals to do the procedure "at cost" for such patients. Currently, the cost is about $5,000 US. This includes the hosptial stay, operating room costs, anesthesia and my fees. It does not include travel.


P17 would be a reasonable adjunctive therapy. I can arrange for you to pick up enough to get you through the entire pregnancy, while your here, for about $250 US. I think, however, that it is widely available in Europe as well.


If you have more questions, or if I missed something, pleazse get back to me. Please be aware that I do not check my email every day. So, if I don't get back to ou right away, be patient.


There is every reason to be hopeful!


Dr. D


-----Original Message-----

From: esmeralda
To: askdrdavis@......
Sent: Mon, May 31, 2010 8:13 am
Subject: Transabdominal cerclage, 3 midsemester losses


Dear Dr. Davis,

My name is esmeralda, I'm 34 years old and live i Norway. I found your address through the group Abbyloopers on Yahoo.

I'm writing to hopefully get some more information on the Transabdominal cerclage, so that I can decide how to proceed trying to fulfill our wish of having children. At the moment I feel that I'm probably one of the most knowledgeable about Incompetent Cervix in Norway, as most gynecologists I meet really don't seem to know much.

"Short" summary of my past medical history:
We have been trying to conceive since august 03, unsuccessfully until we had our first cycle of IVF in november 08. Maybe our infertility was due to my overweight, my doctors have found no apparent medical explanation. (I have now decreased from BMI>43 to around 35). They have found, however, that I have uterus arcuatus (bicornate uterus is the same, right?), but this shouldn't cause any problems in getting pregnant.
In feburary 09 I lost our first baby boy at 16w1d. I had no forewarning, no pain, no smelly discharge, no fever. My water broke as I was having bowel movements, and he was born a few hours later, alive at first admission. The initial bacterial cultures form the cervix was negative, but the placenta had moderate growth of Giardia Vaginalis.
I miraculously got pregnant again shortly after, without any help of IVF. But in august 09 I felt pressure against the cervix and was admitted with full dilation and bulging membranes at 15w5d. I was put on bedrest, but got an infection after a day or two, and the baby died in the uterus. Again there was no bacteria the first days, but after the delivery they found growth of Enterococcus Fecalis in the placenta. This time the Gynecologists suspected IC, and I would get an TVC if pregnant again.

January 10 I had my second cycle of IVF, and got pregnant. I had the Shirodkar cerclage placed at 11w4d, it was really difficult to place, as they during the procedure found that I had virtually no portio vaginalis at all. He managed to pull the whole cervix downward and put the stich about 1 cm up. I think my gynecologist don't believe in bed-rest, because although my cervix was shorter every time he measured it, and to me it looked like it was starting to funnel, he insisted on that I should be up and doing close to normal activities. His explanation was that the gravity and weight of the fetus is not what causes pressure on the cervix, instead it's the growth of the uterus and pressure of the uterine muscles that does this, and theres no way of preventing that (would love to hear your opinion on this!). They did bacterial cultures numerous times during the pregnancy, all negative. This pregnancy lasted until I was admitted at 17w5d with a small bleeding and on inspection they found dilation and bulging membranes at 3-4 cm. After 1 day on bedrest my water broke and the cerclage was removed. One day later labour was induced, and our third angel boy was born. Culture from the placenta showed moderately growth of enterococcus again.

So here we are,- searching for a way forward.
I had read about TAC before, but there's almost no experience with it here in Norway. I have been referred to a doctor who might know more about it and have some experience, but I doubt someone has done more than a handful of this procedure in this country. In your opinion, how many TACs should someone have done to call themselves even a little experienced?
And how do you regard our prognosis for a successful pregnancy concidering the bicornate uterus and the IC? I'm having doubts as to if I can survive another loss, but I'm also eager to give it one more try if the chances are there. I understand, of course, that there are no guarantees.
Thinking about our fertility issues, would you recommend a pre-pregnancy or in-pregnancy TAC? I am worried that pre-pregnancy may decrease our chances to conceive naturally, but if we need IVF anyway maybe it doesn't matter? If pre-pregnancy, how long after do we have to wait until the next IVF? And how soon after the last loss can the TAC be placed?
As I understand you also treat patients from abroad, and for us cost is obviously an issue; do you know how much it would cost for me to come to your clinic and have the TAC done by you?

I have also read about progesterone supplements in one way or another (we don't have the 17-P shots in Norway, but maybe I can buy them elsewhere if needed) and am wondering if this also could help in my situation. Although I definitely have not had contractions prior to the losses, maybe it would relax the uterine muscles and put less pressure on my cervix? Just a thought.

I think these are my main questions for now. I hope to hear from you, and thank you for your help.
If you need any more information before answering, I'm happy to help with that.

Sincerely,

esmeralda