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Infertility/Fertility/Miscarriage - D&C - Asherman's Syndrome - Successful pregnancy ?


Hello Doctor,

Greetings. I am writing this to you from Tennessee. Me and my husband has been married since September 2012. By April 2013, I got a positive pregnancy test and had an ultrasound at 8 weeks. But, unfortunately the fetus didn't grow as it should be and there were no heart beat heard at that time. There were two sacs found in the ultrasound and I was told it was supposed to be twins. The gestational sac size and its growth were normal. We waited till 11 weeks and did an ultrasound again but it was the same. So, I was told to proceed further with the D&C option, since my HCG levels were too high to drop down by itself because of the twins.

By June 2013, I did my D&C and had bleeding for about a month and after that my menstrual cycle was regular and normal. I am 26 years old and have regular periods before and after my D&C. My cycle length would be from 29-31 days.  

By March 2014, I got a positive pregnancy test. But, it lasted only for about 10 days or so and I miscarried as a normal period for the month. (My cycle start date was March 12th, got a positive pregnancy test on March 17th, my Progesterone levels were 23.6 and my HCG levels were 60 and it dropped to 12 following a couple of days and I started bleeding on March 22nd)

I had a consultation with my OB/GYN, she suggested me to take all the tests to find the reason for recurrent miscarriages. They took tests to check Progesterone levels, Prolactin levels and also Karyotype and APA Testing. All the test results were normal and there are no infections too. With the progesterone levels, I was confirmed with my ovulation too.

Even my husband had Semen Analysis and Karyotype performed which turned out to be normal. But, at times he was having some erection problems. After consulting with the urologist, we were informed that this would be because of the psychological things and stress. If necessary, he prescribed Viagra 15mg pills before the intercourse for prolonged erection.

Finally, I was suggested to go with sonohysterogram to find any possible problems with the uterus. With sonohysterogram, they found (mild) scar tissue (Asherman's syndrome) which is due to the D&C that was performed before.  I was told that by performing Laparoscopic Hysterectomy this can be removed. We are yet to decide with this removal.

After the second miscarriage, I had one normal menstrual cycle. I use Ovulation Predictor Kits and track Basal Body Temperature along with Cervical Mucus to predict my ovulation. But, by April 2014 I was out of OPK sticks and was able to track only BBT chart and there were not  much of cervical fluid too. With that I suspect that there was no temperature rise and I might not have ovulated.

My period also was due the following month for about 10 days, pregnancy tests were negative. On inquiring with the doctor's office, I was given Provera, 10mg for 10 days to initiate my bleeding. Now, I am on my 4th day of taking the Provera pills and yet to start with my cycle.

I would request you to answer my following queries:

1. Whether it is necessary to remove the scar tissue for me to get pregnant ?  After performing the surgery, will this assure that it will not regrow again ? Because, I am afraid if this is going to damage my uterus  further. I would like to take a second opinion on this before performing the procedure.

2. I was told that once the ovulation is confirmed with the progesterone levels, it is very unusual for the ovulation to occur irregularly. Is this possible ? i.e. Am I ovulating regularly ?

3. Does these Provera pills affect my regularity of the menstrual cycle and ovulation ? Can I stop taking the pills once I start bleeding ? Because, I am afraid if this is going to imbalance cycle and my ovulation.

4. What options you would suggest for a successful pregnancy ? or how long should we wait for a successful pregnancy ?

Thanks for your patience and your time for this. Your response will be of great help! Thank you and the team for this opportunity once again !!

Hello Vidya from the U.S. (Tennessee),

1.  I believe you were recommended to undergo operative hysteroscopy to remove the adhesions, NOT laparoscopy hysterectomy.  Laparoscopic hysterectomy would be to remove your entire uterus and you definitely DON'T want that.  If you have scar tissue within the uterine(endometrial cavity), then it needs to be removed but this can be difficult at times.  These adhesions can return and may require multiple procedures.  Rather than rely on the sonohysterogram, and indirect visualization of the cavity, I would recommend a diagnostic hysteroscopy to be absolutely sure that there are adhesions, then proceed from there.
2.  That statement is not true.  Progesterone verifies that ovulation occurred in that particular cycle, NOT all subsequent cycles.  Cycles could definitely change from ovulatory cycles to irregular cycles for many reasons.  However, if you have a mid luteal phase progesterone that confirm ovulation and you subsequently have regular period, then you can assume that you are ovulatory.  One basic rule of thumb: if you don't ovulate, you won't have a period and so the cycles will be irregular.
3.  The only purpose of the Provera is to induce a bleed (period).  It does nothing else.  Once your period starts, even if you are in the middle of the medication period, you can stop.  I only use the Provera for 5 days.
4.  I cannot suggest options for you without a thorough review of your medical records and history.  I do have a protocol that I use but that is not necessarily the accepted protocol by all Physicians.  One recommendation I would make is to see a Reproductive or Infertility specialist and NOT your general Ob/Gyn for this.  However, you don't need to wait any length of time to try again except if you have the hysteroscopic surgery to remove the adhesions, you should wait at least 6 weeks and be on Estrogen therapy to help the cavity heal.  Also, we often place a Foley catheter with the balloon inflated after removing the adhesions so that the sides cannot touch eachother and form new adhesions.  It is kept there for the 1st week after the procedure.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program

Monterey, California, U.S.A.

for additional information check out my blog at check me out on twitter with me at @montereybayivf and facebook @montereybayivf.  I now provide personalized fee for service consultations/advice/direction via email and payable via Pay Pal.  If interested, contact me via my email at  This service will allow you to have your own personal on-demand infertility expert  


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Edward Joseph Ramirez, MD, FACOG


I am a specialist in infertility and advanced gynecological care. I can answer questions about infertility, gynecology related ills, menopause...virtually anything that affects women's health. PLEASE tell me where you are writing from as I am always interested.


I have been practicing as an Ob/Gyn and Infertility Specialist for over 23 years. Gynecology, advanced laparoscopic surgery, basic infertility, IUI's, IVF, reproductive surgery, and ovulation induction are all areas of my expertise. I am Board Certified. I have been doing In Vitro Fertilization in my clinic for 19 years.

American College of OB/GYN, American Board of Obstetrics and Gynecology, American Society of Reproductive Medicine, California Medical Association, American Association of Gynecologic Laparoscopists, Fellow of The American College of Obstetricians & Gynecologists

American Journal of Obstetrics and Gynecology, Wall Street Journal, Monterey Herald, SERMO, Women's Health and Fertility Blog

Medical Degree from Stanford University, Residency at Tripler Army Medical Center, Reproductive Training at Pacific Fertility Center, San Francisco

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