Tuesday, December 7, 2010

Patient With Short Luteal Phase Has Spotting With Progesterone Suppositories, Is This Normal?


Dr. Ramirez, I am hoping that you can help answer some questions for me as I am feeling confused and hopeless...I am 30 years old and I am trying to concieve. I was on the birth control pill for 9 years and stopped taking it in June. I have been charting my Basal Body Temps and discovered that I have a short luteal phase--

I begin spotting 9 days after ovulation and start my period the following day making my luteal phase 9-10 days. My period is very light-- only lasting a few days. I have been taking Vitamin B6 supplements and my doctor started me on Crinone Progesterone Suppositories this month. I began 3 days after ovulation and am taking 90mg once per day.

Yesterday, 9 days into my luteal phase, I began spotting very lightly when wiping. This was very discouraging as I usually begin spotting on day 9 before starting the suppositories. I was convinced that I was starting my period as I had in previous months and that this was not implantation spotting due to the coincidence of the spotting on day 9.

However, now on day 10, I am wondering if I gave up hope too soon. The spotting is still VERY scant and does not seem to be increasing as in previous months. Also, the actual flow of the bleeding seems a little different than previous months. Upon intially wiping, there is no blood on the toilet paper. After wiping a couple of times, a very small amount of red blood appears on the toilet paper. In fact, as I continue to wipe, the bleeding seems to increase with each wipe. Also, it does not resemble my usual spotting (blood mixed with a wet discharge) but just small amounts of blood smears. The flow only appears when wiping.

Should the progesterone suppositories have increased my luteal phase count at least a little bit? It's very discouraging to think that there was no increase at all. If my period is beginning, does this mean that it is not a progesterone issue? What else could cause a Luteal Phase Defect? Can your period begin while you are taking the suppositories? I read online that your period will not begin until you stop taking the progesterone? However, I have also read conflicting info as well.

Could this be "break-through bleeding"? Is this common with suppositories? Could you explain what this is? Does this sound like implantation spotting? I called my Dr. and she said to stay on the progesterone for a few more days and see if my period does start. She has admitted that she is not too familiar with LPD isues and has referred me to a Reproductive Endocrinologist however the earliest appointment I could get is March. I am feeling really confused and discouraged. Any help, guidance or suggestions would be greatly appreciated! Also, I did take a pregnancy test today and it was negative but realize that it may have been too early. I am writing from Massachusetts.


Hello D. from Massachusetts,

I have found that vaginal spotting is very common with the use of Crinone in my IVF patients, so I don't think you need to worry about it. Supplemental progesterone is the appropriate treatment for suspected luteal phase defect. A pregnancy test will be required because your natural period will not occur if you are on supplemental progesterone. The incident that causes the withdrawal bleed (your period) to occur is the abrupt drop of progesterone in your system if a pregnancy has not occurred. Therefore, I would recommend a scheduled serum bHCG at 14 days after ovulation. If it is negative, then stop the progesterone but don't stop until you have that result.

There are gynecologists out there that are well versed in infertility treatments. You don't necessarily have to see an RE for your level of care. You might want to call around and see if you can find one so you don't have to wait so long to undergo proper treatment. However, be very careful because there are many general Ob/Gyn's that say they do infertility that know very little and don't render proper care. You might want to ask them specifically how they diagnose and treat luteal phase defect. You also might want to find one that does IUI treatments, and avoid the ones that don't do this level of care.

Follow Up Question:

Thank you so much for your quick response! This was very helpful. It is encouraging to know that spotting is common when using Crinone. From your response, it sounds like my period will not start until I stop taking the progesterone. Do you feel confident that given the info that I provided that it is not my period starting and just due to the progesterone? Is this "break-through bleeding?"Also, do you think 90 mg once per day is adequate? I read about women taking the supplements 2 times per day. Again, thank you for any help you can provide and for your timely feedback. I appreciate your advice re: the RE as well. March seems like it will never get here!!

Follow Up Answer:

Hello Again,
I am confident that this bleeding is not your period, but keep in mind that there are always exceptions. It is most likely breakthrough bleeding as I explained previously. Crinone has been extensively studies for use in infertility and once per day is adequate.

I am happy to have helped clear up some of your fears. Good luck with your treatment and don't hesitate to write again!

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


  1. Hello Dr Ramirez,

    I was interested to follow one of your conversations from October and have a couple of questions, to which I'd be grateful to have your response.

    I'm a 37 year old woman living in London in the UK. I'm fortunate to have a beautiful 5 month old baby conceived after one cancelled IVF cycle (due to poor response) and two high dose short-protocol cycles. My husband and I would like to try to conceive again, sooner rather than later, as we know from our years of TTC that this may take awhile, if at all. I'm exclusively breastfeeding my son, but my menstrual cycle has returned (2 cycles, both 25 days).

    I have severe endo, for which I've previously been treated by laparoscopy, although I currently have two large cysts on one ovary, with the other inaccessible for egg collection behind my uterus (viewed via Doppler ultrasound).

    I've recently visited a consultant gynaecologist to discuss natural IVF, with the aim being to retrieve only one egg from the dominant follicle in my natural cycle. Her opinion is that this is my best shot at attempting to conceive again, with both my ovaries compromised and AMH levels of less than 1 (I'm sorry not to recall the unit of measurement). I have two antral follicles in each ovary and these range from <5mm to >5mm in size. She also tested my prolactin levels, which were described as being very high (in the 600s).

    My questions are:

    – Do you know whether excessive prolactin can have a suppressive effect on AMH levels? Can AMH levels fluctuate?

    – Is there a concern about miscarriage (should I be lucky enough to fall pregnant) because of continued breastfeeding/prolactin levels?

    Many thanks,


  2. Hello Denise,

    I have to say frankly that I cannot answer your first question with certainty. I would suspect that prolactin would not influence AMH, but I don't know the asnwer to that question.

    An elevated prolactin level usually influences pregnancy because of its effects at the pituitary level and influence on other hormones produced there. If your cycles have returned, and in fact you are ovulating (keep in mind that uterine bleeding does not necessarily indicate ovulation has occurred), then the prolactin levels should have no effect on your chances of miscarriage. Your primary chance of miscarriage will be from the decresed quality of eggs due to age.

    I'm not sure I would recommend a "natural cycle" IVF, because I don't think that does anything with the age factor. The way to overcome the age factor is to try to retrieve as many eggs as possible. Despite the decreased AFC and AMH, that is still not completely predictive of your response and I think that you should try to get as many eggs as possible. If you are going to attempt natural cycle IVF, you have to be prepared to do it multiple times because you are essentially reproducing your natural chances of pregnancy based on your age. If you can afford that financially and emotionally, then it would be an option.

    Good Luck,

  3. Hi Dr Ramirez,

    I really appreciate your taking the time to respond. Your comment regarding prolactin and miscarriage is very reassuring, thank you.

    My two previous completed IVF cycles each yielded only five eggs, of which only two each time were viable to be transferred. My poor response to the high drug doses in combination with my very low AMH levels lead my new consultant to recommend taking the 'natural cycle' approach. I remain in two minds, as I understand that maximising the number of eggs will maximise the chance of a successful outcome. Would you consider it possible that, despite my previous poor response, I could produce more eggs?

    Many thanks and best wishes,


  4. Hi Denise,

    Consider that in your previous IVF cycle, out of 5 eggs retrieved, only two yielded embryos to transfer. Now consider that in a natural cycle you will only retrieve 1 egg. There is a high possibility that it will not yield an embryo to transfer statistically. For that reason, I stand by the thought that it is better to stimulate maximally in order to have the maximum number of embryos to transfer.

    In terms of could you yield more eggs, studies have shown variations in response between cycles. That means that the way you respond in one cycle does not necessarily mean that you will respond similarly in the next. Each cycle is unique. You could have more or less. But, if you don't stimulate, you can be sure that you won't have more than one egg.

    Good Luck

  5. Thank you Dr Ramirez!

    Your comments make perfect sense and are helping me negotiate a very difficult and emotional set of choices. I feel much better informed and appreciate your very lucid and rational opinion.

    Thank you so much.




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