Inadequate Luteal Phase Support In IVF Cycle Can Cause Bleeding & Failure

Hello Dr. Edward,

Thank you in advance for your answer! I'm from Paraguay. I just went through my second IVF-ICSI and both times I started bleeding 7-8 days after day 3 transfer, just when implantation should be occurring. Do I have an implantation problem? Are there any tests I should do? What should be done to prevent this early bleeding? I'll appreciate your expert opinion on this!

Here are the details of the case:

He: 38, had testicular cancer 6 years ago (unilateral orchiectomy and radiotherapy), very low count, morphology and motility. Now healthy, treated autoinmune hypothyroidism, BMI 26.

She: 34, no known fertility concerns, healthy, BMI 27.

Went directly for IVF-ICSI due to male factor.1st IVF/ICSI: 12 eggs, 6 fertilized, 3 transfered (day 3, 2x 8 cell + 1x 7 cell, fair quality), none to freeze. Long agonist protocol: suppressed with BCP + Lupron, stimulated with Menopur + Puregon, triggered with HCG, after ER Dostinex (8 days), anti-inflammatories and antibiotics (3 days), luteal support with Prometrium. Early bleeding 8dp3dt: BFN.2nd IVF/ICSI: 14 eggs, 8 fertilized, 3 transferred (day 3, 1x 9 cell + 1x 8 cell + 1x 7 cell, good quality), 4 frozen. Same protocol, added Estrace and more Prometrium for luteal support. Early bleeding 7dp3dt: BFN. Thank you!

Answer:

Hello E. from Paraguay,

Thanks for the information. You don't mention how much Prometrium you used in your cycles but I think that may be the problem. I think you may have inadequate luteal phase support i.e not enough progesterone. Certainly prometrium should be adequate to cover the luteal phase, and many studies have shown that vaginal progesterone only is adequate, but the dosage has to be adequate as well. I think the minimum used should be 100mg three times per day. In my practice, because I don't want patients to not get pregnant or lose a pregnancy because of inadequate progesterone, I use both injectable progesterone 50mg per day and vaginal progesterone (I use Endometrin) 100 mg per day. That is what I would recommend for you. You should not be having bleeding that soon after embryo transfer.

Protocols and technique are what distinguishes IVF centers and their respective pregnancy rates. So, that is what you need to carefully evaluate.

Good Luck,

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