Tuesday, August 18, 2015

History of Miscarriages, Now 9 Weeks Pregnant: Continue Progesterone Supplement (Crinone) ?


I'm from the U.S. After a long struggle with secondary infertility and 2 miscarriages, I am pregnant again, 9 weeks along. I'm on supplemental progesterone, Crinone 8% once a day. When can I feel okay about stopping the Crinone? I was supposed to see my doctor in 2 days, but he experienced a family tragedy, and I'm not sure when he'll be back. I think he had talked about stopping the Crinone at 9 or 10 weeks, but I was going to confirm that with him at my appointment, and I have no way of asking now.
Thank you for your time. M. from the U.S.

Hello M. from the U.S.,

With your history of two miscarriages, I will usually be very conservative and continue the progesterone until 12 weeks gestational age.  However, medically, it would be okay to stop at 10 weeks.  By then, the placenta should be fully functional and providing all the hormone necessary to maintain the pregnancy.

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 my readers who are unfamiliar with the use of progesterone to support a pregnancy, here are some additional facts: "Progesterone is essential for the normal functioning of the reproductive system. After ovulation, the corpus luteum (which is the empty follicle from which the egg was released) produces progesterone, which acts on the womb lining and causes it to thicken in preparation for a fertilized egg to implant. This is known as the luteal phase of the menstrual cycle. If an egg implants successfully into the womb, the corpus luteum continues to produce progesterone to maintain the pregnancy until the placenta develops fully. The placenta produces increasing amounts of progesterone until it is fully developed, when it then takes over the production of progesterone to continue to support the pregnancy.
In some women, insufficient progesterone is produced during the luteal phase and this causes problems with implantation of fertilized eggs into the womb lining and maintaining a pregnancy in the early stages. Crinone vaginal gel is used to treat this hormone deficiency. One applicatorful is inserted into the vagina every day, starting either one day after ovulation is known to have occurred, or on day 18 to 21 of the woman's cycle. (Day one is the first day of your period.) The gel is usually continued until the placenta is producing enough progesterone to support the pregnancy.
Crinone vaginal gel is also used to support pregnancy in women having in vitro fertilization (IVF). In this case the gel is used daily, starting after the embryo has been transferred into the womb, for the first 30 days of confirmed pregnancy."


  1. Hello Dr. Ramirez,
    I could not figure out where to post my question... hopefully this will find its way to you.

    A little about me... I am 41 years old. I have no children. No medical issues other than infertility. I have a bicornuate uterus which was confirmed by 3D ultrasound. I do not take any medications other than low dose aspirin daily, which was recommended by my original fertility doctor before she moved out of state. I've had 3 miscarriages since the age of 36; two occurred from natural pregnancies, one from IVF pregnancy. I have also done one round of FET... resulting in no pregnancy. Each miscarriage happened around 8-10 weeks, which leads one to believe that they were chromosomal abnormalities. Unfortunately my gynecologist neglected to test the fetal tissue of my third miscarriage, which may have shed some light - frustrating to say the least. Suffice it to say he is no longer my gynecologist.

    I recently did a second attempt of IVF, again with my own eggs, which resulted in negative blood test on Sept 3. My husband and I are trying to determine what our next step should be and whether or not we will try again. It’s obviously frustrating and emotionally and physically draining but we aren’t ready to give up just yet. We are just trying to make a formulated, rational decision but like so many other women, we haven’t really gotten any answers other than the usual… I am older… my egg quality is probably not great. But is it just the quality of my eggs or is my bicornuate uterus playing a part… or both? Or something else completely? And how do we find out? We are considering trying one more round of IVF but then using a gestational carrier (using my eggs) but wishing, praying, there was a way to get more answers before proceeding. So I have some questions that I will ask my current doctor but after reading your amazing blog I felt I wanted to ask for your thoughts as well. So my questions are as follows:

    1. As you can imagine I have had many tests/labs that come with IVF over the past 5 years... my medical file is the size of a small phone book. Most came back as normal but I have had a few odd results including multiple abnormal readings for Anticardiolipin antibodies, lupus anticoagulants and prolactins. When the doctors received the abnormal results, I retested and they came back within normal limits and the doctor seemed to be okay with the normal results. But wondering if these abnormal results can have a bigger implication on my ability to get pregnant/carry. Why do I test positive sporadically? Is this normal? Should I perhaps go to an endocrinologist for further investigation?

    2. I have been to two different IVF specialists/centers for each round of IVF. We didn’t feel that either seemed to do anything specifically geared towards my age. I was just told that with my age I will most likely get less quantity and less quality eggs, which I understand, but I've been reading about many different things that have been done for women over 40, and resulted in successful pregnancies including assisted embryo hatching, uterine lining testing, recommendations of using DHEA and COQ10… and I also read that it may be more successful to immediately freeze the embryos rather than transferring them 3-5 days fresh. Any thoughts on these procedures/protocols?

    I realistically know that I may never get any answers… but I feel I have to ask the questions. Maybe my persistence will one day pay off and our prayers will be answered.

    Thank you.
    ~ K Simpson

    1. Hello,

      1. I have no explanation to offer why your tests would be positive the 1st time and negative the second. However, if a patient has positive anticardiolipin antibodies and recurrent miscarriages, that is an indication for treatment. I use low dose aspirin, low dose methylprednisolone and low dose aspirin. This may have contributed to your miscarriages but your age, and therefore spontaneous genetic mutations, is a more common reason.
      2. You've mentioned a gamut of things that have been tried, some of them have been helpful, others not. I use CoQ10 in all my patients because of a study, in animals (no human studies), that show improved egg quality. I figure that it doesn't cost much, has some potential benefit and has no harm. I do not use or advocate DHEA. I use ICSI and AH in almost 100% of my patients, but that will not alter the "age factor." I am not convinced, yet, that freezing and then transferring in a different cycle makes any difference. I have two recommendations for you to consider: (1) keep in mind that because of your age, most (>90%) are probably going to be bad eggs leading to bad embryos. There are only two ways to overcome this: (a) keep trying multiple times in the hope that in one of those attempts you'll get a good egg (assuming that there are still some left) or (b) use younger eggs (donor).; (2) If you decide to continue trying to use your own eggs, I would strongly recommend that you consider doing PGS (preimplantation genetic screening) prior to embryo transfer to determine if any are normal. They you will only select for the normal embryos. Studies have shown this to increase success rates in older patients and patients with recurrent pregnancy loss. However, keep in mind that it can take several attempts, costs more and may result in no embryos to transfer.

      Good Luck

  2. When does it become necessary to go for correction of biconuate uterus?

  3. Dear Dr Ramirez,

    I hope that you receive this. I wasn’t sure how to make a post other than commenting on this post on home page.
    I live in Australia and regularly read your blogs and find your explanations very useful. I really hope you can help me as I really don’t know where to next.

    I have a long and complex infertility history.
    I have been told that I have PCOS and when I go off the pill have no cycle. My LH tends to be very low compared to FSH.

    2013: began IVF.
    First stimulation round I had 55 eggs after FSH injections. 8 of these made blastocyst.
    From this batch we transferred 2 x SET and 1 x double ET. None were successful. We were told to leave the last 4 embryo’s as unlikely to work due to large number of original eggs.

    2014: transferred to different DR. We decided to use menopur to stimulate as it contained the LH as well as FSH and I seemed to respond better to this.
    My 2nd fresh transfer produced 2 eggs, both made to blastocycst and transferred day 5. Neither took.
    3rd fresh transfer (we added prednisone steroid) I had 15 eggs with 4 blastocyst. 2 transferred on day 5 after pickup and both took. I miscarried one at 9 weeks, the second is our little girl who is now nearly 2. Other 2 frozen.

    May 2015 – we went back to see our Dr early as wanted to get started on trying to conceive a second (my daughter was only 4 months old)
    We attempted to thaw the 2 left over embryos from my daughters batch however neither thawed. Instead we decided to transfer 2 from the original batch of 55. Both took and we fell pregnant with twins. I carried them until 20 weeks when they were born prematurely and we very sadly lost them both.
    December 2015 I underwent surgery to implant a stitch to my cervix which would hopefully prevent further pre term labour.

    Since Jan this year we have undergone back to back IVF, details are below.
    - Frozen SET from 55 original – did not take (prednisone)
    - Frozen SET last of 55 original- miscarried at 5 weeks (prednisone)
    - Fresh stimulation. (I panicked and we made a stupid decision to freeze all 15 embryo’s on day 1 as my Dr thought this would be the only way to undergo PGS testing this round). Only 1 survived thaw to make blastocyst and this did not take on single FET.
    - Fresh stimulation (we increased levels of menopur and also added luveris) – 3 day 5 blastocyst embryos frozen and sent away for PGS testing. 2 came back as genetically normal. Both were implanted single FET and neither took. At this point we also added clexane injection and aspirin every day around transfer. I was inserting 2 crinone a day. Implantation was following around 18 – 20 days on progynova eostrogen.
    - Most recent fresh cycle we did low doses of menopur over a longer period of stimulation. We implanted a morula (with assisted hatching) on day 3 with embryo glue. I had a small bleed 4 days after transfer and some cramping. Day 11 after transfer I received a HCG level of 80 and today day 13 after transfer it had only increased to 112. I am a bit sad as realise this most likely means the pregnancy will not progress. We will do a third blood test on day 15.

    I am really seeking some advice as where to next. Is there something I am missing? We have 6 blastocyst embryos frozen from this most recent round and I have been told at least 5 are good-excellent quality (although we are always told this and very rarely get pregnant).

    Would you go straight into more single FET’s? (my Dr has said he won’t do a double transfer given our history which is understandable but difficult also) Would you add anything? Would a break be beneficial?
    Thank you so so much




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