Progesterone Supplement For Luteal Phase Defect

Question:

Hello Dr. Ramirez,

I am turning 34 later this month and have been trying to get pregnant for the past 4 months. I never have any spotting during the first half of my cycle, but have had light spotting usually for 3 - 5 days before my period starts (as long as I can remember except when I was on the pill). About 7 years ago my doctor did some tests and sent me for an ultrasound and when he found nothing wrong, put me on the pill to regulate this. I stopped using the pill about 3 years ago and have lived with the light spotting (starts very, very light and gets a bit heavier each day until my real period starts - usually starts on Day 27 to 32 of my cycle).

Over the last 4 months, I've been recording basal body temperatures while trying to get pregnant. I've noticed my temperature only stays high for about 8 days. It drops usually on the 9th day and the day after that very light spotting starts. After doing my own research, I'm concerned that I may have a luteal phase defect and need some sort of progesterone to help get/maintain a pregnancy. I went to my doctor and he said I would need to try for a year regularly before determining I have a fertility problem and he doesn't think testing is necessary yet even thought I think my temperature readings and spotting indicate there may be a problem. I understand it may take a while to get pregnant, but if there is a possibility of a problem that could be helped with progesterone, I would rather find out now than wait until next year when I'll be almost 35. Especially if I do need a referral to a specialist at some point, it could be a 6 month wait to get an appointment.

Does it sound like I may have a problem (hopefully treatable) or should I continue trying for another 6 or 8 months before undergoing any testing?

Thank you very much for your help, L. from Canada

Answer:

Hello L. from Canada,

I have had many letters from Canadians lamenting the fact that their Physicians are uncooperative and it is a long wait to see a specialist. You certainly have not tried long enough on your own to warrant an infertility evaluation, but I am surprised that you doc won't give you progesterone supplements. It is such a simple thing with no side effects and potentially helpful.

Yes, the BBT findings and pre-menstrual spotting are consistent with LPD. The diagnosis is made with an end cycle endometrial biopsy for dating. Since your doctor won't do that, we can make the assumption and you should go on progesterone supplements. There are many sources of natural progesterone. I believe you can even get natural progesterone creams in health food stores. I will usually prescribe the pharmaceutical versions such as Prometrium, Endometrin, Crinone or Prochieve. You have to take them starting from day #16, but the problem is that the supplementation may prevent your natural menses from starting because it is the dropping of the hormones that leads to a menses. So, you would have to do a pregnancy test to see if you are pregnant then stop the meds if you are not (you would continue them if you are).

For now, I would recommend that since none of this is easily obtainable for you, you should continue trying on your own for the next six months. If you should become pregnant, the pregnancy will produce the hormones that you require via the corpus luteum cyst that forms from ovulation.

Follow-up Question:

Thank you. I really appreciate your response and think I will go to a walk in clinic next month to at least get a day 21 progesterone test to have some idea of my levels.

I started taking a B50 complex vitamin this month as some women have reported B6 helps with the luteal phase (contains 50 mg of B1, B2, B3, B6, Pantothenic Acid, Choline and Inositol; 50 mcg of B12 and Biotin; and 0.4 mg of Folate.) Would there be any known problems with these vitamins if I were to become pregnant? I am also taking a prenatal vitamin that contains very low amounts of the above noted vitamins (except for Folate which is 1 mg in the pre-natal). Again, thank you very much for your help. It is very much appreciated.

Answer:

Hello Again,

It is okay to continue those vitamins for now, but discontinue them should you become pregnant and stick with the prenatal vitamin only.

Good luck with your treatment!

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

Luteal Phase Defect While On Clomid For Timed Intercourse Cycle

Question:


Hi. I am 26 years old and have been trying to conceive for 2 years now. So far my infertility is unexplained. All tests have yielded normal results. My husband's sperm analysis was normal in all categories. Count was 170mil although he did have moderate sperm aggregation (clumping) which I was told should not be an issue since its moderate and there were plenty more sperm doing the right thing. While I do ovulate and have a period on a frequent basis it is not on a 28 day cycle, in fact my cycle lengths range from 26 days to 35 and go up and down from month to month.

I just finished my first round of Clomid. Ultrasound at day 12 indicated one good follicle, my lining was good. At day 21 my progesterone was 22.5. I did ovulate. However, my period was only 1 day in length with a 2nd day of spotting. Normally, I have 2 days of moderate bleeding and then 1-2 days of spotting. Is it normal to have a shorter menses with Clomid?

Also, my cycle was only 27 days. I had a confirmed sugar at day 14. I believe I ovulated on day 16. It has apparently also caused a shorter luteal phase. Is that normal? I was under the impression it would lengthen my cycle. My menses came 6 days after my 21 day progesterone showed 22.5. Is that too sudden of a drop in hormone?

Answer:

Hello. Yes, very often Clomid will shorten a cycle. I am concerned, however, that you had a short luteal phase. This should not be the case, but can happen with Clomid. We call it a "luteal phase defect". If this is the case, it could impair implantation leading to failure or loss of the pregnancy. For this reason, I always add and recommend adding progesterone from day 16. It is an easy thing to do and does not have side effects. The only problem is that it will inhibit a spontaneous period if you don't get pregnant, so a pregnancy test will need to be scheduled.

I also recommend ultrasound surveillance when doing Clomid cycles. Most non-fertility specialists will not do this, as in your cycle. It is the best way to monitor progress and lets you know how many follicles are about to be ovulated. HCG can be given to stimulate ovulation (which also helps with the luteal phase) and helps to time your intercourse best. You should ask your doctor to do this. If he/she looks at you curiously, and without understanding, then you need to find a real fertility specialist. Also, only 4-6 cycles of Clomid are recommended by ASRM and reproductive specialists, after that you need to look at other options.

I hope this answers your question.

Sincerely,

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