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.

PCOS Patient Taking Natural Progesterone Cream For Cycles: NPC Does Not Help You To Ovulate, Only Regulates Cycle

Question:

Hi,

I have long cycles and was recently diagnosed with PCOS. Prior to my diagnosis I have tried everything under the sun to regulate them and help me to ovulate. Vitex, Evening Primrose Oil, Dr John Lee's Shutdown, (in which Natural Progesterone Cream is applied for CD's 5-26, then stopped) a couple unmedicated cycles, soy isoflavones, currently on 1000mg/day of Metformin and the ONLY cycles I had "normal" cycle length with ovulation, is when I took NPC (25mg/BID) from CD's 5-26 (or til Aunt Flow) I know normally NPC should suppress ovulation, but instead for me it helps me ovulate. Why would that be? I cannot make sense of it at all, but am impressed that this is all it took.

I recently had an appointment with my dr, who actually told me that the NPC would do me no good in the beginning of my cycle and I should stop the NPC and start BCP's for a while to help get my cycles regulated again.

Thank you,

L. from Oregon

Answer:

Hello L. from Oregon,

Natural progesterone cream (NPC) will NOT get you to ovulate, but will help to keep you regular. In fact, you don't need to take it as many days as you are taking if all you want is to have a period on a regular basis. All you have to do is use it on CD#16-25 (10 days). When you withdraw the progesterone, you will have a period, because that is what happens in the luteal phase of the cycle. The progesterone is working directly on the endometrial lining and causing it to "luteinize" which is why withdrawal of the hormone causes it to breakdown and bleed. We use other forms of "natural" progesterone such as prometrium, Crinone, Procheive, Endometrin and Provera to accomplish the same task. But the progesterone does nothing to the ovary so ovulation does not occur. In large enough doses of progesterone, as that contained in birth control pills, it will cause a suppression of ovarian function.

The birth control pill is only a treatment to regulate your cycles. If a woman with PCOS is not intending to become pregnant, then the treatment of choice is to use the birth control pill. On the other hand, if your goal is to start ovulating, because you want to get pregnant, then as a woman with PCOS you need to use a medication that will induce the ovaries to ovulate such as Clomid, Femara or injectable medications.

I hope this helps to explain things,

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.

Kuwaiti Woman Asks: How To Thicken My Endometrium Lining?

Question:

Hi Dr. Ramirez,

I feel am really blessed to find someone very expert and caring like you :)

This is N. from Kuwait, I am very concerned about my endo thickness (was between 6.5 to 7.9 on CD14). On the other hand, I don’t want to take medicine that may harm me. The dr. is giving me Duphaston and Progyluton. The Norgestrel is combined with Estradiol valerate in one pill that comes in medicine call Progyluton (I don’t know if you know it). 11 white tablets each containing Estradiol valerate and 10 light brown tablets to be taken from CD16, each containing Estradiol valerate and Norgestrel). You have said previously that the Norgestrel is not used in the USA to treat endos.

What about the Duphaston which is Dydrogesterone 10 mg- Orally – 2 times a day from CD14? Should I take it Vaginally? Does it hurt? What do you suggest? Should I take natural Progesterone instead of the Duphaston? If yes, would you please give me name of the medicine?

Unfortunately it seems there are not that good doctors over here, they are RE and Gyno. This is the 3rd doc. The 2nd doc believes that clomid will increase the endo because it produces eggs; and she sees endo thickness 7 or 8 mm is not bad!!! Dr. Ramirez, If you don’t mind to give me Online Consultancy and I will PAY for it (I can call). Write me a prescription with what should I take and when and how? For example estrace from CDx to CDx, and then XXX medicine from CDxx. (I can order them online)

I know that it sounds weird, but with the globalization and the existence of internet the behaviors and habits are changing. I will go to the doctor on CD14 (or whenever you think is the best) to do the ultrasound and then will let you know about the size of eggs, endo and so on :)

Thank you!

Answer:

Hello N. from Kuwait,

The Duphaston can be used vaginally. Progesterone is important to help with implantation. I would NOT recommend the Progyluton. It is used from hormone replacement therapy and cycle control. It is not used in infertility because of the Norgestrel. Although the Estradiol component is okay, and necessary to increase the uterine lining, the Norgestrel (progesterone) will compete with the estrogen and keep the lining thin. With this combination women don't usually have periods, which is the reason why it is used for menopausal hormone replacement therapy. In fertility cycles, the first half of the cycle needs to have unopposed estrogen stimulation so that the lining will grow. Then once ovulation occurs, the progesterone is introduced to help the lining convert to a luteal phase lining so that implantation can occur.

Your proposal for an internet consultancy is interesting, I will send you an email. I'll have to think about that one. In terms of your supplementation, I use the following protocol:

1. I use the estrogen patch for estrogen supplementation such as the Climara patch. I use two 0.1 mg Climara patches beginning at the start of the cycle and continuing until the pregnancy test. If it is positive, then I continue it until you are 10 weeks pregnant.

2. For progesterone, I use a product called Endometrin 100 mg vaginal tablets. You place 1 vaginally twice per day beginning on cycle day # 16, or beginning with the HCG injection if you use an HCG trigger for ovulation. You would then continue this until the pregnancy test or 10 weeks gestational age if you get pregnant. Other forms of progesterone that you can use in the same way are Prometrium 100 mg or Crinone/Procheive 8% cream.

If you look up my blog regarding how I do Clomid ovulation inductions, it will give you directions on how I recommend doing Clomid cycles. Normally, as the follicles are stimulated and grow, they produce increasing amounts of estrogen. This then goes to the uterine lining and increases it. The problem with Clomid, however, is the way it works. It blocks estrogen receptors in the reproductive system and tricks the brain into thinking that it is not producing enough estrogen. So the brain responds by increasing the amount of stimulation of the ovary, hence ovulation is stimulated or multiple eggs are stimulated. By blocking the receptors, however, it can cause the uterine lining (endometrium) to no grow sufficiently.

Don't stress too much over all this, please take your time and copy these instructions. Take the time to discuss this thoroughly with your physician and good luck!

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.

Spotting In First Trimester Not Placenta Previa

Question:

Hi Dr. Ramirez,

I am a 35 yo with no children. I found out I am 7 weeks pregnant and went for blood work and a sonogram since I have been spotting and had sporadic cramps for a few days. My doctor discovered I have low implantation of the embryo and placenta previa from the sono, and low progesterone levels from my blood work.

My doctor said my progesterone levels are 13.5 and should be higher (around 15) so he prescribed Prochieve Vaginal Gel. Is Procheive a good thing and is it needed? Will it produce side effects in the baby?

For the placenta previa, I have read so much negative information which speaks of hemorrhaging to hysterectomy and C-section. While I am okay with the thought of a C-section as it may save my life and the baby's, is there any statistical information available which discusses the probabilities of fatalities and hysterectomies?

With that being said, I am pro-choice and would like to make an educated decision on if I should carry this pregnancy to full term. With all the obstacles in front of me, in your experience and opinion, what are the chances of having a healthy child?

Answer:

First of all, I don't think you need to consider terminating this pregnancy because there is nothing seriously wrong at this point.I think that your doctor is over-calling things. To be frank, the recommendations and diagnosis he/she has given you is inappropriate at this gestational age.

Placenta previa CANNOT be made at 7 weeks gestation. That is a third trimester (after 28 weeks) diagnosis. At your gestational age, the entire amniotic sac is filled with the placenta. The mature placenta has not even developed yet. Placenta previa is when the placenta blocks the cervical opening, which then requires a c-section. As the uterus grows, the placenta will move and 99% of the time, the placenta moves out of the way. So you don't need to worry about it.

In terms of the progesterone, he/she is mistaken about that as well, however, we use progesterone all the time with infertility patients to help support the pregnancy. It is usually started before implantation, however. It would not hurt and Endometrin is the prescription that I use. It will not harm you or the baby. The alternatives to Endometrin, which are just as good, are Crinone and Procheive.

Spotting is very common in the first trimester. We see it all the time with our IVF patients. It does not necessarily mean that anything bad is occurring. However, you are still in the miscarriage risk stage so sometimes, spotting or bleeding could mean that the pregnancy is not doing well and will eventually end in miscarriage. There is no way to know this unless the ultrasound does not show a viable fetus i.e. no heart beat or not growing.

I hope this helps. Don't worry too much.

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California, U.S.A.

www.montereybayivf.com

Progesterone Injections & Travel After IVF

Question:

Dear Sir,

Our first IVF (during June 2008) failed and so, we are going for the second IVF which is FET (frozen embryo transfer). I have the following questions:

a) Progesterone-in-oil shots: During the last IVF it was very difficult and stressful to have the intra-muscular shots every day. After a week, the muscle became very rigid and at some point could not even poke the needle into the muscle. Will it be okay if I do a hot water massage after every shot? I am concerned because some nurses are saying it may raise the body temperature and could cause problems.

Are there any alternatives for intra muscular injections (for progesterone)? One of the nurses is suggesting to apply directly into the vaginal area. Since we haven't done that before we are not sure how tedious is that and the possibilities it could go wrong.

b) Will it be okay to travel long distance (approx. 3 hours) in a car - three days after the transfer?

Thanks so much in advance for your valuable suggestions.

Roger

Answer:

Dear Roger,

The progesterone injections are probably the worst of all the injections because it requires a bigger needle and the fluid is thick. I have changed from a prgesterone in sesame oil to a progesterone in canola oil that my pharmacy make us (MDR). Because it flows easier, we can use a smaller bore needle to reduce the pain and it doesn't harden up. You might want to check into that formulation. MDR Pharmacy is an infertility specialty pharmacy and you can get your meds via mail. It is also less expensive.

In terms of hot packs at the injection site, that would be fine. I don't expect that will change anything at all if it stays local.

Also, make sure you are rotating the sites i.e. one buttock then the other. You can also change the specific sites in the buttocks as long as you are in the upper outer quadrant. Make sure your nurse shows you all the areas that you can use.

As an alternative to IM progesterone, you can also use vaginal progesterone. There are several formulations: Crinon 8%, Prochieve 8%, Endometrin 100mg and pharmacy formulated versions. Several very good studies have shown equal efficacy to IM progesterone. However, most RE's are trained on IM Prog and so don't want to make any drastic changes. I happen to use both. Some programs, such as USC, have switched to vaginal completely. If your wife cannot tolerate the IM Prog or has an allergic reaction to it, then you can switch to the vaginal version. Crinone and Procheive are twice per day, and Endometrin is three times a day. They are messy but they don't hurt.

In terms of travel, yes it is okay to take a three hour trip after the transfer. As long as your wife is in a resting position, such as sitting, then you can travel. I only don't recommend strenuous activities such as exercise, karate, horse back riding, running and the like.

I hope this helps!

Edward J. Ramirez, MD

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California, U.S.A.

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