Seventh IVF Cycle Brings Success But Patient Worried About Progesterone Levels

Question:

Hi Doctor!

I have recently become pregnant after my 7th IVF, and am currently 6 weeks. I had 2 very good quality blastocysts transferred and am awaiting my 7 weeks scan next week to see the heartbeat and hopefully tell if it's twins. I have been going in for blood tests to monitor my progesterone levels and initially I was taking 2 cyclogest (400mgs) a day, it then increased to 3 and now 4 a day. This was because my prog levels were fluctuating from 80 and 150 and my FS feels 150 is a good level. My last test showed it at 200. From doing my research, I realise that normal prog levels can be anything above 30 and less than 100. Are mine too high? IS there any danger of having prog at 150-200?

My Bhcg has also been monitored every 2-3 days and they have been climbing nicely, from 193,447,1863, 4990 and now 13900. Are those indicative of a viable pregnancy?Many thanks for your help and advice.

Regards, N. from the U.K.

Answer:

Hello N. from the U.K.,

Congratulations! I'm glad you persevered because most patients would not try IVF 7 times. All your levels are fine. Your progesterone is not too high and there is no danger with a level of 200. I'm surprised your doc is chasing the levels. Your bHCG levels are great. With a level of 13,900, the gestational sac should already be visible within the uterus, so your doc should go ahead and do a scan this week rather than wait until next week. At this point it is important to confirm the uterine pregnancy because there is a 2-5% risk of ectopic pregnancy with IVF (tubal pregnancy). If it were in the tube, this would be the time to treat it as medication can be used instead of surgery.

I don't mention this to scare you, but I normally do my first ultrasound at 6 weeks gestational age for this reason. You might want to ask your doctor to do so as well. More than likely everything will be fine. Again congratulations!

Follow-Up Question:

Hi Doctor,

Thanks so much for your advice, I really appreciate it. I took your advice and scheduled a scan for today, which confirmed a single uterine pregnancy and we saw the heartbeat. So it is a relief! I am currently 6 weeks and 4 days. Is there any chance of things going wrong after seeing a heartbeat? I haven't had any bleeding or haven't had any major cramping. I also haven't been experiencing nausea and morning sickness, but I have had lower back pain, fatigue, and strangely enough throbbing ankle or feet pain now and then. Thank you for your time and help. Regards, N.

Follow-Up Answer:

Hello N.,

Congratulations! At 6 weeks with the findings of a fetus of appropriate size and a good heartbeat, those are good signs for the pregnancy. There is still a risk of miscarriage that runs about 40% until 8 weeks gestational age. Your doctor should probably repeat the ultrasound in two weeks. If everything looks fine at the next ultrasound (8+weeks), then the risk of miscarriage drops to 5% until 12 weeks gestational age.

Of course there are lots of problems that can occur in pregnancy. Everyone has the same risks. But if you worried about every possible risk, you would go crazy and not enjoy your pregnancy. For now, I would recommend that you take things in stride and day to day. Don't worry about the future because you don't necessarily have control over it. Hope for the best because that is the most likely outcome. And as the sailors of olde used to say, pray for good winds!

Good Luck,

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.

Twitter with me at @montereybayivf, and follow me on Facebook at http://bit.ly/9Iw9oV

Use of Ovidrel after BFP in an IVF cycle - Did It Cause My Miscarriage?

Question:
Good afternoon Dr Edward,

I'm 36yrs. I did IVF for the first time and it resulted in preg. Upon a positive pregnancy result, my doctor prescribed Ovidrel 250 iu inj to be taken immediately: This inj was given to me once a week thereafter. My dr also placed me on gestone 100mg(1 inj daily), progynova 2mg (1tab 3ce daily), folvite 5mg (1tab 2ce daily)& Ecosprin tab 75mg (1 tab daily). However, progesterone and estrogen test were not done on me.

I went for my ultrasound (U/S) on the 6th week and the sonologist said she could see a gestational sac (6x6mm), yolk sac but no embryo and no fetal heart beat. Another U/S by the 7th week revealed 2 gest sacs ( 11x11mm & 7x7mm) but no yolk sac, and embryo could not be visualised. Their prognosis was a missed abortion.

I did a search on Ovidrel and this revealed that Ovidrel is used for ovulation induction 36hrs before egg collection which was done in my case. The articles I read said women who became pregnant or think they may be pregnant after IVF treatment with Ovidrel must discontinue the use of the drug immediately because it may cause harm to an unborn baby, intrauterine death & impaired parturition!

My question is this, is it possible that Ovidrel could have caused the miscarriage I had? Secondly,under what condition should ovidrel be prescribed for a pregnant woman? I'll appreciate your honest opinion.

Thank you. O. from India.

Answer:

Hello O. from India,

I'm sorry to hear about your miscarriage. Indeed the primary indication for Ovidrel is to induce ovulation when a woman is undergoing ovulation induction with fertility medications. However, Ovidrel, which is HCG, can also be given after ovulation in order to help with implantation and support of the pregnancy. It is not used much for that indication, but some doctors will. The other medications used are also very commonly used in IVF cycles, again to support implantation and the early pregnancy. HCG has not been found to lead to birth defects or increase the risk of miscarriage. The pharmaceutical companies put that warning because of the risks of being sued in the U.S., but that is not clinically true.

At 7 weeks gestational age, the fetus should be nearly developed and will be clearly seen and with a heart beat, so your ultrasound showed that the fetus had not developed. The most common reason for this is that there was a chromosomal abnormality in the fetus, and so the fetus did not develop. At your age, you are at an increased risk of spontaneous chromosomal abnormalities because the chromosomes in eggs are more fragile in older women. This miscarriage was not due to the medications.

In the U.S., the medications you took are given as part of the IVF cycle, and many are started before or during the IVF cycle, rather than waiting until a pregnancy ensues. Most important: If they are going to help the pregnancy, and prevent a miscarriage, they need to be within the body prior to the pregnancy occurring. I don't use HCG in the manner that you were prescribed. I don't personally know any fertility specialist in the U.S. that does but I have read papers by doctors that do. HCG acts in the same way as progesterone does.

I think you just need to keep trying. The fact that you got pregnant on your first try is a very good sign and you will eventually be successful. If you don't trust the treatment or protocol that your doctor has used, then maybe you should find a different doctor to work with. Trust is of the utmost importance in a Doctor-Patient relationship.

I hope that answers your questions.

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/