QuestionHi Dr,
My name is Valerie and I am writing from New Hampshire. I am a 32 year old female with secondary infertility (I have two children). I started trying for our third child about 9 months ago. I had a miscarriage in February and since then, my cycles have been irregular with spotting on days 8-10, ovulation on days 15 or 18 (they alternate from 15 or 18 every other cycle), and periods starting 10 days after ovulation. I chart my BBT and while my elevated temps aren't high (they hover near the coverline), there is definately a downward spike and jump after ovulation. The at home kits and mucus seem to indicate I am ovulating as well. My tubes are open and my husband's sperm is normal.
Based on my own research, my suspicion was that my progesterone was too low. However, I took a bloodtest on day 21 and that was normal. However, I have a concern about those results. I took that blood test on day 21 during a cycle in which I ovulated on day 18. Should I have really taken that blood work 7 days from ovulation instead of day 21? That would have been my guess but my Dr. said that as long as the progesterone was there, I was OK. I'm feeling different about that though and think that if I had taken it 7 days after ovulation, the results would have shown a decline in progesterone. Your thoughts?
I talked again with my Dr and really stress that I think my progesterone is an issue so he perscribed me 00 mg of prometrium orally this past cycle. My period still came again 10 days after I ovulated. Should I look to increase the dose to 200 mg or should I be using the cream or different form of progesterone?
Lastly, is there a cause of luteal phase defect that does not involve progesterone? I was told Clomid would be my next option but I really want to try the minimal approach first and I'm not ready to give up on the progesterone.
Thanks for your insight.
Valerie
AnswerHello Valerie from the U.S. (New Hampshire),
Luteal phase defect is not made by checking the mid-luteal progesterone level. That level, usually done 7 days after ovulation (as you have correctly described) is to help determine if ovulation occurred because the progesterone level will increase (which also increases the basal body temperature). Luteal phase defect is when there is inadequate progesterone to prime the endometrial lining and support implantation. That diagnosis can only be made with an end luteal phase endometrial biopsy looking at histologic development (timing). Certainly the early spotting could indicate a LPD, but one cannot be sure of that as the cause.
I ALWAYS use progesterone supplementation with my infertility treatments, and I think that most specialists do as well. That is because it is such an easy thing to do, there are no drawbacks or side effects, doesn't cost a lot and insures that a treatment doesn't fail because of simple deficiency in progesterone. It is obvious to me, from how you describe your cycle and how your doctor prescribed the progesterone, that you doctor is not proficient in infertility. We NEVER use oral progesterone. Multiple studies over multiple numbers of years have shown that when given orally, most of the progesterone is lost in the first pass through the liver and minimal amounts gets into the blood and endometrial lining. The level in the endometrial lining is where it needs to be (that's why only the endometrial biopsy can diagnose LPD). Blood levels do not adequately reflect endometrial levels. In any case, the GOLD standard for progesterone supplementation is either by injection or vaginally. If he is going to use Prometrium, then it needs to be used vaginally three times per day to get adequate levels. Other forms of vaginal progesterone supplementation includes Endometrin (almost the same as Prometrium but made to dissolve in the vagina) and crinone 8%.
My recommendation would be to go see an infertility specialist, so that your time and money is not wasted, but if you decide you want to stay with your general Ob/Gyn, then you should use on of the aforementioned progesterones for luteal phase supplementation. I also recommend that you start it between 2-4 days after your OPK indicates ovulation (that is not necessarily the date that you ovulate but indicates that ovulation will occur between 24-52 hrs). You should also have intercourse daily, once per day only and only one ejaculation per day starting on that date. You should have abstained from intercourse 3 days prior to the expected date of ovulation.
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.
for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on twitter with me at @montereybayivf and facebook @montereybayivf
