QuestionHi. I am writing from northwestern Wisconsin. I am currently 35 years old. I had a miscarriage in 2003, then gave birth to my son without complication in 2005, and have since had 3 more miscarriages. Of the most recent 2 out of 3, we saw a heartbeat at 8 weeks and then I miscarried shortly thereafter. My last miscarriage was a blighted ovum and was chromosomally abnormal. I have short 24 day cycles with only a 10 day luteal phase. My husband and I have both been tested and have no chromosomal abnormalities. I have also been checked for clotting and autoimmune disorders. All tests have been normal. Doctor will not check hormone but prescribed Prometrium. I have actually seen 2 doctors. The perinatologist prescribed 100mg 2x/day. She said she would not check progesterone levels after I was pregnant because she would not increase my dose. My OB/GYN prescribed 400mg/3 day. She also said there would be no point to checking progesterone after I was pregnant. I am very confused as to what is the best dose. I plan to start after ovulation and use them vaginally. Could you advise what a good, standard dose might be to prevent miscarriage if, in fact, my progesterone is part of the problem? Thank you.
AnswerHello Monica from the U.S.,
Unfortunately, neither of the specialists you saw were specialists in infertility or recurrent miscarriage so there has been a wide variation in dose. The perinatologist is closer to the correct dose, whereas your gynecologist is using an extremely high dose. That dose, however, will not hurt but is overkill. Prometrium is okay for progesterone replacement, and to use vaginally, but is not optimal. There is a better preparation made specifically for the vaginal application called Endometrin. It is 100 mg and used three times per day. If you want to use prometrium (it is a capsule and does not dissolve as well), you would use 100 mg vaginally three times a day. Both meds would start on cycle day#16 and continued until the pregnancy test. If it is negative, then it can be stopped. If it is positive, then you would continue it until 10 weeks gestational age. The other medication that is made specifically for this purpose is a vaginal gel called Crinone/Prochieve. It is used each morning.
I am skeptical that the reason for your miscarriages were due to a lack of progesterone. Most miscarriages caused by luteal phase deficiencies occur before 6 weeks gestational age. Beyond that point, the corpus luteum of the pregnancy and the placenta take over progesterone production and produce adequate progesterone for the pregnancy to continue. The most likely cause of miscarriage in your age group is a spontaneous chromosomal abnormality, meaning that there was a chromosomal breakage during cell division leading to an abnormal embryo. In that case, the only options would be to keep trying, because 85% of patients with this cause will eventually have a viable pregnancy, or proceed to IVF where the chances of getting a good embryo is increased because multiple eggs are retrieved and used.
The other meds that I use in recurrent miscarriage patients is Medrol 16 mg per day beginning with the start of the cycle and ending with the pregnancy test (it must be tapered down to 8 mg per day one week prior to the pregnancy test) + heparin 2000U injection twice per day beginning with the start of the cycle and continuing until 10 weeks if pregnant + low dose aspirin 81 mg per day beginning at the start of the cycle and ending at 10 weeks if pregnant. Lovenox 35 mg can be substituted for the Heparin. These meds increase uterine blood flow by preventing micro-clot formation in the early blood vessels to the implantation site and pregnancy, and decrease the immune response to the pregnancy.
Recurrent miscarriage is considered an infertility problem so if you want additional information or consultation, you might want to consult a reproductive endocrinologist/infertility specialist.
Good Luck,
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 follow me on Facebook at http://bit.ly/9Iw9oV
