QuestionQUESTION: Hi Dr. Ramirez, I am 40 yrs old. Just had CD25 Prog drawn and its 4.2. Dr says I did not ovulate this cycle. I took the test at 9am, but ate breakfast, not sure if that affects anything. I did get positive dark line on OPK at CD15 of same cycle, and have very regular 28 cycles. I am reading conflicting things on Internet about what level of Prog sigifies ovulation. Is 4.2 too low? Is it possible to not ovulate but still have very regular cycles? Or have positive OPK but still a low Prog? Thank you for your time.
ANSWER: Hello Gina,
A low CD#21 progesterone is an indirect indicator of a lack of ovulation (progesterone should be greater than 10). However, if you do not ovulate, you don't have a period and don't have regular cycles, therefore, something is not right. Could it be a lab error or luteal phase defect?
At 40, I am not sure why your doctor is even checking he progesterone level. Why aren't you being treated more aggressively? That is, why aren't you undergoing some form of fertility treatment? Your chances of natural pregnancy is only 1% per month. At the very least, you should be undergoing ovulation induction with fertility medication to enhance ovulation (ie get you to ovulate at least 5 eggs per cycle) and that automatically will place you on progesterone to supplement the luteal phase. Ideally, you should be undergoing IVF to have the maximum chances of pregnancy (27% per cycle). As time passes, you chances decrease significantly so don't waste it!
Sorry for the preaching but I always worry that patients are being misled by their doctors, and will end up regretting it when they cannot even do IVF because they are too old.
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.
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QUESTION: Dr. Ramirez, I sincerely appreciate your candor. We tried to first ttc 6 mos on our own, then decided to seek help. In Jan'09, went to PCP for OB referral and had a blood test, I was on CD4 that day. I got a FSH 13.4 which is pretty bad it seems. LH = 7.1, Estradoil = 66. She referred me to OB who said to check Prog. and do HCG to rule out things. I now have to do another CD3 FSH next cycle. Hopefully after that OB will have enough information to begin some treatment. I too have a hard time understanding how I can be so regular each month (28 days) and not have ovulated. This cycle I got a postive OPK at CD 15. But it was weird coz I had cramps at CD25 night and some very light spotting which was not normal, thought it was implantation, but period started CD28. Could it be too much estrogen (I was on the pill 5 yrs, got off Apr 2008)? Any other tests you recommend?
AnswerHello Again,
The only worrisome part of your story is the 13.4 cycle day # 4 FSH level. That is a little elevated, but we prefer the test to be on cycle day # 2 or 3. So, I would repeat it on one of those days to confirm. If it is 10 or above, then you need to request to see a fertility specialist to get things moving along. That is basically an indication that time is short i.e. your ovaries are getting closer to menopause, which in your case would be early.
There are some OB/GYN's that are very knowledgeable and good with infertility. They know what to do and how to proceed. However, there are more than have very little knowledge or limited knowledge. You want to querry your OB/GYN and find out what their knowledge base is. The first question I would ask is what treatments they do (Clomid, Letrozole, Gonadotropin ovulation induction, IUI's, IVF)? I would recommend seeing someone that can at least do IUI's, but preferable all levels of treatment. The second question, if they do IUI's, is how many IUI cycles do they recommend before sending you to IVF? I only recommend four. Studies have shown that the pregnancy rates decrease significantly after four i.e. most patients will get pregnant by four IUI cycles, so it does not make any sense to go past that. If they say they do more than four, then they are holdng on to you needlessly because that is all they can do and they get paid for it.
I hope this information helps,
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.
