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Infertility/Fertility/Crashing Progesterone Levels

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QUESTION: Hi Dr. R,
I have been under care of RE for about 6 months and we have done clomid/injectable IUI cycles with no success.  My tubes are clear, uterus is great, and husband's sperm count/quality is excellent.  Month after month I have excellent response to the medications in terms of follicle development.  When my progesterone levels are tested right after ovulation they are very high (usually >45), but when tested 7-8 dpo they invariably crash to <10, and I end up getting negative pregnancy test.  Several months, including this one, I have had definite pregnancy signs in mid-luteal phase, but then they disappear around time progesterone drops, so I'm convinced this is having an impact on implantation or support.

By way of further info I am in my mid-40's so I know egg quality is an issue, but my hormone levels are fairly good and I am an good responder to meds.  I think the progesterone issue is further complicating my chances.  Thank you so much!!

ANSWER: Hello Stephanie from the U.S.(Delaware),

You don't give a specific question, but I assume you are asking about progesterone.  Are you not on any progesterone supplementation after the IUI's?  If not, I am very surprised because it is a standard of care to give progesterone supplementation after IUI, especially if you are seeing an RE.  We tend to be overly aggressive in terms of treatment and make sure ALL the bases are covered.  IUI is no exception.  To verify whether or not you are in fact seeing an RE or infertility subspecialist, just ask him/her the question, "do you do IVF?"  Only sub-specialists do IVF.

If you are not using progesterone then that is the answer to your problem.  It is used either by injection or vaginal suppository.  The vaginal route (Crinone or Endometrin) is what I prefer with IUI cycles.  I try not to use too many expensive medications with "low yield" treatments like IUI (pregnancy rates less than 25% per cycle).

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.  Skype and internet comprehensive consultations now available via my website for those who want a more extensive evaluation that this site can accommodate

---------- FOLLOW-UP ----------

QUESTION: Thank you for your response!  And I realized as soon as I sent the message that I had forgot to mention that I HAVE been taking progesterone supplements every cycle, starting a few days after ovulation.  I have tried progesterone suppositories, Endometrin and Crinone, but every time I have had the same 7-8 dpo crash.  Crinone worked best in terms of less of a drop, but it was still a significant drop.  

So, I guess my question is, if supplementation isn't helping, what else can I do?  With such low levels just at the time an embryo would be implanting, I know I won't get pregnant even if sperm does meet egg!

Answer
Hello Again,

I think what I would advise is to add progesterone in oil injections, in addition to the vaginal progesterone.  It is most likely that you are NOT getting adequate progesterone via the routes that you have tried in the past.  I don't know how much of each of these medications you have been using, but with Crinone, I usually use it twice per day and with Endometrin I use it three times per day.  These are higher than the recommended dosages.  I increase the amount because I don't like to lose a pregnancy due to inadequate progesterone levels.  In my IVF patients, I use both injectable and vaginal progesterone until they are 8 weeks gestational age, then change to pure vaginal from that point on.  That is the point that the placenta usually starts to produce its own hormones.

This is a problem that your doctor needs to work through and determine a treatment plan.  You shouldn't have to go to the internet to get your own answers.

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.  Skype and internet comprehensive consultations now available via my website for those who want a more extensive evaluation that this site can accommodate

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Edward Joseph Ramirez, MD, FACOG

Expertise

I am a specialist in infertility and advanced gynecological care. I can answer questions about infertility, gynecology related ills, menopause...virtually anything that affects women's health. PLEASE tell me where you are writing from as I am always interested.

Experience

I have been practicing as an Ob/Gyn and Infertility Specialist for over 23 years. Gynecology, advanced laparoscopic surgery, basic infertility, IUI's, IVF, reproductive surgery, and ovulation induction are all areas of my expertise. I am Board Certified. I have been doing In Vitro Fertilization in my clinic for 19 years.

Organizations
American College of OB/GYN, American Board of Obstetrics and Gynecology, American Society of Reproductive Medicine, Society of Assisted Reproductive Technology, American Association of Gynecologic Laparoscopists, Fellow of The American College of Obstetricians & Gynecologists,Resolve-National Chapter, Open Path - Northern California, Board of Directors Monterey Medical Society

Publications
American Journal of Obstetrics and Gynecology, Wall Street Journal, Monterey Herald, SERMO, Women's Health and Fertility Blog

Education/Credentials
Medical Degree from Stanford University, Residency at Tripler Army Medical Center, Reproductive Training at Pacific Fertility Center, San Francisco

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