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Infertility/Fertility/question about Progesterone/FSH/Estradiol levels and AMA


Hello Dr. Ramirez,

I am reaching out to you from Southern California.

I am 40.5 years old. I turned 40 in August 2012, and decided to try to conceive. I got pregnant that first month, but unfortunately, had a miscarriage on Nov 1, 2012 -- I was 9.5 weeks along.

My menstrual cycle got back to normal pretty quickly, but since then, I have found that I have light spotting throughout my luteal phase, usually starting 2dpo through the end of my cycle. I never experienced this spotting before my miscarriage.

I have been charting my temps for the last 3 cycles, and have been able to confirm ovulation between CD12-CD16. I also have sustained temps above my coverline for at least 12-14 days past ovulation, until my menstrual flow starts.

I went to my ob-gyn regarding this spotting, and here are the results of the various tests she ran:

Pelvic ultrasound (done CD9): the uterus measures 8.2 x 5.3 cm. Endometrial thickness is 2cm. The endometrium is somewhat echogenic suggesting possible hemorrhage products. The right ovary measures 2.7 x 2.6 cm. The left ovary measures 3.4 x 2.6 cm. There is a 9mm follicular cyst present.
Impression: Thickened slightly echogenic endometrium. Left ovarian follicular type cyst.

CD2  FSH: 7.3 mIU/ml
CD2 Estradiol: 34 pg/ml
Progesterone CD21 (7dpo): 6.5 ng/mL
TSH: 2.4

Mr dr. said all these test results are fine and normal. I believe that my progesterone level was low, and wondering if that was causing the spotting throughout the luteal phase. I just recently started using natural bio-identical hormone cream for the luteal phase, and have noticed a small, but noticeable improvement in the spotting, however, itís still there most days.

Iím wondering what you would suggest based on these results and my age? Do you think I have a good chance of conceiving a healthy baby on my own, or am I at the point where I have to see a Fertility Specialist? My health insurance does not cover any infertility services, so we would have to pay out of pocket for any treatment.

I appreciate and thank you, in advance, for any counsel you can provide.  Thank you!!!

Hello Melissa from the U.S. (Southern California),

Your age is a significant inhibiting factor in your quest to become pregnant.  It is also the primary influence in your risks of miscarriage, which run as high as 50% per pregnancy.  Because of this, the general recommendation for women over the age of 37 is to pursue IVF.  It is the most efficient and successful way to get pregnant successfully at this point.  Now, keeping in mind that you got pregnant on your own not too long ago, despite it being a miscarriage, your fertility is heightened and there is a good chance you might be able to achieve pregnancy naturally within the next six months.  But, time is working against you so I would not waste too much time trying.  I think I would probably recommend IVF as well, despite the cost.  Another option would be to try with superovulation induction or IUI but these are natural treatment methods that will not significantly increase your chances.

In terms of progesterone, the midluteal phase progesterone is not a good measure for determining of you have an adequate or inadequate luteal phase.  That diagnosis is made by an end cycle endometrial biopsy for dating.  But give your situation, I would agree that using progesterone supplementation is a good idea and harmless.  I give progesterone to ALL my fertility patients to cover the possibility of a luteal phase defect.  The OTC "natural" progesterone is probably insufficient.  You will need to use pharmaceutical grade higher dosage progesterone such as Prometrium, Endometrin or Crinone.  Your gynecologist could prescribe it for you and you would start it AFTER ovulation has occurred (so around D#16).  Do not stop it until you have done a pregnancy test.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program

Monterey, California, U.S.A.

for additional information check out my blog at 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


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.


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.

American College of OB/GYN, American Board of Obstetrics and Gynecology, American Society of Reproductive Medicine, California Medical Association, American Association of Gynecologic Laparoscopists, Fellow of The American College of Obstetricians & Gynecologists

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

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

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