Infertility/Fertility/Estrace after fresh transfer
Hello Dr. Ramirez,
I'm 37 and am in the very early days of my first successful IVF. (I have low AMH - 0.38, high FSH - has been as high as 15 and a low AFC - ranges from 3 - 9).
This was our third IVF attempt (1st = converted to IUI, 2nd = zero fertilization of 4 eggs retrieved).
This cycle we retrieved 6 (5 immature even though I had 4 follicles between 1.6 and 2.0 on trigger day, but the mature and 1 of the immature fertilized via ICSI) and we transferred an 8 cell and 5 cell on day 3.
In the past I've always had low progesterone and a short luteal phase of 10 - 11 days. Spotting has often started 5 days past ovulation and continued for the remainder of my cycle. (I've had polyps removed, but that didn't solve the issue). On my many IUI attempts, I never made it to test date without starting my period despite being on 200mg progesterone suppositories 3 x day. I seem to be very sensitive to any e2 drops and even a minimal drop seems to cause me to start spotting.
For this attempt, I switched clinics after zero fertilization on our last IVF attempt. My previous doctor told me if I made it to transfer, he would prescribe me estrace to take after transfer in addition to the progesterone in the hopes it might help me make it to test date without bleeding.
At my new clinic they didn't want to prescribe me estrace (they said in an IVF cycle your e2 is already high and they don't want to add to that and it is never part of their protocols to take estrace after a fresh transfer) PLUS they only prescribe progesterone suppositories 200 mg 2 times/day.
I was really uncomfortable with this. I still had the estrace prescription from my former doctor and an extra progesterone prescription. I have been taking 200 mg progesterone suppositories 3 times/day and 1 mg estrace vaginally 2 times/day without my clinic's knowledge as they would not consider allowing it.
For the first time in more than 3 years of trying, I got a positive pregnancy test and made it to the test date without any spotting. The beta was low at first (60 at 11 days post 3 day transfer and by yesterday at 16 days post 3 day transfer it had gone up to 1275).
It may sound crazy, but I feel the estrace helped me prevent my period from starting early and without it I may not have gotten pregnant.
If I'm fortunate enough to have this pregnancy continue, I plan to continue the progesterone suppositories three times a day (I'm uncomfortable with my clinic's directions of twice a day). As for the estrace, I would plan to continue with the estrace up until about 10 weeks and then start weaning off it by slowly lowering my dose until 12 weeks - would that be a safe time to discontinue the estrace and is there likely to be any potential harm from using it?
Thank you so much for taking the time to provide answers to our questions.
Lucy from Toronto, Ontario, Canada
Hello Lucy from Canada,
It's too bad that you had to take matters into your own hands. I use both estrogen patches and extra progesterone in my IVF protocol. I hate to risk a failure just because there was not enough hormonal support. Estrace vaginally works just as well as the patches but I prefer the patches because it is less messy. I also use higher doses of progesterone in the form of injectable progesterone and vaginal suppositories. If I were using suppositories alone, I would recommend 3 times per day. In my regular IVF patients, I have them stop all their medications at 10 weeks pregnancy. In patients that have had a history of miscarriage, I have them continue until 12 weeks gestation just to make sure (by that point they are out of the miscarriage risk period). So, I think you are proceeding correctly. Once you get past the 12 week mark, you should let your doctor know so that they can reconsider their opinion.
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 http://womenshealthandfertility.blogspot.com
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