Infertility/Fertility/Recurrent miscarriage

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Question
Hello,

I am a 33 year old healthy female. My first pregnancy last year ended in miscarriage at 7 weeks. I did not require a D&C. I was told by my OB that I can start trying right away and I got pregnant again right after. I did not have a period in b/w the miscarriage and 2nd pregnancy. The second pregnancy ended in miscarriage at 4-5 weeks. I had a w/u which included normal estradiol,FSH at day 3 of my cycle and then normal progesterone day 21 cycle along with normal thyroid and no autoimmune etiology. A hysterosalpingogram was normal. I did not have karyotyping performed yet(mine or husband's done yet).
We are going to start trying to conceive again soon. I have had 2 normal cycles. I was given an rx for Crinone, but it was not covered by insurance so I was given an rx for compounded Progesterone intravaginal tablets 25 mg QD. I called the OB to verify the dose b/c I thought upwards of 200 mg QD were used for recurrent miscarriage, but he said that was the traditional intravaginal dosing used. I understand that the bioavailability of oral progesterone is much less so higher doses need to be used, but is the 25 mg QD compounded enough? I do not have a "luteal phase defect" per se or low progesterone, but I asked to try the progesterone b/c I felt it would not hurt even though the evidence based data for recurrent miscarriage is lacking.
Thank you in advance!

Answer
Hello Maggie from the U.S. (Massachusetts),

25 mg vaginally is not sufficient.  The vaginal tablet that has been approved by the FDA specifically for infertility/luteal phase support is the same compound as the oral progesterone and is 100 mg.  We (infertility specialists) recommend 1 tablet 3 times per day for a total dose of 300 mg per day of the vaginal tablet.  Crinone 8% is only once per day because it is a concentrated formulation specifically for the vagina.  There is no equivalent for it.

I might also advise that you take a low dose aspirin tablet (81 mg) per day to help with endometrial blood flow.

The good news is that most patients that have recurrent miscarriages are eventually successful and two miscarriages is not enough times to give you the diagnosis of recurrent pregnant loss.

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.  I now provide personalized fee for service consultations/advice/direction via email and payable via Pay Pal.  If interested, contact me via my email at info@montereybayivf.com.  This service will allow you to have your own personal on-demand infertility expert

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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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