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Tuesday, September 27, 2016
Low progesterone at weeks 11 LMP
Some background: I am 11 weeks LMP with #1, conceived through IVF. I have PCOS and a history of low progesterone. All my HCG numbers were good and a 7w ultrasound showed the embryo measuring correctly with a heartbeat of 138. At that point I was referred back to my OB. At 10 weeks LMP, my P4 with support was 25.7 and my OB (at my RE`s recommendation) took me off progesterone support. (I had been doing Crinone 2x/day and rectal suppositories 200mg 3x/day.) We checked again 5 days later to verify that the placenta had taken over, but my P4 had dropped to 10. Ultrasound revealed that the fetus measured correctly and the heartbeat was 178, so the fetus appears to be thriving. I am back on progesterone support. The current plan is to do weekly serum checks. After two consecutive weeks where the progesterone level is over 20, I will going off progesterone support and re-test after five days. My question is how to proceed if after the retest my progesterone is still low. At that point, I will be in my second trimester. All the research I`ve done seems to agree that the placenta should have taken over progesterone production by now. I’m concerned that it hasn’t or that it is not producing sufficient progesterone to maintain a healthy pregnancy. From what I’ve read, I am more than two standard deviations away from the mean progesterone level for 11 weeks LMP. It seems like many physicians would just take me off support at 13-14 weeks and wait and see. However, there is anecdotal evidence of women who had low progesterone into their second trimesters and continued support until birth. I’m not willing to just accept the low progesterone levels and wait to miscarry, when everything looks like it is progressing normally. (Obviously if the fetus did not appear to be thriving, the situation would be different.) I was wondering if there were other options out there for me if the placenta doesn’t get up to speed in the next 2-3 weeks. I know that progesterone support is highly controversial, and that if we ask 10 physicians, we might get 15 different opinions, but I feel that it is imperative that we pursue every avenue available to us to see this pregnancy through to a successful live birth. I was hoping one of the perinatologists could comment and also let me know if this is a situation that warrants making an appointment with a perinatologist near my home. Thank you.
I am a board certified reproductive endocrinologist/infertility specialist. While the use of supplemental progesterone in IVF is somewhat empiric, it is generally used in most programs in either the intramuscular or vaginal forms. Blood levels of progesterone are typically lower with vaginal administration. This is because of local absorption and utilization and has nothing to do with effectiveness.
Supplemental progesterone is given for a variety of reasons following IVF but is usually stopped when the placenta takes over production of progesterone (around 7 to 12 weeks). I personally do not measure blood levels of progesterone and simply stop at 10 weeks of gestation. It is important to remember that patients undergoing IVF make a number of cysts, which make progesterone after the eggs have been retrieved.
In your case, the current plan is to stop progesterone at 13-14 weeks and to recheck blood levels. If the levels are "low" (, 15-20 ng/ml), you have expressed concern about stopping the progesterone. The fact that the pregnancy has continued to do well despite the drop in blood levels after initially stopping, should be reassuring. It is also important to realize that the significance of the drop is unknown. However, it is understandable that you would have anxiety regarding this pregnancy. Therefore, if the levels are "low" after stopping the supplemental progesterone, it would be reasonable to continue the progesterone through the end of the second trimester for your peace of mind.
Finally, in patients with PCOS, the use of metformin has been advocated through twelve weeks of gestation to reduce the risk of miscarriage (which is higher in PCOS patients).
Daniel B Williams, MD
College of Medicine
University of Cincinnati