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Last Updated:
Jan 3rd, 2010 - 00:09:53
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Question
Hi. I am 32 years old with 8 and 5 year old daughters. (no difficulties conceiving using NFP) Since 10/01, my husband and I have been trying to conceive. Finally, my physician did some hormone levels and discovered that on day 21 my progesterone was only 13.1. I definitely ovulate every month based on BBT, cervical mucous, cervical position, mettleschmerz and positive ovulation predictor kits. However, my physician felt I should start clomid. I'm hesitant to try something so aggresive. I was wondering if I could just take a progesterone supplement. What would your opinion be?
Answer
This progesterone level in itself is only a little bit below the optimum for a peak progesterone level. I wonder if there isn't some other reason suggesting low progesterone (or luteal phase insufficiency) such as a short cycle or premenstrual spotting that is pushing your physician in the direction of prescribing Clomid. Without knowing more about your situation, it is hard to know if this is the best intervention for you at this time.
Have you been identifying the peak mucus day for several months, and having intercourse on that day for at least six months? What is the quality of your cervical mucus? Did you have an infection since the birth of your last child that might have caused a tubal blockage or uterine inflammation? Have your thyroid levels been checked? Have you had an ultrasound that might show a polyp or fibroids? Has your husband had a semenalysis?
With two prior pregnancies, it might be a little soon do a laparoscopy to check for endometriosis or other problems but if infertility persists that might be in order.
Clomid is a legitimate therapy in the medical literature for luteal phase insufficiency as well as lack of ovulation. But it can also cause poor mucus and a thin endometrial lining in some people. A more thorough workup of the luteal phase (the time in the cycle after ovulation) might be helpful in determining the best therapy. At Pope Paul VI Institute, the type of workup for this problem might include THREE determinations of progesterone AND estrogen five, seven and nine days after ovulation (as determined by ovulation predictor kits or peak day in charting). Estrogen levels should be in the range of 110 or 120(or 11 or12 depending on the lab). Progesterone should be at least 12 on peak plus five days, 15 on peak plus 7, and 12 on peak plus nine.
Sometimes progesterone will drop off rapidly nine days after ovulation even though values to that point are optimal. We diagnose a late luteal phase insufficency if the progesterone nine days after the peak drops 50% below the value seven days after the peak. If only one progesterone determination is made,you will not be able to diagnose a luteal phase insufficiency. If you have good mucus and estrogen, there are no other problems, and only progesterone is deficient, my feeling is progesterone vaginal capsules in a 600 mg. dose may be a better therapy. These are available by prescription from Kubat pharmacy in Omaha, Nebraska.
If both estrogen and progesterone are deficient AND you are ovulating, the method most often used at Pope Paul VI is very low dose Clomid (25 mg. day three, four and five of the cycle) followed by HCG injections (2000 units every other day for four doses starting three days after the peak). This is a more complicated therapy, but the low dose of Clomid given earlier in the cycle has less adverse effect on the mucus than standard regimens and is very effective if you are already ovulating and have luteal phase insufficiency of both progesterone and estrogen.
Dr. Mary Davenport is an obstetrician-gynecologist in private practice in El Sobrante, California.
She graduated from Tufts University School of Medicine and completed her residency at the University of California, San Diego.
Dr. Davenport is also a Fellow of the American College of Obstetrics and Gynecology.
She has an NFP-only medical practice and is a Medical Consultant in Natural Family Planning.
She is a board member for CANFP and the American Association of Pro-Life OBGyn's.
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