Progesterone levels have been measurable in the blood since the 1970s. This test is now easily and inexpensively run, with results often available on the day of blood draw. Progesterone serves a number of functions in the body. For this hormone to produce an effect it needs to bind to a receptor within a cell. Therefore, certain body cells with no progesterone receptors will not be impacted by this hormone. Progesterone in the uterus will change a lining (primed by estrogen) to prepare it to accept an embryo for implantation and pregnancy.
Without progesterone the uterus has an extremely difficult time supporting a pregnancy. Very old studies showed that the removal of the ovary that is making progesterone early in pregnancy, results in a miscarriage. Replacing progesterone prevented that loss. Because of its importance in pregnancy, treatment of a "low" progesterone has excited our expectations for a long time. Unfortunately, many of these hopes have proven unrealistic and/or unproven.
MEASURING PROGESTERONE IN THE SECOND HALF OF THE MENSTRUAL CYCLE (LUTEAL PHASE).
A progesterone level of less than 1 ng/mL is generally felt to be associated with lack of evidence of ovulation. This level, however, does not indicate a progesterone "deficiency," as this low level is perfectly normal during the first 2 weeks of the menstrual cycle and again just prior to the initiation of the period. After a surge of a hormone called LH (that induces ovulation), the small cyst in the ovary (the follicle that holds the egg) then begins producing progesterone to support the pregnancy that the uterus is innocently expecting every month. Progesterone levels rise and peak about 1 week after ovulation (i.e., 1 week before the next menstrual period if pregnancy does not occur).
Unfortunately, measuring progesterone in the luteal phase is highly variable, as the day on which the progesterone is drawn may not always be at the time of peak production (7 days prior to the next menstrual period). In addition, progesterone is released in pulses. One study during the midluteal phase (second half of the menstrual cycle) showed values ranging from 5 to 35 ng/mL in a single day. It is no wonder that there is no such thing as a "normal" progesterone in the luteal phase. We use this hormone measurement simply to tell us whether an LH surge has occurred and whether the ovary has responded to this surge.
PROGESTERONE TO SUPPORT PREGNANCY.
A second major misconception involves the use of progesterone to support pregnancy. We physicians are often as or more confused than our patients. In a study that evaluated physicians' self-reported practices in 2016, progesterone was given by many doctors for a wide range of proven or presumed defects of ovulation and infertility. For example, 70% of doctors gave progesterone for prevention of miscarriage and 24% of physicians "always" used progesterone in patients who were receiving medicines (clomiphene or letrozole) to induce ovulation. Despite the frequency of prescription writing, it has been difficult to scientifically justify these practices. In an excellent report in the New England Journal of Medicine this past year, progesterone supplementation was found to be ineffective in preventing miscarriages. It has also long been known that giving progesterone after a pregnancy test is positive does not alter the subsequent miscarriage rate.
THEN WHY DO SO MANY PHYSICIANS PRESCRIBE PROGESTERONE FOR WOMEN WITH THREATENED MISCARRIAGES?
The answer is complicated. The first reason is that an abnormal pregnancy will often be associated with a low progesterone. The reason is not that the ovary is unable to produce progesterone but that the pregnancy itself (that is, the placenta) is not asking the ovary to produce higher progesterone levels when the pregnancy is failing. It is therefore no wonder that adding progesterone is of no benefit, as we are treating the messenger and not the actual cause of the problem. Nonetheless, both patients and physicians focus on the actual level of progesterone, and both are desperate to do something that might help support their pregnancy.
WHERE IS PROGESTERONE HELPFUL?
Progesterone may be of some use in patients with a very short second half of the cycle. However, we will often treat this condition (called "short luteal phase") by helping ovulation start out correctly in the first place. Progesterone also may help in patients with uterine abnormalities, such as uterine septation or a bicornuate (double) uterus. Later in pregnancy, progesterone is used to reduce preterm birth in women with either a history of preterm births or women with a short cervix an ultrasound scan after 18 weeks gestation. Progesterone is given in virtually all in vitro fertilization (IVF) cycles prior to implantation and continued into early pregnancy.
If you have been unsuccessful in conceiving, schedule an appointment with Dr. Maxson at one of our convenient South Florida infertility clinic locations.
By
Dr. Wayne Maxson IVF FLORIDA at 14 Dec 2016
Ovulation timing has been practiced for many years, either as a form of contraception to avoid the fertile days of the month or to help increase the possibility of pregnancy. It is now known that the egg is most healthy for less than 24 hours, while sperm can function for many days. Some methods of estimating ovulation, based on a rise of basal body temperature in the second half of the menstrual cycle after ovulation or observation of increased mucus amount and thinness just prior to ovulation, are now mostly of historical interest. Although some of my patients still try to use these very natural methods, they can miss the day of ovulation by four or more days.
The recent grafting of cell phones into our lives has blossomed over 1000 apps that purport to help in ovulation timing. At the same time, urine testing for LH has become a more accurate and less expensive option, utilizing kits that are widely available through pharmacies, grocery stores, and online.
Which of these are most useful?
Smartphone apps.
How smart are these apps really?
Basically, the app averages the length of each menstrual cycle and estimates that ovulation occurs about 14, plus or minus 2, days before the subsequent period. Thus, a woman with a 26 to 30 day cycle will be presumed "fertile" from cycle days 10 to 18(counting the first day of menstrual flow as the first day of the cycle).
Advantages of using smartphone apps for tracking ovulation:
- Easy recall of menstrual periods, intercourse, and other symptom dates.
- Avoidance of urine tests, ultrasounds, and blood draws.
- More natural.
Disadvantages of using smartphone apps for tracking ovulation:
- No pinpoint accuracy, just educated guessing.
A recent article by Moglia et al (Obstet Gynecol 2016:127:1153-s60) evaluated 1116 apps. After limiting those that cost money, were not in English, or did not track the cycle, 108 remained. Of these, their investigation deemed 20 both accurate and free of charge. As noted in their article, the apps felt "most reliable" were:
Clue, Day After, FemCal Lite, Fertility Cycle, The Flow, Free Girl Cal, Glow, Groove, iPeriod Period Tracker Free, It's a Girl Thing, Lily, LoveCycles Menstrual, Ovulation and Period Tracker, Menstrual Calendar, Menstruation and Ovulation (now known as "Menstrual Period Tracker"), Mom and Baby to Be, MonthPal (now known as "Touchable Period Tracker"), Period Tracker, GP Apps, Period Tracker, Free Menstrual Calendar, Pink Pad Period and Fertility Tracker Pro.
This list should not imply an endorsement, as I have not personally reviewed or used any of these. The list is provided to help you as you research the 1000-plus options available to you to find the one that works best for you.
Because the urine testing apps just produce an estimate, more sophisticated tests are available to time ovulation.
The LH surge can now be accurately measured in urine. Physiologically, the pituitary gland releases a large amount of LH when the brain is primed with sufficient estrogen from the ovary. In this way, the follicle (egg sac) in the ovary actually controls egg release by signaling the brain when it feels it is mature enough for ovulation to occur. A massive amount of LH is produced, and ovulation (egg release) occurs within 36 to 40 hours after the initiation of the LH surge. When we measures LH in the urine, we are not necessarily picking up the onset of the surge but its first detectability. It has therefore been found that egg release generally occurs within 12 to 24 hours after the LH surge is first detected in urine. Many kits are available for this use. My preference is the simplest kit that just measures the LH surge. Some people prefer a kit that provides a single "yes", such as those with a “smiley face”, while others like to get a kit with two lines, one representing the positive control and one representing the patient’s actual urine result.
Several tips on the use of the urine ovulation predictor tests:
- We prefer to have our patient check her urine the evening, beginning abut four days before an expected positive. If the couple is seeking a baby, they then should have intercourse twice after the positive surge is detected in the urine, for example that night and the next night. These are the two "business days" of the month. Intercourse the remainder of the month should be for fun, as it will not affect the chances of being pregnant that month.
Reasons for a negative result on the LH surge kit:
- Actual absence of LH, as is seen in patients who are not ovulating.
- Malfunction of the kit.
- Positive but inadequate LH surge.
- Mistiming (for example, too early or too late).
- Urine too diluted (therefore limit water intake)
An easy way to see if ovulation has likely occurred when no LH predictor test is seen is to measure a serum progesterone level one week later. Any value over 3 ng/ml is likely consistent with ovulation.
False positives: There are also a number of false-positive LH surge tests that must be remembered, and your physician can help you in interpreting these.
- Menopause.
- Polycystic ovarian syndrome.
- Pregnancy.
- Testing the urine immediately after taking clomiphene.
- Testing the urine immediately after a GnRH agonist injection (for example, Lupron).
If you are unsuccessful in achieving pregnancy after one year of trying, consider seeing a fertility specialist at IVF FLORIDA for professional help.
By
Dr. Wayne Maxson IVF FLORIDA at 5 Dec 2016