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Monday, November 26, 2007

Progesterone: shots vs suppositories

I really think that most doctors are actually afraid of shots. I remember as a Duke medical student the scene during my first year when we were all lined up to get our hepatitis vaccines….what a bunch of weenies. Boy, we were shaking in our boots over a stupid little shot. Of course, now I am on the other side of the needle.

So why do we use the barbaric progesterone in oil shots after IVF or for an FET or donor egg cycle? Honestly, there is no really satisfactory answer. We know that progesterone suppositories work as well and yet we have a hard time using them as first line progesterone replacement. I am as guilty as the next RE in this behavior. However, I have no problem using non-injectible forms of progesterone if needed.

Fortunately, hope may be on the horizon. Ferring has a new FDA approved vaginal progesterone tablet called Endometrin. Preliminary data looks good and patient acceptance is high. On the other hand, we thought that Crinone Progesterone Gel would be the answer to the prayers of thousands of IVF patients and that did not work out so well as some patients ended up having this lump of gel extrude from their vagina after a couple of doses. Needless to say, patient compliance suffered.

So here is today’s Question of the Day (which has ended up becoming more like the Question of the Week…but hey, it’s free).

65. I had an allergic reaction to the progesterone in oil shots. Does this mean that I cannot do IVF?


Following follicle aspiration, most clinics place patients on progesterone supplementation. The rationale behind the supplemental progesterone is that following egg collection, ovarian hormone production may be impaired because many of the hormone-producing cells are removed at the time of follicle aspiration. In addition, the use of GnRH agonists such as Lupron may diminish ovarian steroid production following egg collection. Progesterone supplementation has evolved over the years to include patients undergoing both stimulated IUI cycles and IVF. Although most clinics tend to use progesterone-in-oil injections, excellent pregnancy rates have been reported in patients who used vaginal progesterone supplementation. Because the progesterone shots are either sesame or peanut oil based, allergic reactions are not infrequent; switching patients to vaginal progesterone preparations usually resolves the problem. Another strategy to maintain progesterone production after IUI or egg collection involves the use of HCG booster shots to enhance steroid production from the patient’s ovaries rather than relying on an outside source. Unfortunately, the use of HCG boosters may also increase the woman’s risk of ovarian hyperstimulation syndrome.

103 comments:

Anonymous said...

Hi,
Thanks for the great blog! Having suffered multiple early miscarriages, I have done the RE testing path.

I do have a question though, can progesterone suppositories cause bleeding? Say two weeks after starting use?

Thanks!

DrG said...

Unlikely that prog would cause bleeding although sometimes we see some spotting with suppositories perhaps from cervical irritation.

Good luck

Thanks for reading.

Charlotte said...

I've had 2 miscarrages in the last 2 years. The first one was close to the end of Jan. 07 I was 9 weeks along. The 2nd was Feb. 9 of 08 I was 12 weeks.
I've done testing and everything came back normal, no gene mutations or anything like that, they've put me on the progetsterone suppositories 2x a day, my cycle started on the 4th and ending on the 11th of June. They told me to start taking them on the 25th, is it too late to have them help. What is the outcome of me being pregnant this time??

Crumbs on the Table said...

Thanks for the great information. I'm currently pg having gone the DE route. My RE has me on estradiol progesterone (crinone) for 16 weeks past donor retrieval which seems like a long time. The reason given is that because we used lupron to shut down my ovaries, my body is not producing any of these hormones. Just wondering from another perspective if this is a typical protocol for ivf patients using a donor. Thanks!

DrG said...

Charlotte, the timing seemed fine. I have many patients in whom we dont start prog until they are actually pregnant because they are getting pregnant the old fashioned way.

Crumbs (?),
We continue prog until 12 weeks of pregnancy. Usually patients are off estrogen by 8-10weeks.

Good luck

DrG

Anonymous said...

This is very informative - thanks!! I currently take crinone after ICSI for Male factor Inf. but bleed 7 days after blastocyst transfer. I have just had my second Stim cycle for this with the same outcome with blood test showing low progesterone. Should I be on the suppositories or could this be an estrogen issue as in non receptivity?

DrG said...

I would probably either consider using HCG booster shots or PIO (prog in oil). I would add estrace if e2 is < 300.

Good luck

DrG

Anonymous said...

Thank you so much for this realy informative post on shots vs. suppositories. A question for you, since you posted this about a year ago, have you had any compelling eveidence either in support of the edndometrin or against it since then? I have had 3 rounds of IVF (2 fresh, 1 forzen), 2 cycles were with Endometrin and were, as a result, so much less stressful, but neither resulted in a sucessfull pregnancy, and I'd hate to be kicking myself for not doing the progesterone shots if there is evidence that they are more effective.

Anonymous said...

Can taking progesterone oil shots cause diarrhea?

kristinaboffing said...

can progesetrone shots cause you too pee alot

I am in one week from finding out if i am pg and i am almost certian i am going crazy.
I cry alot and i am NOT ever sad

DrG said...

Emotional side effects are not uncommon...peeing a lot is not a typical side effect in my experience.

Good luck

DrG

Anonymous said...

Hi Dr.
My doctor first prescribed me with oral progesterone 20mg 2x a day. Are this effective? The progesterone suppositories are really expensive. I was told there are two kinds Crinone & Prochieve? Which one is better? Thanks Doctor!

Anonymous said...

Hi, I've had many early miscarriages. I only go a week or two over my period and get faint lined pregnancy tests. What do you think could be the cause?

Anonymous said...

Hi

I've just had a 3 day transfer and have been put on progesteron suppositories 3twice daily am/fm. However, I'm concerned that this may not be enough. Can I up the dose to 3 times per day. Will that cause complications. I've had two failed fresh cycles and 2 failed frozen in the past. The last cycle in November 09 was a 3 day 8 cell transfer. The quality was very good yet i failed to get pregnant. I'm just concerned that progesterone may be the problem.

Anonymous said...

Hi Dr!
I was just going to start infertility treatments and they did a blood work up at 21 days post period. My doctor checked my progesterone level, prolactin level, thyroid level and glucose. My progesterone came back at 9.2. I found out three days later that I am pregnant. I had a miscarriage at 7 wks and explained my history to my dr. She is not concerned about my progesterone levels and does not want to put my on anything at this time. I got a second opinion, that dr wants me to starting taking oral progesterone twice a day. Is this more effective than suppositories? Which is better to maintain a pregnancy?

DrG said...

I think that some supplementation makes sense but there is no data to support my opinion. We usually use suppositories as oral prog can make you pretty sleepy.

Good luck

DrG

Anonymous said...

Hi Dr,
My doctor put my on oral progesterone 100 mg BID, as my progesterone level was at 9.2 at 21 days post period. I found out I was pregnant, like 9 days after my progesterone level was drawn. Do you think oral progesterone is okay with prevening a miscarriage or do you think suppositories would be better? I had a miscarriage about 9 months ago at 7 wks.

Thank-you!

DrG said...

See above reply....

DrG

Anonymous said...

After an IVF transfer during the waiting stage, is it important to keep the progestrone shot to exact time every day? Can they vary 3-4 hours range? Thanks a lot

Anonymous said...

I have been taking a progesterone shot to help prevent preterm labor. after a few shots I had a reaction to the progesterone shot that had a preservative so I was switched to the progesterone shot without a preservative for people who are allergic to the other shot....I had a reaction to that shot also. Is it normal to not be able to take the shot either way? what way is left to be able to take progesterone?

Anonymous said...

My progesterone level was 6.4 the same day I was diagnosed with a missed m/c at 7 weeks. The week before we had seen a hearbeat, but were told the baby was measuring a week behind. Unfortunately do not know if progesterone was low during the actual pregnancy as it was not tested - we conceived naturally after years of trying (I am 38).
However, I have always suspected that I have low progesterone - over the past 5 years I have had issues with night sweats and hot flashes the week before my period starts and usually have short (3 day) heavy bleeding. I have brought this up to all my doctors but have been told there is nothing that can be done - until my current OBGYN, who is recommending vaginal progesterone suppositories. If I start taking them asap, can they help get and keep my levels up so I can hopefully get pregnant again and maintain the pregnancy?

Anonymous said...

I have been diagnosed with very low progesterone/ luteal phase defect. I have heard conflicting things about when to start progesterone suppositories for them to be effective - is it true that they need to be taken right after ovulation or can they still be effective if you wait until pregnancy is confirmed? I want to do everything possible from the start to be able to maintain a pregnancy.

DrG said...

We assume that all of our patients have low progesterone and thus treat all with vaginal prog starting after IUI (or ovulation). However, if a patient is not pursuing any treatment such as IUI, I will occasionally allow then to use empiric progesterone supplementation. No good studies exist to prove efficacy except in patients undergoing IVF with luteal GnRH agonist (Lupron) suppression.

Good luck

DrG

Anonymous said...

I am 35 years old. Last year my husband and I decided to try to get pregnant. I generally know my cycle length to be around 27-32 days with it mostly averaging at 29 days. I watch my cervical mucous to know when I am ovulating and I knew when I had EWCM I was fertile. We decided to go for it... and lo and behold we were pregnant! For the first time in my life I was pregnant! My hpt didn't show a positive until a full week after my period but then it showed a positive.

Around 9 weeks I started to feel some cramping which I thought was normal from what I read (uterus expanding) and then the next day I noticed some spotting. Not good.

I called the doc office and they sent me to the hospital to get an emergency ultrasound done and emergency bloodwork to check my hcg levels. The ultra sound confirmed that I had an empty gestational sac.

The ultrasound tech said it looked like the development stopped developing at around 5 weeks 3 days. Wow. My poor body took another 4 weeks to realize this apparently. The cause was 'blighted ovum'.

Our doc told us it happens no big deal try again in 4 months.

4 months later we tried. Sure enough- we were pregnant again! Yahoo! This time, again, it took a full week after the day my period was due to show up on an hpt. In the meantime, I started to read about progesterone levels and how they drop in women who are working professionals, are in their mid-30s, have stress, etc. etc... enviornmental estrogens, etc.. cause progesterone levels to drop. I start to realize- this is probably what is happening to me. This is it! My progesterone levels aren't so low that I can't conceive- they are probably just barely low enough that they cant sustain a pregnancy.

So this time we get a qualitative hcg test... my levels are doubling and are great... I beg the docs to check my progesterone levels too.. they refuse... I finally pester one to send me for progesterone check...
No dice. I start cramping. I start spotting. My bloodwork is done and comes back that the progesterone is an 8... then it dropped to a 5 and then its miscarriage city all over again.

This time on the ultrasound though- we had an embryo and yolk sac. They said the same thing- looks like development stopped right around 5 weeks 3 days.

I went to an RE and had all the bloodwork done and everything came back perfect... normal... great! Everything except my progesterone which was 'only a little bit lower' than it should be according to the re... I guess they want it to be at least a 10 and mine was a 9.2... to me- that is significant... that was 7 dpo.

I have been charting my temps and using opk... I ovulate consistently on day 16... the opk shows a strong positive on days 15/16 and then my temp spikes on day 17 but only by 1/10th of a degree... What I mean to say is that my temp is 97.5 before ovulation... and the days after ovulation it only raises to 97.6

My RE told me to not bother with temping as its an inconsistent way to track fertility.

Now that my bloodwork has come back as normal - the RE is sending me for an HSG... this is where I am confused... Why would I need an HSG if I am already getting pregnant? Obviously my tubes are not blocked if I am not having difficult conceiving. I know the pregnancy rate increases for infertile women after an HSG if they cant concieve.. but again- I can obviously conceive. Also- using radioactive dye and xray on my baby parts is not my cup of tea. It sounds invasive and unnecessary.

So I have asked my doc office (left a message) to inquire if I should be getting an HSN (hysterosonogram) instead ... isnt that more accurate for recurrent miscarriage?

Please give your thoughts on the progesterone levels, the recurrent miscarriages, and the hsg vs. hysterosonogram.

I am so forever grateful for any insight you can offer. Thank you for your help!

Anonymous said...

I am currently doing IVF (ER on 8/6/10 & ET on 8/9/10). My RE originally prescribed PIO shots but due to my travel schedule has me on Endometrin suppositories (100mg) and Progesterone in Peanut Oil oral pills (Prometrium 200mg) twice daily. I haven't come across anybody else doing this. Is this a normal protocol?

DrG said...

Well sorry for your frustration. We use empiric progesterone in all our pregnant patients....not scientific but it ensures that no patient suffers from prog deficiency!

I agree with your RE on doing HSG. HSN (H2O sono) is OK but HSG is better to rule out any uterine malformations or septum or scarring. The amount of radiation with HSG is VERY small. I would be more worried that aliens will abduct you this weekend than I would be about the amount of radiation from an HSG.

Good luck

DrG

DrG said...

We often use prog suppositories or prometrium instead of PIO shots. I believe that success rates are similar and often leave the decision up to the patient....most prefer no PIO shots but some think the vaginal suppositories are really disgusting. ORal prometrium is OK but I think vaginal absorption is better....

DrG

Anonymous said...

Hi Dr G.
I couldn't sleep (just 2 days after icsi failure) and I got up at 4:30 a.m. and found your blog... I have a question about i.m. versus vaginal progesterone after ivf. We suffer from unexplained infertility. Have had 4 icsi treatments that have resulted in implantation failure. Our clinic uses vag. suppositories (Lugesteron 300mg twice a day). My physical symptoms during my icsi transfer cycles have followed the same pattern every single time. During the shots prior to egg retrieval, my breasts get extremely swollen and tender. This is mainly a progesterone effect, isn't it (I guess))? Or both E and prog? Anyway, about 8 to 10 days after transfer, the tenderness and swollenness dramatically reduce to normal within 12 to 24 hours, and within 48 hrs from that, bleeding starts (the same happens during my normal menstrual cycles but it's less dramatic). My doc says the implantation failure is simply due to my age (38) while I think the vaginal suppositories don't work. I have had my prog level measured in the mid luteal phase of my cycle and it was low. My FSH was around 8 to 9 but doc refuses to measure E2. I think my hormone levels might be low not only because of age but because hard exercise and mental stress (I'm recovering from clinical depression). I've been begging for p.o. or i.m. progesterone supplement and estrogen supplement after transfer but doc says not needed. What do you think? Thank you - I love your blog :-)

DrG said...

Dear Anonymous,

When you said that you were up last night and couldn't sleep I thought that maybe you were a Pittsburgh Steelers fan....but seriously, although I agree with your RE, I see no harm in switching to PIO and using supplemental estrogen. It is probably an issue with the embryos in terms of genetics but if you WANT to use PIO I see no reason to say no. The symptoms prior to egg collection are estrogen related...those after retrieval are mainly progesterone related.

Good luck

Thanks for your kind words.

DrG

Anonymous said...

Hi Dr G.
This is your "Pittsburgh Steelers fan" again (actually, I live in Scandinavia and I hate football - ok, I admit I had to check whether they play football, baseball or ice-hockey...). I appreciate your word that I'm too old to produce proper eggs but I'm still curious about the swollenness symptoms. Why do my symptoms always last until 24 to 48 hrs before my embryo bleeds out of me, considering I put in my progesterone suppositories as I was told? As if there was some kind of connection between the two events. Are the post-transfer progesterone effect swelling symptoms caused by the shots (Menopur or Pregnyl) or the suppositories?
Btw I just found out that i.m. progesterone is not available in our country. Could I use tablets in addition to suppositories? As for E2, what dose do you suggest? Tablets or patches?
Thank you so much again!

DrG said...

Football is similar to curling but a bit more violent....

After you trigger with HCG the ovaries start making progesterone and unless you get pregnancy and start making your own HCG the corpus luteum cysts that form following egg collecton run out of gas and the estrogen and prog levels plummet initiating a period. I would check with other fertility patients in Scandinavia to see what is avaialble. In terms of estrogen we use oral estradiol 2mg (1-3 times a day).

Good luck

DrG

Anonymous said...

DrG. i am 22 i have had 2 miscarriages...Dr told me to call asap! so i called the following morning. i got my possitive test..i had 3! went in the after noon and they took HCG and progesterone...HCG was around 150 i wanna say..they put me at 5wks(didnt hava pen or paper) and my progesterone was level 2..what does level 2 mean? also prescribed progesterone supp. due to my history..i have read alot on the pros and cons. pretty much 50/50if it happens again there was a reason but if it does not i will forever be greatful of my child.this happened last thrusday. should o had my period on the 5th of this month.went back they tested my HCG monday am and it was near 760. my dr said that she did not have any further concerns because my HCG rose significantly...so i hope all is going well..the lord has tested me twice..i have grown alot since both..just maintaining possitivity and taking one day at a time..sorry i tend to rant about this topic...

Melissa said...

Dr. G,

My husband and I have now completed two IVF/ICSI procedures due to severe MF OAT. We are both 28 years old and I have checked out fine so far. The first cycle (Long Lupron) I had a BFP at 6dp5dt and then that evening I had sudden cramps and heavy bleeding. My BETA came back at 4 at 9dp5dt. The second time I began light spotting at 7dp5dt and the following evening again I had sudden strong cramping and heavy bleeding. My BETA at 9dp5dt was 35 and did not double. I was on Crinone 2x daily.

We are now discussing another cycle. We don't have insurance and refuse to go into debt so have been saving since we found out his problem 4 years ago. Since our funds aren't unlimited I'd like your advice.

Do you think an HCG booster or PIO/Estrogen supplementation would help? Or do you think I should request immunological/clotting testing, get a new Dr. etc.?

Thank you so much...I appreciate your blog and the obvious time that you put into it.

DrG said...

Hi Melissa

Sorry things are not working out. Although the progesterone supplemention recipe is unlikely to be the issue here, I have no problems with changing to PIO and adding estrogen. HCG boosters are fine unless you are a high risk for OHSS type of patient.

Other options to consider are donor sperm inseminations, Natural Cycle IVF or adoption. I dont see any reason to jump onto the immunologic testing bandwagon. Almost all of your losses are likely to be genetic.

Good luck

DrG

DrG said...

Anonymous,

Hope that things work out. I think that adding progesterone is appropriate but ultimately the proof is in the pudding in terms of the outcome.

Best wishes

DrG

Anonymous said...

Hi,
Thanks for the blog. I've just had an IUI a week ago and waiting for another week to pass. I was given suppositories to have 3 days after the IUI. But by mistake I though I had to take them on the first day and had them on the evening of the IUI. Now I'm worried what will happen? Please tell me if it has side effects to pregnancy. Thanks.

DrG said...

No problem with starting prog suppositories a bit early. It will not be the make or break factor in this cycle.

Good luck

DrG

Brittney said...

Dr G,
Hello my name is Brittney.I am 23 years old. My husband and I found out we were pregnant June of last year. I had a vaginal ultra-sound done in July because I kept having severe pain on the right side by my hip bone. I went in and the doctor did a vaginal ultra-sound. I also did blood work to show my HCG levels, they were in right around 850. They never tested the Progesterone levels. Then over the next two days they dropped dramatically to 410 and then to 230. As soon as the vaginal ulta-sound was done I started bleeding. Over the next few days it got worse and worse. I went to the hospital and found that it was a blighted ovum. The doctor stated that it is the most common miscarriage to have and to go home and let it pass at this time they figured by the size of the sac that I was about 9 weeks and the miscarriage occurred somewhere in the 4 week bracket. It took almost another month for it to pass on its own. The doctors at the hospital did not offer or tell me that I could do a D&C. I ended up going to the hospital because of the pain and passed the sac and followed up with a D&C to get the remaining bits left over. They found after I passed the Sac that I also had an infection in my uterus. I followed up with anti-biotics.After I recovered from the D7C and went back to the doctor and stated that I could start trying again. We have now been trying since October with no luck. I have tried the Basal temperature chart and noticed that my temperature doesn't fluctuate but 1/10 of a degree 98.6 to 98.7 or 98.8. I do not feel that this is enough to know I am ovulating. I went to the ovulation testing. I have found that I ovulate on day 16 and my cycles are usually between 24-35 days. It always varies. The last 2 months have been 27 and 25. I think I just started today. I do not see blood in my urine but when I go to wipe there are blood clots and brown blood. What does this mean? Also I am wondering what else I can do to ensure conception? Is there such a thing as ovulating to late and the egg not having enough time to mature before I expect my period? Should I take progesterone to help? I have not gone to the doctor yet because I am afraid of the outcome but I also know I can't mentally handle another miscarriage? Would that Uterus infection affect me not being able to conceive? Do you think it did damage to my uterus or tubes? Sorry for the long post but I am worried and do not know where to turn and I am afraid of going back to the hoospital that did not catch my uterus infection?
Thank you.
Brittney

DrG said...

Hi Brittney,

Miscarriages are never easy and you may want to seek some support in dealing with the emotional repercussions of that loss. Although the infection was very unlikely to result in a uterine or tubal issue, I think that most REs would check an HSG to make sure the plumbing is OK.

You can then discuss options with your MD (perhaps a new MD) and hope for quick success.

Sorry for your loss.

DrG

The Loft said...

Hi, I am starting IVF for the second go around. The first time I used Crinone as my progesterone supplement. This time I have quite a bit of crinone left over and so my doctor said I could decide if I wanted to use that again or use what they usually prescribe, which is the progesterone in oil shots. I want to do what is very best because last time IVF wasn't successful. Does it really matter which I choose? Thanks for your help.

DrG said...

The data on Crinone looks good. Only problem is that blood levels of prog are real low on Crinone which can cause everyone to be a bit anxious...even though the uterine levels are likely superb.

Good luck

DrG

Anonymous said...

Hi Dr. G:
I am 35 years old and had a natural pregnancy 4 years ago and a successful IVF cycle two years ago with the Progesterone suppositories 2X per day during the first trimester. For this cycle, I had a 5 day blastocyst transfer on June 23 and my HPT started to test positive on June 28 (I tested early because July 3 seemed so far off!). I've been on the progesterone suppositories since the day of the transfer (June 23). I am in a bit of dilemma because my progesterone level came in yesterday at 11 (HCG also 11) and my doctor wants to add progesterone shots in addition to the progesterone suppositories that I'm already taking. I read average levels at this stage of pregnancy is 12-90 and generally they go up 1-3 every couple of days so I feel like I'm pretty close to the average. Do you think adding the shots is necessary with an HCG level of 11 this early on in a pregnancy? No history of miscarriages -- knock on wood.

Thanks for your insight -- I am paralyzed with fear of needles and barely made it through the needle-extravaganza that is IVF!!! The stress of the IM shot is going to have cortisol pulsing through my veins and that can't be good for the developing baby, can it? Seriously though, I will do anything I need to do to make sure that this baby has all the progesterone he/she needs for a successful pregnancy but jumping to shots now (when my pregnancy blood test wasn't even supposed to happen until Sunday) seemed a little aggressive. Would sure value your expert opinion. THANK YOU IN ADVANCE SO VERY MUCH!

DrG said...

Well I have had a lot of patients unable to tolerate the shots and a level of 11 while on suppositories seems OK to me....good luck

DrG

Nampa 6th Ward Relief Society said...

I have had 4 miscarriages, and I am pregnant again. I have used the progesterone suppositories with this pregnancy and the last one also. I have not been sick at all and I am not starting to have some bleeding. Is this a sign that I am having another miscarriage or is it just that I am causing irritation?

DrG said...

No way to know except by seeing your doctor...

Good luck

DrG

Anonymous said...

Hi Doc, 38, naturally concived 5 year old, 3 years ago ectopic, 1 tube removed, this year 2 mc ( very early). Thinking, i do not have much time went for ivf, et 2 blasts, just yesterday. Im on 3x vaginal prog, 4mg estrace and 2 hcg shots. My belly is sore, have hard time eating ( very swallen, discomfort), got my us ( ovaries sizes today, both average 55). is it all necessary, seems so much and i almost never see people doing both prog together ( hcg boost and vaginal tablets)

Anonymous said...

Found your blog today and have a question. I am 37 years old and I had AI procedure. They gave me Crinone rx to use after the AI. All my labs and exam show that I am nl -except for being 37... I have never had a miscarriage-although I have never tried before. My question is do I really need this gel? I took it this time and still have a few days to find out if I am pregnant, but I did forget a dose(5 hours late) and had some spotting... so now I am wondering, assuming there is nothing wrong with me, wouldn't it just be better to let my body make its own progesterone rather than risk taking a supplement, suppressing my own production and then forgetting a dose and cause a miss? -am I correct that I could cause a miss if I forget a dose? I am trying to decide what to do for the next cycle. Crinone or not? I hate to think my stupidity could ruin the whole thing.

Anonymous said...

Hi DrG,

im into my 2ww now and this wed is my supposed day of testing hpt (home preggy test).

Im on 100mg Lucrin progesterone inserts 3 times a day + blood thinning jab fragmin daily too for these 2 weeks..then came saturday till now monday, i've been bleeding. Started pinky then became red like normal menses + cramps.

The protocol here is to call clinic and i did and nurse said it seems it's my menses indeed. But Question is :

1) can one get menses (AF) despite having the progesterone inserts 100mg everyday?

2) Can i be pregnant as well? Can i test hpt earlier say today or tomorrow to be sure?

3) Could previous 2 abortions resulted in my bleeding? e.g weak uterus walls.

4) Could my blood thinning jabs resulted in bleeding too?


Grateful for your time! God bless!

DrG said...

HI Anonymous #1

Some clinics use both HCG boosters and prog but the use of HCG boosters will increase the risk of OHSS in patients that have a lot of follicles during stim.

Good luck

DrG

DrG said...

Hi Anonymous #2,

Crinone is natural progesterone and using it should not suppress your own prog production. We use supplemental prog in all our cycles. Its use outside of IVF patients is totally empiric with no good data. However, most patients would rather take it if there is any thought that it may help.

Good luck

DrG

DrG said...

Hi Anonymous #3,

Here are my thoughts:

1) can one get menses (AF) despite having the progesterone inserts 100mg everyday?

YES, it may delay period but many patients bleed in spite of prog supplementation.

2) Can i be pregnant as well? Can i test hpt earlier say today or tomorrow to be sure?

YES, but not a good sign to be bleeding...

3) Could previous 2 abortions resulted in my bleeding? e.g weak uterus walls.

DOUBTFUL, unless there is scarring present on HSG or hysteroscopy then unlikely that previous losses or D&Cs created problems


4) Could my blood thinning jabs resulted in bleeding too?

UNLIKELY, usual dose is too low to result in bleeding changes with menses.

Good luck

DrG

Anonymous said...

Hello Sir,my wife had a FET on 08/31;on 09/12 she got her HCG 73 they didn't check her prog levels she was on PIO 4 days before her transfer but since the day of transfer they put her on Endometrin twice a day;however she had her second HCG today 09/14 thay also checked her prog HCG 159 and prog 6.7;now they increased endometrin to 3x day and 1/2 ml PIO every day;what are the chances of viable pregnancy for her?we are very tensed she had a miscarrige in her previous FET around 6 weeks they didn't check her prog levels that time,we are very tensed

DrG said...

Anonymous

The problem with checking serum levels on patients using vaginal progesterone is that they are always low....I see no reason to think that this will end as a miscarriage!

Here's hoping!

DrG

Anonymous said...

Thank you, her levels on 09/17 hcg 445 and prog is 22.5(it was 159 and 6.7 respectivly on 09/14),looks like PIO is working great,but our RE's office directly gave an ultrasound appt on 10/05;don't you think we should have couple of appoitments before ultrasound

DrG said...

Anonymous

We usually follow betas until they are > 1500-2000....

Good luck

DrG

Anonymous said...

Thank you doctor,we went for another beta today and it is increased to 1038(it was 445 on 09/17)and prge levels are more than 40?don't you think 1300 hcg would be good by now do we need to concern about it

Anonymous said...

Hello Dr. G,

I have a question regarding symptoms, or lack thereof, with progesterone use. We are scheduled for our embryo transfer today. I am concerned that because my breasts are not nearly as sore at this point, compared to previous IVF and IUI experiences. I have been taking POI (as I much prefer that method over the messy suppositories) since the day after my retrieval. I remember feeling breast swelling to the point of being highly uncomfortable, however this time there is only slight discomfort and definitely sore nipples.

Should I be concerned? Should the dose be increased? I'm just your typical paranoid individual during and IVF cycle.

thanks so much,

W

Kelli said...

Dr G, thanks for a very informative article. I'm currently in the 2ww of my 3rd IVF cycle. I used PIO for the first 2 cycles but am now using Utrogestan pearls instead. My questions are: how far in do I have to insert the pearls? Do I push it all the up until I hit my cervix? Also, is there an applicator that would make insertion easier? Thanks for your help.

DrG said...

Hi ANonymous,

Well ultrasound will give us the most information so lets hope things all work out!

Good luck

DrG

DrG said...

Hi ANonymous 2

Well this whole process can certainly cause sane individuals to go round the bend...

Not sure what to make of the breast issue....proof will be in the pudding.

Good luck

DrG

DrG said...

Hi Kelli

I will punt on that question and suggest that you ask the RNs at your RE office. Personally not familiar with prog pearls.

Good luck

DRG

Anonymous said...

Dear Dr G
I have been ttc for 7 years, have undergone 6 full IVF cycles using donor sperm and multiple frozen cycles and 4 years ago had one pregnancy with a frozen cycle that ended in a miscarriage at 6 weeks. All embryos that have been transferred have been at least grade 3 and the vast majority have been grade 4. I have not had any problems producing eggs during IVF though there does appear to be problems with embryo survival (typically 80% die within first couple of days). I have undiagnosed infertility. During the harvest cycles (which have taken various forms, most recently with Lucrin but prior to that synarel and something else) I have exactly the same symptoms as Scandinavian anonymous (6th Feb post) ie all the symptoms of pregnancy for 9 days post harvest (which I put down to the Ovidrel HCG trigger shot which has been consistently used for each harvest) then on day 10 post harvest the symptoms disappear (and in addition I feel totally miserable for the day) and then the next day I start to spot (and despite this feel much better hence I put the day 10 blues down to some hormone issue as well) which within a day or so turns into what is effectively a full period while I am still taking progesterone. From day 2 post harvest onwards I am on progesterone suppositories (200 mg 2x per day). My natural cycle is very regular, unproblematic (ie regular flow, no cramps etc) and averages 30 days. I was on the pill in my 20’s (little did I know...) went off it for a while and then tried to go back on it but gave up due to issues with breakthrough bleeding. I was really interested to hear that there is such a thing as an HCG booster shot and was wondering if it might be indicated in my case (for me to raise with my Dr) as from what I can gather with hormone charts, the point at which I start bleeding seems to be when it is likely the Ovidrel has cleared my system, but even if I were to be pregnant, before the embryo has had time to start producing much HCG? Or if you have any other suggestions would be hugely welcome.
Thanks very much for a great site: I have been trawling the web for days and this is the best one I have found.

DrG said...

Hi Anonymous,

Thanks for your kind words...Sorry for the lack of success but clearly not for lack of trying!

I think that HCG boosters are fine but am worried that there is more to it than that...

I would consider all options at this point...

Adoption
Donor egg
Gestational carrier

Good luck

DrG

Anonymous said...

Hi Dr G,
In regards to infertility treatment, what would you suggest for pink/red/brown spotting consistently 5-7 days after ovulation? It only lasts a couple of days, then I eventually get my period. I conceived naturally 6 years ago with identical twins (born early due to ruptured membranes).
Alison

DrG said...

Hi Anonymous

Not sure what to make of that...we use a lot of progesterone in the luteal phase but some patients still spot and bleed early. I think that patients bleed because they are not pregnant as opposed to not getting pregnant because they bleed!!

Good luck

DrG

Anonymous said...

Hello,

I'm currently 11dp5dt. Transferred 2 fresh embryos. Got a positive hpt days 6-11 but am not feeling any real pregnancy side effects. Could I be getting a false positive from my trigger shot on 11/21? I'm currently on endometrium 3 x/ day, estrace 3 vaginally daily and 1 sublingual daily, 1 cc PIO every other night and wearing estrogen patch 24/7. No hcg supplements though. First blood test is Friday.

I am, however, having a bad reaction tonight from the suppositories or getting a yeast infection and irritation I think from constantly wearing a pad.

Any thoughts on all the positive hpt thus far and the irritation a well?

Thanks!!!

DrG said...

Hi Anonymous (12/7/11)

HCG should be long gone so sounds like a true positive. I guess you could change to PIO only and bag the vaginal prog….

Good luck

DrG

Carolina said...

Dr. G,

Since day 8 after embryo transfer at certain times of the day I feel my uterus heavy and mild cramps.... is it possible to be Endometrin + Prometrium side effects?
God bless you for your answer....

Susie said...

Dr. G,
I just had my progesterone tested on cd22 and It was a 4. My doctor said it was low and gave me progesterone micronized 8% gel. I am nervous about the side effects. I am allergic to alot of preservative things (haven't been actually able to name which specifically). Is there another alternative to take... or could a compounding pharmacy just give me straight progesterone.?

Anonymous said...

Hi. I have been trying to get pregnant for 1 year now and no success. My luteal phase is 9 days but my 21 day prog test is fine. My husband tests are all fine. My cycle is 24 days with ovulation occuring on day 15. My dr is referring me to a specialist so I can have prog suporstories. I had a pelvic scan on day 13 and it showed I have a dominant follicle which my dr said is good. Do you think prog suporstories will help. Is there anything else I can try.

jlcz said...

Hi Dr. G,

I just had an iui on Saturday and started Endometrin 100mg suppositories twice a day the day following the iui. My question is this, my RE wants to check my progesterone level 7 DAys post iui. Will my progesterone level on this day tell me if I ovulated or not since the supplemental progesterone may raise my blood progesterone levels. How then can one tell if you ovulated or not based on progesterone levels if taking supplemental progesterone vaginally? Thank you and great blog.

K said...

hi DrG:
Thanks for your help. I recently had medical vacation IVF in Mexico and on the day of egg retrieval I started PIO shots. After my 3 day transfer, my RE added vaginal progesterone (Utrogestan 200 mg/3 times a day). So now I am taking both, which is their routine prescription. Do I really need BOTH the shots and the vaginal inserts?? (or can I stop the shots :) ??)

Anonymous said...

Hi, I am on my 7th miscarriage in the last year and a half. My last 3 miscarriages I have gone and had my HCG and progesterone checked, my progesterone has been low with each of my last 3 miscarriages. I've used the suppositories, and unfortunately they did not keep me from miscarring. I would like to try again, but I am very fearful of suffering yet another loss. Are the shots proven to be anymore successful then the suppositories? I have also heard that clomid can help your progesterone during ovulation which can carry over into pregnancy and progesterone supplementation may not be needed? I have also had testing done for recurrent M/C's, I do have PCOS.
Thank you,
Krista

DrG said...

Hi Carolina (12/12/11)

There are very few side effects to progesterone supplements. Not sure what to make of the mild cramps but I can say that they are very common.

Hope it all worked out.

Good luck

DrG


Hi Susie (12/18/11)

The progesterone gel is a pretty good place to start. Other options for those with allergies are promethium capsules (oral micronized progesterone). The worst choice with allergies is usually prog in oil injections…

Good luck

DrG

Hi jlcz (12/27/11)

Thanks for the kind words. You are exactly right in that if the prog is >3 ng/mL then you have ovulated but this level could also just reflect the prog you are taking….not sure it makes a lot of sense but then again I use prog levels with caution in interpreting cycle outcome…

Good luck

DrG

Hi K (12/30/11)

Well hope the weather in Mexico was good! I need to start one of these vacation IVF clinics in a warm location!

That recipe is a lot of prog. We usually do one shot and one suppository. I guess that tells you that there a wide variation in prescribing . Hang in there. Hope it worked.

DrG

Hi Anonymous (12/31/11)

Well I use prog on nearly all patients but that doesn't mean that we have any data to prove it helps. On the other hand it is inexpensive, easy to administer with few side effects….

Good luck

DrG

Hi Krista (1/9/12)

Sorry for all of your losses. No one really knows the ideal amount of prog to prescribe in the setting of pregnancy loss. In fact, no study has ever demonstrated any benefit at all to any prog….but we all still do it. I have used clomid, fertility shots and IVF to treat RPL. Some have worked. I had a set of triplets a few years back and some still miscarry. Some women have pursued IVF with PGS as a way to eliminate the genetic factor with accounts for >70% of pregnancy losses…

Good luck

DrG

Anonymous said...

Hi,
Thank you so much for this blog! I conceived naturally back in 2007 (I was 28, am now 33) but resulted in a miscarriage and subsequent D&C at approx 7-8 weeks. After taking time off to recover and just "live", my husband (now 41 and with 3 kids from a previous marriage) and I started trying again early spring 2010 with no luck through the end of the year. In April 2011 my OB referred us to reproductive clinic where we began the cycles of clomid (5 rounds no luck) followed by trigger HCG shots, Follistem and HCG trials (5 rounds, no luck), a round of follistem, hcg and IUI, no luck and now finally IVF. I had the "dye test" which showed tubes were clear and all of my numbers on the follistem, HCG etc have been fantastic according to my Dr and my husbands numbers are beyond perfect, so no issues there. They've diagnosed us as "unexplained" and suggested IVF as the next alternative. We had 5 eggs retrieved, and 2 transferred (1 8 cell grade A and 1 6 Cell grade B). I am currently 10 days post transfer and am also on 1/2 cc PIO shots once a day (have been on them since the day of retrieval). Ive had the typical "symptoms" (breast tenderness, initial cramping, back ache, bloating) but since late yesterday through today, the bloating is pretty much gone, no cramps, and chest is far less sore than it was. I know PIO can be blamed on all of the symptoms but Im wondering if its a bad sign that they are suddenly much less than they were (this happened when I miscarried). My progesterone test last week came back with results > 60 which my nurse tells me is good but I just have a sinking feeling about my first Beta, which is tomorrow AM.

Just wondering if my Progesterone should also be tested in addition to my Beta (if I should ask my Dr this) as my numbers early on (during JUST the Clomid cycles) were fairly low (9-14ish). I certainly dont mind the PIO shots if they can help create a healthy environment for a baby and would hate to think that my miscarriage was due to low levels (I wasnt tested then since I'd conceived naturally).

Any thoughts you have on the "weakened" symptoms, and whether or not I should also be checking the Progesterone levels would be great. Thank you SO much!

DrG said...

Hi Anonymous (3/6/12)

Well I hope that the test was positive. Unfortunately subjective feelings are just that so we really never know for sure until we check a pregnancy test. I have seen it both ways: pregnant patients with no symptoms so they stopped all medications and non-pregnant patients so sure that they were pregnant that they refuse to stop their prog....

Remember that vaginal progesterone products (Crinione, Endometrin, suppositories, prometrium) will all be associated whit very low blood prog levels. We monitor these but usually do not make adjustments because we know that the levels in the uterus are fine even if the serum levels seem low....

Good luck

DrG

Good luck

DrG

Anonymous said...

I've read most of your posts and I think you might have answered it but I guess I just want to hear it from you. I recently had IVF #2 and was given the IM version of progesterone. I am pregnant and they noticed my progesterone level was low at 14 and suggested I add crinone suppository in the morning and the injectable at night. My level went to 26. I now ran out and the injectable and so they told me to use the crinone twice a day. I am currently 6 weeks. Is switching to the suppository after the shot a good idea. I used the suppository during first IVF and I did not get pregnant. I am worried about a miscarriage. Any thoughts.

Anonymous said...

Can PIO IM cause uterine cramping? What about estrodial? After embryo transfer, no successful implantation, can your uterine lining be so thick that you get break through bleeding/spotting prior to beta?

Thanks for input!

Anonymous said...

Hi DrG,

Thanks for this blog. I recently had a FET and I have been taking 100 mg endometrin suppositories daily as well as daily PIO shots (1cc). Yet, when my levels were checked recently at 10dp3dt, they came back as 51 Hcg and 0.5 progesterone. How is such a low blood level of progesterone possible?( considering I have already been supplementing)?

Thanks so much for your help.

Suzanne

DrG said...

Hi Anonymous (3/12/12)

I see no problem going with only Crinone at this point. Serum (blood) levels of progesterone are very low with vaginal administration and do NOT reflect the uterine levels of prog which is what matters….

Hope it all works out.

Good luck

DrG


Hi Anonymous (3/14/12)

Usually PIO will decrease uterine cramping. Spotting can always occur before the beta but may not be a big problem….hence the concept of "implantation bleeding."

Good luck

DrG

DrG said...

Hi Suzanne (3/27/12)

Well that is a bit low given the PIO shots. I would probably repeat the blood test as it really doesnt make much sense given positive beta and PIO plus endometrin...

Good luck
DrG

Rachel said...

Hi, I had a pituitary tumor and history of low progesterone, ( I n ever had periods).

So this pregnancy to me is everything after always being told I couldnt get pregnant. The first few days after finding out I was in major pain and made two ER visits. They told me I was really early along and they werent going to check my progesterone...

When my levels were around 1400 they could only see a gestational sac, and the same day they told me I had low progesterone. ( I had been telling them this for weeks)

At 5 weeks is it too late to have effective results taking 400 oral progesterone a day.

I feel like they are administering this way too late in the game.

DrG said...

Hi Rachel (4/29/12)

Well I hope things are going OK....IN terms of progesterone we really have no idea of how much is really needed or even who would benefit from progesterone...with one exception. Following IVF with luteal suppression with GnRh-agonist (Lupron) the ovaries will simply not make enough prog so supplementation is crucial. In all other patients we treat empirically in our practice so everyone gets prog...not very scientific I admit...

Good luck

DrG

Anonymous said...

Hi Dr.G
I am currently carrying my partners embryos. Transfer was on Monday. We are both young and healthy, no fertility problems known. However, I'm taking shots of progesterone and can barely stand the pain the next day. It's miserable. My doctor is in favor of the shots and says I can switch to Crinone after a positive pregnancy test. What's your opinion.? Should I tough it out the next 7 days or is it possible to switch now. I just want to make sure the Crinone is as successful as the IM progesterone. Please help!

DrG said...

I would personally change and go with vaginal prog suppositories or prometrium or Crinone or Endometrin....

Hang in there!

Good luck

DrG

Becky said...

I'm around 6 weeks and my progesterone levels are 9.2 my doctor seems very concerned and put me on supplements I go back in one week to check levels again. I'm also concerned because we haven't heard the heartbeat yet. Am I worrying too much?

DrG said...

Hi Becky

Well hopefully everything will be good on sonogram...we give prog to all patients regardless of serum levels...not very scientific but no good data on who needs and who doesnt need prog...

Good luck

DrG

Anonymous said...

Hi Dr G,

My husband and I have been going for IUI. The first IUI was unsuccessful. We are now in our second IUI,awaiting pregnancy test this Friday! When I went for blood work one week after the procedure they said my levels were good but wanted me to take progesterone and estrogen pills. Why is this? Are we pregnant?

Sincerely,
MN

Anonymous said...

Hi,
I am 28, DH is 29, we are undergoing a 4th IUI and triggered cd12, the office has split the HCG in 3 doses one (the biggest dose on CD12, second on CD 15 and last one CD 17) but when i asked about supp. he said they dont prescribe it to iui patients, and just said to a baby aspirin daily... I have never done the progesterone in 3 doses this way, is this something new or why was I given it? and what does baby aspirin have to do with this? We have also done 3 other unsuccessful IUI's in the past (with a diff. dr.) my cycles are regular and around 28 days.
Thanks!!!!

DrG said...

Hi MN (7/11/12)

Proof is in the pudding. We routinely prescribe progesterone for all cycles and add estrogen selectively based upon blood levels once patients are pregnant in cases of IUI or even before pregnancy test in cases of IVF. There is NO good data to support this approach but it is the one used by many clinics.

Good luck

DrG

Hi Anonymous (7/16/12)

Well that is a new one on me! Not sure why the HCG triple threat but I guess it must work for that RE. Not harmful but can't say that I have ever done it that way….

Hope it works!

Good luck

DrG

Sherry said...

Hello!

I am 44 years old and am about 10 days post-IUI. I've been taking 100mg Endometrin each day, nut missed a dose (9 hours late), then had a faint brownish/pink discharge a few hours later. I fell asleep an didnt take my next dose for 10 more hours and when I did, the applicator came out with some brownish discharge as well. Is it possible I messed everything up with only one late dose???

Thanks for your help! Sherry

DrG said...

Hi Sherry (8/4/12)

Hard to imagine that being a couple of hours late will scuttle the whole cycle. Especially following an IUI since there is no egg collection and ovarian steroid hormone production should be adequate with supplemental prog essentially guiding the lily.

Good luck. Hang in there.

DrG

TiffyH said...

I have been diagnosed with Premature Ovarian Failure and I recently went through a Donor Egg IVF cycle. We had a positive pregnancy test and I am 12 weeks along.
My concern is with stopping the progesterone and estrogen on Monday. I am nervous because my ovaries do not work properly. What if my body doesn't produce the right amount of progesterone and estrogen on its own? What would the side effects be, or how would I know there is a problem?

Lmarie said...

I am very glad to find this post.

I am pregnant with my first at age 28 after our second round of injectable medication and IUI. I will be 4 weeks tomorrow and my HCG came back at 85 (was 31 2 days ago), but my progesterone level is only 13. I have been on 200mg compounded vaginal capsules since three days after the IUI. I am concerned that maybe I should switch to the shots instead or increase my dosage of the vaginal supplements? My RE does not seem worried, but then again she only put me on supplements and checked my progesterone level because I asked her to. I feel like she is not taking my levels seriously enough. What do you think?

Anonymous said...

I had my first progesterone oil 100mg shot to induce my period because My husband and I are trying to get pregnant. I have polysyctic ovary syndrome and having trouble getting pregnant. Is the shot supposed to cause severe ovary pain. I had the shot three days ago and the pain is unbearable. Thanks for you're help

DrG said...

Hi TiffyH (11/1/12)

It is fine to stop estrogen and progesterone at 12 weeks. In fact, the placenta is probably making enough hormones by 8.5-9 weeks but we usually err on the conservative side and keep the hormones going longer...

Good luck

DrG

Hi Lmarie (11/28/12)

Vaginal progesterone will result in excellent uterine levels but low blood levels. Since the levels of prog in the uterus is really what we care about I dont worry so much about the blood levels. They are often < 10...

Good luck

DrG

Hi Anonymous (1/17/13)

Very unusual for prog in oil to generate any pelvic/ovarian pain.I would hope that you had a sonogram with your MD to further evaluate possible reasons for the pain...

Hope you are feeling better.

DrG

Anonymous said...

DrG
I am very thankful for your words of wisdom!
I just turned 31 have had 4 succeeding pregnancies and in the last 14months have experienced two miscarriages missed miscarried 8wks and one around 5-6wks
I am now 6w2d pregnant with twins - two heartbeats via ultra sound at exactly 6wks
Had my progesterone checked on cycle day 22 It was 7
I O''d on 14/15 as per OPK
Had progesterone checked again at 4wks 22 and again at 5w5d it went down slightly to 21.4
However, at 5w4d had red spotting that turned dark brown and still have scant amounts randomly
My OB put me on prometrium 200mg 1x a day oral
I am experiences some negative side effects
Do you feel this dose is adequate? Do you feel this is the most effective ? If I switch to vsginally do I use the same pill for the treatment or is it different?

DrG said...

Hi Anonymous (2/20/13)

Sorry about your losses. I assume that a recurrent pregnancy loss evaluation has been unrevealing….

We use a lot of progesterone but although it is common to use progesterone (in all its various forms - shots, suppositories, capsules, gel…etc) the only proven benefit to its use is following IVF since the ovary's ability to produce progesterone and estrogen is markedly reduced by the egg collection itself.

So we would empirically place you on progesterone (Prometrium is fine) and empirically we usually place patients on 2x or 3x daily progesterone once pregnant. Again, this dosing is empiric and not a lot of good science in terms of the use of progesterone. Prometrium can be used vaginally. Vaginal suppositories (compounded by a pharmacy) can not be taken orally…yuck.

Good luck.

DrG

Erin said...

Hi Dr. G

Thanks so much for this blog post, especially for continuing to follow up so many years after the original.

I'm current preg. after IVF w/ FET and am taking estrace and progesterone suppositories 3x daily. At first, I was very religious about doing them at 7am, 3pm and 10pm, but as my pregnancy has progessed, I'm getting more tired and would love to get some extra sleep at nights. Do you see any issue with doing them at 7:30, 3 and 9:30 or even 8, 3 and 9?

Thank you so much!!!

Anonymous said...

Hi Dr. G,

I am currently 16.5 weeks pregnant with my first child.I had a miscarriage last July(2012)at 6.5weeks. I asked my Dr. to check my progesterone levels at my first appointment (5 wks) just to see if they were in the average range. They were found to be low. Dr. wanted me to go on shots twice a week but after a bad experience the first time I got them, Iasked if I could do vaginal suppositories intead. She was receptive of that but continues to recommend getting the shot as well. Aren't the vaginal suppositories just as effective as the shot? Can women do multiple suppositories a day? I asked her that and said it probably wouldn't be absorbed very well and just continue with one a day vaginal. My progesterone at 5 weeks was at 11, 9 weeks 17, and 14 weeks 23. So they are trending in the right direction. Can women be on the lower end of normal for progesterone levels and still carry and deliver healthy babies? I really feel that the anxiety I am having over getting the shots is worse for my baby then just continuiing with what I'm doing. Just looking for some reasurrance. Thank you for your help!!

DrG said...

Hi Erin (4/10/13)

Congrats on your success. I see no reason that changing the schedule would be an issue but you are probably done with prog now….

Good luck

DrG


Hi Anonymous (4/10/13)

Beyond 10-12 weeks all the progesterone is made by the placenta. We usually stop at 12 weeks and don't even bother checking levels after 6-8 weeks in most cases.

Good luck

DrG

Erin said...

Thanks for responding anyway Dr. G!! :-)

Erin

Erin said...

I am done with prog, but thanks for responding anyway Dr. G!