A common question that you will inevitably hear repeatedly in any pregnant after IVF group is, “when did you stop progesterone?” Whether it be PIO shots, vaginal suppositories, or pills, the stress surrounding stopping progesterone support is real. The fear, of course, is that you might stop too soon, begin bleeding, and the ultimate fear – miscarry. So when is the right time to stop?
See, we assume there is actually one right answer to that question (how silly of us), but, like all things infertility related, there just isn’t. Some RE’s have their patients stop progesterone supplementation as early as 8 weeks, while others have you injecting, inserting, and popping until a whopping 12 weeks. It seems like 10 weeks is a pretty common stopping point though. But we’re all afraid when the magic week hits. Some women are certainly relieved to finally be able to set the needles down and let the rear heal (and yes, it will get back to normal eventually). But still, there is that touch of fear. Or sometimes unrelenting anxiety.
So why all the variation in protocols? Well for one, if you Google “when does the placenta take over” you will get multiple answers. Of course. The responses tend to range from 8 to 13 weeks. Apparently, each woman can be a bit different. But clearly most RE operate under the assumption that that the placenta will be producing enough of the hormones needed to sustain the pregnancy by week 10. So we’re just supposed to trust that we fall into this norm, right?
There’s another factor that often isn’t talked about, and it has to do with how progesterone is normally made by the body in early pregnancy before the placenta takes over. In a non-medically assisted pregnancy, once the follicle releases the egg during ovulation, the follicle becomes a Corpus Luteum. That little corpus luteum has a big job – it produces all the progesterone needed to sustain the pregnancy until the placenta steps up to the plate. Now think about this. When we do IVF, we retrieve anywhere from a couple eggs (although a few struggle to even get one) up to a crazy amount of eggs that probably results in ovarian hyperstimulation syndrome. Let’s just say, for the sake of argument, that you retrieved 10 eggs. So now you have 10 corpus luteums pumping out progesterone. If one of those buggers can sustain a whole early pregnancy, just think about how much progesterone you’re getting with 10.
So the point of this dive into the ovaries is to say that if you do a fresh transfer following an egg retrieval, or even a natural FET where you ovulate first rather than being suppressed, you don’t actually need any progesterone supplementation. Yep, you read that right. At my last fresh transfer, when my RE said I wouldn’t need to do PIO, I was surprised. When we did my first IVF/fresh transfer 4 years prior, which led to my first pregnancy, I did PIO for 10 weeks. So I asked him what had changed. He explained the ovary operations to me and also told me about a recent study that compared progesterone supplementation to no supplementation in women who had a fresh transfer. They found that both groups of women had comparably high levels of progesterone. So I was happy to forego the dreaded PIO that cycle, but I still wanted more evidence for my own peace of mind. They obliged my paranoia and tested my progesterone levels even before my beta, and sure enough my progesterone was quite high.
So when women who have “ovulated” either naturally or through an egg retrieval say that they stopped PIO at 8 weeks, or whenever, it’s really not the same as it is for women who did a FET and were medically suppressed to keep them from ovulating before the transfer. The former group didn’t actually need PIO in the first place.
The situation is quite different for those of us who did a FET and did not ovulate. We are completely dependent on those injections, or whichever form you take, to support the pregnancy until the placenta starts doing it’s job. And that’s why it’s so scary to stop in this situation. That’s why when I read that the placenta takes over anywhere from 10-12 weeks (or insert other time frames since there are differences depending on what you read), I’m left to wonder, “but what if mine hasn’t taken over quite yet?”
Apparently my RE is just as cautious as me. When I brought up my concern, without missing a beat he agreed with me and suggested we test my progesterone level. That way, we would be making our decisions based on what is actually going on in my body rather than relying on averages and assumptions. I appreciate that. So, at my second ultrasound we drew my blood since I had been off of PIO for 2 days. Apparently that’s enough time for it to be out of the blood enough to get an accurate reading of what my placenta is up to. The ultrasound was great – baby was growing on time, moving, and had a healthy heart rate of 158. Thank the Universe!
Later that afternoon I got a call from my nurse saying that my estrogen was great, and my progesterone was 15.2. She said above 10 is fine, but my RE would have liked it to have been closer to 20. She said mine was low-normal. So, for the sake of being cautious I was instructed to go back on crinone 2 times daily (great- twice the grossness. I fear I may never get all of that wax out of my vagina, but I digress) for one more week and then they will re-test my progesterone. Unlike PIO, which does show up in your blood, vaginal suppositories don’t make it into the blood stream. So by only taking crinone, I would be getting enough support where I needed it, but we’d still be able to keep monitoring just what my placenta is producing. Not bad, and I don’t mind the cautious approach. I know my RE is doing everything to make this work – we all tried so hard and for so long to get here.
Yesterday, one week had passed and I was re-tested. I fully expected to see a jump indicating that my placenta had kicked into gear by 11 weeks 4 days. But my level was 14.6. The nurse that called me, who was different from the first, basically said it was fine and I can stop progesterone. But I didn’t like that answer. I mean, if 15 wasn’t ideal, why would 14 be when the level should be going up? So the nurse checked with my RE, and reported back that he said to stay on crinone for 1-2 more weeks and re-test. So I’m scheduled to re-test in 2 weeks. By then I’ll be just over 13 weeks and my progesterone level should be consistent with the normal range for the second trimester, which is about 17 to 146 ng/ml. So here’s to hoping that my placenta does it’s thing and starts pumping more progesterone. If it doesn’t? Well, some say that is a reflection of an unhealthy baby that will miscarry, and others say that the baby may be healthy and continual progesterone supplementation helps to get to full term. I’m sure the answer varies pregnancy to pregnancy. At this point, I’m reminding myself that my level is still in the normal range and I have about 2 more weeks before I hit the second trimester, so there is plenty of time for that to increase. I also haven’t had any bleeding or cramping, which could (or could not) signal an issue with progesterone.
In case this post has peeked your curiosity about progesterone levels, know that they vary based on trimester and the normal range is pretty broad. Most RE’s don’t test when they discontinue your progesterone, and most women are perfectly fine. I’m overly cautious, and I guess I worry that my age (I turn 41 in 2 weeks!) maybe my placenta isn’t working as well as that of a younger, perkier placenta. Of course, then I remind myself that when I was younger and going through infertility the first time around I found plenty of other reasons to worry about why my body wasn’t working right. I think it’s simply infertility that makes us this anxious and we always find some reason to worry. In any event, below are the supposedly normal ranges of progesterone by trimester, and you can read more about early fetal development and hormones here.
Guideline to Progesterone Levels During Pregnancy:
9-47 ng/ml First trimester
17-146 ng/ml Second Trimester
49-300 ng/ml Third Trimester
* There are many averages for progesterone levels. These charts are a very broad guideline – speak with your health care professional for more specific guidelines for you.
** Remember – these numbers are just a GUIDELINE – every woman’s hormone level can rise differently. It’s not necessarily the level that matters but rather the change in level.
Source: American Pregnancy Association