Trying to conceive- Where do I go from here?

Question

I am 34 and have been trying to conceive for 15 months. In the past I had symptoms of PCOS (irregular periods and one PCO) but it was never definitively diagnosed. But my periods became much more regular from before I started trying to conceive – usually every 30 days (varying from 28 to 36 days). I have ovulated every month, according to ovulation kits.
All my hormone tests have come back normal – FSH, LH, estradiol, thyroid etc – except for my progesterone, which is a bit low (37nmol/L on 7 dpo). I’ve had two ultrasound monitored cycles – one of which was competely normal and one which showed my endometrium starting to break down early.

My gynecologist has put me on progesterone supplements, which have delayed my period by 6 or 7 days, but still no pregnancy after 3 months of this. (My husband’s sperm analysis was very good, so that’s not the problem.)

I told my gynecologist that for the last several years I’ve been having heavy, painful periods, and premenstrual spotting (2 days before period). I am worried that I might have endometriosis but no-one has investigated this. The radiologist said there was no sign of it on my ultrasound.

If the progesterone doesn’t work this cycle, what’s next?

Gina

Answer

Last Updated: October 21, 2013
The first part of your history certainly sounds consistent with polycystic ovary syndrome (PCOS). If you are ovulating now then PCOS is less likely. I would be interested to see if you had androgen levels done and if you had a reversal of your FSH/LH ratio.

You should learn to chart with the Creighton Model Fertility Care as this is the foundation for and the gateway to NaProTechnology which can help you conceive. After charting 1-2 months, a NaProTechnology-trained physician or mid-level provider can order precise hormone evaluations keyed to ovulation.

You likely should also have near-touch laparoscopy at some point in the work-up, unless you become pregnant prior. Near-touch laparoscopy could, theoretically, treat any endometriosis and if needed, an ovarian wedge resection (for PCOS) could be done at the same time.

If indeed progesterone levels are low in the luteal cycle, we often use HCG instead of progesterone. HCG has the following advantage: less painful injections, boosts estradiol as well as progesterone.

George Delgado, MD

Answered By:

George Delgado, M.D., F.A.A.F.P.
President and Founder of Steno Institute and Medical Director of Culture of Life Family Services (COLFS), San Diego, is a Professional Member / Supporter of CANFP. Board certified in both family medicine and hospice and palliative medicine, Dr. Delgado received his medical degree from the University of California, Davis, and completed his residency at Santa Monica Hospital/UCLA. Dr. Delgado is a Natural Family Planning Medical Consultant, trained in NaProTechnology.

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