A Gem from John R. Lee MD!
Dear Mrs. B,
Thank you for your recent message concerning difficulty in conceiving and carrying a pregnancy. As you probably know, the leading cause of this is called “luteal failure.” I hope you have read What Your Doctor May Not Tell You About Menopause in which we explain the role of progesterone in the body.
Briefly, progesterone is the hormone made chiefly by the ovaries. In premenopausal women it is made during the monthly cycle from ovulation until just before menstruation begins. Follicles within the ovaries carry embryonic ova [eggs]. Each month, the FSH (follicle stimulating hormone) awakens about 130 follicles from among which one of them matures an ovum [egg] for ovulation. This follicle then involutes, becomes the corpus luteum (“yellow body”), and starts producing prodigious amounts of progesterone, the function of which is to create a hospitable environment in the uterus for the potential arrival of a fertilized ovum. If none arrives, the corpus luteum gives up on producing progesterone, leading to the shedding of the prepared endometrium, and menstrual bleeding occurs.
If, however, the ovum is fertilized, it produces a chemical signal called human chorionic gonadotropin (HCG) which stimulates the corpus luteum to increase its production of progesterone. It is this increase in progesterone that ensures the survival of the fertilized egg and then the developing embryo. When the placenta develops sufficiently, it takes over the production of progesterone in ever-increasing amounts throughout pregnancy. The time from fertilization until birth is called “gestation” and the hormone that makes gestation possible is the pro-gestation hormone, progesterone.
DDT, PCB's, DES and other xenobiotics (from petrochemical sources) are particularly toxic to embryo development, causing dysfunctional development of ovarian follicles and testes' Sertoli cells (among other things), which later in life are manifested as dysfunctional follicles in women and decreased sperm count in men. Ova production may be erratic, and the ability of the corpus luteum to maintain good progesterone production is impaired. This is very likely to underlying cause of your fertility problem. The question is, what can be done about it?
The reliability of monthly ovulation is up to Mother Nature. The fact that you conceived once this year is a good sign. Let us assume that you will ovulate again and, with good fortune, the ovum will become fertilized. What can be done to insure that sufficient progesterone will be there to optimize the survival of the fertilized egg? If it were me, I would add natural progesterone [cream] from ovulation time or around day 14 to day 26 each month, counting day 1 as the first day of the previous period. [Ed note: Dr. Lee later recommended that women count backwards two weeks from day 1 of their next expected period and use that as the ovulation date. It is important to begin using progesterone cream just after ovulation begins.] I would use about one-third of a jar of progesterone cream during that 12-day time span [assuming about 750 mg of progesterone per jar, or about 20 mg per day], which is very close to the natural progesterone production by a healthy corpus luteum. On day 24 I would have a finger-stick blood test for pregnancy. If negative, I would stop the natural progesterone on day 26, await the period, and start over on day 14 the next month.
If the pregnancy test is positive, I would increase the progesterone by applying a dose twice a day, morning and evening. I would continue this until after the third month of pregnancy when the placenta becomes able to produce sufficient progesterone, then I would gradually taper off the supplemental progesterone over a two-to-four week time period. Many of my patients simply continued the transdermal progesterone for the whole pregnancy and I have no quarrel with that either.
If there is some uncertainty about time of ovulation, you can use a fertility microscope and look for the telltale ferning pattern, get an ovulation test at the drugstore, or arrange to have a saliva or blood spot hormone test at mid-cycle to see if and when the progesterone rises, which it always does when one ovulates.
John R. Lee, MD
Ed Note: For women who want a more detailed fertility profile, there is now a blood spot test available to assess possible causes of hormone-related female infertility.