How much progesterone (in nmol/L) is needed on the day of embryo transfer & to maintain a pregnancy?

[Katiluna]

Hello all,

I had a medicated fresh embryo transfer with donor eggs last month which unfortunately failed. For that transfer, my clinic had prescribed 800 mg Progesteron Besins (vaginal Utrogestan) and 100 mg oral Utrogestan per day which I started taking 5 days before the embryo transfer (transfer done on the 6th day of progesterone).

On the day of the embryo transfer, the clinic tested my progesterone level and it was 58 nmol/L. When I asked them if this was high enough, they said anything above 30 nmol/L is good.

As requested by the clinic, on the 10th day post transfer, I did a Beta HCG and Progesterone tests (test day), the progesterone level came back 34 nmol/L which I thought was too low. At that point, I was still taking my doses of progesterone.

- How much progesterone in nmol/L (progesterone level) does your clinic recommend on the day of embryo transfer and to maintain a pregnancy?

- What form and doses of Progesterone are/were you taking (capsules, pessaries, injections etc) to maintain your pregnancy?

- Will Cyclogest pessaries inserted rectally be absorbed properly into the bloodstream or would it be better absorbed with vaginal insertion?

The vaginal Utrogestan I was taking for my previous transfer has caused itching and irritation which still hasn't gone away. My GP prescribed Canesten Thrush Combi but I didn't see any improvement with it. I have been taking Bio Me Prebio PHGG, Bio Me Femme V, and BioCare for a week now (prebiotic and probiotics) which has improved the itching and irritation to some degree but hasn't resolved completely as yet.

- Do you think these symptoms may affect the outcome of my next transfer that I'm planning to do in the end of January if they haven't gone away completely?

I would be grateful for any advice/input.

Many thanks x

[Hopeful_88]

Hi Katiluna , thanks for asking this question, I was also going to post about this! As I understand, unless you have bleeding before OTD (which is a sign of low progesterone), then the levels should be high enough to maintain the endometrium. Sorry I don't have much advice but it's really good that your clinic are checking your progesterone levels, not all of them do it and it will help them make decisions for future transfers.

I've had 3 transfers at 2 different clinics and none of them have tested my progesterone levels. I'm currently worried because my clinic decided to reduce my progesterone levels for my current FET (I'm 2DP5DT) to 2x cyclogest pessaries per day (800mg); I was previously on this plus 1x lubion every other day and got a BFN. I also previously had a fresh transfer on 800mg cyclogest, but I got bleeding before OTD which ended in a BFN. I am concerned that 800mg cyclogest isn't enough for me, so although my clinic dropped the lubion this time, I have decided to double up and take 4x cyclogest per day to be sure I have enough.

I've read many previous posts that you can't have enough progesterone, but too little will be detrimental, so that's my thinking!

I don't think there's a huge deal of difference between vaginal vs rectal methods - absorption will be via the same mechanism (by the mucous membranes).

I hope the irritation clears up for you, if it hasn't cleared up soon I'd speak to the clinic and ask for their advice and if it would affect your next FET.

Wishing you the best of luck, and I hope others respond with their experiences to give a little more insight! x

[Katiluna in reply to Hopeful_88]

Hello lovely, thank you so much for your reply x. I'm sorry to hear of your failed transfers. It's such a tough and exhausting journey... My clinic which is based abroad checked my progesterone on transfer day as it's part of their package. I had the levels retested when I came back to the UK. I agree, I thought it's good practice from my clinic to keep an eye on the progesterone levels. But what I don't understand is when they say a level above 30 is good. So what's the point of testing and retesting then? IMO anything below 80 should be considered not high enough. So for my next transfer, I asked my clinic to prescribe Cyclogest and lubion injections. They haven't got back to me on that yet. I think you did the right thing doubling the Cyclogest dose. I would also test the levels which would give you some peace of mind. I hope your last transfer will result in a BFP and a successful pregnancy. Wishing you best of luck.

May I ask why your clinic decided to reduce your progesterone dose and exclude the Lubion injections with your last transfer?

RE the thrush, my clinic recommended vaginal irrigation or lavage with hyaluronic acid using Tyndaflor which also comes with vaginal probiotic suppositories. Unfortunately I can't find Tyndaflor in the UK ( I think it's only available in Czech). So I'm using other probiotics and prebiotics for the time being. Let's hope they will help with my issue!

[Hopeful_88 in reply to Katiluna]

Hey love, yes it really is such an awfully tough roller coaster, thank you and I'm so sorry about your transfer last month xxx

Was your first progesterone test done abroad and the second done in the UK (i.e. different labs)? If so, it could be that different labs produce slightly different readings due to how the analysers are calibrated and might not be directly comparable to each other. I had a look online and couldn't find much consensus on the optimal progesterone levels for FET on transfer day, one study said >15ng/ml, another said >10ng/ml, some said if it's too high it can be a bad thing! So maybe it is a bit of trial and error which might explain why different clinics have different approaches.

Thank you so much for the advice, I never thought to test for it myself but I will definitely do that, even if it gives me info for the next transfer. The nurse didn't know and just said the doctor wanted to try it, it was very unclear and I didn't get a real answer so I didn't really trust the decision.

I'm sorry about your irritation issues, I hope the probiotics work for you, I'd definitely try inserting the pessaries rectally next time (this is the method I've been using).

Really wishing you all the best and I hope you find the optimal progesterone levels for you! It really seems like a lot of trial and error xxx

[Katiluna in reply to Hopeful_88]

Hello my dear, thank you for sharing that information and for your kind words. I've done some research online as well. Different articles say different things, so it was confusing. Yes, it was different labs where I tested and retested the levels. Both labs used serum progesterone and the same unit (nmol/L). I could be wrong, but the slight drop in the level after I retested may be related to a different phase of the cycle and due to the absence of implantation in that cycle. I think the level would have not gone down if implantation had occurred...I hope your last transfer is the one for you and will bring you success xxx

[soccerkt6]

Hi lovely, I'm so sorry to hear about your recent transfer. It's such a shit place to be.

For a while I was seeing a gynae who specialised in fertility and she said you want progesterone between 60-100 nmol/L on day of transfer and for the first few weeks of pregnancy. This is the highest I've ever seen anyone recommend (many clinics are like yours and say anything above 30 or 50 is fine), so I feel pretty confident that 60 is a sufficient level. I wouldn't necessarily put down your recent cycle to a lack of progesterone, but your levels were borderline and, of course, you know your body best. As a point of reference, I tested my progesterone levels during the first few weeks of my successful pregnancy, and they were 85 nmol/L at 4 weeks pregnant, 88 nmol/L at 5 weeks, and 85 nmol/L at 6 weeks.

As for the lower level at 10dpt, progesterone natually fluctuates during the course of your luteal phase so testing at 10dpt when you had a BFN is a bit tricky to interpret. I think the best you can do is test on the day of transfer and then maybe check again if you get a BFP, but anything aside from that might just be noise.

Since the vaginal pessaries caused irritation, maybe you can request progesterone in oil injections for your next round? I haven't taken it myself but it's supposed to be very well absorbed and should avoid the symptoms that you got with the pessaries xx

[Katiluna in reply to soccerkt6]

Hello hun, many thanks for your reply and for sharing your experience. That's very helpful! I don't believe my recent transfer failed because of progesterone. Embryo quality remains the main factor for success or failure (70-80%). The rest may be due to other factors (immune, thrombophilia, microbiome etc). According to my consultant(a reproductive immunologist) from my recurrent miscarriage clinic , progesterone provides a better uterine environment and helps sustain and maintain a pregnancy. I think due to my history of recurrent miscarriages, I want to make sure my body has enough progesterone to sustain a pregnancy if I get pregnant again. At least it would be a risk to rule out. I'd rather have more progesterone than less.

I've heard of the progesterone oil injections before. From my understanding, they are intramuscular injections and need be administered by a doctor. Lubion injections can be self-administered, so that would be more convenient for me. I used to take Cyclogest when I was TTC naturally. I had experienced some side effects with it but not itching or irritation. So now I asked my IVF clinic if could switch back to Cyclogest and to prescribe Lubion injections.

[JoleneR]

Hi Katiluna. My current clinic wants levels above 50 nmol/L on the day of transfer. I have been on 3 to 4 cyclogest per day with this clinic and have always used the back passage method. Through all my cycles at this clinic and the last, I've always been told either route is fine.

Regarding your reaction to the pessaries, I would personally ask about switching to cyclogest and use it rectally. I'd worry an immune reaction might interfere with implantation, but this is a suspicion rather than being advised. I've just had a biopsy to test for NK cells on the suggestion of my clinic, so this is on my radar.

I hope this is helpful and I wish you luck!

[Katiluna in reply to JoleneR]

Hello JoleneR, thank you so much for taking the time to reply and for your advice. I used to take Cyclogest in the past and I didn't experience itching or irritation with it. So after the reaction I got from Utrogestan recently (first time I used it), I asked my IVF clinic if I could switch back to Cyclogest and also prescribe Lubion injections.

I have been under the care of Professor Shehata at my recurrent miscarriage clinic since May 2023. He is a reproductive immunologist. He did test my NK cells and they came back high (almost double the normal range). He prescribed treatment for that (Hydroxychloroquine, Aspirin and Cyclogest). With this treatment, I still ended up with another miscarriage in July this year, but that was due to chromosomal abnormalities found in the pregnancy tissue once tested. With my recent transfer, I was taking Hydroxychloroquine, Prednisone, Aspirin and Clexane 40ml. I also had intralipid infusion before the transfer. It's definitely important to explore immune risks and I hope the NK cell test you have done recently will provide you with some answers and more clarity on how to move forward. Wishing the best of luck on the rest of this journey.

[Twiglet2]

Im sorry it didn’t work this time. I got my progesterone in a good place by taking lubion injection (once per day) as well as 2 x 200mg pessaries vaginally per day. They are slightly better absorbed vagibally than rectally although if causing you issues if you also had the injection to top you up rectally should be fine. Fingers crossed for you for next time x

[Katiluna in reply to Twiglet2]

Hello lovely, thank you for your reply and for your kind words. Congrats on your current pregnancy. I'm glad it worked out for you and all is going well x. That's what I'm thinking- try Cyclogest rectally plus lubion injections next time. Hopefully my body will be able to tolerate that. Best of luck with the rest of your pregnancy x

[Twiglet2 in reply to Katiluna]

Thank you lovely xx