Don't Let Me Be Misunderstood!

What do cheese-filled pizza crusts, The Mona Lisa, Valentine’s Day, being your high school’s most likely to succeed all have in common? They are all highly valued by some people and deemed overrated by others.

This is not much unlike our friend Progesterone, or P4, if you prefer a chemically accurate rap name.

P4, or Prog, as it is sometimes called, is one of the most measured and misunderstood, over and under estimated hormones that ever came into world of medicine.

While it is true that progesterone is important (indeed essential) to maintain a pregnancy, what is not commonly known is how little progesterone is actually required. In our experience, too much emphasis is placed on progesterone.

Part of this is our fault. By our fault, I mean the Reproductive Endocrinology Community (REI) as a whole. Years ago REI practitioners wrote papers and chapters in Ob/Gyn text books saying that a progesterone of 10 ng/ml was evidence of a high quality ovulation. This number was easy to remember and this factoid has been passed down through the ranks of Ob/Gyns in training and has essentially become “common knowledge.”

But this common knowledge has mutated over time. It’s like the childhood game of telephone where someone whispers something in ear of the person next to them, and the information is propagated down the line until the last person in line says what they heard. The first person says corn flakes, and it gets ultimately gets changed to something like, “Monkey Diaper.”

Well, that has happened with progesterone.

Today, if a progesterone is <10, some people think ovulation has not occurred at all! This is not always true. Far from it. In fact, long ago, it was known that any progesterone greater than 3 was consistent with ovulation. In fact, after ovulation, progesterone levels can vary every 90-120 minutes from 2 ng/ml all the way up to 40 ng/ml. If you measured near the bottom, you may be told you didn’t ovulate! So Why Do Dr. Murray and Dr. Scotchie Measure Progesterone? And why do they give progesterone to some women? Why to measure progesterone:

Reason Number One: Mainly we at TRM do it to confirm ovulation. Any level greater than 3 tells us that a woman did indeed ovulate. A low level (like 4) either means we caught it when it was just reaching a valley rather than a peak, or that the woman just ovulated, or that she’s just about to have a period. If she doesn’t have a period in 3-4 days, we can frequently check another level and often it’s at a high level.

Why to measure progesterone: Reason Number Two: Sometimes progesterone can tell you about the viability (survivability) of a pregnancy. Assuming a woman is not taking progesterone supplements, in pregnancy a progesterone less than 5 ng/ml is nearly always abnormal. Conversely, a progesterone >23 ng/ml is almost always viable and in the uterus (not ectopic, or tubal). Unfortunately, in most early pregnancies, progesterone levels will be between these two values.

When should progesterone be measured? Ideally progesterone should be measured at its peak. For most women, this occurs 7 after ovulation and around 7 days prior to menses. If a woman conceives, the hormone of pregnancy causes progesterone to rise throughout pregnancy. This is why high levels are frequently seen in pregnancy.

Why do we give progesterone to some patients?

IVF: We routinely give progesterone after in vitro fertilization (IVF). During IVF, we frequently give drugs which make it more difficult for the ovaries to make progesterone. Also, when we get the eggs out of a woman, we remove some of the cells that make progesterone. If we didn’t give progesterone to IVF patients, approximately 10% would lose a normal pregnancy.

IUI: We routinely give progesterone after intrauterine insemination (IUI). There is some evidence that progesterone a few days after IUI may promote pregnancy. There are lots of reasons this may be true, but we don’t really know why this is the case.

What about patients with recurrent pregnancy loss? Progesterone supplements have not been shown to decrease the chance of miscarriage, only to delay the diagnosis of miscarriage. In other words, a pregnancy can quit growing, but the progesterone we give can mask the miscarriage.

That being said, just because studies have not shown that progesterone prevents loss, this does not mean that there is a woman who would not benefit. It may take giving progesterone to several hundred women to prevent one loss. Since progesterone has no known negative effects on pregnancy, and since it’s relatively cheap, I educate patients about the studies, but do prescribe it for those who want it. This way, the patient never has to wonder what might have happened if they had taken progesterone.

In pregnancy, how long should my progesterone level be followed? In almost all cases, as soon as a heart-beat is seen, further progesterone measurements are not useful. The heartbeat can be seen as early as 5 weeks and 6 days. In natural pregnancies, at 7 weeks the placenta will make all the progesterone needed for a woman to stay pregnant. Even if you removed the ovaries and stopped all progesterone, the women won’t have an increased risk of miscarriage! How do we know this? A study was actually done that showed this!

We routinely give our IVF patients progesterone until around 8 weeks of pregnancy, one week beyond this critical week. If a patient wants to stay on longer, fine. No harm should come from it, but it’s not needed.

Measuring progesterone levels at this point are pointless. If the placenta can’t make enough at this point, then the placenta won’t be good enough to support the pregnancy and the patient would miscarry anyway.

We would argue that progesterone levels measured after 7 weeks, especially if a woman is taking progesterone as a medicine, these levels are providing no real useful information.

What if my doctor measures my progesterone and it is low… What should I do? This is a common situation patients face. The question is, what does “low” mean? If a woman is pregnant and progesterone is low… say 5 or less, giving progesterone supplements will not save the pregnancy. Progesterone is more likely a reflection of what’s going on and not a cause. It’s like looking at a car that has been in a wreck. You can see the dents in the body, but just by looking, you may not see that the engine has also been damaged.

If the engine is damanged…. Or in pregnancy, if the embryo is abnormal…. Fixing the exterior of the car may make it look pretty, but it won’t make it run better….. Same with an embryo….. If the progesterone is low, this means the embryo is not doing well…. And you can’t fix and embryo with a hormone.

As you can see….

There are many pitfalls to measuring progesterone and many ways to misinterpret the levels. Outside of IVF, there is no evidence that progesterone replacement is helpful.
In conclusion, Progesterone, P4, Prog is important. It is essential for pregnancy. We encourage any patient or doctor to contact us about questions regarding progesterone.

A Christmas Carol - The Other Ghost

It was just before Christmas about 9 years ago. I was at the Streets at Southpoint, an indoor-outdoor mall in Durham, NC. It was a pretty mall, with a pedestrian street that was lined with stores glittering like Rockefeller Center. The bounty of the season was everywhere. The aroma of hot cider from the kiosk and the carols swelling up from the speakers disguised as rocks along the path, enveloped the crowd, bundled like they were trekking on an expedition to the North Pole itself.

I was trying to figure out what to get my mother, my father, my brothers, my sister, and my wife for Christmas. I confess that I rarely find things at the mall which make suitable gifts; however, I’ve always taken comfort in browsing and confirming my suspicion that this was not where I wanted to make my purchases. I guess this sort of made me an outsider, in a way. While I was glad to be surrounded by the holiday cheer, I did feel a bit disconnected. If I was honest with myself, I was actually a little sad and I couldn’t put an exact finger on the reason.

Then, as I walked down the path past a Crate and Barrel, I saw The Children’s Store. Moms and dads were bustling into and out of the store. As I stood outside the store, peering in the display window at the reindeer jumpers, elf pajamas and angelic ball gowns for little girls, I could see my reflection in the glass. Looking through my own reflection at the warm holiday interior, I began felt like a ghost: empty, vacant, barely a whisper. I felt like the Ghost of the Christmas That Would Never Be.

For people who have lost a loved one, for those separated from their families, for those without a family, with financial woes, with illness … we all know this is a tough time of year for some people. Watching other people, happy families apparently living the life of which you’ve been deprived can seem particularly unfair, or make you feel like a failure if you’ve not achieved these things.

This time of year can be especially difficult for people suffering from infertility. All the hopeless feelings, all the lonely feelings of isolation that infertility brings are magnified by the merriment of the season, the energy and bustle, the long lines at toy stores, by the crowds of twittering kids waiting to sit on Santa’s knee. All the holiday cheer can seem to just mock the pain of childlessness.

To make matters worse, if you feel like you’re on the outside of all of this Holiday fun and you see someone who is apparently blessed in ways that you are not, and you hear them complain about what seem to you trivial issues of the season… it can just make you mad.

In the end, most of us really do want to be happy. The question is, how is a person to rescue themselves from the sadness the season besets upon them?

Few solutions are perfect, but here are some things I have tried. Here are my suggestions, and I’m open to new ideas:

Own your feelings. Acknowledge them for what they are and ask yourself if you want them. If so, embrace them. Sometimes we need to do this first, before we can move on. It may be a miserable December, but it may be the first step to healing.

1. If you do not want these feelings, you should recognize that you may not be able to completely shake them. You may go for hours or days without the negative feelings resurfacing; however, it doesn’t mean you’ve been defeated when they do.
2. Focus on what the season is really about, for you. In my family’s tradition, Christmas, the season is a reminder of the gifts we have received – even though we were not worthy to have received them. Because of the gift already received, the season is about giving to others. (I know we all have different backgrounds and beliefs, but I do think the spirit of the holidays, Joy and Peace, can be enjoyed by all. When I was at my lowest, and thought I’d never have a child I would pray. I did pray that we would be given a child, but more than that I prayed that I could find peace in the event that we never did.
3. If being around children is too much for you, some people say you should avoid areas that are likely to be filled with them. I find this to be an impractical solution for many people, but you should not feel guilty for protecting yourself.
4. Consider devoting your time to someone else in need. This can be healing for you can for them.
5. Get plenty of rest. (Fatigue makes nearly everything worse.)
6. Get plenty of exercise. (This makes you feel vibrant and boosts your metabolism.)
7. Surround yourself with supportive people.
8. Seek counseling. If needed. If you’ve wondered if you should get counseling, then you probably should. I know a lot of wonderful people in the Chattanooga area and can make recommendations.

For some people this year, the Christmas season is going to be something to be survived, not enjoyed.

If this is you, plan ahead. If you need to, give me a call…. do something to help reclaim your life.

What to expect when you're not expecting - or, the slow erosion.

Infertility can make you crazy.

In some previous posts, I discussed how the advice from others can contribute to a sense of anxiety. What we in the world of medicine must also acknowledge is that the infertility investigation and treatment can also be maddening.

Couples embarking down this path need to be prepared for the emotional landmines that can occur. While many couples have very different causes of infertility or may get different treatments, they do share many of the same frustrations.

How it begins:
The first maddening aspect of infertility is that getting pregnant should not be difficult. After all, some people get pregnant with a single act of intercourse. Teenagers get pregnant…. some more than once. Women on the pill get pregnant. We hear women say, “He’d just walk by me and I’d get pregnant.”

So it’s frustrating to have difficulty in an area that seems to be easy for most people. This frustration can turn into guilt, hopelessness, a sense of inadequacy, a sense of injustice, sorrow or anger… or all of them at once.

How it perpetuates:
To get control of the situation, many women start monitoring their menstrual cycles. She and her husband have sex when the calendar tells them to. (Fun at first…. but this can lead to a loss of intimacy.)

Other couples seek the advice of physicians. For many couples, the problem resolves here… problem is found and fixed… medicine is taken… pregnancy happens. But if you’re not one of those fortunate couples, the sense of inadequacy grows, as does a sense of anxiety.

I’ve been on both sides of the desk on this. When my wife and I started seeing doctors to try to get pregnant, it seems every time we had an appointment, we received more bad news.:

“You’re not ovulating…”
“You did not ovulate with the medicine”
“Your tubes are damaged.”
“We tried to fix your tubes, but they’re damaged beyond repair.”
“You need IVF.”
“We got 25 eggs. Half fertilized. Only 5 are still growing.”
“You’re not pregnant.”

Repeat.

Then there those times when the news it at first good, but then turns bad.

Early on, before each IVF cycle, we were told that we were excellent prognosis, but with each attempt, we had the same outcome - failure.

Then there was the time we finally got pregnant. My wife's hormone levels were rising wonderfully. I will never forget the serenity that took over me and my wife at this point. I remember going to the driving range and hitting golf balls while she read “What to Expect While You’re Expecting.” We had 2 weeks of unbridled bliss.

Then, my wife started to experience pain. A friend performed an ultrasound, and where we should have seen an embryo, there was just the smallest amount of fluid in the uterus. Over the next few days, the pain escalated and finally she saw her doctor. She was still in pain, but that didn’t matter. Her emotions soared as he performed her ultrasound. He saw the baby. He showed it to her. It looked normal. It had a robust heart beat and little arm buds. He was saying everything looked good when his assistant tapped him on the shoulder and whispered something. Suddenly the doctor stopped talking and looked closer at the screen. He scanned for a moment, and then looked at my wife.

The other shoe dropped.

It seemed that this perfectly formed baby, with a robust heart beat was not in the uterus, but in the fallopian tube.

Within 3 weeks, we had been taken from the heights of happiness to a breathless sorrow. It was so cruel to be given hope, only to have it taken away. In our hearts, we knew there was nothing wrong with that baby. It was a victim of geography.


The loss of that child has changed me forever. Whenever my wife and I talk of that time, we are crushed. And when I see someone else who is losing a pregnancy or a child, I am swept back in time and feel a rent in my soul.

This is how life was for us. We were given hope. Then hope was dashed.

Still, by some accounts, my wife and I had it easy. There are couples who don’t have infertility at all, but suffer repetitive pregnancy losses. There are couple’s who have identified problems, but lack the financial means to undertake treatment. Then there are those 10% of couples in whom we can find nothing wrong. This can be especially frustrating for them.

There are many roads to the madhouse. Many infertility patients will find themselves on that road. For some, it can ruin a marriage, or enjoyment in life. For some people, the trauma suffered from infertility is not completely healed by getting pregnant or even having a baby.

Infertility patients are likely to be more worried about things going wrong in pregnancy than someone who never had trouble conceiving. I see this in patients, and it was true for me and my wife. If you've gone through a lot to get pregnant, if you've suffered many disappointments, you just simply feel like the pregnancy is high risk. You keep waiting for the other shoe to drop. You've been trained to know that it will.

In my final year of Ob/Gyn residency, when my wife were at what we thought was the end of our IVF journey (we were going to try one last cycle), we got pregnant. At the time a woman misses her menses, the average hCG level is supposed to be around 90mIU/ml. My wife's was 53. We were told that this was okay in an IVF cycle, but we were still deeply concerned. In two days, the hormone did rise as it was supposed to. Two days later, it doubled again.

It was an agonising 2 weeks until our first ultrasound. We were trying to be cautiously optimistic (which, as an aside, never actually worked for us.) I'll never forget how scared both of us were, waiting for our physician to enter the room to perform the ultrasound. Finally, once the scan began, the doctor was quiet what seemed like an eternity. I was looking closely at the monitor, but couldn't see very well from my vantage point.

She withdrew the transducer and put it aside and told us: the embryo was only half the size it should be and it didn't have a heart beat. She recommended returning after the weekend to confirm that the pregnancy was not viable. She said it wasn't hopeless, that sometimes embryos play "catch up," but the truth was all over her face. She was clearly in pain when she said this to us.

I will say without shame that my wife and I broke down. I tried to go back to work, but seeing the condition I was in, my friends volunteered to cover my shift on labor and delivery. I went home. I was badly shaken and felt absolutely abandoned. There was so little hope. Every time I had grasped at hope, I had come up empty.

Fortunately, friends around us had not given up. It's almost like they willed our outcome to be different. When I returned home, Robert Strauss (a mentor and friend at UNC Hospitals) called me and said that he just didn't believe that we didn't have a heartbeat. He said that he would be on call tomorrow and that he wanted me and my wife to come back in and get an ultrasound on the high resolution machine then.

The next morning, we got the scan with Dr. Strauss. The embryo was normal size. There was a heartbeat. A Niagara of relief and thankfulness crashed upon us.

Within days, we once again had been taken on an emotional roller coaster, and now we were on the uphill again.

Of course none of this made me less nervous. It seemed that the very earth beneath our dreams was so fragile. After that, about 3 times per week, my wife came to the hospital where I would do an ultrasound on her. We were almost paralyzed with fear before each scan.

Despite now having a pregnancy on its way, my wife could not give up her progesterone shots and I could not let go of my sense of dread.

I could not give it up until the day I called Jenifer Behrins, a friend of mine who had 4 children but had suffered severely in each pregnancy from intractable nausea and vomiting and multiple hospital admissions. I confided my fears to her. I told her how worried I was, despite how well everything was going. She listened while I spoke, then paused. Then she gave me some of the best advice I've ever received. I share her advice with nearly all my newly pregnant patients who I imagine feel much like I did about our pregnancy.




Jenifer said, "You need to enjoy this. You never know what's going to happen. You need to enjoy every moment of your pregnancy. You need to enjoy every moment of that child's life. Don't worry if he's doing everything he should be, what stage he's at, if he's advanced, or if he's slow.... just enjoy it. Enjoy every stage for what it is, because you never know for sure that you'll get another stage. You never know what the future holds."

To someone else, her advice may have seemed someone dark and pessimistic. To me, it was liberating. She gave me permission to celebrate the here and now. I realized that if I didn't enjoy the small blessings, I might not ever enjoy the big ones. It was my first step out of the madhouse.

Epilogue:
I know not all patients enter this madhouse I allude to. Some people weather this much better than I did. I envy them. I don't know if this experience makes me a better doctor, but I'd like to think it does. I do know that it feels very personal to me when a patient does not get pregnant or has a loss. Those old emotions are like live wires, hidden just below the surface.

I know my experience affects some things that I do. When I do an ultrasound for a heartbeat, I look for the heartbeat and tell the patient as soon as I see it. With that out of the way, I go about my measurements.

I've also realized that infertility doctors can make you feel very high risk, especially if we bring you back for ultrasounds every week of the first trimester. It's a double edge sword. On the one hand, seeing an embryo grow everyweek is reassuring. On the other hand, if I bring patients back every week, it can make them feel like things are more in perile than they actually are.

The truth of the matter is this: as long as things are going well and there is no bleeding or history of recurrent pregnancy loss, once you see a normal heartbeat, the miscarriage rate drops dramatically. For most women under 35 years old, once you see a heartbeat, the miscarriage rate is about 4-7%.

The sad truth for me is that the sooner I get a patient back to her doctor, the more likely she is to feel like a normally pregnant woman. For sure, it can be hard for me to let go. It can be hard for her to let go, too. In the end, it's what we all must do, and we're all better off for it.