Natural Progesterone Treats Infertility
Dana Reed-Kane, PharmD
Reed's Compounding Pharmacy
Tucson, Arizona
In January 2001, a 33-year-old woman with a history
of infertility was referred to our pharmacy. She had read the books
cited in the references(1-3) listed below and was aware of bioidentical
progesterone replacement therapy for infertility. She was convinced
that she would benefit from that treatment.
The patient provided her medical records for our review. She had
a history of regular 28- to 30- day menstrual cycles and had experienced
menarche at 13 years of age. During the first few days of menstruation,
she usually experienced cramping and diarrhea. Several times during
the course of a year, that cramping was debilitating. She had taken
an oral contraceptive continuously from 18 to 28 years of age. In
1996, she underwent cryosurgery to remove abnormal cells on the
cervix indicated by a Papanicolaou test result. Since that time,
her Papanicolaou test results have been normal. At the time of her
evaluation, she was in overall good health. She did not smoke or
drink, and she exercised 4 to 5 times per week.
The patient had become pregnant in October 1997. However,
a fetal heartbeat was never detected, and the pregnancy was diagnosed
as being a partial mole of 14 weeks' gestation. Dilation and curettage
were performed, and the patient was directed to wait 6 months before
becoming pregnant. At that time, she requested an evaluation of
her hormone function, and her obstetrician-gynecologist, who is
also a specialist in treating infertility, referred her to an endocrinologist
with whom she first consulted in April 1998. For several months,
the endocrinologist observed this patient and performed serum tests
to evaluate her hormone levels. He also recommended that she maintain
a log of her basal body temperature. Her obstetrician-gynecologist
and her endocrinologist collaborated to evaluate her test results,
and in 1998 she was diagnosed as having endometriosis and corpus
luteum defect. Her obstetrician-gynecologist recommended that she
undergo laparoscopic removal of the endometrial adhesions, after
which treatment with progesterone should be initiated. The patient
decided to undergo therapy with progesterone and to postpone surgery.
Her prescribed therapy consisted of 1 daily 100-mg vaginal progesterone
suppository, which she described as being messy to use and not compatible
with an active lifestyle. Three months later, she decided to undergo
the suggested laparoscopic surgery after her next menstrual period.
During that procedure, the endometrial adhesions were removed from
the pelvis and bowel, and the patient's ovaries were found to be
sclerocystic and her corpus luteum, weak. Intramuscular leuprolide
acetate (Lupron Depot) 5 mg was prescribed to be self-administered
once a month for 3 months.
During the next year, the patient and her husband decided
to interrupt treatment for infertility. She continued to monitor
her basal body temperature, and she and her husband tried to achieve
pregnancy without medical intervention. Evaluation by a urologist
indicated that the patient's husband had a normal sperm count and
no physical problems. In September 1999, they again sought the help
of her obstetrician-gynecologist, who suggested an aggressive treatment.
He prescribed 50 mg of clomiphene citrate (Clomid), 1 tablet to
be taken orally once daily on cycle days 3 through 9, which was
to be followed by intrauterine insemination with the husband's sperm
on day 14 of the patient's menstrual cycle. She underwent 2 months
of this treatment, after which time the dosage of clomiphene citrate
was increased to 100 mg to be taken according to the same protocol.
Although multiple follicles (12 and 15) developed and
released, pregnancy was not achieved. At that time, the patient
was diagnosed as being estrogen dominant, which was indicated by
the number of eggs she was producing. While performing the intrauterine
insemination, the fertility specialist observed a decrease in the
viscosity of the patient's uterine lining, which made implantation
difficult if not impossible. A viscous uterine lining is an adverse
result of treatment with clomiphene in some patients. The specialist
then prescribed follitropin beta (Follistim) 75 mg to be administered
by intramuscular injection daily for 6 days. During March 2000,
which was the first month of treatment with follitropin beta, six
follicles developed and released, and the patient achieved pregnancy.
However, her level of human chorionic gonadotropin (hCG) indicated
either multiple fetuses or an ectopic pregnancy. After vaginal ultrasonography
was performed at 5 weeks' gestation, an ectopic pregnancy was confirmed.
The patient was given the option of terminating the pregnancy either
surgically or by dissolution with methotrexate. She chose to receive
a series of 3 methotrexate intramuscular injections, each of which
was administered in a dose of 25 mg/2mL, during the 5 subsequent
months to terminate the pregnancy. Her level of hCG was monitored
weekly to ensure a decrease in that hormone, which indicates a dissolution
of pregnancy. After 1 month of that therapy, the patient's level
of hCG had not decreased significantly, and her physician administered
the second injection of the series. In a normal protocol, 50 mg/m2
is administered intramuscularly or intravenously in a single dose
when the ectopic pregnancy is confirmed via sonogram.
The patient's physician knew that she was being counseled
by a nutritionist and had been taking a high-dosage vitamin regimen
designed especially for pregnant women. The nutritionist verified
the high amount of folic acid in the regimen. This vitamin regimen
was thought to be interfering with the methotrexate, because leucovorin,
which is a reduced form of folic acid, is used as the "rescue"
for high-dose methotrexate therapy in cancer patients. The patient
immediately terminated all vitamin supplementation. The third injection
was administered at the beginning of the fourth month of therapy.
Five months after the initial injection, the patient's level of
hCG was normal. At that time, her physician recommended that she
undergo a hysterosalpingogram, which indicated that her fallopian
tubes were patent.
The patient and her husband decided not to pursue further
treatment for infertility. They tried to achieve pregnancy via a
method that included trackinu her basal body temperature. When this
patient was referred to our pharmacy in January 2001, she brought
an elaborate spreadsheet of her menstrual cycles that indicated
a short luteal phase. She had read a tremendous amount of information
about the level of progesterone during pregnancy and its importance
during the luteal phase of the menstrual cycle. She had also consulted
another physician whom she asked us to contact about prescribing
high-dose sublingual progesterone. The physician was reluctant,
but the patient's persistence convinced him to comply with that
request. He prescribed 200-mg progesterone troches that were to
be split in half so that 100 mg was taken sublingually twice daily
on menstrual cycle days 12 through 28. The troches were to be flavored
according to the patient's preference.
We compounded 200-mg progesterone troches that she
split in half. She placed half a troche (100 mg) under her tongue
every morning and every night. Pregnancy was achieved during the
first month of treatment, and the patient continued to take the
troches according to the prescribed protocol until well into her
sixth month of pregnancy. Each month before that time, she called
us and requested a different flavor, because many of the flavors
"got old and made her nauseated after taking them a few days."
She tried butter brickle, coffee toffee, and tangerine but continued
to request raspberry, which was her favorite.
This patient was permitted to exercise by walking and
swimming at 20 weeks' gestation. During her pregnancy, she exhibited
no spotting, bleeding, cramping, or other complications. She reports
"feeling better than ever and loving being pregnant."
At the time of this writing, her pregnancy has attained 36 weeks'
gestation. Although this case was viewed as a high-risk pregnancy,
all indications suggest a healthy mother and baby. The patient is
concerned about experiencing postpartum depression caused by a declining
level of progesterone,(1,3) and we have discussed the possibility
of her resuming progesterone therapy after she has been delivered
of her baby.
References
1. Conrad C. A Women's Guide to Natural Hormones. New York:The Berkley
Publishing Group; 2000.
2. Reiss U. Natural Hormone Balance for Women. New York:Pocket Books;
2001.
3. Ford G. Interview on HRT: Christiane Northrup, MD, FACOG. IJPC
1998;1:12-17.
excerpt from RXTriad, November
2001
|
