What is luteal support?
Luteal support is the name given to the addition of hormones following oocyte collection to support the lining of the womb to allow implantation and growth of the early pregnancy and prevent bleeding.
During a normal menstrual cycle following the surge of Luteinising Hormone (LH) to trigger the release of the developing egg, the cells that line the developing follicle that have previously produced the hormone oestrogen to thicken the lining of the womb start to produce progesterone in addition to the oestrogen. This hormone is responsible for changes in the endometrium to allow the embryo to implant and develop the early placenta. If no pregnancy occurs the progesterone levels fall and a period occurs. If the embryo implants successfully the developing placenta will produce the pregnancy hormone (hCG) that will continue to stimulate the production of progesterone. By five weeks of pregnancy all the production of progesterone to support the pregnancy is from the early placenta.
Why do I need luteal support?
Since the start of IVF treatment it has been noted that there is the possibility that the follicle/ follicles grown to create eggs might not be as effective at producing hormones. However, with modern treatment cycles there is no evidence of follicle dysfunction and it has been shown that progesterone levels are usually very high and the role of luteal support has become more controversial.
What hormones are given for luteal support?
The principle hormone given for luteal support is progesterone. The hormone hCG, which is used to trigger ovulation, can be given as an injection, however this is rarely used as it interferes with the accuracy of the pregnancy test and also may make conditions such as Ovarian Hyperstimulation Syndrome (OHSS) worse.
How do you take progesterone?
This hormone is made synthetically but is broken down and inactivated by the liver and so cannot be given by mouth as a tablet. Progesterone is usually therefore given as a pessary/ suppository vaginally or rectally or as a gel that is adsorbed through the skin. Occasionally if there have been problems with administration previously it may be given as an injection under the skin daily or by a deeper injection on alternate days.
Is any treatment better than others?
There are a large number of products on the market and all are as effective as each other. Different medication may be advised purely on the basis of previous experience or cost. The injections are not more powerful nor more effective than the gel or pessaries.
How long is it recommended to take progesterone for?
There is no agreement or recommendation as to how long luteal phase support should continue for. A survey of practice in the UK suggested that there were three common strategies adopted, stopping progesterone with the pregnancy test, continuing until the first scan at 5-6 weeks or continuing until 12 weeks. The premise for continuing until 12 weeks was thought to possibly effect the risk of miscarriage and improve live birth rate, however a large randomised study found no benefit in terms of pregnancy outcomes if the support was stopped with the pregnancy test or continued until 12 weeks.
We are now suggesting that luteal support should not continue beyond the date of the first scan.
I am having a frozen cycle do I need to take progesterone?
There are two types of frozen embryo transfer cycle, natural and stimulated. In a natural cycle no drugs are used and we monitor the normal growth and ovulation of a follicle. The naturally produced hormones will stimulate and support the development of the lining of the womb. In a stimulated cycle the lining of the womb is grown and supported by hormones that are prescribed to you as part of your treatment plan.
What will happen if I stop taking the medication?
If you are not pregnant, the progesterone may delay the onset of bleeding (this also occurs in the case of a miscarriage or failing pregnancy). When stopping the medication you are likely to experience a bleed within four-seven days. If you are pregnant there will be no effect on stopping.
What is luteal phase deficiency?
In patients who are using its to test for ovulation it will be expected that you will have a withdrawal bleed/ period 14 days or so after a positive surge. There is some evidence that if bleeding occurs much earlier than this that there may be a deficiency in the luteal support and a short course of progesterone (3 months) may be tried after the LH surge.
Luteal Support FAQ's
I had a miscarriage and the tests said my progesterone was low, what does this mean?
In cases when an early pregnancy is complicated by bleeding and it is either too early to perform an ultrasound scan or the scan is not helpful, clinics will take blood to check the levels of the pregnancy hormone hCG. As a further test to help differentiate between a healthy or failing pregnancy a blood test for progesterone may also be taken. A low level of progesterone will diagnose a pregnancy that is failing and shows that the placenta is not producing enough hormone. Unfortunately, adding more progesterone will not rescue a failing pregnancy.
I have had a number of miscarriages, should I have more progesterone?
At present there is no good evidence to suggest taking more progesterone if you have had a number of early miscarriages. A large study looking at this (PROMISE study) showed that there was no evidence to support prolonged use of progesterone for a history of miscarriage.
Are there any times when I should take progesterone for longer?
There are certainly times when longer courses of progesterone will be advised. If you have had problems in previous pregnancies with a very premature labour or short cervix an obstetrician may have advised starting progesterone early and it would be sensible to continue this throughout early pregnancy.
If you have had immunological investigations, including natural-killer cell biopsy, you may have been recommended to continue with progesterone until 12 weeks of pregnancy in addition to steroids.
