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How should I manage the luteal phase support?

Dear Colleagues,

I would like to ask for your advice regarding the use of progesterone for luteal support. I am getting confused when I search the literature and when I ask my colleagues about their practice. There are several available products like: The progesterone vaginal gel, progesterone vaginal suppositories, the new vaginal ring presented by Teva, progesterone IM, the new progesterone SC coming out by IBSA and the oral formulation by Abbott.
Apart from the new and untested progesterones like the ring, SC and the oral progesterone all the rest giving same clinical results.

Is this correct, what should we use if they all, including the oral would give same good results in pregnancy rates and outcome?

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Answer by Dom de Ziegler

Hi there

In essence, all progesterone preparations available for IM or vaginal use are equivalent as far as efficacy is concerned. Side effects vary of course.
Oral progesterone is not effective in infertility due to the high hepatic metabolism. Is effective in menopause though.Synthetic molecules are better not used. SC progesterone by IBSA is being launched at ESHRE in Europe. Teva's ring I don't know. Both are equally effective, but again with different side effects.

Hope this is helpful

Dom de Ziegler, MD
Professor and Head, Div. Reprod. Endocr. and Infertility
Université Paris Descartes - Hôp. Cochin, Paris, France

Additional comment by Dominique de Ziegler

Hi there

Studies by Cicinelli, Bulletti and us have convened to show that vaginal administration of progesterone results in higher uterine tissue concentration, which obviously is fine. There is overwhelming evidence however that there are no fundamental differences in effect however. PRs and endometrial effects are similar. This indicates therefore that 'full' endometrial effects are achieved at uterine concentrations equal or lower than achieved with injectable. The higher concentrations achieved with vaginal have no practical consequences.

This is not the first example in our field. For endometrial thickness for example, similar findings are made in the menstrual cycle and an ensuing ART cycle. This indicates that there too, the E2 levels of the cycle induce max effects with no further effects from E2 levels that are 10 times higher.

The fact that endometrial effects are similar with injectable and vaginal P4 is confronted to some unexplained findings however:
(i) the bleeding patterns are different (more early bleeding with vaginal).
(ii) IM but not vaginal allows normal implantation rates following GnRH ovulation trigger

So, in short, similar , but w/ 2 unresolved issues.

Cheers

Dom

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