Progesterone pessaries vs injections?

[Jenbot78]

Hi there, starting second IVF cycle at Care Sheffield in July after NHS cycle at Christmas which ended in a CP. I was on 800mg progesterone pessaries per day, started spotting 7 dp ET and then had a full blown bleed about 10 dp ET. Incidentally it was Christmas day, not fun.

We have our initial appointment in a couple of weeks with the nurse. I just felt like nothing was explained to us on our NHS cycle, all very rushed. Seeing as we are paying a lot of money I want to make sure I understand all of the decisions that have been made...

The protocol appears to have 600mg progesterone but I am starting 20mg of prednisolone on day 6 of stimms. This is because I have a very aggressive number of antithyroid antibodies, >1300.

My question is, how is the decision made to prescribe pessaries VS injections? I am worried about the spotting last time...Any advice would be really gratefully received, thanks ladies!

I'm not sure this will be of much help because I think you'll need to get a consultant's opinion, but first point would be that pessaries (Cyclogest in my experience) are the cheap option. Generally they would go up to 3 a day - personally never heard of anyone being on more than that (1200mg). The injections (usually under the brand name Gestone) are less usual, and pretty confident you'd not get them on the NHS. The idea of doing them is worse than the reality. It's much more expensive, but the progesterone is more easily and directly absorbed from the injections, and you can be more certain that the dose is actually being absorbed IYSWIM. I was on 3 Cyclogest and 2 vials of Gestone until 13 weeks. Gestone was sort of the firstcline of attack, with Cyclogest as the back up - or at least that was my understanding.

Previously (2 NHS cycles) I bled early in the 2ww both times, didn't even make it to a week in on the 2nd cycle. Suggestion being it was an immune issue. I find it slightly odd that they have given you the protocol without seeing what your body is doing as it goes along - they can't know that 600mg will be the right / ideal amount surely? I think you should ask about that.

Prednisolone is a steroid, am sure you know that though. Are you being offered any other immune treatment? First thing which springs to mind would be intralipids. I'd definitely ask about that if it's not been mentioned.

Generally and as far as I understood, worse your immune issues, the higher the level of progesterone, as a sort of 'fail safe', pregnancy support.

Does that help at all? Think you need to ask some questions TBH.
Has that helped at all?

Hi Jenbot, so sorry to hear about your previous cycle.

I'll be interested to see responses to this thread; I had bleeding before test day on 3 failed nhs ivf cycles last year (at a Care clinic) and it was only on the last one when i made a fuss that they agreed to put me on injections instead of progesterone suppositories - it did stop the bleeding but it was too late in the end and it ended in a CP.

I was the same as you and was really worried about my progesterone levels, as id read about women not absorbing it from the suppositories.

I raised it as a concern after each cycle but was told it was normal and didn't mean anything. Although I was really grateful for our nhs funding, I did find it to be a very 'one size fits all' approach which didn't work for us.

We're having a private cycle later this year and I will most definitely be having the injections. They are painful (the needles are huge!) but we want to try everything. Surely if you're paying privately you can have whatever you want?

Best of luck xx

Thanks a lot for your responses. My gut feeling is to ask more questions so I'm glad that you both suggested this.

Cheapredwine (love the name btw) I also wondered about intralipids as well as the steroids, but I haven't had any specific immune testing-just ATA test with the GP. I should have added before, I have Hashimotos thyroiditis...and a frustrating diagnosis of "unexplained infertility." I have just turned 38. They all blame it on my age :(

The Gestone injections shouldn't be 'painful' exactly, they feel a bit weird, but they shouldn't actually hurt if you're doing them in the right place in your bum. Only times I had problems were 1st injection done by a nurse which had the freak misfortune of being a blunt needle, and towards the end when the muscle was getting damaged from repeated stabbing. Strongly advise not using your thighs - that can hurt and you can get a dead leg.

OP would you consider full immune testing? Do you have a specialist looking after your Hashimotos? Because you might be able to link the two IYSWIM. Intralipids can be prescribed empirically and it's not very expensive (around £200 an infusion? Maybe less)

Angelica they said same to me, I was pretty sure even then (and esp after 2nd time) it was an immune response.

OP you should probably check out the immunes / throid forums on Fertility Friends - IIRC there is a lot on Hashimotos on there and ladies who are in the same situation. There's also more general immune stuff too, and probably specific threads on CARE Sheffield too. Any particular reason you chose that clinic?

Thanks cheapredwine, have not got a specialist looking after Hashimotos. No-one seems to give a monkeys or even think that it is relevant in the NHS. The Care Sheffield guy seemed to think that antithyroid antibodies were the thing to look for, then do a cycle of IVF with steroids and then immune testing should be further down the line if that fails. Cycle planned for July/Aug so probs not enough time to get immune tests done.

Injections sound lovely...but would have anything if it would make it stick!

When you say treat empirically do you mean without having to do IVF? I do feel IVF is like using a sledgehammer to crack a nut, I am ovulating every month, my AMH is 23.5 and there are no other known issues. I would much rather try naturally with immunes but no joy finding a sympathetic doctor!

That's a shame you don't have a specialist with the Hashimotos as they might be able to treat you for that which would also help the IVF immune side of things. I have absolutely no expertise apart from what I've been through, but my gut feeling is your immune system is going to be crucial here. Being a bit direct here, but I really think you need to ask more questions before embarking on the July cycle - yes, the Prednisolone might make the difference but it simply might not be enough. Can you see if they will give you intralipids too? It's very benign. By empirically, mean that they'll give it to you without you having to have the actual immune testing. One option for you might be to press for a referral to Prof Quenby in Coventry, she does immune testing (uterine NK cells I think) and is meant to be excellent. But it would delay your cycle. Definitely recommend Fertility Friends for proper info and ladies who have been in your position with the Hashimotos.

You can also opt for immune treatment without having IVF but I think you'd probably be looking at London - Dr Gorgy? Immunes in IVF is controversial. Would you consider going abroad? Serum in Athens do immunes and it's much cheaper there than from the UK. I honestly think you are probably looking at more support than just Prednisolone, but I could equally be talking rubbish, I don't really know anything about Hashimotos.

Just to say that there is an alternative to Gestone - it's called Lubion and it's a subcutaneous injection, so small needle into the stomach (similar to IVF drugs), much easier and less hurty than the Gestone! It's newer and thus more expensive but private doctors will prescribe it.

I'm on lubion as I had lowish progesterone following a FET and I asked whether injections were an option. The doctor was happy to prescribe. Re cyclogest - I am on 3x 400mg suppositories (apparently they absorb better through the back door) and my doctor told me that was about the upper limit of what you could absorb that way. So I'm doing injections AND suppositories.

I was on 1200mg of cyclogest after our second successful round of ivf on the NHS. I started spotting at 6 weeks and found out we were having twins. I was then put on a daily gestone injections instead of a pessary dose. I found them to be a pain tbh as my partner wasn't allowed to give them to me, I had to take them to a medical professional so lots of waiting in clinics and walk in clinics. I understood they were more better absorbed and calmed the uterus. I stopped spotting at 8 weeks and was put back on pessaries only. One of the twins didn't make it but one is still going strong 11 weeks later x

I did my own Gestone after about 10 days of having to find a nurse to do them (I was away from home so husband couldn't help, though would have hated to do them anyway). It's actually MUCH easier to do them yourself IMHO. And very easy, even on the side of your non-dominant hand (and I don't have terribly long arms!) I injected in loos all over the place - museums, John Lewis, M&S, various Starbucks but proudest of doing it on a Virgin train between Euston and Watford Junction. So OP if you do need to, it's possible. Best advice I can give is get the nurses to draw an aim-for-this-target-area in permanent pen on your bum and if you're thin, use green needles to draw up and then the slightly narrowerer shorter blue needles to stab. Can give you dimensions of both if you need them.

sweet I'm so sorry about your twin We lost one too, at 8 weeks. It's so hard isn't it? I sort of knew things weren't good with our smaller one, even though the signs were good and it was a bit out of the blue. I hope the rest of your pregnancy goes well.

stealth gutted I didn't know about Lubion!

I'm going to be on Lubion and fanjo / bum bullets for my upcoming FET

My consultant (same as stealth) says it's just as effective as Gestone and much more patient friendly as it's subcutaneous not IM. It's a bit more expensive I think - but worth it in my eyes for no bum jabs!

Oh and immunes wise I don't have an autoimmune history and my immunes tests all came back clear but we're treating empirically with prednisolone, intralipids, clexane and aspirin as a belt and braces measure. My consultant treats empirically for failed implantation, miscarriage of a chromosomally normal embryo (as mine was) or autoimmune history

Bananafish your consultant sounds great to be prescribing empirically. Laughing at fanjo/bum bullets! I am going to ask about the lubion. Thanks for all the tips ladies :)

Lubion for sure. 3 cycles of Gestone left my bum so sore I could barely sit down for a month, and I had each injection administered by a nurse.

I've no idea how people manage pregnancies on Gestone.

Self administered the Lubion for 12 weeks and it barely hurt by comparison (successful cycle 4 which resulted in darling DD).

Good luck whatever you decide

Maybe we've just got massive arses w8!

I had one injection a week but still miscarried. After that I had double-dose injections up to 20 weeks for all three of my successful pregnancies. Long time ago so don't know doses. Good luck

Random Gestone tips in case it helps anyone...

Warm the vials in your bra for 5 minutes beforehand

If you're using green needles (thicker, longer) to inject as well as draw up, still change the needle to a new one before injecting - inevitably you'll hit the tip inside the glass and you want it as super sharp as possible.

Get a nurse to draw a target area in permanent marker

Massage muscle vigorously afterwards, before too if you remember (I never did)

Don't skip the mini draw up to check for blood before plunging. If you inject into a blood vessel (by not checking) it'll bruise like buggery and be sore. Perfectly possible to do the mini draw up one handed. Think I had to withdraw twice to redo as there was blood? Just change needle and go again in slightly different area

If you are self-injecting on left (assuming you're right handed) you can let go of syringe completely once it's in the swap hands. Doesn't hurt though looks a bit weird.

I never bothered with a hot water bottle on arse cheek afterwards, mainly as my time to do it was lunchtime so was out and about usually. AFAIK you have about a 2 hour window in terms of same time every day, you don't have to do it within 30 mins, despite what they say

Hi, I have previously had two failed icsi attempts, always bled early at 8 days and 10 days in the 2ww, whilst having cyglogest pessary, 2 daily 400mg. On my third attempt with icsi the consultant suggested Lubion a sub cut injection along withe he cyglogedt pessary. It's very early but we have success. X x