The Science behind Progesterone use in Infertility: A deep dive with Dr. Asha Baxi

PROGESTERONE IN INFERTILITY

WHAT EVIDENCE SAYS?

ESHRE 2019 guidelines recommend 10mg TID for LPS, and dydrogesterone can reduce preeclampsia incidence in high-risk patients. Dydrogesterone is preferred due to its close relationship to natural progesterone, enhanced oral availability, and higher affinity to progesterone receptor with minimal androgenic activity so better patient compliance, effective at low dose, minimal side effects. The use of dydrogesterone, even in high-risk patients, from 6 to 20 weeks of gestation, has been shown to reduce the incidence of preeclampsia.

The management of Luteal Phase (LP) is complex due to lack of consensus on progesterone dose, routes, and duration.

· Progesterone in LP enhances endometrial receptivity, promotes uterine quiescence, local vasodilation, and NO synthesis, while inadequate progesterone reduces uterine contractility, leading to miscarriages.

· LP Support is required by confirmed cases of LPD, unexplained infertility, advanced reproductive age, ART techniques – IUI/IVF/ICSI, hyper-prolactinemia, all down regulated cycles, recurrent pregnancy loss, PCOS, women with strenuous exercises and underweight.

· Routes can be parenteral – in oil or aqueous, oral, transdermal, vaginal. With vaginal route though levels are low in blood but high in tissue. Dose can be vaginal gel 90mg/day or vaginal softgel 200mg TID. Injections can be intramuscular or subcutaneous and they maintain excellent sustained blood levels usually give in dose of 25-50mg/day. Drawbacks of current progesterone therapy is variable & unpredictable absorption, variable plasma levels, unwanted hormonal adverse effects, variable efficacy, unpredictable results, unwanted pregnancy loss.

Speaker: Dr. Asha Baxi, Vice President FOGSI 2022-23

Dr. Neelam, Past President Patna OG Society - LOTUS I & LOTUS II discussed & results well explained where oral dydrogesterone is non-inferior to Micronized Vaginal Progesterone and has similar safety profile which gives more confidence to prefer oral dydrogesterone.

Dr. Rekha Wadhwani, Prof & unit head OBG SZH GMC Bhopal – she agrees to the speaker’s take-home messages from different studies that oral dydrogesterone is equally or somewhat more effective than micronized progesterone.