Progesterone Recurrent Pregnancy Loss | Consultant 101

Termination of pregnancy is a situation that many of us go through in silence. It’s emotionally difficult, confusing, and often isolating, especially when it keeps happening and you’re trying to figure out what’s happening and what to do next.

You may have heard of a progesterone recurrent pregnancy loss link, or read about progesterone optional treatment – ​​the latter being something that is particularly close to our hearts here at TRB HQ. two consecutive defeats at the start of her fertility journey, editor-in-chief Jessie Day received progesterone treatment on several occasions. “Looking back, calm, clear, approachable advice is so important when you’re in that place,” she shares.

This is precisely why we asked the brilliant Dr Shirin Khanjaniconsultant gynecologist and accredited subspecialist in reproductive medicine, and medical director of Fitzrovia Fertilityour London go-to for tailored, evidence-based fertility care.

Read on to find out his answers to the following questions:

• The link between recurrent miscarriages and progesterone
• What the latest research tells us
• When and why progesterone treatment may be recommended
• The dose of progesterone in case of repeated miscarriages
• Progesterone pessaries vs. other treatment methods and protocols
• How rrepeated miscarriage care is personalized to you at Fitzrovia Fertility

Let’s move on to Dr. Khanjani.

What role does progesterone play in early pregnancy?

Progesterone promotes early pregnancy from the start. After ovulation, progesterone helps prepare the uterine lining for implantation. The lining becomes thicker, richer and more supportive, helping the embryo to attach and develop.

Progesterone too helps calm uterine activity And influences your immune systemso that the pregnancy can be established safely.

What is the link between recurrent miscarriages and progesterone?

Sometimes progesterone levels during the luteal phase or early pregnancy are low. In some cases, this is because the pregnancy is not going as planned.

Low progesterone can contribute to miscarriage by:

• not supporting the uterine liningwhich can fall too soon
• disrupt the immune system change in a more favorable state for pregnancy

In some women, the problem is not with the progesterone level but how the uterine lining reacts to it. This is what we call progesterone resistance.A

Studies have shown reduced expression of progesterone receptors in some women with recurrent miscarriages. This is why I would recommend a truly personalized approach to progesterone replacement, especially to those who have experienced recurrent miscarriages.

What does research show about progesterone for recurrent miscarriage?

Two major trials in the UK provide the clearest guidance:

• The PROMISE trial – Examination of progesterone in women with unexplained recurrent miscarriages. It did not show an increase in live births when progesterone was used regularly.
• The PRISM trial – Looked at women with bleeding in early pregnancy. In the subgroup of women with bleeding and at least one prior miscarriage, progesterone actually increased live birth rates. The benefit was greater among women who had three or more previous miscarriages.

What is the typical dose of progesterone for recurrent miscarriages?

The results of these tests form the basis of current NICE guidance, who recommends 400 mg of vaginal micronized progesterone twice daily in women who:

• have bleeding early in pregnancy and
• have ever had one or more miscarriages

It should be noted that higher doses have not been shown to improve outcomes.

In what situations do you usually recommend progesterone?

In line with current NICE guidelines, I will recommend progesterone when:

• There is bleeding in early pregnancy And
• there was one or more previous miscarriages And
• an intrauterine pregnancy is confirmed by CT scan

Outside of this scenario, I would seek to discuss the evidence, uncertainties, and personal factors with each patient individually.

Note – It is important to separate this from the use of progesterone priming in an IVF setting, where it is a standard part of luteal phase support. Read our collaboration article on short and long protocols for IVF to learn more about how it works.

When should progesterone treatment be started and when should it stop?

This varies slightly depending on the situation:

• Spontaneous conception with bleeding in early pregnancy and previous miscarriage – Begin once an intrauterine pregnancy is confirmed. Continue until 16 weeks, when the placenta reliably produces progesterone.
• IVF or assisted conception – Start on the day of egg collection or a few days before embryo transfer and continue until approximately 10 to 12 weeks.
• Suspected luteal phase failure – Sometimes started immediately after ovulation, before pregnancy test confirmation, on a case-by-case basis.

What is the typical progesterone protocol for recurrent miscarriages?

At Fitzrovia Fertility, Most women with early pregnancy bleeding and previous discharge follow the PRISM-based protocol, as follows:

1. Confirm intrauterine pregnancy by scan
2. Start vaginal micronized progesterone 400 mg twice daily
3. Continue up to 16 weeks
4. Regular analyzes at the start of pregnancy to reassure and monitor

For women with recurrent miscarriages or suspected luteal phase deficiency, I sometimes take a more proactive approach and start progesterone immediately after ovulationrather than waiting for a positive pregnancy test.

This strategy is supported by smaller studies and extensive experience in reproductive medicine. I would then review and adjust as the pregnancy develops.

Progesterone pessaries for recurrent miscarriages

Progesterone pessaries are small inserts placed in the vagina. They deliver progesterone directly to the uterus, with fewer body-wide side effects.

Typical use:

• 400 mg pessaries, twice a day, until the point of stopping treatment in the second trimester

Other forms of progesterone

There are several forms or routes of administration of progesterone, each with advantages and disadvantages. Here’s a quick overview:

• Micronized vaginal progesterone (pessary or capsule): Best evidence of recurrent miscarriages, high local absorption.
• Oral micronized progesterone: Easy to take, but absorption varies. May cause drowsiness.
• Vaginal gel: Practical, once a day. Evidence of recurrent miscarriages is more limited.
• Progesterone injections: Useful for fertility treatment or when other forms are not tolerated but may cause pain.

At Fitzrovia Fertility, the journey and formulation will be always be chosen collaboratively. Although I start with the evidence-based standard, I always consider your comfort, cultural preferences, prior experiences, and ability to use the medication consistently.

Are there any side effects or risks?

Most people using progesterone experience only mild, manageable effects, such as:

• vaginal discharge
• local irritation
• breast tenderness
• want to sleep

Research in large studies has not shown an increase in birth defects or serious health problems in the mother at usual doses.

Recurrent miscarriages require a truly tailored approach

But progesterone can play an important role, especially when early bleeding and previous miscarriages are part of the picture.

Research now offers clearer advice than ever, and thoughtful tailoring can help you receive the right approach for your body and situation.

At Fitzrovia Fertility I will review your:

• previous pregnancies and miscarriages
• cycle regularity and timing of the luteal phase
• hormone levels
• your personal preferences and comfort

Your care will then be shaped around both the evidence and your lived experience, with the aim of providing you with consistent and clear support during what can be a really anxious and sensitive time.

Are you determining your next steps? Connect with Fitzrovia Fertility to learn more about their support services, and book as an entry consult here.

With some of the most experienced clinicians in the field of fertility, they offer personalized assessment and treatment options, coupled with excellent mental health support – read our collaborative guide to fertility counseling and its unique “here and now” approach here.