Did you mean 400? 40 is pissing in the ocean.
He/she is right. Labs are taken at trough, which is to say when you would normally inject but before the injection.
I think he’s at 160 mg a week, actually. .4 mL of 200/mL times twice a week should be 160 mg. But he needs to try 200 mg and get new labs at trough. And drop the HCG during dial in.