Tuesday, May 5, 2009

Protocols I have Tried

Some common questions on the message boards include “what protocol is best?” and “has anyone had success using {insert any random protocol or drug here}?”

Unfortunately, there are no easy answers. If there were, we’d all be doing the same protocol.

Over the years, I have seen just about every protocol you can think of work for somebody along the way. And there are others who swear that the same protocol shut them down or caused them to have their worst cycle ever.

For example, you’ll see a lot of posts about how terrible clomid is for us over 40 high FSH ladies. But there are also success cases with clomid and IVF, so clearly it isn’t bad for everyone.

We all respond so differently, and even the same person doing the exact same protocol can have very different results from cycle to cycle!

You can’t really tell in advance what will work best for you, it seems you pretty much just have to jump in feet first, try a protocol and see how you go. Then you can tweak or change from there, depending on how your body does.

The only one that isn’t really common for us high FSH folks over 40 is the Long Lupron Protocol, since it is way too suppressing for poor responders. Note that the Long Lupron protocol should not be confused with the Lupron Flare or Microdose Lupron Protocol, which are common options for poor responders.

The things that tend to be common with the older high FSH crowd doing IVF are the “extras”, ICSI and AH.

ICSI is where the embryologist selects a good-looking sperm and injects it directly into the egg to fertilize it.

Nearly everyone on the boards who is over 40 with high FSH does ICSI. Most of us get so few eggs, we need all the help we can get. The fertilization rates with ICSI are generally higher.

However, there are some studies which say that although the fertilization rate is lower when the sperm are left to fertilize the egg on their own, the live birth rate is higher than with ICSI. If you get a lot of eggs, you might want to talk with your RE about the pros and cons of doing ICSI vs without ICSI.

Since I have so few eggs retrieved (sometimes there is just one), I don’t want to take the chance of not having any fertilize so we have always done ICSI.

Assisted Hatching (AH) seems to be a slam dunk for anyone over 40. Just before transfer, the embryologist will make a small hole in the zona (outer shell of the embryo) to enable the embryo to hatch from its shell. Apparently, the zona pellucida can be harder in older women, so AH is often used.

If you do AH, you will probably be prescribed antibiotics and a steroid (e.g. Medrol) to take before and after the transfer.

I started out in 2006 doing an Antagonist protocol with a short stint (around 2 weeks) of BCPs, which is a fairly standard choice if you have diminished ovarian reserve. I did high stims (600IU) and did poorly. We only got 1 egg at retrieval, and although it fertilized, it was a very fragmented 5 cell embryo at transfer. BFN.

Next, we tried the MDL (Microdose Lupron) protocol, with 10 units of lupron twice a day starting 2 days before stims. We went with high stims again, and did better than on Antagonist with 3 eggs retrieved, we went 3 for 3 for fertilization and had 3 great quality embryos transferred. I think they were all 7 and 8 cells. BFN.

Somewhat encouraged by the better result on MDL, we decided to stick with it for a while (a long while, as it turned out). One time I even had 6 eggs retrieved, but only 1 to transfer that cycle.

After more failures, we experimented with various lower doses of stims while doing the MDL. Still couldn't get any consistent results. If anything, things seemed to be getting worse. Which is sort of expected as I was getting older too.

When we reached the point of getting just 1 embryo most of the time, I started asking about natural IVF. I mean, what's the point of going through the crazy expense of all the injectables when I would get one follicle on my own anyway?

We switched to clomid with a low dose of injectables and an antagonist. We got 2 embryos!

Another try with the same protocol, and back down to one embryo again.

At this point I had done 12 transfers I think. I scheduled a consult with Dr Check at the Cooper clinic in NJ. He does not do phone consults any more so I had to fly in for the appointment. I had put that off for quite a while as it is not exactly convenient to fly across country for a consult, but I was glad I did it.

I timed my consult to be at the beginning of my cycle in July 2008, and I ended up staying there to do my IVF. This was my first time doing a low stim protocol. I was only doing 75IU for the first several days! How could this little amount do anything at all, when my ovaries barely acknowledged 600IU?

They kept drawing my blood every few days and would adjust the dosage according to how I was responding. By the time I reached trigger, I was doing 225IU. They retrieved 2 eggs, both fertilized but one was multinucleated so it was discarded. We transferred 1 embryo, an 8 cell that was free from any fragmentation. Low stim seemed a pretty good idea by now, and a heck of a lot more affordable too.

We did get a BFP, with great initial betas (141 at 14 dpo, then 424 two days later). But unfortunately we lost the heartbeat at 8 weeks. It turned out to be trisomy 8.

I have tried in recent months to cycle and do the low stim thing again. In February, my E2 didn’t rise and my FSH skyrocketed so they put me on estinyl, but my E2 remained under 10 even at CD14. I had to pull the plug on that cycle as I was in NJ and didn’t want to keep paying for a hotel when the cycle clearly wasn’t going anywhere in a hurry.

Then the following month I had a great FSH but my E2 was in the hundreds. It was either a cyst or a super early follicle; either way I wasn’t going to NJ that month.

So now I am waiting for AF so I can see what surprise the next CD2 blood results will bring.


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