IVF#4 - Protocol

Alrighty folks, here's the details, and lots of them! (Family, I apologize as this may get pretty techie)

Back in December when I failed IVF#3, I had a phone consult with Dr. Schoolcraft. You can read all the details from that consult here. In summary, his recommendation if I were to cycle again was to do another long lupron protocol but add CGH genetic testing. He said the only reason to not do long lupron is if you don't produce enough eggs on it, I produced 23. He thinks we have an embryo quality issue and that genetic testing would give us the answer of whether to continue with our own embryos or move onto donor/adoption.

Last week my IVF nurse put in a protocol review. Schoolie came back with the Antagonist protocol. This really caught me off guard and scared me as I've heard this is not his favorite protocol. While I trust the wizard, he does pioneer IVF protocols, it's just my nature to need to completely understand why I'm on this protocol when spending this kind of money. So I spent the next few days researching this protocol as I have never done it before and did not know what to expect from it.

While researching, I noticed that the few patients he has put on this protocol, he combined it with estrogen priming protocol (EPP) suppression. I researched EPP and found it to be quite interesting. Apparently, women who have elevated FSH (that's me!) tend to start recruiting follicles before cd1. This is bad because it can create a dominant follicle issue significantly decreasing your chance of success. In IVF, if a dominate follicle is allowed to develop, that follicle can take over and suppress all other follicles. In a natural cycle, this is how your body prevents you from ovulating more than one egg each cycle. The EPP suppresses the FSH prior to cd1 preventing any follicles from taking the lead. This keeps all follicles at the same size and ready to go when stims start. Sounds great to me!

My nurse never mentioned EPP for my protocol. After a phone call to go over my calendar, I discovered that Schoolie did not include EPP and instead wanted me to do the plain vanilla Antagon protocol with no suppression at all. I peppered my nurse with questions regarding why I was or was not being put on EPP, and how/why Schoolie came up with this protocol. She had no answers and I left the call feeling very unsure of going through with this cycle. No suppression really concerned me as I felt that put me at great risk of the dominant follicle issue.

The nurse suggested I do a regroup with Schoolie to get my answers. It would cost me $85 to speak to him. The principle of this urked me because I feel if I'm going to spend $25k+ at his clinic, I ought to be allowed one phone call when starting a new IVF cycle. You even get one phone call in jail. I whined about it and then she offered to see what she could find out for me.

The nurse called me back a couple of days later with some answers, hallelujah! She had talked to Schoolie about my concerns/questions. He said that EPP is for poor responders and considering that they got 23 eggs out of me last time, he feels that I respond very very well. He said that I can do EPP if I want to, but he honestly felt I'll do fine without it. He said my issue isn't response, it's embryo quality.

His reason for selecting this protocol is that he wants to trigger me with lupron to help with quality and you cannot do that with a lupron protocol, therefore he had to go with antagon. He actually wants me to trigger with lupron and hcg. I've never heard of doing this before, but I would think that would give an extra egg maturation boost. He's really going after quality over quantity.

I addressed my concerns of getting a dominate follicle with no suppression and she said that the doctors are very good at tweaking the meds/timing and will sometimes let the dominate follicle over-mature in order for the smaller ones to catch up. I struggle with this as my theory is that the dominate follicle has the best potential since it proved to be the strongest from the get go.

With lupron based protocols, the lupron shuts down your pituitary gland preventing ovulation. With antagonist, there is nothing preventing ovulation until they start antagon. When they see your lead follicle hit 14mm, you start antagon injections. She said that antagon is really an art, where timing when to start the antagon is very critical. If they start it too soon, they stunt the growth of the smaller follicles resulting in less mature eggs. If they start it too late, they risk you ovulating.

I asked if I get 23 eggs on long lupron, what should my expectations for be antagon. She said I could expect less, but that this is all about quality over quantity, and that even though I got 23 eggs last time, look at the final outcome.

He also wants me to do genetic testing on the embryos. This tests all 46 chromosomes. They will culture the embryos to day 5, biopsy them and then vitrify (flash freeze) them. This is incredibly frightening to me as my embryos are always slow and poop out before day 5. I've only had 1 embryo ever go to blast. But of course, I always transferred my best, so hopefully I can get a few more. The genetic results take 6-8 wks. After the results come back, they prepare you for an FET. This is perfect as I'm unwilling to do another fresh transfer anyway. I truly believe that none of my 8 transferred embryos implanted because my body was so jacked up on stims. Waiting on the results gives my body time to recover between retrieval and transfer.

Since there is no suppression, I’m med free this cycle. I’m just waiting for AF to show. On cd2, I’ll go for an u/s and blood draw and if all is good, I start stims on cd3. I’m doing 2 menopur in the am and 150iu gonal at night. The good part of no suppression is that my med doses are dramatically less, saving me quite a bit of moola.

In summary, my last 3 IVFs were all lupron based protocols with suppression, triggered with hcg and were day 3 fresh transfers. This time I will be on an antagon protocol with no suppression, triggered with lupron and hcg, will be genetically testing the embryos and will be doing a frozen embryo transfer. So we’re definitely changing everything up. In one sense, I’m scared to death of all these unknowns, it could turn out to be the best I’ve ever done, or a complete disaster. On a positive note, I’m very excited to be trying something new as obviously nothing has worked in the past.

To answer a few questions from my last post:

My field of study is computer science. The class that I was giving examples from was concepts of programming languages. 4 more classes and I'm done, but at the rate I'm going, that may take me 2 more years. My final exam for this course is right after stims start, so I’m cramming like crazy trying to get this course completely done before then. IVF and final exams mix about as well as drinking and driving.