Thursday, April 16, 2009

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.


  1. This is very interesting, thanks for sharing the details. I was on the antagon protocol, and it worked well for me. I'm going to do an EPP/antagon protocol if I move on to another IVF cycle. I want to do CGH, but was told that I need to have 10 fertilized eggs on day 1, and fat chance that will happen. However, on my last protocol, I had four embryos go to blast. I wonder why CCRM makes these cutoffs if what really matters is how many blasts you have on day 5.

    I hope the new protocol gives you more quality over quantity. It is scary doing something new, but exciting too. I felt much better on the antagon protocol than microdose lupron protocol or anything having to do with lupron!!

  2. I'm excited for you!!! I would be nervous about the "change up" as well (but excited at the same time)....he is the GURU and he knows his stuff so I would go with that and trust him!!! This might be exactly what your body needs to do the trick and I'm praying like mad that it is!!! I can't wait until you get to CO and I hear all about the wonderful progress you're making this cycle!!!

    Love ya!

  3. I did antagon protocol on IVF #3. I had a better maturity rate but much less eggs. But obviously I have other "issues." It sounds like you really did your research and got your questions asked! I wished I had had Dr. Sch.

    Can't wait to see how it goes!

  4. I'm liking the sound of the antagon without EPP for you! This is most probably what I would do if, god forbid, the transfer next week fails to get me pregnant. I'd not do EPP either, since my response is not dissimilar to yours. I'm excited for you! This could be great! Nice one on getting your questions answered without spending the $85. I'll be following your progress :-).

  5. I did the best on the Antagonist cycles with the best maturity rates with CCRM so I have had good experiences with that protocol. However, I am a poor responder so I was on the EPP part as well (although I don't have high FSH??). It's always good to change things up and approach the problem differently and although you're scared, you kind of already know what happens with the other protocol you've done three times past - scary, but you could have a much better outcome with this new approach so I hope it works well for you! I'm crossing all of my fingers for you and wish that you have a wonderful cycle. Come join the CGH thread on IVFC okay?

  6. Your post definitely helped to understand why and how this cycle will be different. And I totally agree that quality is better than quantity. You're going to do great and will be praying that even all the genetic testing they do on the embies will come back perfect.
    Love you!

  7. I just learned so much! I have done the antagonist protocol with my last 2 fresh cycles. This time around my new RE wants to add the EPP. I am a low responder. I am wishing you the very best with this upcoming cycle. I am glad you were able to get all the answers you needed.

  8. Just wanted to comment that I was on practically the same protocol that you're about to do.

    My 1st cycle at CCRM (July '08), I was on the BCP for 21 days and then started stims and then added the Antagon (Cetrotide shots) and then triggered with Lupron. The reason Dr. Schoolcraft put me on that protocol was because of my history of severe OHSS. That cycle, we had 30 eggs retrieved, 26 mature, and 23 fertilized via ICSI and made it to PGD-FISH (remember, DH has a balanced translocation 13;15). Transferred 2 grade 5AA and 4AA blasts. BFN. At the WTF phone call, Dr. S said it could be due to a lining issue possibly caused by the Lupron trigger. He also said something about final maturation of the eggs may be comprimised due to using the Lupron trigger. So the next cycle, he would do everything the same but use hCG as the trigger instead of Lupron.

    My 2nd cycle at CCRM (November '08), I was on 25 days BCP then started stims then started Antagon and triggered with hCG. We retrieved 34 eggs, 25 mature, 22 fertilized via ICSI, 15 made it to blast for CGH testing. I guess there were issues with the lab that did the CGH, but we got 8 abnormals (13 and/or 15 monosomies or trisomies) and 7 no results. So we had the 7 no results thawed, re-biopsied, and sent for FISH testing for the affected chromosomes. One came back normal. And you know the rest of the story. :)

    What I'm trying to get at is that you're in the very best of hands and I have the utmost confidence in your upcoming cycle. I see a baby or babies in your future!!!

  9. Jill - I think this really sounds great. I really like shaking it up - especially when there is no answer for why it didn't work last time. I must be a serious IVF junkie b/c all this talk has me so excited about your cycle, lol, it seriously almost makes me want to do the same protocol just to see what my response is! It's like I want to get all the answers for how all of us respond to the different things...I think I get why Sch would like his job...very interesting with all these humans to experiment on:-)Good luck! I seriously am excited for you!

  10. Wow...It sounds like you and Dr S have thought this through. It sounds like a good plan to me and it makes sense to try a different protocol. It can be scary doing something new, but I am hopeful that this is a good step forward.

  11. Whoo my brain is dizzy from all the info.haha. We are excited for you and Kerry, especially you, about the new protocol.I know it is a little scary, but I have faith that ell will go great.
    I know you will get your classes finished and do fine on them. Just hang in there.
    Love you bunches,
    Jean and Crew

  12. Hang on while I get google pulled up on my computer to find out what all these words mean!!! lol!!
    Your apprehension is totally expected, but hey-- the excitement can outweight that, right?? I sure hope so. I will be anxiously watching your blog to follow the journey. I bet you've never been more ready for Aunt Flo to show and get this cycle going! :0)
    Best wishes and prayers that this is it!!!
    The Other Jill

  13. I am so glad you push to get your questions answered. That is great self-care. Know you can sit back and mentally prep for getting the very best output ever. :D

  14. wow. sounds like you should be graduating from med school. I haven't stopped by in awhile. I hope you feel good about the doctors advice.

  15. It sounds like you really researched this, asked all the right questions, and got some great answers from Schoolcraft. Sometimes things seem so out of place until you better understand the reasoning behind the mastermind. I truly hope this one is it for you!!

    Oh, and a bonus for doing an antagonist cycle is that there are a lot less injections. (-;

  16. Jill-Just wanted to wish you luck on the antagonist protocol. I trusted pretty much everything Schoolie wanted us to do and you know my story. I used the same protocol (Long Lupron) as the 2 failed cycle IVFs before, so I was scared of repeating it. But you're in such good hands at CCRM, they'll keep a close monitor on you!

    P.S. We let our dominant follie over-mature so that smaller follies could catch up. Convinced we had better quality because of it!

  17. Great job on doing all this research - and I hope this is the protocol that works!

    Computer science? Seriously? I am so impressed. My extent of computer science is knowing how to print, Google, and write comments on blogs :-).


Thank you for your comment! Hugs, Kerry and Jill