10 replies to this topic

[alyj]

I wanted to share the specifics of my last and successful cycle, particularly for women who have diminshed ovarian reserve, or who are poor responders to IVF medication, both of which I have. I also have heterozygous Factor V leiden, a blood clotting disorder requiring me to take low dose heparin while taking any estrogen.

My husband has severe sperm issues. By severe I mean that in order to find any at all, the lab has to do and ICSI prep, and for two of our IVF cycles he had to give a second sample. None of them swim, none of them look "normal", in fact they have to do some osmosis test to see if they're alive. So the cards were stacked against us from the beginning.

1st cycle:
age 32
standard protocol; puregon 200 for 3 days, puregon 400 for 3 days, increased to 450 iu on day 7 after u/s showed only 5 follicles. It was too late by then, and ER on day 14 with 3 eggs retrieved, 1 fertilized and grew to 3 day embryo and transferred. BFN.

2nd cycle:
age 33
Flare protocol; gonal f 450iu, luveris 75 for 7 days; gonal f reduced to 225 for 2 more days then 10000 HCG. ER on day 11. 9 follicles, 8 eggs retrieved, 7 fertilized and 5 grew to 3 day embryos. We transferred 2 and BFP, our miracle son, born in June 2007.

3rd cycle:
age 35
FET: BFN

4th cycle:
age 36
Flare protocol; EXACT same conditions (even time of year) as 2nd (successful) cycle; cancelled on day 7 u/s when only 4 follicles were growing. I also took DHEA for three months prior to this cycle. I never had my DHEA levels tested however, and believe it might have been more damaging than helpful. I found that my voice deepened, and after the research I did on DHEA, thought that maybe the excess DHEA was actually turning into testosterone. I have no medical basis for this, just a hunch.
CANCELLED

5th cycle:
age 36
two months following the 4th (and cancelled)cycle
flare protocol; same as cycle 2; only 1 egg retrieved, and grew to 8 cell embryo and transferred on day 3; BFN

NEW PLAN

I did some research about poor responders and found that Dr. Geoffrey Sher's AGONIST/ANTAGONIST WITH ESTROGEN PRIMING PROTOCOL to best suit me. I approached my RE and he agreed. We'd already exhausted everything else so why not? I presented him with Dr. Sher's published paper and he wrote up a protocol for me, tweaking things somewhat.

Here is a website where Dr. Sher explains his protocol in a clear way:
HERE

And here is the title of the published article, but you will need some kind of membership to read it:

Gonadotropin-releasing hormone agonist/antagonist conversion with estrogen priming in low responders with prior in vitro fertilization failure
Authors:Jeffrey D Fisch, Levent Keskintepe, Geoffrey Sher
Journal: Fertility and sterility

Here is a description that Dr. Sher wrote (scroll down to poor responder):
HERE
http://www.ivfauthority.com/2009/07/ivf-ovarian-stimulation-gnrh.html

I planned out my final IVF attempt months before doing it. I asked to be on the July ER list in January. Following is exactly what I did for this cycle:

In February I started going to acupuncture once a week. I went until ER. She is fabulous and I highly recommend her for anyone in the Calgary area. She is traditionally taught, but knows a lot about western medicine as well, a good combination.

I started seeing a naturopath. I was under a lot of stress because of IF and work. She gave me some stress reducing drops, adrenal medication.

I asked Dr. Fiona about some herbs and supplements, and followed a lot of what other people here were taking.

Beginning in March, so for four full cycles before ER, here is what I took:

AM:
pregvit (pink) - this is covered by most drug plans, a lot cheaper than over the counter prenatal vitamins
emvita (anti-stress drops from naturopath) taken without food
stress remedy (another one from naturopath)
a cleanse (I did not follow the diet portion, just took the cleanse drops)
coQ10
high dose Omega 3
pycnogenol
bee pollen
royal jelly
vitamin D
wheatgrass (flash frozen ordered from a reputable company in Ontario) only 2x per week.
chinese herbs (from acupuncturist, stopped at the beginning of April)

PM:
pregvit (blue)
emvita
stress remedy
coQ10
omega 3
pycnogenol
bee pollen

I followed the instructions on the bottles for everything. I stopped everything prior to starting BCP and lupron (when treatment started).

I also wanted to mention that I did NOT use and DHEA for this cycle.



6th cycle: AGONIST/ANTAGONIST WITH ESTROGEN PRIMING PROTOCOL

This is not the exact Dr. Sher protocol but what my RE created for me based on his theory.

day 4 of cycle before IVF:
low dose aspirin
lupron .5mg subcutaneously (.1ml)
BCP taken for 21 days

lupron stopped when period started.

protocol started on day 2 of period:

day 1 of cycle/protocol: (day 2 of menses):
cetrotide 0.125 mg subcutaneously
4 estradot patches (estradot patches to be stopped when lead follicle was greater or equal to 1.5 cm)

days 2 and 3 of cycle:
600 iu gonal f
0.125 mg cetrotide

days 4 - 6 of cycle:
525 iu gonal f
0.125 mg cetrotide

days 7 - 11 of cycle:
225 iu gonal f
0.125 cetrotide
75 iu menopur

day 12:
trigger shot

day 14:
ER
9 follicles; 9 eggs retrieved; 6 fertilized; 5 grew to 3 day embryo

2 embryos transferred, unfortunately BFN

HOWEVER

This was my best response to IVF drugs in four years. I'm not sure why I responded fairly well to the first flare protocol. My antral follicle count was very low by the time we did this cycle, lower than the number of eggs retrieved.

I do believe that this protocol is the reason why I responded so well for me. Others might see this as not a great cycle but for poor responders like myself you will probably agree that it's really good!



7th cycle:
FET
BFP!!!!! Twins!!!!! Due in June 2011.

So yes, I believe in the estrogen priming protocol; and all the other preparation I did beforehand to help ensure the best quality eggs possible.


If you are a poor responder, please read about this protocol. Don't be afraid to approach your RE about it. My RE had no problem entertaining my idea. Some of the staff on the other hand had a REALLY hard time with a protocol that deviated from the norm, so be prepared for some adversity and resistance (none of which are helpful while dealing with the stress of an IVF cycle). My RE said once to me that the majority of conferences he goes to focus a lot on poor responders, we are a group that they haven't quite figured out yet.

I guess I just had a feeling that I was on the verge of some new protocol, and that I was going to miss the opportunity. 15 or so years ago, my son would not even be here because ICSI hadn't been invented yet. I just wanted to be sure I had tried everything, absolutely everything. Yes, probability does come into play here but the numbers speak for themselves.

If this helps even one person it was worth typing out. And I always appreciated very detailed information, so that's what I wanted to provide.

Good luck to everybody .

Aly

[conky]

Thanks for your post and congrats on your successes!

[silverdollar]

Thanks for posting this. Congrats! EPP was mentioned as my RE's next possible plan on the menu if the antagonist cycle is not successful. I should ask him why he isn't choosing it first.

[alyj]

silverdollar, no one will suggest it at any clinic in Canada right now. I think there have only been one or maybe two others at the Calgary clinic who approached their doctor with the idea and they agreed to do it. Dr. Hudson in Victoria was helpful to me when I had a few questions though. My RE's next plan was exactly what yours is, the antagonist protocol. It's worth asking about anyways. (And they really like it if you bring in the actual published paper). While no one could ever tell me for sure I always felt like suprefact shut things down "too much" for me. That's why I chose lupron when given the option. It's a very small dose of it. Something about the EPP tries to take advantage of your natural surge at the beginning of your cycle, and it seems to help the eggs all grow at the same time. Good luck with your upcoming cycle .

[DeeJay]

While I used Purgegon and repronex for my stim medication, I used an EPP as well, and it's used quite often at the Ottawa clinic.

Congrats on your success, and I applaud you for being such a strong advocate for your treatment!

[silverdollar]

Dr. Hudson is my RE, and he does use Estrogen Priming Protocols with selected patients. He's mentioned EPP a couple of times in our discussions about my last canceled cycle, but for some reason it isn't his first line of attack for me.

I agree about Suprefact shutting things down. Us poor responders can have very sensitive systems. This time there's no suppression at all, just straight into a high dose of stims on Day 3.

Interesting about the DHEA how it had the opposite effect on you than intended. I hope that is not the case for me. I'm on it currently and will be on it through the next IVF cycle.

Thanks for posting the links. I am sure Dr. Hudson is familiar with the research. I will politely quiz him further when I see him again.

[alyj]

Oh wow I'm so happy to hear that other RE's are suggesting this regularly! Here it was not easy for them to be convinced and I got a few weird looks (several actually). But that's great news!

silverdollar I found it tough because RE's all have different reasons for what they choose for us. What I found most difficult is finding exactly the right polite way as you put it to bring it up. Because it felt like I was questioning my dr. And I didn't want to seem rude. In the end I do know they all want this to work for us, and they're all doing what they think is best. Good luck, I hear Dr. Hudson is fantastic .

[parkerdog]

Alyj, congrats on your success on your last protocol! I have been reading quite a bit about the EPP Antagonist protocol and asked my Doc (also at RFP) about it, she was open to the idea, but first we are going to try a superovulation IUI. I have been pregnant before (m/c at 6 weeks) and via IVF did become pregnant but it was ecotpic. Our IVF fertilization record was very good (5/5 eggs fertilized), so we're hoping that I just need the IVF meds to give me a more than one chance to get pregnant. If it doesn't work, then I want to investigate the EPP protocol. I'm just curious as to who your doctor is at RFP? I'm with Dr. Foong and she did seem open to the EPP protocol but thinks we should try the superovulation IUI first (much, much cheaper than IVF).

Thanks,
PD

[alyj]

Hi Parkerdog,

Dr. Foong is so nice. I hope your IUI works and you do not have to spend more money on IVF. Our doctor is Dr. Greene, but I do know that all the doctors discuss each patient they saw at their team meetings together. Lots of good wishes for your upcoming cycle!

Aly

[silverdollar]

Looks like I will be using an EPP afterall. The natural start antagonist didn't get off the ground. This is the last trick my RE has to pull out of his hat to get me to egg retrieval.

[KJ_mom]

Hi there! I'm just wondering if anyone else on the EPP could outline their protocol. After reading Dr. Sher's article on it (that alyj posted the link to), it seems that sometimes Lupron and/or BCPs are still used. I've got my follow-up appointment from a cancelled cycle tomorrow and want to be prepared to talk about EPP and know what are the variances within the protocol.
Thanks so much!