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sonia989 - May 20th, 2006 7:52 PM

I am 35 with decreased ovarian reserve and FSH of 10.8. I did one long protocol IVF cycle 9 months ago with 300 gonal-f, adding 200 Repronex on day 6, at which time they also took me off the Lupron because of few and small follicles. I produced only 4 mature eggs, which were cryopreserved because my husband has to go expensive TESE to retrieve sperm. They thought i should freeze 3 cycles, then fertilize.
On our 2nd cycle, i did the microdose flare, with 330 gonal-f/300 Repronex, then on day 5 switched to 600 repronex and stopped Lupron because again there seemed to be no follicles growing. I produced 8 eggs, of which only 4 were normal and mature. 2 fertilized and I am pregnant, but with low but doubling hcg (35-179 in 5 days). In case this is not a viable pregnancy, they would have me do a cycle without lupron, adding orgalutran later.

My questions are:
-Is using so much Repronex ill-advised?
-Do you think stopping Lupron in the middle of stim is what caused my follicles to grow?
-If my follicles all grow at very different rates, will doing a cycle without lupron result in fewer viable eggs?
-Do you think it was really necessary to give me 600 units of FHS/LH at the start of the cycle, since there was only 1 follicle visible on day 5 despite that?
-What do you recommend for someone who has not responded well to high doses of FSH/LH stims and has follicles growing at varying rates on long and flare protocol?
-Do you think his poor quality sperm (they only found 8 motile sperm)accounts for the fact that only 2/8 eggs fertilized. Should we use a donor?

Time and money is running out and we don't want to blow it. Thanks for your help.

B. Jacobs, M. D. - May 21st, 2006 7:46 AM

I get better quality eggs and embryos if I do not use any LH in my stimulation protocols. Ususally you get more eggs if you do add some LH, but it should not rerquire much. I think your slightly elevated FSH is an important factor. You may be running out of eggs, even though you are only 35. You may wish to consider an egg donor.
Good luck.

sonia989 - May 21st, 2006 9:14 AM

Hi Dr. Jacobs,
thank you so much for this information.
Do you think of my increase in follicles after day 6 was related to stopping lupron at that time? what protocol do you use when there not a great response on long and microdose protocol, and follicles grow at different rates? Would you use antagon?

egg donation is an unlikely option as i live in canada, where you cannot pay someone to donate eggs, and going to the US is not an option because we have spent all our money on ivf.

Sonia

B. Jacobs, M. D. - May 21st, 2006 9:48 AM

I use a micro-dose flare Lupron protocol for my patients who are poor responders. Lupron can decresae ovarian responce to FSH.
Good luck.

sonia989 - May 21st, 2006 7:35 PM

Hi,
They did have me on microdose protocol but the folicles only started growing once we stopped the lupron on day 5.
Are you saying that the lupron itself decreased my response to FSH shots, even on the microdose protocol? Wouldn't this mean I shouldn't use Lupron at all?
Sonia

B. Jacobs, M. D. - May 21st, 2006 7:53 PM

The microdose flare protocol should not impair response to the FSH. Before we had Lupron, we lost about a quarter of our cycles because of a premature sureg of the hormone LH. Some RE's are using a different type of medication to prevent a premature LH surge. Medications like Antagon work a little differently, but we had very poor pregnancy rates when we used it.
Good luck.

sonia989 - May 22nd, 2006 12:25 AM

Hi again,
I really appreciate your taking the time to answer my questions. I did have 8 eggs on the microdose protocol vs 6 on the long, although both yielded only 8 mature, normal ones each. However, all 4 eggs on the microdose protocol were of poor quality. I am starting to suspect this might have been because they gave me 300 repronex/300 gonal-f for 5 days, then 600 repronex for the next 8 or 9 days. Too much LH in the protocol, maybe. Thanks for letting me know about your results with the antagon protocol. I have just 1 more cycle left.

Sonia

sonia989 - June 15th, 2006 9:33 PM

Hi Dr. Jacobs,
My pregnancy turned out to be a blighted ovum and we're looking at doing our 3rd cycle in september. I was wondering what you meant when you said you got poor results with the Antagon protocol and what exactly this protocol involved at your clinic (ie estrogen patch or priming, antagon before and/or mid-stim?)

I have to say I'm really impressed that you take the time to answer our questions. Thanks again.
Sonia

B. Jacobs, M. D. - June 16th, 2006 6:33 AM

Antagon and Cetrotide are almost identical products. We used Cetrotide a few years ago, and our pregnancy rates dropped. We stopped using it, and pregnancy rates went back up. We don't use it, anymore.

sonia989 - June 25th, 2006 12:23 PM

As I mentioned, the last time I did IVF it was with the flare protocol, but I was given high doses of Repronex (300 repronex + 300 Gonal-f for 5 days, then 600 Repronex for 6 days). Despite this, my follicles only grew once they stopped the lupron after the 1st 5 days.
So, if Cetrotide gives poor results, what would you do with someone like me? Flare protocol without LH?

Also, when you give Lupron, do you also have these patients take the BCP at the same time?

sonia989 - June 25th, 2006 12:27 PM

Could you tell me also, when you used Cetrotide, was it given along with estrogen patch prior to stim, or was it only given near end of stim to prevent LH surge?

B. Jacobs, M. D. - June 25th, 2006 12:28 PM

Without evaluating you, I cannot give meaningful recommendations. I do not know if you had a flare protocol, or a microdose flare protocol. If you did not respond to a microdose flare protocol, you may need an egg donor.
Good luck.

sonia989 - June 27th, 2006 10:45 AM

hi Dr. Jacobs,
I had a microdose flare protocol. I produced 6 mature eggs and 2 immature, although 2 mature were abnormal and the other 4 were 'poor quality'. Would you consider that 'not responding' or just not respond ideally?
Sonia

B. Jacobs, M. D. - June 27th, 2006 6:30 PM

Only about 1/3 to perhaps half the eggs a woman makes are capable of a successful pregnancy. The retrieval of 8 eggs is not bad. It is not optimal, but there are patients that I would consider that fairly goo.
Good luck.

sonia989 - June 29th, 2006 3:42 AM

Hi,
well I guess it could be worse. Could you please tell me, what did the Antagon protocol at your clinic involve?

Sonia

B. Jacobs, M. D. - June 29th, 2006 6:45 AM

We started the antagonist when lead follicles were at least 14 mm mean diameter, and discontinued it when we gave the hCG.


sonia989 - July 3rd, 2006 11:22 AM

Hi Dr Jacobs,
So, you didn't use an estrogen patch or Antagon throughout the follicular phase? Cornell U is using a new protocol that involves this and I think that is what my doctor wants to do. So, you just used Antagon alone as described?
Sonia

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