REALITY CHECK on a poor responder protocol
4 Replies
JANE ALLERTON - March 10

Hello Dr. Jacobs:
May I please have a reality check on a protocol targeted for "poor" responders:

1. BCP first, and then Lupron suppression to start
2. Get period, then on day 3 after period
3.start with Ganirelix @ 125mg daily but stopping Lupron
4. After 7 days of Ganirelix, add in 750 IU of Follastim
5. Two more days of 750 IU Follastim
6. Go down to 3 days of 675 IU Follastim, add in one vial of Repronex, continue Ganirelix
7. Go 2 or 3 days of 450 IU Follastim and one vial of Repronex, contineu Ganirelix
8. CD10/11 go to hCG trigger shot of 10,000 IU
     
;     &nbs
p;    
LEGEN
D
(for myself)       
;        
;      
through
out the entire protocol, all Dexamethasone dosages are 0.75 on a daily basis      
       
;     
Lupron
=   A GnRH agonist to suppress      
;       
     
Ganirelix
=
a GnRH antagonist prevents LH surges      &n
bsp;      &nbs
p;    
Follastim=pure
FSH      &nbs
p;       
;    
Repronex=combo
of LH and FSH       &
nbsp;       
;      

S
O
the questions are:
1) why so many days of Ganerilx? About 11? is that much needed to really surpress LH surges??
2) why add in Repronex at the end which has a combo of LH and FSH, when you were suppressing LH in the first place....
3) huge volumes of Follistim to start...does that really recruit more follicles at the start?
4) dexamethasone...a low dosage steroid....helps with uterine lining??? Not sure of its role here...

Obviously, the E2 values in the bloodwork and u/s in the last 5 or 6 cycle days show how to further tweak dosages uniquely for each patient based on quantities and sizes of follicles....Surely, there are computer based modelings done to provide guidelines???

THANKS SO MUCH for your reality checking!

 

B. Jacobs, M. D. - March 10

I have no experience with Ganirelix. I do not know why it was substituted for Lupron. In either case prolonged use of a GnRH agonist analog will suppress ovarian response. Most programs do use products wich are combinations of FSH andLH. I do not. I use straight FSH to stimulate ovaries. For my poor responders, I use a Lupron micro dose flare protocol.
Good luck.

 

JANE ALLERTON - March 10

Dear Dr. Jacobs: THANKS so ever much for you insights!
I do understand that protocols are to mimic and maximize the natural cycle's hormonal responses.

OK, understand your responses. So Follistim being pure FSH....is more really necessarily better? Seems 750 IU is a huge hit, just tapering to 675 and finally 450? It would seem that would JOLT the follicles into size/growth expansion rapidly and then "brake" them down towards CD 10 or so... (sort of like drag car racing out of the gate as I visually picture it)

What's the utility of the the dexamethasone for the entire protocol? Low dose steroid does what precisely?
I heard something about helping the uterine lining, but that does rhyme together for me....hence my question..

THANK YOU AGAIN! Jane

 

JANE ALLERTON - March 10

Dear Dr. Jacobs: THANKS so ever much for you insights!
I do understand that protocols are to mimic and maximize the natural cycle's hormonal responses.

OK, understand your responses. So Follistim being pure FSH....is more really necessarily better? Seems 750 IU is a huge hit, just tapering to 675 and finally 450? It would seem that would JOLT the follicles into size/growth expansion rapidly and then "brake" them down towards CD 10 or so... (sort of like drag car racing out of the gate as I visually picture it)

What's the utility of the the dexamethasone for the entire protocol? Low dose steroid does what precisely?
I heard something about helping the uterine lining, but that does NOT rhyme together for me....hence my question..

THANK YOU AGAIN! Jane

 

B. Jacobs, M. D. - March 11

I do not use a steroid like dexamethasone for the entire protocol. I start a steroid the evening ater retrieval and continue it through embryo transfer. This category of steroid acts as an aniti-inflamatory agent. Inflamation interferes with production of an adhesion molecule in the endometrium felt to be important for embryo implantation. Production of this adhesion molecule is induced by progesterone, after ovulation or egg retrieval.

 

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