Adding LH later in IVF cyc, day 8 of stimulation
1 Replies
julesDA - November 4

At 36 I was a hyperresponder. My FSH:LH dosing for stimulation was 3:1 and I produced many excellent quality embryos and was successful.

Now at 39, I am a low/poor responder. I had two antagonist protocols. The second, Repronex was added at the beginning of stims (FSH:LH 6:1, 450iu FSH, 75iu LH) and I did produce more and better, but not perfect, embryos.

My next cyc is MDL flare with FSH/LH combo at the beginning of stims again (adding AH at transfer for good measure). My question is, after reviewing the clinical studies on adding exogenous LH to stimulation, the conclusions do vary, but I do see a lean that later in the cyc, also depending on specific criteria (ie: age and sometimes serum LH levels are a significant factor), adding LH can be beneficial.

Since I responded well with LH at the beginning of my 2nd antagonist cyc, and for the first successful IVF my FSH:LH was lower as well, I feel comfortable with adding LH at the beginning of stimulation, even with the FSH/LH flare that it will start with. (maybe I'm one of those whose pituitary doesn't secrete the needed amount of LH?)

My question is regarding adding yet additional LH (1 vial repronex more) on day 8 (as some recent studies have concluded for certain cohorts, such as age 39+). Since I've seen successful MDL flare protocols in women who START with 450 FSH and 150 LH and I'm only starting with 75 LH, I felt that the flare would make up for the rest and the beginning, and I could add the additional exogenous LH when some studies show it "really counts", near the end of stimulation.

When I requested the day 8 exogenous LH, my RE's recommendation was to add 2nd vial of repronex (75 FSH, 75 LH) on day 8, but not adjust the follistim dosing (which is 375 each day) + 75 from the 1st vial Repronex.

So I'd be dosed
Stim days 1-7 450 FSH + 75 LH total (375 follistim 1 vial repro),
Stim day 8 (maybe 9) 525 FSH and 150 LH (375 follistim, 2 vial repro)

I've seen other protocols step down FSH dosing, but my RE cites studies of a small % of patients when FSH is reduced or coasting is initiated at the end, a collapse of the follicles could happen. She doesn't want to take the chance.

My question then is, will the 525 FSH on day 8 l be too much of a FSH kick at the end......or, since I'm 10 days into Md Lupron (post flare), is the slight suppression enough not to overkill with FSH.....though, it's supposed to be a small enough amount of lupron that I should still be secreting some FSH endogenously. When the 2nd vial repronex is added, should the Follistim dosing be reduced 75iu since there is 75 FSH in the repronex.

Or, is there just no significance in embryo quality/IVF outcome in small population studies on step up FSH dosing by day 8 ?

phew, hope all that made sense.


Barry Jacobs, M. D. - November 5

I do not add any LH to my stimulations. We get better quality eggs and embryos if we stimulate with FSH alone. The dose of Lupron we use allows a small amount of LH &FSH to "leak" from the pituitary gland, and support the stimulation. Also, I no longer use any antagonist. When we started using antagonists, our IVF pregnancy rates dropped.
Good luck.



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