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In Vitro Fertilization (IVF)

IVF Protocols

Different IVF protocols for different women

Many women going through IVF find comfort and community support in online forums. But when the talk turns to who is taking what medication when, you might wonder why your IVF regimen is so different from others. Some IVF protocols work better than others for certain women.

How we choose the right IVF protocols

To design your IVF protocol we use your ovarian reserve and information from your medical history, including your age, weight and previous responses to stimulation medications. However, your ovarian reserve plays the biggest role in deciding the plan and the starting dose.

Paying attention to the length of your cycle can tell you about your ovarian reserve. Counting from the first day of full flow to the next start of menses, the normal duration of a cycle is between 28 and 32 days. If your cycle has 27 days or less you should seek further testing because short cycles can be an early sign of low ovarian reserve.

Two of the best tests for ovarian reserve are baseline resting (antral) follicle count and serum AMH level.

  • During the first four days of menses, the number of resting follicles on both ovaries is the number of potential eggs that Mother Nature gives you for the current cycle. A total of 12 antral follicles is considered normal, while anything less than 10 should raise concern.
  • Serum AMH level is useful as a long-term indicator of ovarian reserve. Antimullerian hormone (AMH) is produced by the follicles that are even younger than the antral follicles. These follicles are for the future cycles and represent the ‘savings account’ of the ovaries. The normal values of AMH have changed over the years, but based on our clinical experience, a value of 1.5 ng/ml or higher is likely normal, 1-1.4 is borderline, <0.7-1 is low and <0.6 is very low.

The first five days of the stimulation cycle are critical because this time is the egg recruitment phase. The ovarian response seen after four to five days of stimulation can set the tone for the rest of the IVF cycle. Starting medications at the wrong dose can result in too few or too many eggs. For the average woman, we aim for 15 eggs per cycle.

Types of IVF protocols

If your ovarian reserve is normal you will likely benefit from the standard IVF protocols that use either Lupron or a pituitary antagonist (Ganirelix, Cetrotide). Typically, you take birth control pills for about two weeks before starting stimulation medications. In our practice about 70% of women use these regimens.

The tricky part is deciding what protocols to use when a woman’s ovarian reserve is less than ideal, which we see in about 30% of our patients. To determine the answer to this question we have to find out how low the ovarian reserve is.

In many cases, if we think a woman can produce eight eggs or more, we use one of the more aggressive protocols that have proven successful over the years. These protocols use different approaches to provide the best conditions to recruit the maximum number of eggs before stimulation begins.

The main disadvantage of aggressive protocols is the high cost of medication. As you know, the cost of medication in the U.S. has risen across the board. In our experience the total cost of stimulation medications is now 30% higher than it was five years ago. For this reason, women with very low ovarian reserve should think twice before starting IVF using their own eggs.

For women with fewer than seven antral follicles or AMH of 0.6 or lower, using maximum doses of medications would be expensive and may not result in any additional eggs. For example, if you have only three available eggs to use during a cycle, an aggressive stimulation protocol would result in three mature eggs, but no more.

For women with very low ovarian reserve who still want to try using their own eggs, the Mini IVF protocol might be a better choice. In the Mini IVF protocol, clomiphene, an inexpensive and safe medication, is used to release the natural hormones from the pituitary gland to help stimulate the ovaries in conjunction with a milder dose of stimulation medications. Typically the woman uses 1/3 of the medication dose seen in the aggressive protocols, resulting in the same number of eggs and significant cost-savings.

Your best chance at conception

No IVF protocol is guaranteed to be successful, but individualized care can make a difference. We’re proud to say that in all our years of using these IVF protocols, all of them have brought tears of joy to countless women and couples who were finally successful after years of trying to conceive.

To learn more about IVF protocols or begin fertility testing to find the best approach for you, contact us to schedule a consultation at IVFMD.

Sy Le, M.D.
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