# Best Protocol For Over 40



## eskeech (Nov 30, 2016)

I'm so confused. I read an article by the renown US Dr. Sher and he says a long down protocol is best for women over 40. But I have also read (and been advised) that a short protocol is better for older women because it is easier on their ovaries. 
What are your thoughts? Experiences? Advice?


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## Syd72 (Sep 15, 2016)

Hi eskeech.  I can't help a huge amount as I found lots of conflicting information too but I can tell you my experience.  I'm 44 with good amh and fsh for age.  I spoke to the Lister who said short protocol and to Oxford who prefer long protocol.  I decided to go with Oxford and give long protocol a chance but just before we started we worked out I'm not in the country long enough (I live overseas) so I've ended up doing short protocol at Oxford.  I'm on day 9 of stimms today, I'm responding well (for my age) and hoping to do egg collection this Friday.  I was very disappointed when I found out I wouldn't be doing long protocol but now quite pleased I'm on short.  

Have you chosen a clinic yet?  I would go with whatever they advise as they're the experts.  Very best of luck.


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## eskeech (Nov 30, 2016)

Hi Syd72,

I've found a lot of conflicting information, too. I have yet to finalize my treatment plan, but I'm pretty certain it will be short protocol. I'm going with Serum, in Athens. I am very happy with my choice and feel I will get the best care there, my only negatives are that it is very far away (I'm in Washington State) and the length of time I have to be there. Serum says long protocol can be very harsh on our older ovaries. They have found that gently stimulating women our age yields higher quality eggs, though maybe not higher quantity. 

I'm so excited for you! And very happy to hear so far you're responding well! Please keep me updated, if you like. 

Best of luck


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## veracruz (Jan 14, 2017)

Hi everyone,

I thought I would chime in on this one.  I was 42 yrs old on my first IVF cycle with ARGC - good AMH around 14.6 and FSH around 9, and they put me on the short protocol as they said that my ovaries at my age may not be able to cope with the long protocol.  I'm not completely sure any other pros and cons on this but I didn't question it.  Turned out BFN.

I'm now 43 and on my 2nd cycle with ARGC and questioned if I should be doing anything differently - they insisted on short protocol again and again, I went with it.  I'm now in my 2ww and currently 10dp3dt.  My OTD is this Sunday but I could not wait and did a HPT... faint blue lines from a couple of days ago which I am hoping will be confirmed very soon.  Trying to stay cautiously optimistic on this!

Eskeech -  I know all of this can seem overwhelming but I put all my trust in whom I believe was the best clinic for me and *fingers crossed* it works out.  I am sure you will make the right decision for you.  

Syd72 - have you made it to egg collection? All the best luck to you!


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## eskeech (Nov 30, 2016)

@veracruz,
Thank you very much for sharing your experiences. It's really good to hear. 
Fingers crossed those blue lines keep getting more blue!!!
I've since spoken with Serum and am comforted with their response. They, just like ARGC, feel "older" ovaries can't cope with a long protocol. Additionally, they also advocate early ET for older women. CHR in NYC has found ET when follicles are smaller than 18-22mm results in a higher chance of success. 
Baby Dust to all!


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## scattykatty (Aug 1, 2016)

Hi ladies,

I've found this thread really interesting as I start thinking about cycle number 2. Was really disappointed by embryo drop out rate in my first cycle so am particularly interested in a protocol which will aid egg quality (I was surprised that quantity wasn't so much an issue for me). My clinic only does long protocol I think, and I think it's better for endometriosis patients like me, but with my quality issues and time not being on my side, I'm really interested in multiple embryo banking 'mild' ivf cycles, which might *might* = better quality embies? Any thoughts about mild ivf protocols with age/endo issues?

Oh and eskeech, do you have a link for the NYC article about collecting when follies are smaller (I have my suspicions since I had 15+ follies on every scan but only 11 follies were collected from).
Cheers!


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## Claudia H (Oct 2, 2015)

Hello All,

Please can I join your v interesting thread! We have just had our 5th failed transfer (4 fresh, 1 frozen) and I'm feeling pretty hopeless. The embryo was genetically normal and we'd just done an ERA that should my uterus was receptive. However it was a BFN like always. 

Whether we go again really depends on whether I can feel we can do something different this time. I have low AMH and usually get around 5-10 eggs so not loads. I'd love to get the number up in the hope of finding a good one. I've heard good things about Dexamethasone - anyone tried that? 

x


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## eskeech (Nov 30, 2016)

@Claudia H, 
I'm so sorry for your struggle. I have never heard of Dexamethasone. A quick google returned a study (https://academic.oup.com/humrep/article/16/9/1861/2915883/Low-dose-dexamethasone-augments-the-ovarian) and an article (http://www.theatlantic.com/health/archive/2013/01/ivf-on-steroids-the-dangerous-off-label-use-of-dex-during-pregnancy/267187/) against it.

@scattykatty,
That's interesting that long protocol is better for endo. Do you know why? I have endo, but as I'm older short protocol is being advised for me. From everything I have read and all the women I have talked to, short protocol seems better for older women. 
Here is the link regarding early retrieval: https://www.centerforhumanreprod.com/video-gallery/video/early-retrieval-triples-pregnancy-chances/


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## scattykatty (Aug 1, 2016)

Thanks for the link eskeech - interesting although I don't have DOR will try to find the paper to read up a but more. 

As for long protocol I think the downreg basically shuts off the normal surges of oestrogen & progesterone from the previous cycle and, for example, can shrink cysts. I'm not sure of the exact theory I'm afraid. Might need to revise before my review appointment. Although mild ivf or short protocol is not something my clinic does anyway so would have to move. I just want to see evidence that it's at least ok for endo patients but haven't seen it mentioned anywhere...

By the way what do the clinics mean by ovaries can't cope with long - that they might switch off and not respond to meds or something more subtle cf egg quality?

Sorry for all the questions!


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## eskeech (Nov 30, 2016)

@scattykatty,

Here is what my clinic said to me about stimulation/ovaries:

"Because of your age we try to avoid a long protocol because although its a more aggressive option it makes it harder for your ovaries to respond so you  need higher doses which we believe is counter productive as its unhelpful for egg quality.

If follicle count is reasonable we usually try for a short antagonist program in your age group.  If follicle count is very low or FSH very high then its pointless to use stimulation and we try for natural cycle IVF."


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## Syd72 (Sep 15, 2016)

Hi ladies, sorry for the slow response.  Some of you are on other threads that I'm on so apologies for repeating stuff 

In the end I had 10 days of stimms, triggered on day 11, got 10 eggs, 8 fertilised with icsi.  On day 3 I had 3 doing exactly what they should be and two that weren't looking so good but were still a possibility  they decided to do a day 5 transfer.  I ended up getting one early blast and one compacting (or compacted?) morula transferred.

So overall I think I responded well to short protocol given my age, I was on 375 of gonal f per day.

Claudia, so very sorry for the bfn.


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## Claudia H (Oct 2, 2015)

Hi Ladies,

eekeech - thanks for the articles. I'd see the first one but not the second. Interestingly the second is very damning about using Dexamethasone during pregnancy because it is a steroid and crosses the placenta and in some cases has been show to cause bith defects. And guess who they quote in the article as saying they recommend it for women in the first trimester? Dr Sher. To be honest I don't really rate him - I know his clinic is famous but I think he talks quite a lot of poo. So I wouldn't worry about his advice on long v short. 

Veracruz - was that a BFP? I think I saw on another thread that it was. if so - congrats! 

Syd that is a great number of eggs! well done!! 

AFM - just saw my doctor for a follow up after our failed FET. I asked him about Dexamethasone and HGH - he said neither work and studies have proved that. He has though finally agreed that I can take DHEA - he says he doesn't think I'm in the target group that it works for but this is our hail mary round so might as well through the kitchen sink at it. He says it won't do any harm and I don't need my testosterone levels checked as they are v unlikely to be high anyway. 

on Long V Short he says he generally prefers Long - but studies don't show much difference between the two. Long has a marginally better outcome - but it is only marginal (and maybe its because younger patients all generally do Long and have a better prognosis anyway!) He doesn't think cetrotide harms egg quality (another consultant said it did) - but there is some theory that it harms the uterine environment so that is something to think about if you are doing a fresh transfer I suppose. Again - its probably marginal though. 

So we have decided to give it one last bash. We are already on the waiting list for donor but not quite there yet so while we wait we are doing 3 more back to back retrievals (if we can - he might insist on a break in between the last two). We are doing short protocol due to time - its just quicker and I really want to get on with it! We will biopsy everything before freezing and then PGS test the lot. If we are lucky enough to have another normal one, we will do an FET the following cycle. I can't quite believe I am doing this but best not to really think about it. 

xx

xx


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## Altai (Aug 18, 2013)

Syd - that's was a very good outcome. Fx for 2ww. 

With regards whether short or long  protocol - I was looking at it too when did my IVF. Got impression that over 40 ladies who do long protocol are those with good ovarian reserve (both high amh and AFC). 
Those of us with DOR are usually advised to do short protocol.


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## veracruz (Jan 14, 2017)

Claudia H - thank you, yes it's BFP for me but very early days so trying to stay optimistic.  Really sorry to hear about your struggles, I can't even imagine how you must feel.  

Just to say that I did use Dexamethasone my first BFN round but not my second successful (so far) round.  Instead, I was on all the same other meds like aspirin, Clexane, Gestone, and Prednisolone instead of Dex.  Also first round was 11 days of stims and 2nd round was 10 days.  Wish I knew what worked this round vs. last but I'd just be guessing.


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## scattykatty (Aug 1, 2016)

Congrats Veracruz.. fingers crossed x

Syd congrats on being PUPO - I'm one of the I think many 40-43ish ladies who have been silently cheering you and the others in the over45 thread on. Am thinking of you lots x

Claudia H - sounds like you're really going for it - I admire you bouncing back harder than ever... Great! Interesting protocol. The result of my cycle was a non-viable preg which we basically  knew from the start but took 8 weeks to 'call' so I feel like I want to avoid going through this potentially as it hit me that my ovaries will be >6 months older than the last cycle. Eek. Back to back retrieval and short protocol seems a lot easier to recover from and PGS testing is something I've considered but we only had one borderline freezable blast last time so I'm not sure how realistic it is. Plus the £$£$£ it all costs...

AFM Well, I'm debating visiting a couple of clinics slightly further away that do mini IVF as I could imagine banking with them 3-6 times with less stressful stimulation and then doing FET. Then again, it'd mean every month driving further away for repeated procedures. Just keen to avoid the intensity of this last cycle. Might be wishful thinking! My review appointment is in 10 days time so hopefully that'll be a good time to come with my 101 questions about protocols for egg quality etc etc.Then I also debate looking at CRGH as they seem to have the most successful PGS programme from my stats hunting and also an IVF only preg/live birth rate almost double most others for age 40-42... Then again, London trips for a cycle from the Midlands is not something I fancy... Decisions!


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## Blondie71 (Oct 26, 2011)

Serum put me on a short flare protocol based on an amh of 55 or in USA think that would be 5.5, I was 40 at the time and no pcos or anything found although I did have tubal issues which could have blocked ovulation 😕 my protocol was menopur, puregon, decapeptyl, clexane and prednisolone and 5mg folic acid, I managed to get 17 eggs, 10 of which fertilised and were frozen, 4 out of 5 survived thaw and were put back (twins from that) and 5 are still frozen for future x


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## Syd72 (Sep 15, 2016)

Scattykatty thanks so much x

Claudia H I'm really glad you're giving it another go. I may have said this elsewhere so apologies if I'm repeating myself but I had one clinic wanting to do long protocol for me and one wanting to do short.  I decided to give long ago but for various reasons ended up doing short (timing reasons, nothing to do with reserve etc).  I do have good reserves for age so maybe that's why they were considering long for me although the strong impression I got was that they prefer to do long for everyone if possible.  I'm happy that I did short in the end.

Thanks Altai.

Veracruz, huge congrats on the bfp


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## eskeech (Nov 30, 2016)

Hi Ladies,

@Claudia H,
You made me laugh! I agree, I believe his opinions are a lot of "poo!" I'm not worried at all anymore. I'm very excited for your plans while you want for the donor. Who knows what could happen? 

@veracruz,
I can't imagine how excited/nervous you must feel. A BFP!! What a dream. Good for you!

@scattykatty,
I know exactly how you feel about far away clinics. It's one added stress to an already pretty stressful experience. Still, if you feel that one of those clinics could give you a better outcome, I say go for it. 

@Blondie71,
Good to hear what your protocol at Serum was! And great successful! Twins! I'm secretly hiring that might happen to me, as I would really like my child to have a sibling and I can't imagine doing this when I am older. But, you never know. For me, my only issues thus far seem to be age (I'll have just turned 44 when tx begins) and endo. The endo has me more concerned than my age, actually. It seems, given al my testing, that I am likely to respond well to stimms. The endo can prevent implantation or cause early miscarriage. It's such a frightening thought. 

@Syd72,
My guess is that you;re absolutely right. You have great reserves for age and thus they wanted to use high stimms. It seems some clinics, like Serum, still prefer short protocol because of our fragile ovaries.


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