# Protocol Dilemma!



## MrsGoldilocks (Oct 3, 2016)

After numerous failed cycles we are starting IVF number 4 at the end of July.  All previous cycles have been the long protocol however I am always on a high dose of stimms and am starting to have reservations about this and egg quality.  My first cycle ended with no fertilisation, we were shocked and disappointed as we hadn't even considered it failing at that point.  For cycle 1 I used Gonal F (375 iu).  We decided with our doctor to do a combination of Gonal F (300) and Menopur (150) for the next 2 cycles - cycle 2 BFP but MMC and cycle 3 BFN.  Each time I have a higher egg yield but quality seems to be a problem. My doctor has now changed my stimms drug to 450 Menopur in the hope that we get better quality. 
Having done a medicated IUI with only 4 days of Gonal F (75 iu) I produced 6 follicles with 3/4 good sized ones before trigger and my doctor was at the point of cancelling the cycle due to a high risk of multiples, we decided to carry on in the hope that it would work - it didn't, i'm not convinced the follicles contained mature enough eggs at 18mm when on my natural IUI the size of my follicle was 24mm + at ovulation.
So my dilemma is this - do we change to a mild stimulation/flare protocol, and would this be better for me in terms of quality? This is only used in poor responders apparently but I'm not getting the quality with a long protocol and I'm keen to use lower doses of drugs, i'm not comfortable to keep using high doses and with my last cycle I didn't feel well with down regulation.
Time is ticking on and money running out, I want to make sure we give this next round our best shot, i'm not sure how much more I can take emotionally either. 
Has anyone changed protocol and had success?


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## water-lily78 (Oct 21, 2015)

Hej,

Not sure, if I can help, but we are in the same age group and I had similar doses of drugs and number of eggs collected as well. Doctors said that it was mostly a numbers game for us, me with low AMH, DP with not the greatest sperm quality, not an awesome combo. I don't really think that using different stimming drugs made a difference in the end. It was all about increasing numbers to start with to increase a chance of finding a better quality egg and to that end downreg helped us to recruit just an extra 2 or 3 follicles each time. In the last 2 cycles with BFPs (one chemical though) I used Fostimon at high dosage (375iu) after downreg (harvested 10 and 11 eggs). I had used Menopur (I think at 450 iu) before in 2 cycles (yielded 6 and 8 eggs). In the first cycle I think I used an equivalent to Gonal F and had a very poor harvest, 4 eggs, just one poor embie left at day 3. 

I never got to blast stage in any of my cycles and had all 3 day transfers of what looked best at the time, which wasn't always the ideal 8-cell scenario. The reason for 3 day transfer was always that I had few embies to start with and at day 3 it was always clear which one looked best. The leftovers never made it to freeze. To be honest, even this one successful embryo that I'm still pregnant with may not have made it, if I had left it in the dish until day 5. Maybe if the embryos are struggling due to quality, they are better off inside the body... maybe this is something to discuss with your clinic. Hope this helps! Good luck!


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## MrsGoldilocks (Oct 3, 2016)

Thank you for your reply water-lily78.  Congratulations on your pregnancy, it just goes to show that with perseverance things can work out in the end.  Yes we are in the same age group and my AMH is also low.  I too had a poor response first time round with just Gonal F but with a combination of both Gonal F and Menopur I got a good harvest although the quality of the embryos at day 5 wasn't great last time.  Cycle 2 was our best round with two good quality embryos on day 5.  I suppose it is just a numbers game, we are sticking with long protocol and I'm hoping we find a good one this time!
I hadn't really thought about a 3 day transfer, I think with my clinic it depends on how many eggs fertilise as to whether or not they culture them on to day 5, I will certainly discuss this with them.  I had been thinking more along the lines that the high dose of stimms was somehow affecting quality but you have given me something else to think about!  We have had a good fertilisation rate on cycles 2 and 3 so maybe the embryos would be better off in their natural environment inside the body.  Thank you for your help


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## water-lily78 (Oct 21, 2015)

Yes, I believe as long as one produces a decent number of eggs each time, it is worth trying for a little longer than maybe the standard 3 cycles. I never tested for other issues like immunes because it was so obvious that the embryo quality was just bad as a result of both my and DP's factors. My doctors said already after the first 2 failed cycles that with our numbers they'd reckon it would be worth doing a total of 5-6 cycles before giving up on our own eggs, so we planned for a max of 6 and would have moved to donors eggs after that. 
My doctors reckoned that by doing the long protocol it may have improved egg quality also by a fraction as well as getting a couple of more eggs. And we clearly needed just a little edge with higher numbers and a tiny bit of improvement. In my clinics (I switched after the first 3 cycles, always worth changing something to see if that makes a difference!) they would have gone on to 5 days transfer if I had had like 3 or 4 good looking 8 cell embies on day 3. But that never happened for me, so they said there was no point in waiting. If you happen to have several good looking embies on day 3, it may be hard to decide which one should get a go of course and after all, waiting a bit can be a way of making a further selection. Do they transfer more than 1 embryo at your clinic? Here in Sweden they don't want to do that until one is 39 or over, but I did get back 2 in 2 cycles (also the last) as they were pretty confident that I wouldn't end up with twins, looking at my stats. Good luck!


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## ruby100 (Oct 25, 2015)

Hi Both,

I just wanted to add that I too am in the same situation.

I've done 3 x IVF cycles with each one getting worse
1: 11 eggs, 8 mature, 4 blastocysts (I miscarriage)
2: 11 eggs, 5 mature, 2 embryos (nothing tool)
3: 11 eggs, 3 mature, no embryos (no fertilisation)

Really tough decision as we seem to just being given more and more Gonal F too and I'm not sure that the way forward either with regards to quality of eggs.  I'm planning on doing one more cycle before moving to DEs as personally it's very emotionally tiring and I have underlying conditions too.  My next cycle, imminently will be with Menopur as I've not tried that before. And use ICSI

Good Luck!

Ruby x


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## Victorialeanne (Sep 25, 2012)

Hi 

I had two failed long cycles so asked if I could switch to the short protocol I got double the eggs and my little boy was the result with five to freeze I felt so much better throughout that cycle too would definitely recommend


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