# Can we compare med combinations for the over 40's



## pucca (Dec 12, 2008)

I have had 2 3 cycles, and have always been on 300 gonal-f or 375 menapur, stimulation has been for 8 days, and I have been unsuccessful.I have a clinic offering to monitor me closely, and in the last 4 days increasing the dose to 600 manapur a day. My FSH is always between 8. x.

Has anyone else has such high doses? I am thinking of one more try with my own eggs but trying to arrange donor eggs at the same time, so if mine are not up to scratch again, it wont be a total waste of time.

Let me know thanks


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## ElsieF (Nov 26, 2009)

hi there
I have been on antagonost protocol with 300 gonal-f for both my ivf rounds. the first was for 10 days, this one was for 9 days.
the first one made 14 eggs, but 6 were immature. we got 4 embies from the remaining 8, which  have been told is about average (50% for someone my age)
the second made 12 eggs, but 5 were immature and resulted in only 2 viable embies.

I would be defintely be interested to hear what prescription/ protocols others in our age bracket are on.
is there anyone on higher than 300? (the pen goes to 450!)

ecf


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## ☼♥ Minxy ♥☼ © (Jan 13, 2005)

Hi there

All my fresh IVF cycles have been long protocol with downregging starting cd21.  Gonal F (pre-filled pens) doses have varied between cycles and have been increased/decreased according to my response.  My FSH levels have been between 6.3 iu/l and 7.9 iu/l and my recent AMH was 16.3 pmol/l.

1st IVF (age 37):  Started 225IU Gonal F and increased to 450IU after 1st stimms scan.  21+ follicles - 10 mature eggs - 7 fertilised - 6 grade 1's on day 2.

2nd IVF/ICSI (age 3:  450IU GF for first 4 days, 300IU GF for 4 days, 225IU GF for 2 days, 75IU for last injection.  28 follicles (risk of OHSS) - 19 mature eggs - 10 fertilised with ICSI.  Day 2: 7 grade 1's and 3 grade 1-2's;  Day 3: 5 grade 1's and 3 grade 1-2's.

3rd IVF (age 3:  300IU GF for 6 days, 375IU for rest of cycle.   27 follies - 16 mature eggs - 8 fertilised.  Day 2: 5 grade 1's and 3 grade 2's; Day 3: 1 grade 1 and 7 grade 2's

4th IVF (age 39):  450IU GF for 3 days, 300IU for 5 days, dropped to 75IU after 2nd scan.   40+ follies (high risk OHSS) - 30 mature eggs - 14 fertilised.  Day 2: 10 grade 1's (don't know grade of remaining 4 but believe they were grade 2's);  Day 3: 6 grade 1's;  Day 5: 4 blastocysts 

5th IVF (age 40):  450IU Gonal F for 3 days, 300IU for rest of cycle.  23 follies - 12 mature eggs collected - 6 fertilised.  Day 2:3 grade 1's and 3 grade 2's; Day 3:  2 grade 1's and 2 grade 2's


So quite a bit of variation in drugs doses and responses through all my cycles.

Take care
Natasha


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## pucca (Dec 12, 2008)

I was on Gonal f 300 units for 8 days.I had no tests at all, but had 2 scans to look at the follicles.So when I hear about your doses being increased or decreased, I am a little suprised. I did not have any blood tests, except on day 21 the cycle before treatment, I would test my fsh, which was 8.xxx.I cant remember. 

The Menapur was 375 units a day, and it was the same process, one scan on day 7, there were 3 follies but this time there was nothing. So I went on to DE, and there is this niggling thought at the back of my mind that perhaps I should try again with my own eggs , just once, if I get the chance, and coincide it with DE for backup. I do not think I can ever go through the "no eggs to fertilise" chat again and time is running out at almost 43!

I know that Gonal  f is much more expensive than menapur , but I wonder which is the more effective, or are we all just different so there is no better or not? So I am thinking the fact that I had a better response with Gonal f , indicates that I should maybe go for that as opposed to Manapur? Has anyone tried both? Any differences in  egg numbers to fertilise?

I find it all a bit mind boggling, and I want to understand what is going on. Then when I make decisions they are kind of informed, or I can ask alot of questions so I get a better chance of success. I realise that the fact that I have had no real monitoring except one scan, indicates that I probably need a clinic that offers a better process especially when using my own eggs. I cannot complain about my clinic as I believe that they offered me a good price on DE based on the fact that they knew they had not given me the monitoring I needed for me to actually produce any eggs. 

Then again maybe my ovarian reserve is really low. It was not really explained to me. I read on the site that one woman said that at her clinic they give the same protocol doses to everyone no matter what their ages. I was shocked at this, and so was she so she changed clinics, but she had already had 2 cycles with them, so it was a bit of a waste , as she was also in the older category.

I have no time for recriminations but I do definately need to know more.

Thanks for your posts.


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## ladyroxton (Sep 26, 2003)

I'm 41 and had two rounds this time.  The first was with Menopur at 450 per day - I was on it a week, had two scans and was in for my EC before I knew it!

Second time was 450 Gonal-F - was on this for 10 days before I had EC.

I tend to find that Menopur makes my follies grow like wildfire but the quality is not so good.  Gonal-F takes longer and there are less follies for me but they're better quality.

Also had FSH and AMH tested.  FSH was 9.  AMH was 13.9 first time around and 11.3 the second.


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## pucca (Dec 12, 2008)

Thanks for your post. I tend to agree with you. I Gonal actually produced more follies and eggs, than the Manapur did nothing for me. We know that at my age the chances are 5%, but then if one is goign to give it a go, then it shoudl be a good go. I have not had AMH tested ever, I do not really know what it is, but this was the reason for this thread. I am sure that we can all learn from each others experiences, and ask questions so we can get more answers about our given treatment.

Though they are the experts I think they can get a bit over confident about what they know, and forget that all we are paying for is a chance, so no stone should be left unturned while we still have that chance.


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## ElsieF (Nov 26, 2009)

hi everyone,
I think this thread could be really useful

Pucca - AMH is where they test your ovarian reserve - i.e. how many eggs you have left. I asked my doc about this and he said that our age, our age is a better indication than any expensive test. The test is good at identifying prematurely aging ovaries (rather than already aged!) 

By the sounds of things there is quite a difference between different clinics as regard treatment protocol / monitoring / environments

I am at 92 Harley St, and I have been on the 'antagonist' (or short) protocol for both my IVFs'. 
I get the following 
1st scan - day 6-8ish
2nd scan - day 10ish
and then I have had egg collection on day 12
I have been on the same dose of gonal F throughout (300ml)

No 92 is a lovely place, with nice sofas and a big screen in the scan room so you can see everything. They are not open weekends, so scan times work around this (or you have to go to the Hammersmith Hospital) They also work regular hours, so scans are within the 9-5 period.
For ec and et, this happens at Hammersmith Hospital which, although the fertility centre has a seperate waiting room & treatment rooms from the rest of the hospital, it is still an NHS hospital so customer service (i.e. commuication etc) is as you would expect. They are quite efficient though and have a good system (i.e. you don't have to wait for hours in the waiting room etc)

From scanning some of the other threads, it sounds like ARCG (?) and some other places do a lot more varying of meds, and scanning throughout the cycle. 
Do any of you ladies have any expereince of this for over 40's?

(i guess I am trying to work out if there is a way of dealing with my producing 12-14 follicles, but only half of them being mature at day 12.. would varying meds be able to kick start the slow ones earlier so they catch up?)

elcf


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## pucca (Dec 12, 2008)

I wish I produced that many follies!
Once they have fertilised the eggs, how do they explain the cell splitting? Do you take it to day 5, or day 3, before egg transfer, and how has the little egg been splitting? I think that this is vital, because there are alot of us in our age group who produce an egg(s) that are fertilised, but when ET takes place how has the egg(s) been performing? If it is fragmented or has been slow at splitting, it is an indicator that it may not work.It seems harsh , and is by no means fool proof, but the quality of the egg produced is apparent at this stage.

If the egg can keep splitting away, I know I am not using the correct terms here, and can reach that day 5 Blastocyst, then we have a good chance. It was very hard to find information on this


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## ElsieF (Nov 26, 2009)

the embryo dividing is called cleavage, and the embryo is graded according to how much (or how little) fragmentation there is.
I think that the decision to take things to blastocyst (day 5) before ET is only really relevant to those people who have enough good quality embryos that they need to select the best ones. Watching how they develop in a petrie dish allows them to make a better choice.
for us older people, we rarely (if ever!) have that problem! so I think the doctors like to put whatever they have back asap, as it is better for them to be inside the mother than out!

I don't have the reference handy, but if you google 'rate of cleavage' and 'embryo quality' you might find a paper I read on some research that said that the rate of cleavage has little effect on BFP, but that embryo quality does have some effect.

but basically - they really don't know. once it is in there they can't see anything!!


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## pucca (Dec 12, 2008)

tHis is so true, it says that the eraly cleavage is a good indicator or egg quality, and so of pssible pregnancy. I very warn you it is a long paper,but very interesting(that embryos with a slow cleavage rate in vitro are less likely to produce pregnancy following IVF-ET and that the cleavage stage is a valuable criteria in the selection of the best embryo for transfer) I would not say it is fool proof as nothing is in this game, but it should allow us to be more realistic with out hope.The full article is below.

http://humrep.oxfordjournals.org/cgi/content/full/16/12/2652:
A stepwise logistic regression of all data showed that the total number of  good quality embryos and female age were independent predictors of both pregnancies and birth. For intracytoplasmic sperm injection (ICSI) embryos, early cleavage was found to be an independent predictor of birth. CONCLUSIONS: Early embryo cleavage is a strong biological indicator of embryo potential, and may be used as an additional embryo selection factor for ICSI embryos.


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## teresal (May 2, 2009)

Hi Ladies

can i join in

on my first go at IVF i was on the short protocol and that was Gonal F 300iui for 14 days and Cetrotide for 10 days, got 8 eggs 6 fertilised but only 2 good enough for transfer on a 2 day transfer, unfortunately it was a BFN

second try i was on the Flare protocol and that was taking Norethisterine tablets for 10 days, started af, took Syrenal sniffer for 8 days and Gonal F 300 iui for 5 days, we got 6 eggs, 4 fertilised and had 3 that that were good enough for a 3 day transfer, put all 3 back and have ended up with a singleton pregancy

teresa xx


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## catwaving (Jan 15, 2010)

Hello Everyone

I'm quite interested in protocols too!!!  

Mine were as follows:

First IVF - Short protocol of 450 menopur plus cetrotide to prevent ovulation (got pregnant, overstimulated and miscarried at 14 weeks)
Second IVF - short protocol of 375 menopur plus centrotide (got pregnant, miscarried at 8 weeks)
Third IVF - frozen transfer (got pregnant, miscarried about 8 weeks)
Fourth IVF - short protocol of 375 then 450 menopur plus cetrotide (cycle was immediately following miscarriage, didn't get pregnant that time)
Fifth IVF - short protocol of 225 menopur plus cetrotide (6 eggs, 5 fertilised, 4 grade one embryos, 3 transferred and singleton pregnancy now at 9 weeks)

I really do think they should tailor protocols for different people.  I also think we're pumped to full of drugs.  It was 2 whole years ago that I was on 450 menopur and I overstimulated, this year I used half that and have the same result.  I think they want to get big numbers and sometimes forget that all we really need is just ONE good quality egg really.  My clinic felt the same so I chose them for the most recent try.


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## pucca (Dec 12, 2008)

So you took centrotide with Manapor , or one before the other?


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## teresal (May 2, 2009)

Cat -- like you i aggree we only need one good egg not lots of rubbish ones, at our first clinic they seem to do the same protocol for everyone, but when we changed they took their time and looked at me as an individual and i used a lot less drugs the second time and only got 2 less eggs but they where better quality the second time and we had 3 to put back, so maybe more drugs doesn't always mean better results

teresa xx


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## Kateu (Mar 22, 2010)

Hi all

We start our 1st attempt in a few weeks, just after my 42nd birthday. My prescription is for Buserelin (0.3ml a day for ovary suppression), puregon (FSH) and then pregnyl for the stimulation at the end, together with cyclogest pessaries (ooh, sexy!).

I've no idea if it's short or long but as long as it works I'm not fussed!

xx


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## ElsieF (Nov 26, 2009)

As regards getting better quality eggs - does anyone know the relative merits of clomid versus regular IVF drugs (i.e. Gonal-f, menopur etc)?
Here is an article (well advert actually!) on the 'japanese mini-ivf' protocol. Essentially they are claiming that for older women, taking clomid instead of injectables results in higher quality eggs. Does anyone know of any literature that backs this up? why would that be the case? perhaps because there is less drug interference / less potential stress damage on the ovaries/eggs? (i am guessing here!)

This advert does point out some obvious merits of this protocol 1. it is cheaper as clomid is cheaper than injectables 2. no (or fewer) injections! 3. less stress on our ovaries(?) 
but essentially we are still talking about undergoing egg collection + fertilisation and then FET, so the reduction in cost is negligable really.
As I understand it, clomid isn't as stong as the injectables, so this is only likely to work on women who produce a relatively good number of eggs on injectables. (i.e. those producing 8 or 10 follicles with injectables are likely to produce only 2 or 3 with clomid)

So, the only reason this would be worth it is if it really does help with the quality.

http://www.infertile.com/inthenew/lay/Health-Harmony-07.htm

elcf


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## pucca (Dec 12, 2008)

The thing is it is not an exact science.In older women there is evidence that the results from injectables and the results from clomid are similar. My Gyno had said to me that he would have put me on Clomid first before all of the injectables as it does not mean better results, I ofcourse was already in Czech for IVF so was not really taking it in,He said if I was czech this is what he would do first.

With hindsight, and all the drugs and all the money I have spent with no success so far.I can say it is a valid point. Looking at the drug combinations we all take, and all the rest, they cant make us have a baby, it is still our bodies that have to do alot of the work.All the drugs do is try to make you produce more. This is relying on the fact that on that cycle you can produce any, or the few we do produce are of any usable quality.

The exact science we all spend so much money on relies 80% on your body doing what it needs to do any how. Clomid makes the body do more of what it is supposed to do, so it is not such a bad idea to give it a go.Yes it is much cheaper, as we spend on average 2.5k on meds for a round at our age, and 3 months of clomid must be less than 10th of that. I find the end bit of the treatment, the ER and ET the easy bits, though having the leggs in the perched with people prodding is not plesant, but the fate is already sealed at that point. While we are taking the injections and stuff we are all over the place as we feel that every step is vital and we do not know whoich one is making the difference.

I cannot say that a cycle would hurt success rates, it just might work because it would be unexpected and less stressful.One would not need to do the ER and the ET really, unless there is a valid reason for it ie blocked tubes, low sperm count etc. One could just try the clomid in between cycles and see what happens.Can you see my logic? Stats show that the over 40's are as likely to get pregnant naturally as with IVF. We go for IVF to increase our chances of success, but, the reserves for most of us are so low, that you do not know when you are going to produce the great quality eggs, and so cant be sure that that will coincide with treatment.

This is our reality, don't you think?


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## pucca (Dec 12, 2008)

I just read the article again, and it is saying that it uses clomid to induce ovulation and egg collection. Then it has a new technique for egg freezing which means that you would be producing as many eggs as possible first.Then because our lining cant get thick on clomid they would do ET on a clomid free cycle , using progesterone to make sure the environment is conducive to ET. Very interesting, and would be less streessful too, if we lived in Japan!


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## pucca (Dec 12, 2008)

It would seem that it is quite popular for the over 40 s.
......New York that are looking pretty affordable compared to regular IVF http://www.newyorkfertility.com/affo...natural)_cycle $3,000 per cycle and http://www.newhopefertility.com/cost...nsurance.shtml $7,000 for 3 cycles. I also just found http://www.olywomen.com/natural.htm .... I am guessing that there must be many other clinics that do it rather than just Japan.

I have started looking for clinic all over europe, and there are quite a number, so I guess it is an option to consider.This is what I love abou tthis site, someone says something, and you go and look it up, and you never know how many people might just get spurred into getting pregnant, and having a live birth. It is priceless! Gotta sleep now.


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## ElsieF (Nov 26, 2009)

the problem I find with US sites is that I find it difficult to distinguish between IVF clinic marketing, and actual scientific facts. The 'market' is so well developed there, that it could be perfectly feasible for a clinic to want to market to the segment of women who  don't like the idea of lots of drugs, so claim that clomid 'increases the quality' of eggs. I can't see how it can, and I can't find any actual scientific evidence..

anyway, considering that all it takes is a prescription for clomid, then a scan on day 12, folowed by a decision as to whether to continue to EC/ET as ususal, then surely there is little reason for any ivf doctor not to give it a go if it is what we want? I am thinking of just asking mine. travelling to the USA / Japan seems a bit drastic! 
My understanding is that the downsides are:
- clomid can cause cysts
- clomid can thin the lining (so they sometimes wait a month before ET)
- and if the above happens, then you run the risk of the embryos not surviving defrost.


The US clinic go on about 'vitrification' as a new (special!)  method of freezing, but I understand that is is fairly normal in UK hospitals.


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