Protocols at different IVF clinics - sorry it's long

Hi everyone
By starting this post I guess it's pretty obvious I plan on having another crack at it. #-o
I know from previous posts in here that a lot of you have a lot of knowledge of drugs and dosages etc. I chose to be ignorant this cycle as I used to obsess about everything on my previous cycles. Now I'm sorry. I know I'm 8 years older now than my last stim cycle but I only ended up with 1 good egg this time out of 7 follies. 4 of them were 20mm? I still ovulate lock clockwork naturally and have 5 days of EWCM (sorry if that's TMI).
I was on Synarel (twice a day), Gonal-F (300), Ovidrel for trigger, then Crinone (one at night). From reading some of your posts, I think I was under hormonised (I think I made that word up). During the cycle I had no side effects and thought that was great. Now, I'm questioning if that was because my dosage wasn't high enough?
My first stim cycle (1995 SIVF) I was on Lucrin (15 u?), Metrodin (3 amps?), Pregnyl (10000iu) for trigger then Pregnyl (2000iu) twice post procedure. The dosage was reduced though as I started to get sick. 20 follies and 10 eggs.
My second stim cycle (1997 - CityWest) I was on Synarel (twice a day), Metrodin (225), Profasi for trigger then Profasi (2000iu) every 3 days x 4 times post procedure. 22 follies and 10 eggs.
If anyone out there can help me about dosages etc, I'd really appreciate it before I meet with my specialist next week.
I am also thinking of changing clinics - anyone out there with Hunter IVF (affiliate of Monash) or Monash? I've had very positive feedback from HunterIVF about my situation as well as FertilityFirst (Hurstville is a bit too far to travel from here).
Sue

I have to say that Im not really sure on the dosages on the particular dsrugs you have listed Sue (ie. Metrodin & Profasi). I have only had experience with Gonal F and Puregon.

Sorry...

Thanks Keen
I was starting to think my post was just too long and boring for everyone to take in. It probably is!! :-({|=
Do you mind if I ask how much Gonal-F or Puregon you take? Do you taken Crinone? I was only using 1 a night but I've seen in other posts where most take 2.
Considering I'm almost 43 8-[ I would have thought I'd have been on high dosage.
Hope all goes well for you this cycle.... [-o<
Sue

Sue,

I am curious as to why they kept changing your meds, and each cycle seems different from the other.

My gripe with my clinic was always that they seemed to want to not change anything, and kept trying the same old same old, but I can see from your posts how this may have been worse.

My first two cycles were flare, 100iu puregon and we got 6 and 7 good quality eggs respectively, of which 5 and 6 fertilised. Dr then decided to try for more eggs, and put me on 100iu with a down reg cycle. I didn't respond at all.

Next cycle I was put on 200iu down reg which yielded 10 eggs, only half of which were good quality and only these 5 fertilised. My last (and successful) cycle was also on 200iu down reg, 10 eggs, 9 fertilised, 3 made it to blasts, and bingo, a BFP.

What was different about this cycle? I did a blast transfer instdea of a 2 day transfer. The meds and other stuff was the same. I didn't get the teenist, tiniest bit of HCG in all previous 4 IVF or 3 FET cycles. In fact, I was beginning to believe that I was one fo those women for whom IVF wouln't work.

Also re Crinone. I asked my clinic recently about why I wasn't being given as much LP support as other women, and apparently your P4 levels dictate whether you need more or less. You should ask about your levels and why you're only getting 1 Crinone application a day.

After my 4th cycle, I thought of changing clinics, coz the feedback I was getting from other women at Concept made me believe that they weren't progressive enough. But there is something to be said for being assertive, not only did I get the green light to do blast transfer, I could have had PGD if I wanted, plus I'm the first patient my Dr has allowed to have 2 blasts transferred. Yes they are conservative, but you need to be read up and be able to have a strong hand in managing what you want done. I only decided that after my last failed cycle. I wish I had done it months ago!

I'd been meaning to reply to your post for a while, but coz of the length of it (sorry!) needed a good quiet ten mins. If you want, I'll be happy to have a chat about protocols and what you're had done before, and what you want to try. And maybe give you some idea on how to tackle this next appt.

Good luck.

love
sushee

I'd love to chat about it Sushee. Thanks so much. Trying to find out stuff on the internet is too confusing and I really want to go in this time telling them what I want.
If I'm sensible, I won't change clinics. I'd have to travel to Newcastle and that's around an hour north - a bit difficult for me working full-time and having just had so much time off. I just don't like the fact that my clinic only do EPU one day a week. I still feel that had a negative effect on my follies.
I don't even know what 'flare' means nor 'down-reg'!!!
As for Blast, I didn't even know what that was either. Serves me right for not reading the book but I was trying to be ignorant. Apparently, I'd paid for it - the doctor didn't even tell me about it. But, as I only ended up with one emby they put it back after 2 days. They told me they only do blast if there are a good number to choose from, then transfer the best. They probably didn't want to risk it not making it to 5 days? When the nurse finally contacted me (4 days after I left a message about AF) she said "oh, you'll probably have to go for donor eggs now". I don't really want to do that after just one attempt without adjusting the drugs first.
Anyway, I'm so glad you've contacted me - I knew you would know about this stuff.
I know you are a very busy person, but if you've got 10 minutes here or there to discuss I'd be so grateful. I am unable to PM through BB so here is my email:
smc41003@bigpond.net.au
Thanks again
Love
Sue

Sue,

not busy so much as not really allowed to surf the net at work (have to be sneaky) and not enough strength to fight off the teenagers from the puter at home!

I'll email you...

love
sushee

Sue,
I was on for a stim cycle....puregon or gonal f 150 which was reduced through the injection period to bring up the smaller stubbon bugga's (I usually only had one or 2 big follies) this could give me a pickup of 12 or so , synaral 2 sniffs( I have been known to be sniffing 3 weeks before starting inj) a day then I was triggered with Profasi. Night of P-U I started with pessaries 2 a day.
My Fet cycles were a bit different...I did the hmm can't think of the name of the tablets...hmm starts with P it's the one all the girls take.
My IVF nurse told me about how they were trialling doing Stim drugs and triggering for FET cycles and doing a transfer 3 days later ( this was over 12 months ago) First go at that and bingo.... I wasn't happy with the quality of mine...I was getting so many but not good size, it's a bit of a bugga to go back for scans almost daily and altering drug dosage.
Ohh proganova..thats the P word.
The result of the FET cycle is crying better run...I am so glad you are going to give it another go.
Bec

Hi Sue,
My IVF cycles were down reg stim cycles. First one I was on synarel - 2 sniffs a day - plus 187.5 gonal F. Dr was worried about OHS so he brought me down to 150 gonal f. I apparently had over 20 follies at EPU but only got 5 eggs. I there was only one or 2 that were able to be fertilised but apparently they didn't take.
2nd cycle I was put onto Lucrin jabs instead of synarel and the Dr kept me on 187.5 gonal f. I drank lots of water that cycle and from 17 follies they got 13 eggs.
I can't remember what drugs I used for the trigger sorry.

I'm not sure if there is a protocol for the amount of drugs or type that they use - from my experience (I was using gonal f during my AI attempts as well) they just seemed to be playing around with the dosage until they get it right? I guess next time they will be playing around with my luteal support dx!!

Hope that helps you.
blue xx

Thanks Blue.
I was on down-reg too (Sushee had to explain that and a few other things to me - thank goodness). It's all changed so much in 6 years. Sounds like you and I were on the same drugs. Except my Gonal-F was double yours!!!! But, I had absolutely no side effects! Did you have any luteal phase support?
I don't really have enough time left for them to keep playing around with dosages so I hope they get it right. I really think it was the timing of my EPU that was messed up.
I'm probably just looking for excuses too!!
See what happens on Thursday. Thanks everyone for your comments. I can go to my appointment a lot more informed and know what questions to ask. Wonder if I should throw him and ask about levels????
Sue

Hi there again Sue!
My luteal support was 1 progynova tablet x3 a day plus 1 x progesterone pessary twice a day. That was upped to 3 a day when I started to bleed.
He he - the GP was looking at me strangely when I was talking about "proggy-nova"... then he said, "ohhhhhh pro-gynova..." I like my pronounciation better though!
Yup, I say ask away!! My Dr forgot that he had decided to change me from the synarel to lucrin - had to remind him. Good luck for Thursday. I'll probably chat to you before then - bb addict that I am!!
cheers
blue

hi suzieq

i have heard different things about Hunter... I am cycling through Sydney IVF and so far all good. If you want to email me on leisajane75@yahoo.com.au I can fill in the bits for you..

Love Leis x

Sue- the thing about stimming is this, the drugs do not discriminate as to exactly what follies and eggs are produced. In that you have some good and some bad eggs in your ovaries, which ones react to the stimming drugs cannot be selected. It's a numbers game I believe. Being conservative in your dosage of follicular stimming drugs is always best given that increasing your dose can adversely effect your quality.

Hi Sue, after reading your long long story. Can I ask you whether you have ever tried herbal medicines before?

I know the IVF process is somehow very invasive, maybe you need letting your body adjust a little bit. I know plenty Asian women given birth to their babies around 40. Surely, herbal medicine needs to take longer time so I don't know whether it is suitable for you or not. But for me, I took them for nearly four months this year, I can tell the difference.

Thanks girls.
Sheree, you have echoed what I have been worrying about. Given that I still have 'text book' ovulation during natural cycles, I think my dose of 300 Gonal-F was way too high. I think I may have been overcooked as a very wise woman has suggested. Interestingly, I had no ovarian pain whatsoever during the stim cycle. Even after the trigger. I am in my ovulatory phase naturally at the moment and have had pain for around 24 hours and some bleeding. My poor ovaries are probably still trying to recover.
Hi Luckydraw. Yes, my ex and I tried natural therapies for 2 years before IVF - tok me that long to get him to the clinic. I also used to have 12 months break between IVF attempts and would go back to the natural stuff. The last 2 years we were TTC I tried so many things - chinese medicine, hypnotherapy, aromatherapy, reflexology, massage, the blood-type diet - I could go on and on. I have a chinese massage therapist who is going to make me some rice wine. Just 1 tbsp a night. Not sure if it's any good for fertility but she says it's good for warming the whole system - circulatory/digestive. I really believe it's all connected. Can't hurt!!
Thanks again.
Sue

Actually Sue I get no O pain while IVFing but on natural cycles I do!

Oh, that makes me feel a bit more normal. I was starting to worry they'd done some damage to my poor old ovaries.
Excuse my ignorance, what is OI? Ovulation Induction?
Der
Sue

Yep Ovulation Induction= clomid

Ya, to make the system warm is the way to say (warm or cold). Having herbal medicines is bit complicated esp cooking. But as you say, this sort of medicines doesn't harm your body.

Sheree,

I bow to your expertise, hunny :D Sue was saying earlier that her clinic only does EPU once day a week. Doesn't that sound too easy to miss the right time for EPU?

love
sushee

Sue
Synarel 1 sniff morning and night
then I was on puregon 300iu
I had 29 follicles with 15 of large size on Monday before Thursday OPU -they were going to cancel me because of risk of OHSS.
I ended up with 17 eggs -13 fertilised
11 still on day 1
8 on day 2 - 2 transferred and 6 snowbubs

Trigger was 500iu on Pregnyl and 1500iu daily of transfer
I had crinone gel morning and night
On my FET I was on nothing as supposed to be natural because I 'O' regularly - I asked for Pregnyl for luteal phase support and they finally agreed
on 1st FET they thawed 5 to get 2
Doing this again this cycle with my last little snowbub if it makes it through the thaw...
I always thought 300 was too high but now I am not so sure - not sure what they will put me on if go back for stim cycle in Oct

Trish, it's so good to see you back here (I think - you know what I mean).
Are you ok?
It's all a bit confusing with different dosages etc. I really do think they gave me too much stim, but not enough luteal support.
I have lots and lots of questions for Thursday though.
Have everything crossed for your little icypole to stick!!! Would love to cycle with you again but I don't want to (again - you know what I mean).
Take very good care of yourself and take it easy.
Love
Sue

Hi everyone.
Well I saw Dr Quinn today. He was very good I have to say. Didn't mind all my questions and had no hestitation showing me the entries on my file. I won't be changing clinics. Leisa, you're right, better the devil you know and he really took a lot of time and didn't mind any of my questions.
So, here is the upshot.
My down-reg cycle
7/7 Day 22 P4 - 31.1 Synarel started 8/7.
19/7 Base E2 - 100, LH - 1, P4 - 1.4. Day 12 of Synarel.
28/7 E2 130. Day 6 of FSH.
2/8 E2 945. Day 11 "
4/8 E2 2200. Day 13 "
8/8 E2 3455. Day 17 " Day 32 of Synarel.
11/8 EPU.
Follicles
I ended up with 7 - 20mm, 21mm, 15mm, 15mm and the other 3 too small.
Eggs
Only 2, 1 didn't fertilize.
Embryo
B Grade, 2 cells at transfer (Day 2 past EPU).
My drugs
Gonal-F - he felt 300 was fairly high, wouldn't want to go any higher.
Crinone - again, he felt 1 pessary was sufficient didn't want to overstimulate.
Verdict
My ovaries took a long time to respond and kicked in a bit later than they would have liked. He felt this could have been because it was a down-reg cycle. Could have been the Synarel. I'd been taking it for 26 days before my E2 started to rise. He also said he was surprised and disappointed I only ended up with 2 eggs. I mentioned my age (of course) and while it's obviously a factor, he didn't think that was the sole reason. He seems to be leaning toward the fact it was down-reg. His comments regarding the 1 EPU day were that it worked out well because of my late response to the E2 - it sounded feasible I guess. We discussed ovarian reserve checking. He said doing an IVF cycle is the best way to check that. He didn't seem concerned about that but was honest and said that obviously, my little store is rapidly declining!!
Where to?
He wants me to do a short protocol (flare Sushee?) cycle. Double the dose of Synarel (which doesn't seem to make sense given the above...) :-s and start injections Day 2/3. I asked if Puregon was any different/more successful than Gonal- F - he said no. He said I can try Puregon this time if I want. Any comments on that would be appreciated.
He also suggested injections post transfer (I forget the drug name) instead of Crinone if I want, again any comments on that welcome!. We talked about when I may possibly need to consider egg donation. He thought if the next cycle doesn't yield better results re # follicles/eggs, that in all honesty it would probably be the best option. Think about that if I get to it. He said that most of the hormones should be out of my system so could not explain my still bloated tummy and swollen bbs now at CD14.
So, there it is. I'll probably wait until the cycle after next to jump on the merry-go-round again. That will be mid October. Hopefully, it will be nice and short and not 49 days like the last one!
The best bit I went to Medicare and got $1905 back - a nice surprise. That will help pay for the next one! :smt038
I know this is long and reads a bit like a science paper, but, if any of you have any comments, I'd really appreciate them.
I'm feeling a lot better with regard to my age and it's effect on this little journey now.
Love
Sue :luck:

You sound really calm in this post, like you have direction and are confident with it, thats such a good thing (and not always easy to come by!)
I can't help answer your queries, but it was so good to read how you went, and to hear you feeling positive and determined.

Sue,

There is no difference between Puregon and GonalF, I far as I know. None whatsoever. Just who manufactures it, and what the doctor prefers. I believe Sheree has been on both, and it didn't make a difference.

The short protocol is the flare protocol, which I believe is what is usally used in more mature women (like you and me #-o ). I was surprised to be put on down reg after a couple of flare cycles, but have since found out that my Dr is Mr Conservative himself and generally never does flares. Having said that, of the three down regs I did, the first I didn't even respond, the second, AF was 1 weeks late, and my third, it was nearly 2 weeks late. The flares were infinitely easier on my body.

The Luteal Support your Dr seems to be suggesting is pregnyl, which are HCG shots. It'll mean no HPTs, I'm warning you first, coz they can give false +ves, but in general easier than pessaries and probably more convenient. I've never had them myself but *Tam* has for all her cycles. I reckon I would have preferred them myself.

Your E2 levels are on the lowish end of the scale, where you'd generally be looking at about 1000iu per follicle just prior to surge. Still, I would have expected more than 2 eggs by your levels, but unfortunately the E2 levels are an approximate only.

On the other hand, it is believed that often doctors don't necessarily go for the higher dose of FSH to get more eggs because they want quality not quantity. Where quality may be an issue, there is a belief that trying for fewer eggs will mean better quality.

On the whole, it looks like you're on the right track (and definitely asking the right questions) Are you going for a 2 day transfer again this time? Or will you try for an older embryo if you end up with more to choose from?

Ah decisions decisions! Lol! I hope I haven't confused you even more, but you know my email if I have, matey!

love
sushee

Hi Sushee
Thanks, no, I'm not confused.
Your comments previously about down-reg being used so they have pretty much total control of cycles was right. He told me that.
I mentioned a lower dose of Gonal-f (thinking quality not quantity as you mention) but he wanted to stay at 300.
Pregnyl, that's right. He said I can have it if I want but he did seem to think I'd be better with Crinone. Concerned about overstim.
Thanks for the Puregon comments. Don't really want to go changing everything!!!
We're aiming for Blast (we did last time too). Unfortunately, because I only had the 1 emby, they decided it was best to transfer it. He explained their reason is they go to blast so they can pick the best to transfer. No choice when there's only 1!!!
Thanks for your help.
Are you feeling better? How's the ms??
Love
Sue :luck:

Hi sue

I have replied to you by email.

Sue, so glad your appointment went well and you are all infoed up & in control

I can't help too much on the technical side of things, I consider myself to be a newbie, just do what they tell me.

I used Puregon for my stims & then Pregnyl for trigger & also support shots every 3 days afterwards.

On a couple of my cycles I had to use Progynova (oestrogen) & Progesterone pessaries during my LP as well.
I am using both of these now on my HRT FET. Also had to have a couple of Primogyn (oestrogen) shots to boost up my levels (600 at day 10, should be 800 & at day 13 was over 3000).

Sometimes I go between thinking I should know what they are doing & should pay more attention, but then I think/hope that I will get pg & won't have to/don't want to know anymore.

Hope all goes well

sue,

it sounds like your Dr is balancing the quality/quantity issue quite reasonably by keeping you on the same dose. 4 follies in a good number to aim for, I reckon.

I have had empty follies as well, but it does seem to chop and change between cycles, so am hoping for a better collection this time round for you. I completely understand not going to blast with 1 embryo - I would have wanted to transfer it as well!

I'm fine too, thanks for asking. No ms for two days and then bam! last night it was back with a vengeance. I gather that some foods (like Chinese) seem to bring it on! Lol! Have taken my own MHD today to get over neurosis of vanishing/returning symptoms, and also coz I'm still a little green in the gills.

So, it all start again for you In Oct? So exciting!

love
sushee

Hi Sue,

Yay!

Sounds like your appointment went pretty well. What is a down-reg cycle? It does sound like a bit of science paper :D But it is really exciting that you will be trying again. Hopefully we will be cycling around the same time.

It's great that you money back from medicare. How much out of pocket expenses did you have?

ttys.

Hi girls
*Tam* Thanks for the info. I remember now I had Pregnyl for my first GIFT 10 years ago. They had to reduce the dose after the 2nd injection post procedure though as they were worried about overstim. I'm still not sure what to do about the post EPU support. Plenty of time to think. When I was on IVF before, I questioned and researched everything. Drove myself around the bend and worried about everything. I was determined not to do that this time. It meant I remained relaxed throughout the cycle, however, when I was unsuccessful I started to question everything. I guess it depends on how much of a worrier you are. I still believe sometimes ignorance can be bliss. 8-[
Hi Chris, still getting to my emails!!! Thanks for responding though, will have more time tomorrow to get stuck into them. :smt024
Hey Sushee. Glad you're feeling better. Good on you for having a MHD. Pamper yourself while your pg, no point pushing yourself for your job (especially a govt one!!) - bub comes first. I'm pretty happy with my dr, he was very patient and didn't treat me like I was trying to be an amateur doctor. I'm hoping it was just a flukey off cycle - it's been 8 years since my body has been through this. Everything is still sore in my internal girly bits though. He said it's probably bruising from the EPU. Funny that I didn't feel it as much before as I am now. I actually believe I know exactly where my ovaries are now. I've just ovulated so they're probably a bit sensitive. Yep, probably start around 6 weeks from now. Definitely want a cycle's break considering the bloating and pain I still have from this one. How long did your flare cycles go for? The only other suggestion he had for me was a good multivitamin. Any suggestions? I'm taking folic acid and calcium supplements.
Hi Teagan, I ended up being $1910 OOP for a long-protocol ICSI cycle. That included all drugs and monitoring.
My first day payment was $4025 (not much if you type it fast and don't reread it). :-$
That included $3270 for ICSI, $650 for blast - that didn't happen so they refunded that. It also included $105 for donor sperm. My appointment yesterday was $90.
Medicare gave me back $1905. So, the clinic got $1560.
My counsellor's appointment was $100 - not claimable. I forget how much my initital appointment with Dr Quinn was or whether I could claim it.
I had to pay $250 excess for the hospital (haven't looked into that with my fund yet).
I don't think a flare cycle is any cheaper, however, ICSI is $200 cheaper for subsequent cycles.
Sorry it's long again ladies. I'm a bit of a jabber-jaws :-#
Love
Sue :luck:

Teagan, I hope I didn't scare you with all that info. Sushee and a few of the other ladies have been helping me with lingo and dosages so I put it all in - they're experts.
I didn't know what down-reg meant either until Sushee explained it. My clinic calls it 'long protocol'. A 'flare' cycle is what my clinic calls a 'short protocol'. Down-reg they start you on Day 22. You take hormones for longer so they can have almost total control of your cycle. Mine went for 7 weeks, I think 6 weeks is probably closer to the average.
As Sushee said, they usually use 'flare' cycles on we "mature" women.... They start you on the drugs on Day 1 and it should be a bit shorter and easier on the body.
That's not an explanation - I know. But, again, don't get ahead of yourself, you're young and healthy so am sure you won't need a proper explanation! [-o<
Love
Sue :luck:

Actually Sue, I forgot to add in that my IVF cycle was a flare cycle. Seemed to go pretty quickly. Don't know if I could handle sniffing the Syneral any longer than I did!