Antagonist protocol

[rena]

All,
Does anyone use the antagonist protocol for IVF cycle? I did some reasearch about this protocol and found that the pregnancy rate for this protocol is lower than the long protocol (lupron protocol). I am very concern about this since I would start IVF cycle at this month.
Thanks in advanced!
Rena

[fishdoc]

Hi Rena,

we did the antagonist protocol last round. As for the success rate - it depends on who is using it. So, if you took all women undergoing IVF, and ran half on the standard lupron flare and half on antagonist, you would have a lower pregnancy rate on the antagonist. That is because there is a higher cancellation rate (ovulation will happen before retrieval) somewhat more often with the antagonist protocol.

Also, if you just look at the pregnancy rate for women using antagonist protocol vs those using std protocol, you would ALSO see a lower success rate, but that is because antagonist is generally used with women who are low responders, so naturally they don't do as well.

If, however, you look at just women of advanced maternal age and low responders, and compare the results of standard lupron protocol vs antagonist, you would see that antagonist does better. My personal experience is in line with this - Mrs Fish had 4 follicles on the standard lupron protocol, but the next round we did antagonist (my choice after researching and reading papers on the topic), and she had 14 follicles. Still a BFN, but at least a step in the right direction.

So - is this your first round of IVF? I can't recall - but if you did poorly on the clomid challenge, have a high FSH, or maybe just because you are older than 35, it makes sense that the doc might go straight to antagonists.

Fish

[rena]

Fishdoc,
Thank you so much for your info. Yes, it's my first IVF. I am 42 years old. My FSH is 6.05 but my AMH is 0.5 (which doctor thinks it is not good for AMH). I didn't do Clomid challenge test when I took Clomid. I had very bad side effects when I took Clomid so the doctor skip CC test this time. I tend to ovulate early ( less than 9 days of stimulation) during IUI and that's why I am so concern the if I used antagonist protocol I will ovulate before retrival. I just heard a story about antagonist protocol. She ovulated before retrival and ended up with only one egg to work with and that resulted in BFN. She did the standard protocol before and success with a son. I am so concern about the time of ovulation. Do you think I should talk to doctor tomorrow to change the protocol? The problem for me is if I change the protocol now I have already booked the air ticket on 5/21 and I have to change the ticket as well. Will Mrs. Fish do the antagonist protocol the upcoming cycle?
Thank you so very much for your help!
Rena

[fishdoc]

Rena,

I can't really offer much advice on this, other than to say that I don't give too much weight to anecdotal stories. That is, everyone knows someone who had a particularly good/bad experience with a certain protocol, acupuncture, medicine, etc., but you have to play the odds, and so I tend to read*through the medical literature and base my decisions on that. And the literature suggests that for people with low ovarian reserve (and while your FSH is good (like Mrs Fish), your doc seems to think your AMH is low (we have not had that test, but I know it is simply another way to measure ovarian reserve). And for folks with low ovarian reserve, either microdose Lupron or antagonist protocols are generally more successful that standard Lupron ones. Of course, we are all individuals, so some folks react differently than normal, and you never know.

Right now, there are no good studies that show a definitive difference between microdose and antagonist, but both have been shown to be generally better for low responders than the standard protocol.

My advice would be to call your doc and tell him or her your concerns, and see if they can reassure you. If not, changing a ticket, in the grand scheme of things, is not that big a deal, but definitely listen to your doc - you do NOT want to go making medical decisions against your doctor's knowledge, just because a person you know had an unusual experience.

Keep us posted!


Fish

ps we are doing microdose Lupron this round - our doc and I sat down and went over the scientific papers, and decided that there was no logical reason to choose one over the other (antagonist vs microdose). He said "it isn't rational, but sometimes, if there is no science suggesting one way or the other, I like to try somehitng new to see if it helps", so we are doing microdose. Believe me, it was an agonizing decision - I decided that no matter what we did, if Mrs Fish responds badly, we will kick ourselves ("Oooooh - we should have domne the other thing!"), so we basically flipped a coin.

[rena]

Dear Fishdoc,
Thanks a lot for your help! Did you do microdose lupron for the 1 IVF or the standard lupron? I am just very worried about the antagonist protocol. I asked the nurse about the protocol and she told me there is not name for it since the just tried for now. But I figured out it is antagonist protocol. I read your old post and knew you Mrs. Fish took bcp before the injection. My protocol didn't have me taken bcp. Instead, I will take estrace (don't know if it is right) 10 days after my LH. Then after I get period this cycle around May 16 I will do baseline and start stimulate on day 3. I will take Gonal-F, Menorpur first and 5 days later I will take Genorilix and then trigger.
Is this the same as Mrs. Fish took for 2 IVF.
I truly wish you and Mrs. Fish success this time.
Thank you !
Rena

[fishdoc]

Hi Rena,

we did the std Lupron protocol for the first round. One thing to remember - there is some "endogenous" and some "exogenous" parts to every treatment cycle - that is, even if you did the same protocol, with the same meds every time, sometimes you would get more eggs, other times less - so while the protocols try to maximize success, and some definitely work better than others, there is always variability in response. So, we are not SURE that we would not have had a good repsonse if we did the std protocol the 2d time - but if something is NOT working, there is no sense in not trying soemthing new!

So, let me see - I just had to look some of this up, because I never thought about it in depth - my understanding of taking bcps (technically "combined oral contraceptives" or "coc's") before IVF is not very technical - simply that it sort of "calms things down" in prep for the stimulation. So I looked it up, and the coc's are a combination of estrogen and progestin. Each of those does different things when acting as a contraceptive, but it looks like (base don what I am reading now) the estrogen (which is what "estrace" is) acts to thin cervical mucus, inhibit ovaries, and increase endometrium - all things that you would want getting ready for IVF! Why doesnt your doc use COCs? I have no idea, but to me (as a non-medical doc), it sounds like this will be doing the same thing. I should note that there IS good evidence that COCs improve results in low responders.

Your Ganirelix is one of two types of antagonist they make - it is a generic version of Antagon. We used Cetrotide, but they are basically the same.

Day 3 start of stims is pretty standard (although various docs argue back and forth about day 1 vs day 3 vs day 5, there are no definitive studies showing any difference, and most seem to do day 3 these days). The Gonal F and Menopur (what we are on this cycle) stimulate the ovaries, both in slightly different ways, and then after a few days of stim, you need to start the antagonist to make sure you dont ovulate. Be VERY precise about taking your antagonist at EXACTLY the same time every day. Many of the cycle cancellations are from people taking meds incorrectly - if you do it 2x a day (I think that is it, but cant recall), then make sure you do it at precisely the same time every day.

If I were you, I would call and talk to the doc, if possible (not just the nurse, although the nurses are incredibly knowledgable, it will ease your mind if you can talk to a dr., I bet). Ask him about the COCs, tell him you are weorried about the cycle, and let him/her reassure oyu.

Hang in there!

Fish

[rena]

Dear Fishdoc,
Thank you very much for your help. I found out there is another protocol called"Estrogen Priming Protocol" which is very similar to antagonist protocol.
Have you heard about it? Is the antagon medication IM or sub - Q?
Thanks a lot!
Rena

[fishdoc]

Rena,

I have never heard of the estrogen priming protocol, but it sounds like it is just a variation of the standard antagonist one. Basically, there are tons of "protocols", in that some docs give bcps, others dont, others use menopur and gonal, some just gonal, etc etc - the varieties are endless, but the basic protocols are pretty similar. The antagonist drugs are the newest thing for us advanced maternal age folks - they have not been shown to be definitely better than microdose lurpon, but they havent been shown to be worse either, so many docs are trying it.

A lot of this depends on statistical concepts like sample size and effect size - it is very, very difficult to get a ton of people in a controlled, randomized study for these things. It is expensive, people don't want to be "guinea pigs" ("hey, why do I get the experimental treatment when they get the proven one?"), etc. But imagine there is a very small effect size - say one drug is about 3% more effective than another. It takes a HUGE number of people to be able to statistically prove a difference that small. And yet, even a "small" effect like 3% would mean 3 out of 100 owmen might get pregnant who would not otherwise - when you think of it in human terms, not statistical ones, that is a big deal. 3 lives permaanently changed.

I guess I am just thinking out loud here, but the bottom line is that a lot of this is an art, luck, intuition....your doctors may not be able to "prove" that treatment A is better than B, but if they have a hunch that it works, I tend to go with their experience (if I trust them generally).

Anyway, sorry for rambling - was just in a conversation with a woman I know, who (while young) was ttc for 3 years, and was told to give up, because she "has the eggs of a 50 year old". They were looking for an egg donor when she got pregnant by accident! Got me thinking about this stuff a lot today...

Fish

edited to add - it is sub-q

[rena]

Dear Fishdoc,
Thank you very much for your help!
I talked to nurse today (the doctor asked the nurse to answer my question, he thought it's need to talk to me) and she said the reason the doctor put me in antagonist protocol is he thought I would be over supressed if I took bcp which required by microdose lupron protocol.
Anyways, I just go for it. My insurance doesn't pay anything for IVF. I am so stress out. If it doesn't work we would go for adoption. The IVF process is very stressful and the doctors are difficult to reach.
I am so thankful for you to answer all my questions.
I truly wish you and Mrs. Fish success this round.
Thanks again!
Rena