yes, thanx doctor one more thing are all this protocol last the same time like in weeks like the long protocol i was told it takes 6weeks?????? thanx so much......
ivf protocol
August 27, 2008
hi doctor Q. they told me there is diff protocols like short protocol and microdose protocol and antagonist protocol and long protocol and i would like to know what is the diff. between all this and if they are all the same in time cause like they told me long protocol is 6 weeks so i was woundering if all the protocols are the same time thanx
Garcia- this might help:
Long Lupron Protocols - also called "down regulation" or "mid-luteal Lupron" protocols
Long protocols are more commonly used for most patients going through IVF. In general, pregnancy rates are thought to be better with the use of this type of stimulation. The Lupron is started about 7 days prior to the next expected menses (what we call mid-luteal), and the FSH product is started within the first 2-6 days after menses begins. The Lupron dose is usually reduced when the FSH product is started. The exact dose and "flavor" of GnRH-agonist (e.g. Lupron, Synarel) and FSH product (e.g. Follistim, Gonal-F, Repronex) will vary according to the individual biases of the physician and the specifics of the patient's case.
Stop Lupron Protocol
Some women are "over-suppressed" by the standard long Lupron protocol, or are low responders for some other reason. A "stop Lupron" protocol is one possible way to get a better response to stimulation. The "flare-up" protocols are another option. Some reproductive endocrinologists will try a stop-Lupron protocol in the next attempt after a poor stimulation and others prefer to use a flare. To a great extent this is trial and error - we are never sure what the stimulation will be like until we do it.
The Lupron is started at the same time in the cycle, but usually at a lower dose, e.g. at 5 units daily instead of 10 units. The Lupron is then stopped completely after the woman gets her period and the FSH product is started.
The LH suppressing ability of this protocol is not as complete as with the standard "long" Lupron protocol. However, the risk for a premature LH surge is still low, and blood tests can be done during the cycle to watch for any LH increases.
--------------------------------------------------------------------------------
Flare Protocol
In this type of stimulation, the Lupron (or other GnRH agonist) is started on cycle day 2 in the same menstrual cycle that we will retrieve the eggs - instead of starting it a week prior to the start of menses. We are trying to take advantage of an initial "flare-up" response of FSH and LH release from the woman's own pituitary gland that usually occurs in the first 3 days of Lupron administration. Continuing Lupron for more than 3 days temporarily suppresses the pituitary gland so that it has very low output of FSH and LH.
The FSH product (e.g. Follistim, Gonal-F, Repronex) is then started on the following day (day 3). The idea is that the Lupron will stimulate release of a large amount of FSH (and LH) that will jump-start (flare-up) the follicles so that we might have a better ovarian stimulation with more mature follicles and more eggs to utilize with IVF.
Birth control pills are usually given for the month before the flare so that there will not be a leftover cyst (corpus luteum) that could become reactivated by the high LH levels at the onset of the flare stimulation.
An example of one flare protocol is given below - there are many variations on the theme.
1. Birth control pills for 1 month
2. Stop birth control pills - no meds for 2 days
3. Start Lupron on the third pill free day. We use a 50ug dose of Lupron twice daily -AM and PM- for these flare cycles.
50ug is a very small dose as compared to the usual Long Lupron protocol dose of 0.5mg (500ug). The Lupron needs to be diluted by the pharmacy or the doctor's office in order to be able to inject such a low dose.
4. Start injections of the FSH product (once or twice daily) on the day after starting Lupron
5. The Lupron is usually continued at the same dose until the HCG trigger shot is given.
Ovarian Stimulation Using GnRH-antagonists
Ganirelix acetate, also called Antagon, became available in the U.S. in the spring of 2000. It has been used in Europe for much longer. Cetrorelix acetate (Cetrotide) is another GnRH-antagonist that is now available in the U.S.
Ganirelix and Cetrotide - as well as Lupron - prevent the woman from having an LH surge. However, Ganirelix and Cetrotide are antagonists instead of agonists. Ganirelix works by competing with native GnRH molecules at their binding sites in the pituitary - while Lupron works by "down regulating" the pituitary's ability to produce the LH surge. This distinction is not important to understand. The bottom line is that both kinds of drugs, antagonists and agonists, prevent LH surges (in different ways).
Ganirelix or Cetrotide are usually started on (about) the sixth day of giving the FSH product that stimulates the development of follicles in the ovary. They are commonly given subcutaneously once daily and continued until HCG is given. Cetrotide can also be be used as a single shot (in a higher 3mg dose), rather than as daily injections of the lower 0.25mg dose. When the single 3mg dose is given, Cetrotide is supposed to give 4 days of suppression (no LH surge for 96 hours). If the patient needs more days of stimulation beyond the 96 hours, the daily 0.25mg Cetrotide injections are given until the stimulation is completed and HCG is given.
Use of Ganirelix results in less total number of shots being taken during the stimulation cycle than with the use of Lupron. However, there is some evidence from the published literature that there are slightly fewer eggs retrieved (on average), slightly less embryos available on the day of transfer (on average), and slightly lower pregnancy rates than with the use of Lupron. However, this is when all patients are given the same protocol (Lupron vs. Ganirelix). Pregnancy rates are excellent with Ganirelix when used properly in selected patients. We use it for almost all of our egg donation cases and see excellent pregnancy and live birth rates with it in the donors. More studies are needed to further clarify this important issue.
Some clinics are reporting that women who are low responders to ovarian stimulation protocols that involve use of Lupron might be able to stimulate better if an antagonist such as Ganirelix is used instead. This deserves careful study in randomized controlled trials of previous low responders to see whether it will be a viable alternative to the other ovarian stimulation regimens for low responders such as the "stop Lupron" and flare protocols.
Long Lupron Protocols - also called "down regulation" or "mid-luteal Lupron" protocols
Long protocols are more commonly used for most patients going through IVF. In general, pregnancy rates are thought to be better with the use of this type of stimulation. The Lupron is started about 7 days prior to the next expected menses (what we call mid-luteal), and the FSH product is started within the first 2-6 days after menses begins. The Lupron dose is usually reduced when the FSH product is started. The exact dose and "flavor" of GnRH-agonist (e.g. Lupron, Synarel) and FSH product (e.g. Follistim, Gonal-F, Repronex) will vary according to the individual biases of the physician and the specifics of the patient's case.
Stop Lupron Protocol
Some women are "over-suppressed" by the standard long Lupron protocol, or are low responders for some other reason. A "stop Lupron" protocol is one possible way to get a better response to stimulation. The "flare-up" protocols are another option. Some reproductive endocrinologists will try a stop-Lupron protocol in the next attempt after a poor stimulation and others prefer to use a flare. To a great extent this is trial and error - we are never sure what the stimulation will be like until we do it.
The Lupron is started at the same time in the cycle, but usually at a lower dose, e.g. at 5 units daily instead of 10 units. The Lupron is then stopped completely after the woman gets her period and the FSH product is started.
The LH suppressing ability of this protocol is not as complete as with the standard "long" Lupron protocol. However, the risk for a premature LH surge is still low, and blood tests can be done during the cycle to watch for any LH increases.
--------------------------------------------------------------------------------
Flare Protocol
In this type of stimulation, the Lupron (or other GnRH agonist) is started on cycle day 2 in the same menstrual cycle that we will retrieve the eggs - instead of starting it a week prior to the start of menses. We are trying to take advantage of an initial "flare-up" response of FSH and LH release from the woman's own pituitary gland that usually occurs in the first 3 days of Lupron administration. Continuing Lupron for more than 3 days temporarily suppresses the pituitary gland so that it has very low output of FSH and LH.
The FSH product (e.g. Follistim, Gonal-F, Repronex) is then started on the following day (day 3). The idea is that the Lupron will stimulate release of a large amount of FSH (and LH) that will jump-start (flare-up) the follicles so that we might have a better ovarian stimulation with more mature follicles and more eggs to utilize with IVF.
Birth control pills are usually given for the month before the flare so that there will not be a leftover cyst (corpus luteum) that could become reactivated by the high LH levels at the onset of the flare stimulation.
An example of one flare protocol is given below - there are many variations on the theme.
1. Birth control pills for 1 month
2. Stop birth control pills - no meds for 2 days
3. Start Lupron on the third pill free day. We use a 50ug dose of Lupron twice daily -AM and PM- for these flare cycles.
50ug is a very small dose as compared to the usual Long Lupron protocol dose of 0.5mg (500ug). The Lupron needs to be diluted by the pharmacy or the doctor's office in order to be able to inject such a low dose.
4. Start injections of the FSH product (once or twice daily) on the day after starting Lupron
5. The Lupron is usually continued at the same dose until the HCG trigger shot is given.
Ovarian Stimulation Using GnRH-antagonists
Ganirelix acetate, also called Antagon, became available in the U.S. in the spring of 2000. It has been used in Europe for much longer. Cetrorelix acetate (Cetrotide) is another GnRH-antagonist that is now available in the U.S.
Ganirelix and Cetrotide - as well as Lupron - prevent the woman from having an LH surge. However, Ganirelix and Cetrotide are antagonists instead of agonists. Ganirelix works by competing with native GnRH molecules at their binding sites in the pituitary - while Lupron works by "down regulating" the pituitary's ability to produce the LH surge. This distinction is not important to understand. The bottom line is that both kinds of drugs, antagonists and agonists, prevent LH surges (in different ways).
Ganirelix or Cetrotide are usually started on (about) the sixth day of giving the FSH product that stimulates the development of follicles in the ovary. They are commonly given subcutaneously once daily and continued until HCG is given. Cetrotide can also be be used as a single shot (in a higher 3mg dose), rather than as daily injections of the lower 0.25mg dose. When the single 3mg dose is given, Cetrotide is supposed to give 4 days of suppression (no LH surge for 96 hours). If the patient needs more days of stimulation beyond the 96 hours, the daily 0.25mg Cetrotide injections are given until the stimulation is completed and HCG is given.
Use of Ganirelix results in less total number of shots being taken during the stimulation cycle than with the use of Lupron. However, there is some evidence from the published literature that there are slightly fewer eggs retrieved (on average), slightly less embryos available on the day of transfer (on average), and slightly lower pregnancy rates than with the use of Lupron. However, this is when all patients are given the same protocol (Lupron vs. Ganirelix). Pregnancy rates are excellent with Ganirelix when used properly in selected patients. We use it for almost all of our egg donation cases and see excellent pregnancy and live birth rates with it in the donors. More studies are needed to further clarify this important issue.
Some clinics are reporting that women who are low responders to ovarian stimulation protocols that involve use of Lupron might be able to stimulate better if an antagonist such as Ganirelix is used instead. This deserves careful study in randomized controlled trials of previous low responders to see whether it will be a viable alternative to the other ovarian stimulation regimens for low responders such as the "stop Lupron" and flare protocols.
August 27, 2008