Short or Long Protocol - which one is best?

[GlummyMummy]

Going to be having my third round of IVF in the summer. We have a nearly two year old from our first round (long protocol, medium dose of drugs) and our second attempt failed in March (short protocol, high dose of drugs)

I have low AMH, am 35, and although our infertility is unexplained, doctors have said recently our issue could be one of embryo and most likely egg quality. On both rounds of IVF we have only had 7 eggs retrieved and only one embryo left by day 5.

Doctors aren't really giving strong advice either way for this next time. I have had no side effects with either protocol so been really lucky. I am probably erring towards the long protocol again, just because that worked for us! Wondering what experience others have had?

I've done both. I also have low Amh-although primary diagnosis is endo with almost fully blocked tubes. My first 3! Cycles Were short. I got bfps for the first 2( 1 dc who is 3 now and 1 mc at 9 weeks). The first 2 cycles I got 9 eggs( aged 35, 37). The 3rd cycle ( age 39) only 2 were collected ( this is when I saw my Amh nose dive) and start to become an issue eg doses of stimms( went from 225 gonal f in first cycle to 450 in the last 2).

As my fourth cycle was abroad ( other side of the world) the clinic needed to have more control over my cycle so I had the long protocol. I suffered from many side effects during the down regging-not surprisingly as it is putting your body into early menopause. We also included omnitrope and acupuncture into the plan and we got 3 eggs, 2 made it to day 5 and they were implanted. Unbelievably at age 39 I am now almost 17 weeks with twins.

If the clinic isn't giving you advice either way, I can understand why you would want to go back to what worked for you initially. Just out interest given you had a successful cycle resulting in a child on the long protocol why did your clinic change protocols?

Hi danaust, thanks for post. Congrats on your pregnancy....twins, wow! With a 3 year old you're going to be busy!!

Drs changed me to short protocol last time as I only had 7 eggs first time and they thought as I was 3 years older I might only get 3/4 eggs on long protocol again so they wanted more eggs to play with. On short protocol i got 7 again, they had hoped for 8-12 with the higher drugs too.

I'm just concerned with the long one that it might shut ovaries down completely!! Think Dr suggested this for next time to avoid assymetry of follicles which was a slight issue last time, plus my lining took time to thicken up although it did get to 8.9 by ET.

Not sure which protocol focuses on egg quality as that seems to be issue for us

Thank you-it's definitely going to be a big challenge.

I think any doctor will tell you it's a numbers game-so they will recommend the protocol which will give you the biggest yield. As both your cycles yielded the same quantity I think it's more about what they recommend( aside from the standard long and short protocols) to improve quality eg coq10, dhea, growth hormone etc. There is "some" evidence that growth hormone does improve quality. I only requested it as a friend had used it in her 4th cycle( the only one which worked) got her bfp and now has a 10 month old at age 40. For her it was the only difference in the cycle which worked.

If you are happy with your clinic I would put it back to them to suggest options to improve quality-if not maybe consider other clinics. The main impetus for us in changing clinics for cycle 4 versus cycle 3 was that they weren't willing to make any changes, i.e. They just wanted to replicate the failed cycle, and seemed adverse to the additional stuff I suggested. That's when I knew I had to explore other options.

My clinic isn't great to be honest. I feel like a lot of it is guess work with them (which I can understand when it's unexplained infertility) and they very much do things by the book. The Doctor I saw there last week hadn't even heard of estrogen priming protocol which I had heard about on here! Logistically speaking it would be better to stay where we are. With a child already it would be tricky to have to travel to another clinic (in my last cycle I was there every two days). How did you find it going abroad?

What supplements were you taking prior to your last IVF round?

Yes I can understand that, it needs to be in a convenient location Esp when you already have a child. For cycle 3 ( in the uk) I had to bring our daughter which wasn't ideal but but with no family within 11000 miles it's was a challenge (we are expats).

Actually we timed our 4th cycle with a planned trip back home to Australia. We always thought we wouldn't be able to do it logistically (as my husband could only stay for 3 weeks), but it worked out well. We had a conf call with the clinic in November. The came up with the treatment protocol, couriered me the synarel within 24 hours. I started that then the bcps. When we arrived back we visited the clinic and met the Head of it. It was worlds apart from what we experienced here-so much more professional and advanced. Stims started Christmas Day, omnitrope I think was added for the last 4 days of stims, transfer was day before my husband left. It was actually an easier process as we had all our family and friends to look after our dd and had their support. I had the hcg test which was very high so the nurse suspected twins. Of course it wasn't until the scan at 8 weeks when it was confirmed.

I did coq10( cycles 3+4), acupuncture ( cycle 4) 2 visits in the stim phase , and then 1 immediately before transfer and 1 immediately after. Also the omnitrope, which for me, I believe made the difference. I cut out caffeine just prior to starting stims( standard in all my cycles) and tried eating lots of protein. I didn't do dhea-I can't recall why as I definitely brought it up...but if that cycle hadn't worked I would have tried it....

Hi Glummy, as you know from other threads, I’m a low AMH-er and my consultant said he wouldn’t risk putting me on long protocol, due to the risk of being over suppressed

This handout by lister shows different strategies for low-AMH-ers

ivf.org.uk/images/downloads/Lister-Fertility-Clinic-low-ovarian-reserve.pdf

BTW more info on the oestrogen priming protocol here: ivfmd.net/fertility-treatments/in-vitro-fertilization-ivf/ivf-protocols-for-low-ovarian-reserve/estrogen-primed-luteal-antagonist-protocol/

CRGH also use growth hormone, which is quite popular in the US but not used so much over here

Dr Sher in the US uses oestrogen priming and growth hormone in his special agonist/ antagonist conversion protocol for women with diminished ovarian reserve - haveababy.com/fertility-information/ivf-authority/individualized-approach-to-ovarian

He DOES use a long protocol for DOR, but he doesn’t use it in the standard down reg way we do over here (or indeed most clinics in the US do long protocol

The protocols were broadly the same for both my cycles, except the 2nd cycle came off the birth control pill (which Lister actually describe as a kind of oestrogen priming) to quiet my ovaries before we started stims, to stop any follies from racing off

Both cycles started off on 450iu Gonal-F, which was dropped down pretty quickly

Cycle 1: Baseline AFC of 5 follies, came straight off a natural cycle. 450iu Gonal-F for 4 days, start Cetrotide, drop Gonal-F down to 300iu for 3 days, then 5 days of 225iu

That got 7 eggs, 6 mature, of which 4 fertilised - but nothing made it past day 3

Cycle 2: Baseline AFC of 10 follies, came off the BCP. 450iu Gonal-F for 6 days, start Cetrotide, drop Gonal-F down to 222iu for 2 days, then 3 days of 150iu

That got 17 eggs, all mature, of which 12 fertilised, 7 made it to blast, of which 1 was put back and 4 were frozen

I got a BFP but miscarried at 10w - however the results of the tissue testing showed the baby was chromosomally normal, i.e. the miscarriage wasn’t due to poor embryo quality

Before the first cycle I had only been taking supplements for 6 weeks

Before the second cycle I had been taking egg quality supplements of 4 months

• DHEA (micronised) 75mg daily
• CoQ10 as ubiquinol 300mg
• Vitamin C 1000mg
• Vitamin D 10,00iu
• Vitamin E 1000iu
• Resveratrol 500mg
• DHA fish oil
• Prenatal
• Folic acid 5mg (prescription strength for epilepsy)

thanks for the link to the handout Banana, that was really useful. I am going to go back to my clinic to query the protocols again, I am really in two minds about what would be best for me. This might be our last shot so want to get it right!

Good luck glummy! As soon as my hCG levels are zero (which after Weds hysteroscopy they hopefully will be, after the 6 week long neverending miscarriage) I'm starting another fresh cycle, short protocol again, high stims, Gonal-F and Cetrotide as before xx