Priming protocols for IVF
Updated: Nov 4, 2020
I would like to address a very debated topic and one of huge interest for those who carry the tags DOR or POF and need ovarian stimulation for assisted reproduction.
The way IVF works, we all know the more eggs we make, the better it is. And this because in vitro fertilisation is all about narrowing down the chances to finding the best egg(s). It is a matter of logic because more eggs retrieved will give us more fertilised eggs, hence higher chances of pregnancy. Also, women who respond better to stimulation protocols usually have a better egg quality (PCOS do not enter in this category of better egg quality, we will discuss this later on). Last but not least, "the more eggs the merrier" principle has also financial connotations. With prices so high for stimulation meds, monitoring, retrieval and laboratory, you're far better off paying thousands and thousands for ten eggs than for one.
While women over 35 and those under 35 but dealing with POF and DOR might be worse responders than the fertile population generally is, lots of protocols have been invented and experienced over the years, some of them with great results and quite encouraging pregnancy rates. One of the approaches is that of using luteal phase adjuvants, hoping to create a better environment for the follicles and preparing the ovaries for the following stimulation cycle.
BIRTH CONTROL is by far the most used approach before a medicated cycle. Its main purpose is to simply give your ovaries a rest, and offer them the chance to start the next cycle with a clean slate. Useful for reducing cysts, birth control comes, unfortunately, with a bad side effect: the dreaded suppression. BC pretreatment in IVF protocols establishes an estrogenic environment and increases sex hormone-binding globulin levels while decreasing follicular androgen levels. But by putting the ovaries to sleep, the risk is they might not wake up well enough... Sometimes, we end up with a lower antral follicle number, and we are facing the need of stimulating for a longer period of time, and with higher doses of stims, which might in turn, affect egg quality for older patients.
Here is a very interesting study, where even young egg donors have experienced lower AMH levels and lower numbers of oocytes after being put on birth control.
If in the case of a young donor, having 5 eggs retrieved instead of 10 might not make much of a difference, because donors are chosen to be young and healthy, with great egg quality, things are quite different for us, older women, where quality as well as quantity might be a problem.
TESTOSTERONE PRIMING is relatively new and pretty controversial. If you listen to Dr Sher, a very famous and respected Reproduction Endocrinologist, you should run away from testosterone exposure, especially if you are not very young anymore. If you listen to my own personal experience, my biggest failure of a cycle was the one I primed with testosterone gel. While I usually would have an antral follicle count of 9-10, one week of testosterone gel reduced my AFC to a whopping 2 (two), and thats what I got until the end of stims, when I told my RE there is no way I am going to waste an IVF cycle on two eggs, and decided on converting to IUI. He admitted later on that testosterone priming was a mistake in my case (I was 41 at the time, this might have been a reason). And it was no coincidence: all the other cycles I ever did (and we are talking 12 with full protocol, my afc was never under 8)
This being said, there are many studies out there who scientifically prove testosterone priming works for many low responders. I personally believe there is no way of knowing until you try.
ESTROGEN PRIMING avoids the very suppressive effect of birth control on the ovaries yet while preventing the premature recruitment of follicles it can reduce the number of follicles available for stimulation. Studies have shown that this protocol allows more gradual and coordinated growth of follicles resulting in improvement of embryo quality and quantity. For me personally this has been the only way I managed to ditch the lead follicle, the scarecrow of IVF...I personally took estrace pills, but patches are used with the same success.
I believe that in this journey, stressful as it is, it is essential to have a doctor you can really trust.
I also believe that accessing as much scientific information as possible in order to educate myself on matters concerning my health and my life helped me survive during this period, by giving me a sense of control. I was never one to follow blindly and I always need to keep a clear mind and understand at every moment what is going on with me.
Would this auto-education give me a medical degree? Obviously not! And I do not pretend it does. What it does give me, is at least basic knowledge, so useful in understanding where I stand, and if the direction I am heading to is the good one.
It gave me the power of standing up and saying NO, when I knew for a fact that the approach I was suggested would be wrong for me.
It gave me the courage to insist on trying the estrogen priming protocol. And I was right, estrogen priming got me my best results albeit a negative pregnancy test.
It also gave me the power to say no to yet another high dose stimulation protocol, and try a low dose one that got me 8 eggs instead of my usual 2-3.
I don't know if it is my journalistic background, or maybe just me being a stubborn Aries, but I am a strong believer in the "Knowledge is power" part, as much as it might sound like a cliche.