This purpose of this blog is to pull together information on a form of IVF: Estrogen Priming Protocol. In my questioning Dr. Google for details about this protocol, details were few and far between, but I found them bit by bit. Hopefully the research on my own behalf will help out some more of you struggling with infertility., particularly my fellow poor-responders.
What is the Estrogen Priming Protocol (EPP)?
Like BCPs in longer IVF protocols, estrogen is used in EPP to down-regulate FSH receptors. By providing external estrogen, the hope is that the pituitary gland will think a follicle is developing (follicles product estrogen) and will thereby reduce the amount of FSH (Follicle Stimulating Hormone) it pumps out. This "break" in follicular development give the ovaries a little time off at the spa, and allows the RE (Reproductive Endocrinologist, aka puppetmaster) to take control of the woman's cycle. In addition, it will promote estrogen dominance in the follicular fluid, which is believed will help protect the developing eggs.
Estrogen is given in the cycle before the actual IVF stim cycle - varying from all cycle long or just the week before, depending on your clinic's preference and your own personal situation.
Why EPP?
EPP is an aggressive form of an IVF Antagonist Protocol. It is used for low/poor responders -- often women with high FSH and/or over 35 years of age. It's a sort of "slow burn" methodology — the hope being that they slow you way down and protect egg quality while allowing you to stim longer. In addition, the slower stimming allows the hope that all active follies can catch up to each other, allowing for as many mature eggs at retrieval as possible. This would be an appropriate protocol to consider if you have a low antral follicle count, and not for anyone who responds well to fertility medications or is at risk for OHSS (Ovarian Hyper Stimulation Syndrome). If EPP were a nation and they needed a motto for their coinage, it would very likely be: Quality over Quantity – In RE speramus.
Showing posts with label IVF. Show all posts
Showing posts with label IVF. Show all posts
Friday, May 15, 2009
Friday, May 1, 2009
My Estrogen Priming Protocol Cycle #1
Here is the day-by day breakdown of my cycle. It's just my experience, not indicative at all of how any one else might respond.
Sunday 5/24/09 (CD minus 7)
- Bloodwork to confirm I am mid-luteal phase. Confirmed.
- Apply first estrogen patch.
Monday 5/25/09 (CD minus 6)
- Ganirelix shot
- Keep estrogen patch #1 on
Tuesday 5/26/09 (CD minus 5)
- Ganirelix shot
- Keep estrogen patch #1 on
Wednesday 5/27/09 (CD minus 4)
- Ganirelix shot
- Change to a new estrogen patch
Thursday 5/28/09 (CD minus 3)
- Keep estrogen patch #2 on
Friday 5/29/09 (CD minus 2)
- Keep estrogen patch #2 on
Saturday 5/30/09 (CD minus 1)
- Change to a new estrogen patch
Sunday 5/31/09 (CD1)
- Keep estrogen patch #3 on
- 1st day of period, call to schedule baseline u/s and b/w
Monday 6/1/09 (CD2)
- Keep estrogen patch #3 on
- Baseline u/s and b/w. Confirms hormone levels are baseline and gets antral follicle count as a basis for cycle prognosis. In my case, antral follicle count is very poor, but RE decides to proceed.
- Start stimming: Gonal-f 450 (FSH) + Menopur 150
Tuesday 6/2/09 (CD3)
- Keep estrogen patch #3 on
- Continue stimming: Gonal-f 450 (FSH) + Menopur 150
Wednesday 6/3/09 (CD4)
- Keep estrogen patch #3 on
- Continue stimming: Gonal-f 450 (FSH) + Menopur 150
Thursday 6/4/09 (CD5)
- Keep estrogen patch #3 on
- Continue stimming: Gonal-f 450 (FSH) + Menopur 150
Friday 6/5/09 (CD6)
- 1st follicle check u/s and b/w. E2 level 96.4. Right ovary has 2-4 follies<12mm
Saturday 6/6/09 (CD7)
- Keep estrogen patch #3 on
- Continue stimming: Gonal-f 450 (FSH) + Menopur 150
Sunday 6/7/09 (CD8)
- Keep estrogen patch #3 on
- Continue stimming: Gonal-f 450 (FSH) + Menopur 150
Monday 6/8/09 (CD9)
- 2nd follicle check u/s and b/w. E2 level 137. Right ovary has one 13mm follie, possible one more <12mm.
Tuesday 6/9/09 (CD10)
- Keep estrogen patch #3 on
- Continue stimming: Gonal-f 450 (FSH) + Menopur 150
- Add in ganirelix antagonist shot to prevent natural ovulation
Wednesday 6/10/09 (CD11)
- Keep estrogen patch #3 on
- Continue stimming: Gonal-f 450 (FSH) + Menopur 150
- Continue ganirelix
Thursday 6/11/09 (CD12)
- 3rd follicle check u/s and b/w. E2 level 254. Right ovary has 17mm, 8mm (teeny) follie. 2-4 tiny ones, too small to measure. Continued poor response.
- Keep estrogen patch #3 on
- Continue stimming: Gonal-f 450 (FSH) + Menopur 150
- Continue ganirelix
Friday 6/12/09 (CD13)
- Keep estrogen patch #3 on
- Continue stimming: Gonal-f 450 (FSH) + Menopur 150
- Continue ganirelix
Saturday 6/13/09 (CD14)
- 4th follicle check u/s and b/w. E2 level 401. Right ovary has 18mm, 7mm. Left ovary cannot be seen. Continued poor response.
- Keep estrogen patch #3 on
- Continue stimming: Gonal-f 450 (FSH) + Menopur 150
- Continue ganirelix
- RE decides he is willing to proceed with IVF with just one follicle, if I am willing. Due to good/lucky insurance coverage, we decide to go for it.
Sunday 6/14/09 (CD15)
- Keep estrogen patch #3 on
- Continue stimming: Gonal-f 450 (FSH) + Menopur 150
- Continue ganirelix
Monday 6/15/09 (CD16)
- 5th follicle check u/s and b/w. E2 level 415. Right ovary has 25mm, 7mm. Left ovary cannot be seen. Continued poor response. Cannot wait any longer for smaller follicles with 25mm.
- Schedule egg retrieval for Wednesday at 10:30am
- Finally remove estrogen patch (gross)
- Ovidrel HCG trigger at 10:30pm
Tuesday 6/16/09 (CD17)
- Surgical instructions
- Nothing to eat or drink after midnight
Wednesday 6/17/09 (CD18, O-day)
- Husband provides semen sample to andrology lab at 9:30am
- Egg retrieval at 10:30am
- Surprise! Three eggs retrieved: the large follicle seen all along and two smaller ones that grew enough since Monday and/or were not seen on u/s.
Thursday 6/18/09 (CD19, 1dpo)
- Fertilization report: 1 of the 3 eggs fertilized. Not surprising as the 2 "surprise" eggs were likely not mature.
Friday 6/19/09 (CD20, 2 dpo)
- Waiting
Saturday 6/20/09 (CD21, 3 dpo)
- Egg transfer. Embryo was a grade 1, low fragmentation, given a HIP (High Implantation Embryo) stamp. As good as I could possibly hope.
- Acupuncture, before and after transfer.
- Beta scheduled for July 1st
Tuesday 6/30/09 (CD31, 13dpo)
- One day before beta, period arrives. BFN.
As you can see from above, I had a particularly poor and slow response, even on this aggressive protocol. However, I believe the RE and I may have learned some things, particularly in regard to adding the antagonist into the cycle earlier next time. Once the lead follicle started surging ahead, it was impossible to wait too long for the slower follicles to catch up. Maybe next cycle we can stop that lead follicle earlier.
Updated to add (July 2009): happy ending here. We had decided to take a break from all the meds over the summer and try IVF#2 in September. Shockingly I became pregnant naturally during my first cycle after the failed IVF above. Never give up, ladies! If somehow this low responder can get pregnant (in whatever way), then anyone can.
Sunday 5/24/09 (CD minus 7)
- Bloodwork to confirm I am mid-luteal phase. Confirmed.
- Apply first estrogen patch.
Monday 5/25/09 (CD minus 6)
- Ganirelix shot
- Keep estrogen patch #1 on
Tuesday 5/26/09 (CD minus 5)
- Ganirelix shot
- Keep estrogen patch #1 on
Wednesday 5/27/09 (CD minus 4)
- Ganirelix shot
- Change to a new estrogen patch
Thursday 5/28/09 (CD minus 3)
- Keep estrogen patch #2 on
Friday 5/29/09 (CD minus 2)
- Keep estrogen patch #2 on
Saturday 5/30/09 (CD minus 1)
- Change to a new estrogen patch
Sunday 5/31/09 (CD1)
- Keep estrogen patch #3 on
- 1st day of period, call to schedule baseline u/s and b/w
Monday 6/1/09 (CD2)
- Keep estrogen patch #3 on
- Baseline u/s and b/w. Confirms hormone levels are baseline and gets antral follicle count as a basis for cycle prognosis. In my case, antral follicle count is very poor, but RE decides to proceed.
- Start stimming: Gonal-f 450 (FSH) + Menopur 150
Tuesday 6/2/09 (CD3)
- Keep estrogen patch #3 on
- Continue stimming: Gonal-f 450 (FSH) + Menopur 150
Wednesday 6/3/09 (CD4)
- Keep estrogen patch #3 on
- Continue stimming: Gonal-f 450 (FSH) + Menopur 150
Thursday 6/4/09 (CD5)
- Keep estrogen patch #3 on
- Continue stimming: Gonal-f 450 (FSH) + Menopur 150
Friday 6/5/09 (CD6)
- 1st follicle check u/s and b/w. E2 level 96.4. Right ovary has 2-4 follies<12mm
Saturday 6/6/09 (CD7)
- Keep estrogen patch #3 on
- Continue stimming: Gonal-f 450 (FSH) + Menopur 150
Sunday 6/7/09 (CD8)
- Keep estrogen patch #3 on
- Continue stimming: Gonal-f 450 (FSH) + Menopur 150
Monday 6/8/09 (CD9)
- 2nd follicle check u/s and b/w. E2 level 137. Right ovary has one 13mm follie, possible one more <12mm.
Tuesday 6/9/09 (CD10)
- Keep estrogen patch #3 on
- Continue stimming: Gonal-f 450 (FSH) + Menopur 150
- Add in ganirelix antagonist shot to prevent natural ovulation
Wednesday 6/10/09 (CD11)
- Keep estrogen patch #3 on
- Continue stimming: Gonal-f 450 (FSH) + Menopur 150
- Continue ganirelix
Thursday 6/11/09 (CD12)
- 3rd follicle check u/s and b/w. E2 level 254. Right ovary has 17mm, 8mm (teeny) follie. 2-4 tiny ones, too small to measure. Continued poor response.
- Keep estrogen patch #3 on
- Continue stimming: Gonal-f 450 (FSH) + Menopur 150
- Continue ganirelix
Friday 6/12/09 (CD13)
- Keep estrogen patch #3 on
- Continue stimming: Gonal-f 450 (FSH) + Menopur 150
- Continue ganirelix
Saturday 6/13/09 (CD14)
- 4th follicle check u/s and b/w. E2 level 401. Right ovary has 18mm, 7mm. Left ovary cannot be seen. Continued poor response.
- Keep estrogen patch #3 on
- Continue stimming: Gonal-f 450 (FSH) + Menopur 150
- Continue ganirelix
- RE decides he is willing to proceed with IVF with just one follicle, if I am willing. Due to good/lucky insurance coverage, we decide to go for it.
Sunday 6/14/09 (CD15)
- Keep estrogen patch #3 on
- Continue stimming: Gonal-f 450 (FSH) + Menopur 150
- Continue ganirelix
Monday 6/15/09 (CD16)
- 5th follicle check u/s and b/w. E2 level 415. Right ovary has 25mm, 7mm. Left ovary cannot be seen. Continued poor response. Cannot wait any longer for smaller follicles with 25mm.
- Schedule egg retrieval for Wednesday at 10:30am
- Finally remove estrogen patch (gross)
- Ovidrel HCG trigger at 10:30pm
Tuesday 6/16/09 (CD17)
- Surgical instructions
- Nothing to eat or drink after midnight
Wednesday 6/17/09 (CD18, O-day)
- Husband provides semen sample to andrology lab at 9:30am
- Egg retrieval at 10:30am
- Surprise! Three eggs retrieved: the large follicle seen all along and two smaller ones that grew enough since Monday and/or were not seen on u/s.
Thursday 6/18/09 (CD19, 1dpo)
- Fertilization report: 1 of the 3 eggs fertilized. Not surprising as the 2 "surprise" eggs were likely not mature.
Friday 6/19/09 (CD20, 2 dpo)
- Waiting
Saturday 6/20/09 (CD21, 3 dpo)
- Egg transfer. Embryo was a grade 1, low fragmentation, given a HIP (High Implantation Embryo) stamp. As good as I could possibly hope.
- Acupuncture, before and after transfer.
- Beta scheduled for July 1st
Tuesday 6/30/09 (CD31, 13dpo)
- One day before beta, period arrives. BFN.
As you can see from above, I had a particularly poor and slow response, even on this aggressive protocol. However, I believe the RE and I may have learned some things, particularly in regard to adding the antagonist into the cycle earlier next time. Once the lead follicle started surging ahead, it was impossible to wait too long for the slower follicles to catch up. Maybe next cycle we can stop that lead follicle earlier.
Updated to add (July 2009): happy ending here. We had decided to take a break from all the meds over the summer and try IVF#2 in September. Shockingly I became pregnant naturally during my first cycle after the failed IVF above. Never give up, ladies! If somehow this low responder can get pregnant (in whatever way), then anyone can.
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