Our New “Antagonist” Protocol

Good evening! I had hoped to post this afternoon, about our appointment this morning, but the time got away from me. Just one of those busy days…

The appointment this morning went well. Though we had to wait an hour (past our scheduled time) to meet with our RE, we were pleased with the information he shared with us and his approach going forward. He reiterated that he did not like how my follicles were developing last cycle and in effort to “save” our insurance tries, if made the most sense to him to convert to IUI. He explained that he wouldn’t and couldn’t have predicted at my monitoring appointment on day 5 of stimming that my follicles would turn out as they did. Thus he addressed one of our concerns, being why we didn’t get warning earlier that this cycle might not make it to IVF. He also told us that after our first two attempts, he now considers me (my follicles) to be a “poor responder.” However, being on the younger end of the spectrum of women who try IVF (age 32), he told us that my chances are still good that we can have success. He said that typically women in there early 30s may not respond well to stimulation medications, but can still get some high quality eggs. Whereas, women in their early 40s who don’t respond well to stimming, also may not have high enough quality eggs for IVF to work.

The new antagonist protocol he gave us for this cycle is designed to help poor responders’ chances for success with IVF. The medication antagon (brand name Ganirelix), hence the name of the protocol, will serve a similar role in this cycle as Lupron did the last two cycles, in that it’s purpose is to keep my follicles from ovulating until the time is right for Egg Retrieval. However, the past two cycles I used Lupron daily for 7-14 days before I began stimming and with antagon, I will not begin using it until day 6 of stimming. With this protocol, I will finish my pills one week from tomorrow, Tuesday, July 17, and will go in for an ultrasound and blood work. Assuming that there are no cysts or other red flags, I will begin my stimulation medications 4 days later (regardless of if I have gotten a period yet). This time I will be on 300 Ius of Follistim (75 Ius less than last cycle and the same as I ended up on for the last 6 days of my first IVF cycles) and 150 Ius of Repronex (twice what I was on this past cycle).

So based on all of this, the schedule appears to be as follows (give or take some days on either side):

Begin stimulation medications on Saturday, July 21.

Monitoring appointments on Monday, Wednesday & Friday the week of July 23, with possible monitoring appointments at the downtown office that weekend of July 28 and 29.

Trigger shot (HcG) between Saturday, July 28 – Monday, July 30.

Egg Retrieval (ER) between Monday, July 30 – Wednesday, August 1.

Embryo Transfer (ET) between Saturday, August 4 – Monday, August 6.

Beta blood test (to determine if we are pregnant) between Tuesday, August 14 – Thursday, August 16.

Estimated due date (EDD), if it works, between Monday, April 21 – Wednesday, April 23, 2008.

Feel free to laugh with me now, that I take the time to figure all of that out, instead of just going with the flow, but it really does help me to feel some level of control in this whole process. Some other notes from our follow-up appointment today:

Our RE explained that if my follicles continue to respond poorly, as they did this past cycle, at some point he would stop canceling IVF and/or converting to IUI and proceed no matter what, trying for the best quality eggs/embryos, even if he can’t get the quantity he would like to have. But that for now (at least with last cycle) he wanted to give us more fair (insurance covered) chances at IVF, than he felt that cycle was able to provide.

He clarified that the “formal criteria” for triggering prior to ER is 3 follicles greater than 18mm. He also said that he likes to see the “lead” follicles around 19-20mm prior to triggering. I asked about the set of three follicles that measured 11mm on the day of the trigger (why he didn’t push through another day or two, two see if they would catch up and be fruitful). He explained that if they had been between 13-14mm on the day we triggered, he might have had more hope for the cycle, but that by the time they caught up the larger ones could have been over mature, still leaving us with a low number of potential eggs.

Bob and I shared with our RE that we do not believe in selective reduction and are not comfortable with it being used in the future if we were to conceive twins through another cycle converted from IVF to IUI. We explained that going forward if we have another IVF cycle that is not going well, and he wanted to convert to IUI, we would only be okay with it if there was only one dominant follicle, unlike this time when there appeared to be two. We said that we understand that we might need to cancel a future IVF cycle completely, if conditions are otherwise, and that we are willing to take that set back, rather than risk twins, if he strongly believes that my uterus cannot (or should not) handle multiples. We respected that our RE heard us out and though he assured us that he wasn’t worried we would conceive twins through IUI this past cycle, with only 4 follicles over 14mm on the day I triggered, he would note and honor our beliefs and choices that relate to them.

He also explained why he chose lower the dosage of the Follistim with this new protocol, because more and more the research shows that higher doses of medications, though they can produce higher quantities of eggs, often lead lower quality eggs. He also cited another recent research study (that came out in the past month or so) that continues to support the use of Repronex (LH) to balance out Follistim (FSH) and thus lead to higher quality eggs in many patients.

The appointment was definitely worth the wait and we continue feel very confident in our RE and positive about our new protocol going forward! This new antagon protocol is a little “faster” than the Lupron and Double Suppression of Lupron protocols we tried the last two cycles and thus, as you can see, by the schedule I shared above, things are going to move relatively quickly, especially since I am already on day 13 of the pill today. We decided not to adjust how long I stay on the pill to accommodate our vacation plans in the coming month, as it appears, amazingly, that with this protocol we will still be able to do most of what we have on our calendar, understanding that somethings may have to give (such as leaving a day or two later for our week in Michigan in early August).

The only other concern we have, in terms of conflicts that may arise with this IVF cycle, is that one of our extended family members is getting married on August 4, which could end up being the day of our ET. Ironically, I missed her bridal shower in April, because it was the day of my ET for our first IVF cycle. We are torn about this, as I want to be there for her special day, especially having missed her shower. However, even though we could stay on the pill a few more days, it would still be difficult to predict and work around it, because of how ERs and ETs fall in a cycle and then would put us in potential conflict with other important events in our life (there is always going to be something). So we will take our chances and if the ET falls on the day of her wedding, Bob will still attend, after the ET, and if I felt up to it, I might still try to go. But we’ll see. One day at time…

We had a wonderful 4th of July week in both Evanston with my family and in Michigan with Bob’s family! We are glad to be in town the rest of this week to catch up around the house and such, however me and my crazy-over-planning-self, still has a lot on our schedule for the week, so it should be a lot of fun, but definitely on the busy side!

To update you on my prayer requests from early last week:

1) My PUPO friend will have her Beta blood test tomorrow morning! She has had some brown discharge over this past weekend which could either mean implantation spotting or her period beginning. Please continue to pray for her, no matter what the outcome is tomorrow and I will certainly let you know if this IVF cycle was successful for her, her husband and their daughter to try to expand their family.

2) My friend who is 25 weeks pregnant and had some bleeding last week is doing well! She has not spotted since and basically her OB/GYN told her that everything looks good and that many women have spotting episodes during pregnancy and their babies turn out just fine. She told my friend that sometimes if may be because the pregnant women is “overdoing things” in her life and as a busy mother of two young boys that can happen and to just try to take it easy when possible.

Also, another one of our loved one’s is due to have a baby any day now, so please keep her and her family in your thoughts and prayers as they prepare for their new addition.

I appreciate your continued positive thoughts and prayers for my PUPO friend, my 25 weeks preggo friend, our loved one and their families!!! 🙂 🙂 🙂

Thank you also for your continued support, thoughts and prayers for Bob, Sean and me as we move forward with this new protocol! We feel a renewed sense of hope for this 2nd try at our 2nd IVF cycle and will keep you posted in the days to come!