QuestionI've moved quickly to IVF due to low AMH (0.38 on the U.S. scale), high FSH (ranging from 7 - 13) and low AFC (6 - 10). I am 36.
I responded well to 50mg of Clomid and had 3 follicles for an IUI (negative).
With my first IVF, I did a short cycle with a natural start. Beginning 150 Menopur & 150 Gonal F on day 3. I responded very, very slowly. (I'll convert all numbers to U.S. values).
AFC was 10 this month (my best ever). FSH was 14 which was the worst I've ever had (it was 9 all the last few months). E2 started very low at 25 on Day 2. After 3 nights of stims, I had no follicles at 1.0 and E2 only rose to 40. I finally got a follicle at 1.0 after 7 nights of stims. To make a long story short, after 11 nights on stims, I had 2 follicles at 1.8 & 1.4. I don't have the E2 value for that date with me, but after 9 nights of stims it was 600 so I am assume it was higher 2 days later since it rose steadily mid-way through stimming. I was started on Orgalutran (Ganirelix) on day 10 of stims for 3 days. My stims were not increased during my cycle.
I was converted to IUI. I spoke to my RE about the Estrogen Priming Protocol. He said he doesn't use it and I can try it if I want, although it has been proven to be ineffective. He said it was used years ago and just doesn't work, but he'll let me do it if I want to although it isn't a protocol my clinic uses.
The month my Clomid cycle went well my FSH was 9 with E2 on day 2 at 36, so it started lower this month. I'm wondering if Clomid may have caused my FSH to increase. I thought EPP was fairly new and only some clinics use it so I was surprised that my RE said they found out years ago that it doesn't work.
Do you think EPP would be worthwhile to try or is there a better protocol?
Lucy from Toronto in Canada
AnswerHello Lucy from Canada,
Yes, some clinics are re-evaluating the use of an estrogen priming protocol. The thinking is that in patients with a high FSH level, having this level decreases ovarian responsivity and so by giving estrogen, the hypothalamus will decrease FSH production in the Pituitary. Unfortunately, this has not been shown to be of much benefit. Most IVF clinics in the U.S. use the birth control pill to suppress the hypothalamus and ovaries prior to starting the stimulation cycle. The high dose estrogen in OCP's would theoretically do the same, but it does not necessarily help the stimulation when there is an ovarian reserve/poor responder situation. More than likely, the uptake mechanism within the ovary (picking up the FSH to grow a follicle# is already and permanently compromised.
I don't think that this is the only option for you, however. In fact, you were on a low dose stimulation protocol #300IU total of FSH#. In your cycle, with the low CD#5 and CD#9 Estradiol levels, I would have increased your stimulation. The maximum protocol I and most of my colleagues use is 600IU of FSH #can be a combination of Gonal-f and Menopur. I use 450IU Gonal-f and 150IU Menopur).
You have two options. You could try to convince your doctor to drastically increase your stimulation OR you could find a doctor that is more aggressive with patients that have decreased ovarian reserve.
Good Luck,
Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
Monterey, California, U.S.A.
for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on twitter with me at @montereybayivf and facebook @montereybayivf. Skype and internet comprehensive consultations now available via my website for those who want a more extensive evaluation that this site can accommodate
