Previous endocrine lab tests on day 2 3 or 4 (Estrogen, Follicle Stimulating Hormone-FSH and AMH), as well as the baseline ultrasound (US) to count the number of small antral follicles (AFC) indicate the woman’s “ovarian reserve” of eggs or ‘egg supply’ and helps determine the medication dosage and the IVF protocol to be used for stimulation of the ovaries.
There are essentially 3 primary types of ‘stimulation protocols’ for IVF. They are defined by the type of ‘blocking’ medication used to prevent premature ovulation from occurring during the stimulation, by preventing the pituitary from releasing LH- Luteinizing Hormone, which is the hormone that triggers ovulation to occur. This is referred to as the “LH surge”.
Long Luteal Protocol
This protocol uses Leuprolide (Lupron) injections starting on day 21 of the cycle the month before the IVF stimulation. It involves many more injections and is not ideal for women with PCOS or large numbers of eggs since the risk of ovarian hyperstimulation syndrome-OHSS is too high. Also not a good choice for older women or those with DOR, since the prolonged Lupron injections may suppress the ovaries too much.
This protocol uses Cetrotide or Ganirelix injections, usually starting on the 5th or 6th day of stimulation. These are rapidly acting medications that quickly block the pituitary so then LH hormone won’t be released which could cause premature ovulation. An ideal protocol for women with PCOS and/or many eggs in order to prevent ovarian hyperstimulation syndrome-OHSS. Involves fewer injections as well.
Microdose Lupron (MDL) Protocol
This protocol uses a very low dose of Leuprolide--Lupron. It is called ‘Micro dose’ since it is only 5% of the strength of the regular ‘Long Lupron protocol’. For older women or those with DOR, the regular Long Lupron protocol may suppress the ovaries too much so then one would not be able to respond to the fertility drugs. This Microdose Lupron is actually started at the beginning of the fertility drug stimulation. It stimulates the pituitary to start releasing all of its own FSH and LH hormones so that after 5-6 days of using the Microdose Lupron, the pituitary has no more FSH or LH to release so then the so called “LH surge” should not be able to occur and premature ovulation should not happen. This MDL protocol is also often referred to as the MDL ‘Flare’ Protocol, because the woman’s own FSH & LH hormones are released by the pituitary or flare up during the 1st 5 days of fertility drug stimulation when she is doing injections of FSH and/or LH hormones. This may have an additive effect to boost the stimulation of the ovaries
Many large studies confirm that for older women or those with DOR, both the Antagonist Protocol and the MDL Protocol are comparable in terms of pregnancy rates…but some women simply stimulate or respond better to one protocol than the other. Therefore, if one responds poorly to one protocol, we will generally switch to the other protocol.
Minimal Stimulation (Min Stim) Protocol
For women with diminished ovarian reserve and/or a history of poor response to standard aggressive high-dose gonadotropin stimulations, the option to proceed with a series of "minimal stimulation IVF" cycles may offer a reasonable chance of conception (in those not yet interested in doing donor egg).
In poor responders, or those with poor ovarian reserve, gentle ovarian stimulation protocols have been shown to have some advantages over more conventional high-dose ovarian stimulation protocols. There have been several reports of an increased % of good quality eggs/embryos in IVF protocols with less medication, despite obtaining fewer eggs