What makes and what breaks an IVF protocol?

Most women that have underwent IVF, are probably familiar with the short antagonist protocol, that nowadays is used as the ‘first choice protocol’, by most of the IVF Units and is the one that dominates the I.V.F protocols sector ,on its simple version or on its variations.
For you that you have never heard the word ‘short antagonist’, I am sure that you will understand straight away, when we say that this is the protocol in which you start straight after your period injecting yourself with injections that have weird names, like Gonal F, Ovaleap, Menopur / Meriofert, Benfola and few days later you also start injecting your self with a second one that is called Orgalutran / Cetritide etc.

This is of course an amazing protocol ,that changed the direction of IVF, turning it into an easier journey with significant advantages. There are more than one reasons on why it has dominated. Is quicker, more cost effective, requires lower doses of gonadotrophines and allows the use of an agonist trigger, helping to eliminate the hyperstimulation syndrom, together of course with the vitrification, freeze all technique.

A smaller percentage of you, might have tried and thus, been now aware, of the long agonist protocol, which used to be the rule in most of the IVF centers, few years before the introduction of the ‘short antagonist‘ protocol. This is the protocol in which you started injecting your self for 10- 14 days before you actually started your ovarian stimulation in order to downregulate first the ovaries, before you stimulate them.

Is the long protocol still useful ?
Yes it is, as far as you know when to use it and for which reason.
Long protocol, can still be a useful protocol only in specific cases of previous discordinant growth of follicles or when the quality of the eggs retrieved from an antagonist protocol was significantly compromised and at the same time the AMH was not either, too high or too low. In both of these protocols, like in every single protocol, the most important factor, is a single magic word.

Personalization:

What we usually like to say to our patients, is that their follicles and blood tests, show us the right way to go, but we cannot show the right way to their follicles.

We just need to be there, understand and feel their reaction and respond accordingly to their signals.

So even when two doctors apply a short antagonist protocols, on the same patient, they can make through their day to day decisions and management, significant difference to the outcome
Like :
• The decision behind the initial dose
• if you will follow a step down or a step up technique
• The choice of the right medication to use
• The decision on adding more LH gonadotrotrophines or not depending on the LH results thougout the cycle.
• The knowledge behind the need of avoiding a daily dose of GNRH antagonist or not
• the correct timing of the trigger injection
• the time interval between the trigger and the egg collection
• the knowledgeable decision behind agonist only trigger, bhcg trigger or combined double trigger

Each of these factors and all of them combined together, can make significant impact on the amount of eggs a woman will get, the maturity rate of them and possibly their quality too. Generally we prefer to keep the protocols simple. In the big majority of our cycles, a personalised low dose or high dose short antagonist protocol will do the job. But when personal and simple has not worked, then we need not forget that we have many more secret weapons, to fight subfertility, as far as we know the physiology behind these.

For poor responders especially, double stimulation protocols, with gonadotrophines or combination of letrazole and Clomid, luteal start protocols, short flare protocols or GNRH agonist Stop plus GNRH antagonist protocols, can sometimes make a difference. Reproductive medicine is a wonderful and very delicate science that requires deep knowledge in order to use it towards the benefit of the subfertile woman.

To debrief :
The golden standard rules, behind IVF success:
1. Chose the right protocol
2. Know why you have chosen that
3. Personalise
4. Κeep it simple when you can
5. Improvise when simple and personal, has not worked.