Choosing the correct IVF protocol

My response to the IVF protocol, the agonist flare protocol, where I got a microdose of lupron from day 2 continuously followed by stims (with a mix of follistim and menagon, which contains equal amounts of both FSH and LH), was truly awful- we got a lot of eggs (11 eggs from 13 follicles), but most of them were immature and failed to mature and fertilize and even though we produced one 'good' Day 5 embryo, that failed to implant.


Why was this? I've always thought that maybe my protocol was not best suited for me, but never thought I'd be able to find a good (or any) explanation as to why and how.

However, I just found a recent opinion by Geoffrey Sher, which gave a plausible explanation of what may have been the issue:

Some background- there are two ways to shut down the pituitary gland, which is the master remote controller of ovulation:

1. The first method developed is through agonists- these work by a weird method- they first stimulate the pituitary gland, but such a strong stimulation however later shuts it down completely.
2. The second developed method is antagonists, which directly shut down pituitary activity (or is it just LH secretion?)

Dr. Sher makes that the point that if you start the agonist at day 2 or 3, it first produces a spike of LH at this point,  and THEN shuts it completely. His theory is that this increase in LH, on CD2/3  (which is, importantly, also out of time with this natural process, though he does not put it this way), may be bad, especially in vulnerable populations like PCOS patients or older women.

I really think this point makes sense for one reason, and here it is: What is associated with annovulatory PCOS? A really high ratio of LH to FSH, on CD3. This is a hallmark of this syndrome and if his interpretation that agonist use first causes that LH spike is right, it may actually mimic the natural situation that produces annovulation in PCOS, if first given on CD2/3.

He makes several other less important, and less strong, nonetheless plausible points:

Ideal curve of LH in a healthy ovulatory cycle, courtesy Wikipedia.

• Menagon (which is equal doses of FSH and LH) may be less than idea- This may be true- it deviates the natural bell shaped curve of LH found in nature in health, but nonetheless, it clearly works for many.
• Femara may also increase LH at the wrong point

Dr Sher's opinion really makes for interesting reading- I'm very glad I came across it. See above the bell shaped curve of LH in the natural cycle- maybe protocols that deviate from this may not serve optimally. Maybe too much LH at the spike or any other point may be bad too- its difficult to say

All i know is, if I'm doing IVF, I need to go away from what was done the last time. Based on what he said, I've also decided to avoid Femara and Clomid.

I may go straight to low dose FSH from an early point. I'm going to figure out if I want to use antagonists or not. The reason I'm vacillating on this point is that LH IS important- the gradual increase of this as ovulation nears, resulting in that spike, may be a good thing. But too much LH may be a problem too, and the reason pituitary shutdown was introduced was that 51 % of women had a premature LH surge which resulted in cycle cancellation.

Trying natural cycle IVF is so very alluring- except I have 2 IUI and 1 IVF vial of swimmers, and the really steep costs of IVF come in during the pickup and fertilization. Finances are not a problem, yet nor can I act like money grows on trees.

There are many choices to be made, but the good news is, right now, I'm pursuing the next option without the angst and hand-wringing and feeling that time crunch. Other people are always telling me my attitude is awesome, and I have to say, I'm impressing myself at this point.

What needs to be done.

I'll be flying out to India tomorrow, I'll have the D&C there and they can do a karyotype of the embryo. After that, the healing process begins.

I keep thinking, why does this tear us up so much? There is the love you have for that 7-20 mm mass you have growing inside you which was going to be your baby, but honestly, that bereavement is much easier to handle than losing your baby after having known him or her, or even at birth- that pain has to be unimaginable. You cannot really bond with you baby this early on, never having felt him or her, but yet you love the idea of them so much that letting go of that is not easy.  But you have to. Its easier if you believe in destiny. Bighead was not meant to be, neither apparently, was Turbulence. So I have to let them go, their souls were meant for other places, other bodies and I pray that wherever they end up, they are happy.  You still mourn though, I've broken down over my first baby so many times, and I'm sure there will be many moments in the future when I'll be doing the same for the second. But this is not the hardest part.

Neither is physical pain/ discomfort involved. When involved, in itself  pain is a trigger for depression. But, in my case, physical discomfort is pretty minimal. Right now, physically, I'm fine. I've never been through the pain of a real miscarriage, I'm in the pink of health both before and after the D&C.

The real torture of one early loss, or repeat early losses, is fear. Fear that your dreams will ultimately be ashes, that you will never have a baby. Fear that you have to go through this again. Fear of walking into an ultrasound and having the doc coldly inform you that he does not see a heartbeat (both  my losses, I've had non-empathetic jackasses for docs). Fear of walking around with a dead baby inside of you. Fear of getting your hopes up and seeing them dashed into the ground. And that is the true torture

As I told my mom, this is like a boxing match, and you are up against nature. You can keep getting back up to fight, but it has all the power. If it knocks you down, you keep getting up until a) you either give up and change course or b) it lets you win. To this, my mom said, so go into the fight unemotionally. You know what needs to be done, just do it without engaging your hopes and dreams and fears and letting this trio jerk you around like a puppet.

A good idea in theory, impossible to do, or maybe somewhat possible after being knocked out repeatedly numbs you to everything.  I'm not there yet. The prospect of an other loss, of walking into an ultrasound and finding out the worst, has me literally whimpering.

But are what are my advantages? Lots of easily fertilzable eggs. Financial freedom (I've got a good amount saved up and my family is well off as well). Lets also throw in that I'm pretty darned pragmatic, resourceful and don't really care how I get to my current end goal  (a healthy child with my genetics in my arms). I also get pregnant very easily, but don't count this as an advantage any more because I do not know if  this is about genetics or my body is killing off my babies.


Because I can, I  am seriously considering taking my body out of the equation.  These losses are hell on me, and its much harder to face because I don't have that supportive partner who is suffering as much as I am at the moment.  I'll get through this one much more easily because I am flying 24 hours (not fun) to be with my family, but I cannot do that every time I have a loss.

I looked into gestational surrogacy in India, I contacted a clinic yesterday, and this is what I got back.

Program Fees  
The charges (in USD $) for Single Gestational Surrogacy program are as given below.
Stage I $ 8,900 (three free attempts for surrogate, SI charges and lawyer charges)
(Surrogate booking; Agreement; IVF / ICSI procedure; Pregnancy test)  

• Surrogate investigations, preparation, endometrial priming & booking  
• Legal (agreement) charges, Surrogacy India fees
• Follicular monitoring, Procedural (IVF / ICSI) charges, Hospital stay, semen freezing, ET, surrogate care, pregnancy test.

Stage II $ 7,900
(Antenatal care; Medications, investigations, special care, special accommodation, child care, diet, lost wages, Insurance, surrogate clothing)  

• First trimester (3 months)  
• Second trimester (3 months)  
• Third trimester (3 months)  

Stage III  $ 5,900
(Delivery; Post natal surrogate care; Visa assistance)  

• Delivery process (normal / caesarean)
• Birth Certificate
• Surrogate care (2 months) (Medications, stay, care, diet, lost wages)

Mulling it over. Its affordable, for sure. And possible for me, because this is the city where my parents live and resources are not an object.

What the future holds is unclear. But I'm trying to get to the end goal with minimal additional damage to myself.