A tale of 2 ovaries, surrogacy, and the pitfalls of day 3 transfers

I've become aware, over my TTC journey so far, that my 2 ovaries may behave differently with respect to egg production. I think all 3 of my pregnancies (not sure about the first) came from eggs from my left ovary. The one time I had a BFN was when my right ovary was in play.  This IVF, when it became clear that my right ovary follicles were smaller than my left, I asked the embryologist to keep track of the eggs from the right and left. At egg collection and fertilization, it seemed, surprisingly, that the right did better than the left.But.....as things progressed,things changed.

Right Ovary Day 1 2 PN 2 PN 2 PN 2 PN 2 PN 2 PN 2 PN 2 PN 2PN Day 2 4A 4A 4A 4A  4A 4B 4C 4C no data provided Day 3 8A 8A 8A 8A 8A 6C 6C 4B 2A Day 4 early blast early blast early blast morula morula 8C/B 8C/C fail fail Day 5 4AA 4AA 3AA early blast early blast fail fail fail fail Day 6 frozen  frozen frozen poor  blast poor  blast fail fail fail fail
Left Ovary Day 1 2 PN 2 PN 2 PN 2 PN 2 PN 2 PN 2 PN Day 2 4A 4A 4A 4B 4C 4C 2A Day 3 8A 8A 8A 8A 6C 6C 5A Day 4 Early blast Early blast morula 10 C/A comp 8 C/B 8C/B 5A Day 5 4AA 4AA 4AA 2AA 1AA fail  fail Day 6 frozen frozen frozen frozen frozen fail  fail
If you plot the fate of each embryo to figure out where the blasts came from, its amazing how much better my left is than my right. I still can't understand why the mojo appears to be in the left and not in the right (70 % of my fertilized eggs from the left made it, as opposed to around 37% from my right). I'm sure such a dichotomy may also exist in other people, it may just be difficult to spot. Another point I want to emphasize...sometimes the embryo you think has no chance on day 3 CAN actually make it to blastocyst, like my 6C  Day 3 embryo that became my 1AA blastocyst. I was reading a post from a lab who only does day 5 transfers and  the doctor commented on how often they are surprised by poor quality day 3 embryos actually go on to become Day 5 or Day 6 blasts and produce healthy children.  I think a lot of people look at poor quality day 3 embryos and think that they may be saved if they go into the uterus and are certain that, if they wait till Day 5, they will end up with nothing. But I think a little faith is needed, because from all scientific and anecdotal accounts, that location seems to make no difference. Embryo cell culture is something that HAS been optimized, then tried and tested by many labs around the world. And while the uterus is a great place to be, there is definitely a body of studies that show that in a subset of women, the uterus may itself contain hostile factors. Basically, its a level playing field if you are comparing the petri dish to a uterus. If a day 3 embryo has the developmental potential to go the distance,  it will,  no matter where it is. And if it won't, it won't. And this part is just pure idle speculation but I would think, technically,that a day 5 embryo may be able to hold its own better against the hostile uterus a touch better than a day 3 embryo...I'm saying this because a day 5 embryo would make more HCG, a hormone known to cause immune cell apoptosis, and possibly other factors that aid in implantation. The issue with day 3 transfers (in addition to all the risks associated with multiples) that I see is that it puts you through a so much longer period of uncertainty- if none of the embryos will make it, it is actually easier on you to find that out after a phone call from your doctor, as opposed to going through a transfer, a 2WW, paying (monetarily and physically) for your progesterone, your blood test, all of it. Importantly, if your Day 3 embryo transfer fails, you remain in the dark as to what the issue was: was it embryo quality, or implantation issues? On the other hand, if a blastocyst transfer fails repeatedly, its a little bit more likely that the issue may lie in uterine receptivity or immune-related causes. Anyway, moving away from preaching (I am sorry to be doing so much of it; I just can't bring myself to stop), my new surrogate is going through the preparations for transfer. I don't have a transfer date yet, but I HAVE decided to  be brave and only transfer 1 blast.  The last time I picked a surrogate, I was hoping it would be somebody I was comfortable with. Now, I'm finding myself desensitized and starting to treat this the way surrogacy in India is meant to be treated: emotions should be left at the door. Obviously, this is a deeply different process compared to say, the one in the States. As a point I am thankful for, this is not her first rodeo, so to speak; this is the second time she is attempting surrogacy. The first time, she got pregnant on the first shot and had a natural delivery. With so much possibility (in terms of embryo availability), I'm still not tempted to try to carry the baby myself. When I first got pregnant, and heck, even the second time, pregnancy was joyous. Now, the thought of getting pregnant, finding myself at the mercy of hormonal upheaval, of getting 50,000 blood tests and waking up 4 times a night--- I just don't want any of it. I know how much good stuff I am going to miss out on and I still don't want to do it. If my eggs don't work and adoption does not seem easy either, then I may have to go through donor embryo IVF (with PGS) in the States, and that thought makes my blood run cold---just because I'll have to go through pregnancy myself. I am aware that I am missing out on an incredible and important life experience  by choosing to avoid pregnancy---but I remain comfortably numb about it all.

IVF#2: the postmortem and the spewing of many opinions

First, my last 2 blastocysts (which we hoped to freeze on day 6) did not look good, so they did not freeze them. It is so awesome that I was able to respond to this news with a shrug. I'm just so grateful things have gone well so far. Final tally: 8 blastocysts frozen, 5 of which are the best grade my clinic assigns.

The aftermath of the retrieval was ugly though. I had bad OHSS. I  went 3 days without eating; I was so bloated and was ridiculously weak, really no picnic. I have to salute the women who queue up for an embryo transfer when they are feeling like that.

Anyway, here are some of the factors that I felt may have made the difference between this cycle and the last.

•  My physiological state: Inexplicably, after my vitamin D levels went really high, I feel I fell into a reproductive slump: one failed IUI cycle, a pregnancy with my first autosomal trisomy (bad news), and then that disastrous IVF. As I tapered down my supplementation (from 5000 IU to 2000) IU/day), things did change, but slowly. The most noticeable change was a change of my natural ovulation day (day 17 during the slump period), now moved back to day 20/21.
• A more natural IVF cycle: The first IVF, LH was very high around day 2 (because when you first give the agonist, it first triggers a burst of LH production, and then the pituitary shuts down) and the LH (300 IU /day)  because of the menagon. This is the exact opposite of what my natural cycles look like. So I picked a cycle that was much closer to my natural cycle: lowish LH throughout, except at the time of the surge, mild FSH stims (only 150 IU/day, as opposed to a staggering 450 IU/day the last cycle).  
• 1000 mg/day myo-inositol: This one is supposed to help in increasing the proportion of mature oocytes at retrieval in women with PCOS: this is exactly what happened with this cycle, mad coincidence or not. In non-PCOS women this effect has not been observed, but it does help improve implantation slightly. Btw, any women with PCOS considering myo-inositol should read this: the effect of a combination of myo-inositol and D-chiro inositol.  From my own experience, I think I can now vouch for myo-inositol (1000 mg/day).

Now, for the opinions.

I've spent the last few days just thinking about some of the standard practices in IVF clinics, and a lot of them just seem logically flawed in certain ways.

1) High dose Menagon/menopur use, which gives you as much LH as it does FSH. My RE remarked during my cycle that many clinics like to keep blood LH levels  below 2 ng/mL. How many people do a LH blood test while taking 300 IU/day menagon? What would the blood level would be at? I'd say its a fair bet that it would be above 2: do you need that? No. Can it be detrimental to embryo quality? Maybe.

2) Use of higher dose stims so you can increase the egg yield: Multiple studies have shown that if you up your dose of stimulation (from a mere 150 to 225 IU/day), the aneuploidy rate also goes up...from 40% to 70%. The issue is, both the doctor and patient just want the illusion of security provided by many follicles on the ultrasound and a high egg yield . It makes the cycle look good on paper, if say, you get a total of 20 eggs versus 10.

If you can get 10 embryos (with only 3 of them actually being good quality, but you don't have the technology to figure that out), or only 3 embryos that are much more likely better quality, which one should you pick? Sadly, everybody goes for the approach that maximizes quantity, because that is a tangible,albeit potentially misleading measure, as opposed to quality, which is something which is difficult to assess.

This approach puts one through many more embryo transfers and PIO shots and painful 2wws than oone actually may have needed. You could also end up wasting valuable time in trying to find that good embryo among the bad ones. Sometimes, when you are trying to find the one good embryo among a slew of frozen embies, it could take years!


3)Day 3 transfers instead of day 5 transfers: With the improvements in embryo culture, one thing is definitive: the womb offers no advantage over the petri dish. If a embryo can't make it in the petri dish from day 3 to day 5, its not going to do so in the uterus either. This is understandably a really tough pill to swallow, so many people chose not it to swallow it at all. Nobody wants to end up on day 5 with nothing to transfer, so they would rather prolong the receiving of the possibly negative verdict, by paying for a transfer (or do you pay the flat IVF rate), those godawful PIO shots, and the hell of a 2ww. Doctors also perpetuate this when they should be doling out tough love and waiting till day 5. Much respect for the clinics who only do Day 5 transfers.


4) Progesterone supplementation without checking if you need it. First, if you having a FET done, please insist on doing it during your natural cycle, instead of the down regulation + administered progesterone combination. What is the SENSE in this if you have a normal luteal phase? Why not just wait till ovulation, when your body starts to make progesterone naturally? The only time this would be necessary is if you have luteal phase defect, or are undergoing a surrogate cycle (you sure as hell don't want them ovulating).

This brings me to my second point: progesterone supplementation. Doctors just assume you will need progesterone in assisted reproduction. How many people have had their natural progesterone checked? If you make enough naturally, you don't need the PIO shots or the suppositories. Women the world over can provide luteal support naturally. So can many infertile women! But they are still made to suffer through the pain of a PIO shot, just because their doctor cannot be bothered to order a blood test and check.

I've expressed a lot of strong opinions here, and it may offend some people. But this is all coming from a place of trying to make things easier while undergoing these treatments. Many times, you don't need 500 injections to get you pregnant, you just need 50 or so of them. But you still get 500 injections, because no medical professional can be bothered, and everybody just follows standardized protocols without asking...why am I doing this? Is this necessary? Is there an easier way?

IVF#2. The final tally

The results of this round have, frankly, been miraculous-looking. Whether they are actually miraculous (i.e., can produce a drooling, pooping bundle of joy still remains very much a question).

But here we go:

19 eggs, 15 mature, 16 fertilized.
Day 3: 9 eight-celled grade As, 1 five-celled Grade A,  2 six-celled grade Cs. (Plus 1 four-celled and 1 two-celled)
Day 4: 5 embryos are early blasts (!!), 2 reach the morula stage,  2 ten-celled, 4 eight-celled, 1-5-celled (grades AC-CC)
Day 5: 10 blasts!
Five 4AAs, one 3AA, one 2AA, one 1AA, and 2 early blasts (will get the final grade today, when they freeze these last 2 on day 6)

One source says that 40% of "good-looking"embryos make it to blast; Another source says that around 33% of all fertilized eggs make it to the blastocyst stage.

Either way, the results of this cycle are well above average. Last time, the issue was that I had very few mature eggs, but my blastocyst generation rate, from all fertilized eggs, was around 33%, which is dead average.

So why was it so good this time when it was so crappy last time?

More on that later, but this is definately one of those celebrate-becuase-you-bloody-well-can moments. You never know when things will change.

Oh, and I lost my old surrogate and found a new one in the space of 2 hours. And I was lucky enough to find somebody whose cycle began 2 days ago- so a transfer is imminent. More on surrogacy in India soon- have to say, it's SUCH a different set of rules.

More on all of this later, this post has been typed from my phone, so please excuse any typos.

But for now---wheeeeeeeee!!

Decision, and depressed as hell

Thank you all for your input on my last post- I agree with you in that 2 vitrifications should be off the table.  What I was hoping to do was collect the biopsy on day 5, and freeze the biopsied cells. But it looks like that won't be possible, even though I may have been able to get my hands on the materials needed in time.

Doing things in India has the advantage that it won't break the bank, and this is a tremendous advantage that should not be taken lightly. And then, there is the tremendous emotional support that is offered to me by my family.

But one can never have their cake and eat it too- this is a technologically retarded country. NICUs are primitive compared to the setup in the developed world. Fetal DNA analysis from maternal blood (like Sequenom's Tri21 test) during pregnancy is going to take years, if not decades to get here. There is probably one guy who can do a decent aminoicentesis, and I may have to fly my surrogate to another city to find him.  A trophectoderm biopsy is not here yet, or atleast, it is not there with my doctor, who expressed extreme reluctance in doing this procedure. My lack of preparation had an extremely large part to play in this, I just sprung this on him, so he did not have time to prepare, with dummy runs etc.


But there it is- no testing.  I have to just collect whatever grows till day 5, and transfer to the surrogate.

Atleast 40-50% of the day 5 blastocysts  (there was a study definitively showing this) are going to be abnormal. My RE countered that despite such odds, people get pregnant and deliver healthy babies. What was left unsaid was how this is achieved: you transfer multiples. Out of 2 or 3 embryos, 1 may be normal. I'm starting to believe the theory that most women's wombs can distinguish between a normal and abnormal embryo. This may very well be the reason for the high frequency of BFNs in IVF and in natural pregnancies as well. The transfer of 2-3 embryos can also sometimes result in a pregnancy with multiples, which may be slightly or tremendously detrimental to the lifelong health of the resulting children, even if the pregnancy is without complication.

So now, I may have to do what everybody else does: transfer 2 at a time, or I may be doing this for a while, at tremendous cost.  I just have to then pray that if my surrogate gets pregnant, it is with a singelton, not twins. A twin pregnancy is considered high risk in the developed world. Here, given the standards of management, you would have to rely on luck for everything to go ok, and I'm somebody who has had absolutely no luck in this process so far, and now, I have to pray that I find that luck. Scary as hell.

Day 2 report and a difficult decision to make: Need your input!

All but one of my 16 embryos are now 4-celled:


8 are 4-celled As
2 are 4-celled Bs
4 are 4-celled Cs
1 is a 2-celled A (this we can probably write off)

I think there is a good chance I'll get a decent number of blastocysts, of varying grades. This is the sort of thing where I'd want to do an embryo biopsy to see how many are aneuploid.

The issue is, I  was stupid and left it too late, because I did not envision getting anything, after my last experience. The only lab (the Spain-based company Iviomics) doing this in India is not functional yet. We could collect the biopsied cells and freeze them down, but we need a special medium and special tubes to do this.

I just got off the phone with the Spanish guy who is the India head for this organization, and I asked him if we can overnight this from Spain to get here by Day 5 (Sunday). He said he could talk to his people and get back to me.

The other option, which I really don't like, is freeze everything down on day 3, thaw them all, herniate, and biopsy on day 5, and freeze again. This involves double vitrification, which I'm not a fan of.

The other option is going with fate--- just freezing whatever we get on day 5,  transferring and seeing what happens.

Lets hope they can overnight. Even if things work out that ideally, there are still risks: the clinic does not do this routinely.

What would you guys do in my shoes- do the day 5 biopsy on Sunday (if I could get the materials on time) or go with hoping to get lucky?

Fertilization report

Things are still looking good: Turns out I had 19 eggs, 15 of which were mature (M2).


16 of them became 2PN embryos (i.e., they fertilized)!!! All my M2 eggs, barring one  large "cyst" fertilized. Heck, even my immature eggs (M1), a total of 2, fertilized.

That is a total fertilization rate of 85% (93% for M2 and 100%, for M1), which is at the upper end of the ICSI range (70-85% of total eggs). Compared to the last IVF, where the overall fertilization rate was 29%  (75% for M2, and 0% for M1), this is awesome.

I also asked my RE to try an experiment: to dilute, aliquot (i.e., divide), and refreeze the sperm, and see how many survive per aliquot. This would be interesting, and may work for repeat IVFs, and is a great way of thwarting the evil sperm banks, who charge a fortune per vial, and for every service they can dream up. While this would not be advisable for IUIs or ICIs, it may work for IVF. This was my backup plan if I decided to go for natural cycle IVFs.

Now begins another stressful period- waiting to see how many will make it to blastocyst.

I also have OHSS, and yesterday was absolutely miserable. Today is slightly better, but I'm still as weak as a kitten.

But I've been wanting to say this for a while: despite everything I have gone through, I am a lucky person, when it comes to my family. My parents are the most amazing, selfless people. I met a woman recently at the fertility clinic. She was older, unmarried and wanted to freeze her eggs (no insemination). She told me her mom stopped communicating with her once she started going ahead with the IVF process. My mom, on the other hand, gave me all my injections (even the trigger at 3:30 am, due to which she had a mostly sleepless night), has drawn blood for me at home to send to the path lab, and was allowed into the OT to hold my hand when they put me under. And she has done all this without complaining, ever. Even though my plan wasn't her plan for me. I hope if I get children out of this journey, that I will be able to manage even a fraction of what my parents have done for me.

Retrieval update

It is not often that I get to post awesome news... If I wait till tomorrow to post, things may become less amazing again- so without further ado----They got 19 eggs! And a lot of them were very easy to obtain, as opposed to the last time, which was apparently a nightmare of flushing and re-flushing in the hopes of getting something.  This hopefully is a good sign, as apparently, the more immature eggs remain stuck to the follicle walls, resulting in the so-called empty follicle syndrome (Dr. Sher has a useful blogpost on this).

Dunno how many will be mature or will fertilize, have to wait till tomorrow to find out.

I posted today for one reason- I'm determined to celebrate any positive news, for as long as the universe lets me enjoy it. Find joy now- that is  my new, hard-learned philosophy.

IVF #2: One day from trigger

According to my doctors, my response has been *much* better than the last time.

I'm on CD13, and the 12th day of stims. I have around 16 follicles growing; around 10 in the left ovary and around 6-7 in the right ovary.

All 10 follicles in my left ovary are marching in ranks, they now range between 17-21 mm, and have been synchronous from the start. Unfortunately, its a different story in my right ovary, while the follicles within are synchronous, there the average follicle size is around 13 mm.

Basically, my right and left ovaries have not been communicating. My left ovary, interestingly, has always been the dominant player, atleast 2 of my 3 pregnancies came from this one.

E2 levels over this cycle:
CD08 E2 = 324, LH = 0.82
CD11 E2 = 1501, LH = 1.02
CD13 E2 = 2574, LH = 0.45

The last value is lower than what I expected. My RE, who uses a particular lab said they had been reporting lower than expected values all day for different patients, which makes her think that there are some testing-specific issues, and this crops up from time to time. I hope to god that is indeed true and my level is a bit higher than this.

Assuming a peak E2 of around 230 (remembering this from my IUI days), I have around 12ish follicles. Hopefully of these have pretty little mature eggs within...one can hope right?

Anyway, the truely cool part- all of this is on a MUCH lower dose of stims than the last time.

Last time, I was stimming with 300 rFSH for the first 4-5 days and 450 IU FSH and 300 IU LH (thanks to the menagon, which is equal parts of FSH and LH) for the remainder. It was like getting hit with a Mac truck of hormones, the multiple injections were a trial, and I had the mother of all breakouts. My EWCM abruptly went away around the 10th day of stims. And most importantly, though I got 11 eggs, only 3 managed to fertilize and only one made it to blastocyst.

This time, its 150 IU FSH/day, with an additional 75 IU LH on the last day of stimulation. With this itty-bitty dose, my response is similar, if not better. I have more follicles (albeit with a slightly lower E2), I have not broken out. I've had EWCM all throughout.

So far, this is what I am really pleased about, that I have had a better-looking response to a much lower, more physiological dose. There is some hope here now.

The biggest difference between this cycle and the last is that my LH levels this time around have been FARR lower. We'll see how that shakes out, in terms of a response.

Trigger is early Monday morning, at the ungodly hour of 3:30 am. All I can do at this point, is pray.

Your antral follicle count could vary depending on....

I'm now five days in to my IVF cycle. On CD1, I went to my RE's for the baseline scan. I was expected an antral follicle count of around 25, because that is what two scans in the past few months have shown.

To my dismay, this scan showed an count of around 16. I was depressed and did not know what the heck was happening. I had a scan at another place that had a prehistoric looking setup, and the count (after 1 minute of examination) was 15. This prompted a major crying jag and wondering if I should halt the IVF because there was something funky at work...again.

But then, a confirmation could only come from the place where I had  done the last scans, which  had  a much fancier 4D machine. So, I took myself back to the other place, and there the scan (done by another operator, as the ) revealed a count of 24. 

In other words, in the same cycle, 2 days apart, my counts were 16 or 24, depending on the machine used (!!!)

I just also realized...my big "drop" in follicle counts from 30 to 16, which I had thought was so momentous, and what I though represented a big shift in my physiology, may just be attributable to the machines used. A face palm moment, to be sure.

Here is a sum up of the scans I've done:

August 2010: San Diego RE, Dr G: 33
December 2010: India, 4D machine: 30
Mid 2011: New York, 2D machine Dr. L: 16
Late 2012: India, 2D machine, Dr. M:13
Jan 2013: India, 4D machine: 25
Feb 2013: India, 4D machine: 16 (big drop in the AFC in my left ovary)
March 2013: India, 4D machine: 25 (phew!)
June 2013: India, 2D machine, Dr. M: 16
June 2013: India, another 2D machine: 15
June 2013:  India, 4D machine: 24.

Note: what is really unknown here is what kind of machine my San Diego RE used. But, I have to give credit where it is due, I LOVED this guy's setup. Having gone to multiple different clinics around the world, I have to say that they had the most organized, systematic way of doing things. Every ultrasound scan was monitored by a nurse (standard practice) and the details were recorded in a form created for this purpose (only they did this). When I got my medical records from him, the minute details of each ultrasound I had ever done was printed out, without me having to memorize it.  Everybody does more or less the same thing, but what I am coming to value more than anything is the attention paid to the little details.

But I digress: here is the sum up: my ovaries have never stopped looking polycystic, or rather multi-cystic. I think that there could be a mild inverse correlation between my vitamin D level and my antral follicle count (in other words, the higher the blood Vit. D  level, the lower the number of AFC recruited), and there was a theory for that, but the drop may never been as dramatic as I thought it was.

I asked the doctor at the place with the fancy machine why there was a difference between 4D and 2D scanning, and she said well, the ovary is a 3D round structure, so  its possible that a 2D scan may miss some.I looked up papers on this subject which said that the fancier machines may be better at getting an accurate count in somebody with a higher AFC.

 The more you learn, you realize how little you knew. But anyway, this cycle is underway; wish me luck!

What matters in an antagonist IVF protocol

There have been many, many studies conducted to optimize the IVF protocol. I looked at some of the questions that seemed relevant to my situation, and this blogpost discusses what I found.

Fairly conclusive: Stimulation  with a lower dose (150 IU follistim/day) may be a good idea

• Study 1: The proportion of chromosomally normal embryos was higher in patients subjected to a mild stimulation (150 IU/day, antagonist started when lead follicle reached 14 mm) than in those subjected to a convention stimulation (long term downregulation with agonist, 225 IU FSH/day).
• Study 2: Another group (which compared 225 IU vs. 150 IU, with both groups receiving agonists) reported a similar finding, and also observed that the fertilization rate was higher.   

Note: As expected, the low stimulation dose elicited fewer eggs, with a greater frequency of cycle cancellation. But here is the striking part: the total number of chromosmally normal embryos was similar between the two groups.  So basically, stimming with a higher dose puts your body through the wringer
for no real advantage and even a possible disadvantage in that it may decrease the quality of the embryos you produce and make you go through the emotional and financial turmoil of more embryo transfers and possibly pregnancy losses, while not affecting the live birth rate.

No real difference evident:  Comparison of Follistim and Menagon

• Study 1: Study in women of advanced reproductive age: Comparison of Follistim and menagon on aneuploidy rates:  follistim is slightly better, but this difference did not reach statistical significance. The clinical pregnancy rate was significantly increased in the Follistim Group

Mixed findings: Agonist vs. Antagonist

• Study 1: The agonist protocol produces more embryos, but is associated with a lower clinical pregnancy rate.
• Study 2: No difference in the clinical pregnancy rate observed, but the antagonist protocol conclusively reduces the risk of OHS.

Conclusive: The antagonist dose can be reduced

• Study 1: Giving the antagonist (0.25 mg/day) daily or every other day does not appear to make a difference.
• Study 2: Doses of 0.25 mg/day (standard) or a 0.125 mg/day dose of the antagonist elicited similar results in IVF

Difficult to figure out: The best time to start giving the antagonist

The choices are Day 1-4 (with the FSH), Day 6, or individualized (when the lead follicle reaches 14 mm).

• Study 1: A study comparing the day 6 and the individualized protocols found that the individualized one worked better (generated more oozytes, while requiring a lower amount of FSH) 
• Study 2: No difference seen between Day 1 start and a day 6 start.
• Study 3: A day 4 start was better than a day 6 start. 

 Difficult to figure out: To supplement or not with LH?

• Study 1: A analysis of a large number of clinical trials examining the effect of LH supplementation in an antagonist protocol showed a benefit (increase in pregnancy/live birth rate) only in the poor responder/pregnancy loss group.

So--- based on all that, all I know is that a low dose FSH regimen is a good idea, and I should not get greedy and increase this, because quantity (growing follicles seen on the ultrasound) is not what matters, it is the quality of what is recovered in the end. Additionally, I could take the antagonist every other day without it making a difference.

Where I am in the dark about: When should I start the antagonist? Should I take any additional LH? In other words, am I a poor responder, who may benefit from a little, but not a lot of it?

Here are my choices....

Protocol choice 1
Start Follistim (150 IU/day) CD2 onwards
Start antagonist (0.25 mg every other day) on the day when the lead follicle hits 14 mm.

Trigger 10,000 units HCG

Pros: super easy on me, only 1 injection/day for a while.

Cons: A higher LH level early on may be detrimental.

Protocol Choice 2

Start Follistim  (150 IU/day) CD2 onwards
Start antagonist (0.25 mg every other day) CD2 onwards
Trigger 10,000 units HCG

Pros: Not so many injections

Cons: A total lack of LH early on may be detrimental.

Protocol Choice 3

Start Follistim (150 IU/day), CD2 onwards
Start antagonist (0.25 mg every day) CD2 or 3 onwards
Low dose Luveris (37.5 IU/day) CD4 onwards
Trigger 10,000 units HCG
Pros: Everything is very controlled; you cut off LH almost completely and supplement with a measured small quantity every day. This has shown to do no harm, and there is the slight chance it will help.

Cons: Luveris is expensive. Many more injections required.  Plus, it comes in an ampoule form containing 75 IU, which means I'd either waste half an ampoule, or have to take 1 injection every 2 days.

If anybody can wade through this knowledge dump and offer any feedback after, please do. Please, please, please, share your own experiences with regard to any of the points discussed in here: FSH dose, Antagonist dose and regimen, and the choice of adding back LH.