Long Down Regulation

Overview

In Vitro Fertilisation (IVF) and Intra-Cytoplasmic Sperm Injection (ICSI) are two of the most common forms of fertility treatment. IVF and ICSI vary only in the way that the egg is fertilised. The treatment process up until this point is the same.

Your fertility specialist will individualise your treatment and recommend one of several treatment cycles, depending on your particular circumstances. Two of the most common treatment cycles are an Long Down Regulation Treatment Cycle, or an Antagonist Treatment Cycle.

View the Long Down Regulation treatment timeline here.

Step 1: Day 1 of your cycle	Make an Appointment: Within a few days of the start of your period phone the clinic nurses to arrange an orientation visit with them in about 3 weeks time. Some women, commonly those with irregular periods, will be asked to start taking Provera tablets (from day 19) once a day for 5 days.
Step 2: Day 22	Orientation Visit: On day 22 of your cycle (or a day or two either side) visit the clinic for an orientation visit with a nurse, a blood test, and collect medication. You will also be asked to pay the first day fee. The nurses will explain the treatment cycle to you, the medications you need to take and the times when you will be required to visit the clinic for blood and ultrasound tests. The blood test conducted on this day is to determine your progesterone level - this will tell us if you have ovulated. GnRH Analogue (agonist) medication begins: From this day, you will start taking GnRH analogue medication in either a nasal spray (Synarel) or injection form (Lucrin). This is used to suppress your own natural hormones (referred to as down regulation) so that we can control your cycle. When your eggs start to grow it will stop them from being released naturally. You'll continue this (GnRH analogue) until your trigger injection, just prior to egg collection.
Step 3: Day 22 - Day 34	Blood test to confirm down regulation: You will continue using medication every day for 12 to 14 days until you revisit the clinic for another blood test to make sure your own hormones are low (we call this 'down regulated'). In that timeframe, you will have most likely had your period (or you period will have started). Even if your period hasn't started we still like you to come in for the blood test as occasionally people can get pregnant naturally while using the nasal spray, but this will not harm the pregnancy. FSH treatment starts: Once we know that your hormones are 'down regulated', you are ready to start treatment. The nurses will phone you the afternoon following your blood test with the results to let you know that it is time to start the FSH (Gonal-F or Puregon) injections. You must keep taking the GnRH analogue medication (Synarel or Lucrin) throughout this time. When to give injections: We recommend you give the injections at the same time each day. We normally suggest the evening is a better time to do this, so that when we do blood tests and ultrasounds in the morning, if we need to change the dose then the dose can be changed that same day.
Step 4: Day 1 to day 6 or 8	Treatment Monitoring: From 6 - 8 days after you begin FSH injections you will have another blood test. In the meantime continue with the nasal spray. If you have your FSH injections at home please do not have one on the morning of these later blood test and/or ultrasound (but do have your Synarel or Lucrin). How FSH injections work: The Follicle Stimulating Hormone (FSH) injections work by stimulating the ovaries to produce more than one follicle (egg). Naturally there will be a number of follicles that are receptive to grow every month but only one reaches maturity. By giving a higher dose of FSH than is naturally produced each month, we are able to recruit some of those follicles that wouldn't normally grow to maturity. IVF treatment does not use up your supply of eggs and you will not reach menopause any earlier than normal. Regular blood and ultrasound monitoring: We will continue to closely monitor you with blood tests and ultrasounds until you have an optimum number and size of developed follicles. To do this you will be required to come to the clinic every couple of days.
Step 5: Day 8 or 10	Blood test and ultrasound monitoring: On day 8 or 10 you will have an ultrasound and another blood test. The ultrasound will show us how many follicles are growing in the ovaries. We can't see the eggs on the ultrasound however we know that when a follicle reaches approximately 18mm it will contain a mature egg. There is not a set time in which the follicles will reach this size. There is a 3-4 day window when your eggs reach maturity allowing us adequate time to collect them.
Step 6: Approx Day 12	Trigger Injection: Once we know you are ready, we will advise you when to have your hCG trigger injection and we will schedule the egg collection for usually 36 hours later. The exact time for the trigger injection: The trigger injection is the only injection we specify the time that it is given. The time is very important as it related to when we actually collect the eggs. It is normally given in the evening and the egg collection will occur approximately 36 hours later. Once you have the trigger injection you stop the FSH injections and the Synarel (nasal spray) or Lucrin (injection). How the trigger injection works: The hCG trigger injection is the same hormone that is produced in pregnancy, but it has the effect of maturing the egg so that it is ready to be collected. For example, if you had a trigger and waited 48 hours your body would naturallly release the egg on its own ready for fertilisation.
Step 7: Approx Day 12	Egg and sperm collection: Egg collection is undertaken in a day surgery/hospital under a light general anaesthetic and takes around 30 minutes. You will be at the hospital for around 4 hours and need someone to drive you home afterwards (don't plan to work that day). The procedure is performed using an ultrasound guided probe (similar to the scans conducted in the clinic). Attached to the ultrasound probe is a needle, which pierces the follicle and draws the fluid (and egg) out. Semen Sample: On the morning of your egg collection your partner will need to provide a fresh semen (sperm) sample so we can immediately fertilise your eggs after collection. After egg collection your progesterone level will be supplemented by inserting a vaginal gel every night until your pregnancy test 2 weeks later. This is to prepare your uterus for embryo transfer by supporting the lining of the womb ready for a pregnancy. Before going home we will give you an instruction leaflet. We can provide medical certificates (which do not mention the type of treatment you are having or have any IVFAustralia addresses on it, to protect your privacy). After egg collection: You may feel a bit sore after your egg collection - abdominal cramping is normal - and you may take Panadol or Panadeine and use a hot pack to ease the discomfort. If you find this is not sufficient then please contact the clinic for advice. It is not recommended to take Aspirin, Nurofen or Naprogesic unless specified by your doctor as these may interfere with implantation. You can expect some light red or dark brown bleeding for a few days, which comes from the puncture sites in the vaginal wall. If you experience heavy bleeding contact the clinic.
Step 8:	Egg Fertilisation: Your egg and sperm will be taken directly to the laboratory where they will be prepared for fertilisation. If you are having IVF, the egg and sperm will be placed in a dish allowing fertilisation to occur naturally. If you are having ICSI, an embryologist will insert one single sperm directly into the egg, allowing fertilisation to occur.
Step 9:	Embryo Development: The day after egg collection the scientists will call (usually between 10am and 2pm) to let you know how many eggs have actually fertilised. The scientists will keep you informed on how the embryos are growing and will let you know the date and time of your embryo transfer. Your embryos will normally grow in the laboratory for five days.
Step 10:	Embryo Transfer / freeze: We transfer the embryos back into the uterus in a simple procedure, similar to a pap smear. You can go about your daily activities after this procedure and the embryo will not fall out. Any extra suitable, healthy looking embryos are usually frozen at this time if that is your wish.
Step 11:	Pregnancy Test: Continue with the progesterone medication until your pregnancy test, two weeks after egg collection. You can expect to hear from the nurses throughout this period, however if you have any worries or concerns please contact the nurses. Following a positive pregnancy test, we will organise for you to attend the clinic for an ultrasound normally at around 7 weeks - this will confirm the number of sacs (that is number of babies) and heartbeat. Your GP or fertility specialist can refer you to a local obstetrician, if you do not already have one. Should you not be pregnant, we recommend you attend a follow up appointment with your fertility specialist for a review of your cycle.
	Support throughout your cycle: The counsellors are available for additional emotional support and advice at any time throughout your treatment cycle and all patients are encouraged to access these services. Counselling sessions are free while on cycle, as well as one counselling session post treatment.