IVF Treatment Protocols
IVF treatment is tailored to your specific needs by your fertility specialist. Most patients who undergo IVF will be prescribed one of two main treatment protocols: Long Down Regulation and Antagonist treatment cycles.
Long Down Regulation (Agonist) treatment cycle
Long down regulation treatment is the process of suppressing a woman’s natural hormones before fertility medications.
Approximately 3 weeks after your period starts you will have a blood test and begin pre-IVF treatment [GnRH analogue] in the form of a Synarel nasal spray or Lucrin injection to control your natural hormones before the fertility medication starts.
About 12 days later another blood test will be taken to make sure your own hormones are low [or down regulated] and you will be instructed when to begin daily hormone Follicle Stimulating Hormone injections [Gonal-F or Puregon]. You will continue taking the Synarel or Lucrin throughout this time.
5 days after you begin FSH injections you will have a blood test and ultrasound of your ovaries. You will be monitored closely with blood tests and ultrasounds until you have an optimum number and size of developed follicles. Once you are ready will we advise when to have your hCG trigger injection and schedule your egg collection 36 hours later.
After egg collection you will use supplemental progesterone either as a vaginal gel, pessary or subcutaneous injections until your pregnancy test two weeks later.
Antagonist treatment cycle
Antagonist treatment uses injectable drugs called antagonists to prevent premature ovulation. It is the most commonly used treatment protocol because the shorter cycle makes it more convenient for patients and reduces the risk of hyper-stimulation.
Starting on the second day of your period you will have a blood test and providing all your hormone levels are low, you will be advised to begin Follicle Stimulating Hormone (FSH) injections [Gonal-F or Puregon] that day.
After four days of injections you start a second injection [Cetrotide or Orgalutron] to switch off your own hormones and prevent premature release of the eggs. 6-8 days after you begin FSH injections you will have a blood test and ultrasound of your ovaries. You will be monitored closely with blood tests and ultrasounds until you have an optimum number and size of developed follicles.
Once you are ready will we advise when to have your hCG trigger injection and schedule your egg collection 36 hours later After egg collection you will use supplemental progesterone either as a vaginal gel, pessary or subcutaneous injections until your pregnancy test two weeks later.
IVF Protocols Explained
Welcome to Fertile Minds.
I'm Professor Michael Chapman, I work with IVFAustralia. Today, we're gonna talk about the protocols we use in an IVF cycle. What we're trying to do is get you pregnant, and this is the way we're gonna be doing it.
The commonest protocol used in Australia and in about 85% of cycles, in fact, is what's called the short protocol, so let's go through that. We start on day two, usually, giving injections of FSH. That's the hormone that normally comes from your brain to tell your ovaries what to do, and what we give you is a synthetic version of that at a much higher dose than your brain normally does so we get lots of eggs.
So we start that on day two and in most cases, that's a daily injection in your tummy, like a diabetic does for their insulin injections, with a little pen which has got a tiny little needle on it, and that happens every day. And then at day five or six, we start a second injection. So the first one was to try and make as many eggs as possible. The second injection, which is on a daily basis, called an antagonist, a GnRH antagonist, cetrotide or orgalutran, that is to stop you ovulating, stop you releasing the eggs before we get to collect them. Obviously, it would be a waste of a cycle if you ovulated yourself before we were able to harvest them. So you're taking two injections a day, usually at the same time, it's recommended they're taken in the evening but the time is not vital, it doesn't need to be on the same hour every day, but in the evenings on a regular basis.
From that point on, you'll probably probably have one or two or three blood tests and ultrasound scans, transvaginal ultrasound scans, to watch the follicles growing and to measure the hormones that are being produced by those follicles. Then the specialist will see those results on a daily basis and make decisions about whether to change the dosage of the drugs that you're using, or to make that final decision of it's time. It's time to collect the eggs.
At that point, time is then set for the egg collection to take place. When the eggs are ready for collection, they need a final maturing injection, an injection that makes the eggs go from 46 chromosomes to 23. It's what happens in nature, just before ovulation, so that your 23 chromosomes can meet up with the 23 chromosomes of the sperm, and that requires a trigger injection, it's called. These days we use a synthetic version of the pregnancy hormone hCG, but we also can use hCG itself. And that is given quite precisely, and you will be told by your nurses to be precise about taking that, 'cause once we give the injection, we know the eggs are gonna be released at about 40 hours after that.
So what we're doing is timing your egg collection to be between 36 and 38 hours after the injection is given. So if we've set a time, say tomorrow morning, eight o'clock in the morning to do the egg collection, you will have had your injection at eight o'clock last night. 10 minutes, either way, is not important, but if you forget it, it is a major problem, because your eggs won't be ready. Once you have had that injection, then as I say, you're gonna be coming to the egg collection room 36 to 38 hours later, eggs are collected, then we begin what is called luteal phase support.
In every IVF cycle, to make sure the lining of the womb is good, we need to keep progesterone levels high, and that's done either with pessaries or tablets in the vagina. That's fairly uniform throughout cycles. You can use hCG injections instead of the progesterone pessaries, but that has a risk of causing hyperstimulation, so we rarely use it.
So that's the short protocol. I'll just run it again. Starts on day two, daily injections, starting on day five, another set of injections, the trigger injection, egg collection, and then luteal phase support. That's the majority. That came to pass about a decade ago in Australia.
The previous regime, and that's what's used by the other 10 or 15% of patients in Australia, is called a long protocol. It's called a long down-reg protocol. That begins in the third week of the cycle before the cycle that we're going to collect the eggs. So 21 days on a normal cycle, we will do a blood test to make sure you've ovulated, and after that, we will be giving you either a nasal spray or an injection to switch off the ovaries, so that when we get to the day of your period, the ovaries are quiet, there's no activity, and then we start the daily injections of the FSH. Again, those injections will continue all the way through until the day of the trigger injection. That's about, usually, an average of 11 days of injections. Could be 10, could be up to 14, but the average is around 11 days.
Same injection as we talked about in the short protocol at that point, but we've already switched off your pituitary gland with a nasal spray or the downregulation agonist injections. Again, there'll be the same monitoring with bloods and ultrasounds, and a decision will be made by your specialists that it's time to collect the eggs and the trigger will be provided. Again, it's the same trigger, 36 hours before the operation, to collect your eggs. The luteal phase support, again, is identical to a short protocol.
Now, the reason why 85% do it that way, it's not because it's any better, it's just that it's easier for you, the cycle is shorter. Studies that I've personally done have shown 99% of patients prefer the short protocol, compared with the long one, just because it's all over in the one month.
There are other protocols. Some people would do natural cycles where you only get one egg and you don't need any medication. In some countries around the world, Japan's one of them, where the drugs aren't covered by Medicare, natural cycles are done a lot, but it means you need to have lots of cycles to get the same cumulative pregnancy rate as we get in Australia, so it's usually not the way to go.
Some people will start the injections later to get one or two eggs only. Again, it's a numbers game. The more eggs you have, the more chance ultimately you have of getting pregnant. In some cases, we even go as far as the long, long downregulation. So we started on day one of a cycle, not in the cycle that you're gonna be having the egg collection, but a month later. Some people do that where there's endometriosis, for instance. It may suppress endometriosis, although in a month, it's unlikely to.
So there are multiple protocols. The majority are pretty straightforward, short protocols that, as I said earlier, are much, much easier and much less burdensome than in the past. So when you sit down in front of your IVF doctor, that's what they'll probably give you, at least as your first cycle. The dosing of those is dependent on your clinical situation, age, weight and previous history. I'm not gonna go into that today but it will vary from patient to patient, so don't necessarily compare my cycle with your cycle . It can lead to confusion.
What you want is a specialist who understands what the best is for you, someone who's experienced, and our doctors at IVF Australia are all in that category. So thanks for watching, I hope that was useful, and if you've got any questions or comments, please make them, and please subscribe to the Fertile Minds.
*All opinions expressed on the Fertile Minds YouTube Channel belong to the individual doctors, scientists and specialists, not the Virtus Health group.