Protocols of multiple follicle development
Most common protocols
There are three main ovarian stimulation protocols: long, short and antagonist protocol.
The choice of protocol is made based on the individual nature of each woman?s cycle, the response of her ovaries to previous attempts, her age and other factors assessed by the doctor.
However, the application of the protocols is flexible as each organism responds to the drugs differently. In each case, an important part of our task is to define the best stimulation protocol and the ideal drug dosage.
Long protocol
The long protocol involves two phases:
1st phase: Downregulation using GnRH antagonists (Arvekap, Daronda, Suprefact). Duration approx. 10-14 days.
2nd phase: Ovarian stimulation using gonadotrophins (Puregon, Gonal-F, Altermon, Metrodin, Menogon) during continuous downregulation of the pituitary. Duration approx. 10-14 days.
The total duration of the long protocol is about 1 month.
Onset of downregulation in the long protocol
Downregulation of pituitary and ovarian function is checked at the end of the 1st phase. You may be informed of the exact date of your downregulation check you may contact the midwives of our unit either on the day of analogue administration or on the first day of your period, so they can schedule your next appointment. The downregulation check usually involves a transvaginal ultrasound and measurement of certain hormones. If downregulation is sufficient you will be given instructions to start the gonadotrophins.
Onset of stimulation in the long protocol
We will contact you in the late afternoon of the downregulation day to confirm the completion of your downregulation and the start of your stimulation. You will be given instructions on the dose, start date and times to take your gonadotrophins. Meanwhile, you will continue to take the GnRH analogue until the end of the treatment at the dose suggested by us.
Antagonist protocol
In this protocol, gonadotrophic stimulation begins on the 2nd or 3rd day of the cycle, while the downregulation using the antagonist GnRH analogue follows. The duration of the antagonist protocol is approximately 8-12 days.
The antagonist administration can start either blindly on the 6th day of stimulation with gonadotrophins, or based on ultrasound and hormone criteria. In our Unit, antagonist administration is based on individualised criteria and corresponds to statistically higher pregnancy rates.
Our related study was published in the scientific journal Human Reproduction, official journal of ESHRE (European Society of Human Reproduction and Embryology), with the title ?In a flexible antagonist protocol, earlier criteria-based initiation of GnRH antagonist is associated with increased pregnancy rates in IVF (Lainas et al., 2005, Hum Reprod, 20(9): 2426-2433).
Application of the protocol based on individualised criteria maximises your chances of success.
Short protocol
The short protocol (or flare-up GnRH agonist protocol) is selected usually for women with poor response to ovarian stimulation.
In the short protocol:
- The administration of GnRH agonist usually starts on the 1st-2nd day of the cycle and the gonadotrophins on the 2nd-3rd day.
- It is not divided into a downregulation and stimulation phase and its duration is about 10-14 days in total.
Natural cycle
It is recommended as an alternative to patients with particularly poor response to ovarian stimulation, such as patients with several previous failed attempts and embryos of bad quality. The development of the follicle and the endometrium is monitored with a series of ultrasounds and hormone measurements.
If deemed necessary, the natural cycle can be modified using antagonists and gonadotrophins (modified natural cycle, MNC). The drawback of the natural cycle is that we have to manage with only one follicle, from which we will hopefully recover a mature egg that will fertilize and develop normally into a good-quality embryo for transfer.
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