Okay, so you have ticked all the boxes in the checklist and are ready to proceed. In your early conversations with your doctor, he will most likely discuss your protocol with you. During the cycle, the ovarian stimulation medication may be administered in a variety of combinations called protocols. Generally, there are two types of protocols; the long protocol and the short protocol. The drugs administered in both protocols are the same; but the dosage and the durations differ. Certain factors like the woman’s age, response to the medication, and the outcome of previous attempts, largely determine which protocol will be chosen for the treatment cycle.
This, as the name connotes, is a longer protocol, starting with the down regulation of the ovaries. Certain drugs, such as Buserelin, Leuprorelin, Triptorelin, Cetrorelix, or Ganirelix, are started about 1 week before the expected period day 21 of a 28-day cycle. Alternately, the drugs can be started on day 2 of the cycle. It all depends on your Physician. These drugs act by suppressing two hormones which normally cause your ovary to produce eggs and ovulate. By suppressing these two hormones called follicle stimulating hormone (FSH) and luteinizing hormone (LH), the ovaries become suppressed so that they neither produce eggs nor the ovarian hormone called estradiol. Down regulation, or ovarian suppression, allows the physician to have greater control over the ensuing ovarian stimulation, providing for an even growth of ovarian follicles, and preventing the body from prematurely ovulating on its own.
The down regulation drugs are taken for approximately 10-15 days, at the end of which, an ultrasound scan of the uterus and the ovaries and blood estradiol test are performed. If down regulation is not complete, the drug administration is extended for another week. At the end of the down regulation process, the uterine lining should be sufficiently thin and the ovaries should not be producing any eggs.
Once ovarian suppression has been achieved, ovarian stimulation using gonadotropin fertility medication, (such as Follitropin Beta, follitropin alpha, Menotrophin and follicle stimulating hormone – FSH) will commence on what is referred to as the cycle start day. The medication dose is based upon the woman’s age, weight, number of ovaries, FSH and estradiol levels and response to previous stimulation cycles. The initial dose could start low, and could be ramped up, or even reduced, depending on the response. Ultrasound scans are conducted starting on Day 7 of the stimulation period, to start to monitor follicular growth. Follow-up ultrasounds are preferably run every 1 to 3 days. Towards the end of ovarian stimulation patients are asked to return to the clinic more frequently for observation. Most women require 8 to 12 days of ovarian stimulation, and 4 to 6 ultrasound scans during this period of time. During ovarian stimulation, the down regulation drugs are continued, but at a lower dose.
Once the growing follicles have matured into ripe eggs, the drug hCG (human chorionic gonadotropin) is administered about 36 hours before egg retrieval. Once this is injected, all the other drugs are stopped. Administration of hCG is referred to as follicle triggering, as it triggers the release of the eggs by the ovary. The timing of the administration of this drug cannot be over emphasised. Missing this window can prove catastrophic to the whole cycle.
For both my cycles, I was on the long protocol. I went through both the down regulation and stimulation motions. However, because of my polycystic ovaries, as well as my history (I had almost over stimulated on a previous round of clomid and injectibles), I was placed on the lowest possible stimulation dosage in both cycles. This is incredibly important in order to prevent over stimulation, which is itself another beast.
The short protocol is a more aggressive approach, typically for poor responders or those with reduced, or diminished, ovarian function. It is similar to a normal cycle, in that it has a timescale of approximately 4 weeks (compared to the 6 weeks of the long protocol).
The primary difference between the short protocol and the long protocol is that, unlike in the long protocol where there are 2 distinct stages of down regulating and stimulating, in the short protocol the patients go straight to the stimulating stage. On day 3 of the patient’s cycle, a scan and/or blood test is carried out, to make sure that the womb lining has thinned out after their last period. If it has, the administration of stimulating injections commences, sometimes also accompanied by some dosage of down stimulating injections. Scans are then carried out every few days, but preferably daily, until the eggs are ready for retrieval.
As is with the case of the long protocol, once the eggs are ripe for retrieval, the hCG injection is administered 36 hours prior, also bearing in mind the sacrosanct time window.
The advantages short protocol has over the long protocol are that there are fewer drugs involved and, as a result, is a faster treatment cycle. But it is also the more aggressive protocol and in some cases, having the time to slowly shut down and then build up ovarian function, as is the case with the long protocol, is an advantage.