* Author Topic: Natural, mini, mild (etc) IVF chat thread  (Read 69996 times)

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Offline katkat2014

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Natural, mini, mild (etc) IVF chat thread
« Reply #150 on: 4/09/15, 14:31 »
Scary but exciting,  thanks. Will attend an open day this weekend at Create although am still totally unsure if mild IVF is right plus costs are high here.

Tigger - if it is just the OHSS holding you back on a normal protocol, the last time I had 11 follicles and 9 eggs and it was the first time I was zero bloated and the first time I also did as my nutritionist advised: 2-3 L water a day PLUS 20mg organic whey protein powder in a pint of milk per day.

Crazy horse,  that's the thing I just don't know if it is right then that we are advised if lower stims mean better quality eggs. The way the Dr explained it is that at our age we have a pool of aneuploid eggs with a few euploid ones and with higher stims the chances are higher to get that one good egg as part of the bunch of eggs you retrieve on that normal cycle. So how can a mild cycle create better quality eggs. Do the higher drugs have a negative impact on the eggs maybe?

I have a call lined up with Serum but by email they already suggested chlomid embryo banking cycles. So I would assume the only reason for this is the genetic analysis one can do after banking. However this option should also exist with a normal protocol. I am really confused by the science behind it.

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    Offline CrazyHorse

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    « Reply #151 on: 4/09/15, 15:02 »
    Crazy horse,  that's the thing I just don't know if it is right then that we are advised if lower stims mean better quality eggs. The way the Dr explained it is that at our age we have a pool of aneuploid eggs with a few euploid ones and with higher stims the chances are higher to get that one good egg as part of the bunch of eggs you retrieve on that normal cycle. So how can a mild cycle create better quality eggs. Do the higher drugs have a negative impact on the eggs maybe?

    This is the traditional model used to understand egg production in IVF -- as you age, a progressively smaller percentage of euploid eggs remain, there's nothing you can do to improve the percentage of euploid eggs remaining or to change which follicles are randomly selected for recruitment on each cycle, therefore the most important thing is to maximise egg yields per cycle in order to maximise the odds of finding a euploid egg among those collected. Hence the focus on collecting as many eggs as possible with relatively large doses of stims. However, there are significant numbers of women, including myself, who see embryo quality and pregnancy rates per embryo transferred improve with eggs collected from cycles using lower amounts of stims. Clearly there are factors at work affecting egg quality, at least in some patients, that the traditional model does not account for. Because there's not yet a good explanation and because the data collected on it is not yet of good quality, many clinicians choose to deny that this phenomenon exists, but I've read too many individual histories of women whose embryo quality and pregnancy rates per embryo have improved with lower doses of stims to believe it's not a real thing. Even my very conservative, evidence-based doctor at IVF Scotland wouldn't give stim doses higher than 300 iu / day to poor responders for the same reason -- his clinical observation was that it was bad for egg quality. If > 300 iu / day is bad for egg quality, it's not illogical to believe that significantly less than 300 iu / day might also provide a boost to egg quality for poor responders who are having issues with fertilisation, embryo fragmentation, etc., under standard protocols where they are stimming at high doses for long periods.

    Also, in some older women with poor response to higher doses of stims, like myself, as many or more eggs can be collected on a cycle using lower stims -- again, due to factors that are not yet understood. However, you're very unlikely to fall into this category as your AMH and AFC are pretty good.


    I have a call lined up with Serum but by email they already suggested chlomid embryo banking cycles. So I would assume the only reason for this is the genetic analysis one can do after banking. However this option should also exist with a normal protocol. I am really confused by the science behind it.

    The other reason they really push embryo banking with Clomid mini-IVF cycles is that Clomid causes thinning of the endometrial lining, and for many women the endometrium on a Clomid cycle is not in optimal condition for embryo implantation. The lining will recover after Clomid is stopped, and then the FET can be performed when the uterine environment is more receptive.

    Offline Tigger99

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    « Reply #152 on: 4/09/15, 18:06 »
    Katkat - No I didn't get ohss but was wondering about the egg quality thing. And of course it's a lot cheaper to do mini IVF. So what do people think I my case - stick with conventional IVF??

    Offline katkat2014

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    « Reply #153 on: 5/09/15, 18:08 »
    Hi Tigger, sorry as I didn't read your post properly, realised there wasn't an issue with ohss for you.  Not sure what to suggest. As you seemed to have implantation perhaps chg testing of your embryos with IVF gives you a better picture of what's wrong with the emrbyos (if it is not the immunes)? I am really not sure, yesterday I would have said don't go for mild IVF but just coming back from the open day at Create and now am considering it for myself again.

    Crazyhorse, I was now told why mild IVF could result in better eggs. The way Geeta at Create compared it to was a bunch of people in the room sharing oxygen. If there are lots then each gets less, if there are less people then each gets more and hence better quality. She also says it is natural selection (not sure about that as you take drugs on a mild protocol). She claims that a young woman with normal protocol getting say 8 eggs will have only 2 euploid ones. And on a mild protocol getting only 4 eggs she will also have 2 euploid ones. I am not entirely convinced about it also not what that means in the case when you're older, but I may give it a shot abroad. When you say Create don't do a proper mild IVF, what do you think a maximum dosage for say Menopur or gonal f would be on a mild cycle? I know everyone is different but kind of what have you heard what do other people take?

    Offline CrazyHorse

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    « Reply #154 on: 6/09/15, 09:27 »
    Hi, Katkat, I'm not saying Create don't do "proper" mild IVF at all, just that I have seen ladies on short protocol at 300 iu / day having the protocol described to them as "mild", which I would dispute as lots of clinics do short protocol at that stim dosage and just call it "short protocol"! It's very possible that Create do mild protocol with, say, 150 iu/day for women who are better responders or had bad results on higher stims, but it really stood out to me when women talked about having these higher dose protocols described as "mild", I guess due to no downreg and starting Cetrotide slightly later than many other clinics do on regular short protocol.

    To my mind, the key aspects of mild protocol are: no GnRH agonist (e.g., buserelin); minimising any use of GnRH antagonist (e.g., Cetrotide) so that it's just used near the end and only if needed to prevent premature ovulation, rather than for longer periods to even out follicle growth; and injectable stims maybe half of what would normally be used for your age and AMH/AFC by most IVF clinics (e.g., 150 iu / day or less), and even lower (e.g., 75 iu/day) if they are combined with an oral superovulation drug like Clomid. Basically, nothing that artificially slows down your ovaries, except if necessary to prevent eggs escaping before EC, and drug dosages that are more in line with what you would see for stimulated IUI than for conventional IVF, with the objective being to obtain 1 to 2 mature eggs at a time. Obviously, there is no agreed definition in medical practice for what constitutes a "mild" protocol, which is a big part of the difficulty! But personally that's what I'd look for if I were wanting to do mild IVF due to poor results on more conventional protocols. However, I'm coming at this from the perspective of a very poor responder whose ovaries do much better if they're not hampered by GnRH agonists or antagonists.

    There is definitely a school of thought, which it sounds like Geeta belongs to, that your body tries to select the euploid eggs first on a natural cycle, and that on a stimulated cycle it's really important to catch the eggs from the lead follicle(s), even if it means sacrificing the immature eggs from smaller follicles, as the eggs from the first follicles to start growing are the ones more likely to be euploid. I haven't really seen a lot of evidence for this theory, though, so I've kind of reserved judgement in my own mind as to whether that's one of the main drivers for the better embryo quality some people get on mild protocol.

    Anyway, I don't know if that helps, but that's just my take on things. ;)

    Offline Briss

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    « Reply #155 on: 6/09/15, 14:40 »
    I have had two cycles at Create, mild stims and modified natural and can briefly explain how this worked (or in my case did not). Natural modified is basically adding low stims around 150 menopur a bit later on in cycle from day 6 or so + cetrotide. I had 2 follicles on this protocol (I am a very poor responder). However, i have had quite a few completely natural IVfs since then and apparently my body grows 2 dominant follicles naturally without any stims on most cycles so basically adding the menopur/cetrotide was quite unnecessary. I would have got the same result without them. 

    the second cycle was mild stims that started on day 2 with 125 of Gonal F which was later increased to 250. increasing the dose mid cycle added one additional follicle so I had 3 growing but despite cetrotide somehow one follicle disappeared at EC, either ovulated after trigger or something else happened. Geeta could not explain. they got 2 eggs but none fertilised.

    I since had 450 menopur short protocol which resulted in 4 eggs but zero fertilisation and several natural IVfs which resulted in up to one egg per cycle and 100% fertilisation. my conclusion is that it's actually not about the dose of stims but more about egg maturation.  neither low stims nor high stims worked for me because somehow when the clinics try to control my cycle and egg maturation process it goes wrong. it's only when my body is left alone to mature the egg it gets it right every time. for some women it seems a delicate process so when you add hormones at the wrong time or in the wrong amount the egg is compromised and won't fertilise.  Geeta as some other clinics tend to blame it on egg quality but my experience shows that it's the fault in maturation process that's critical in resulting egg quality. 

    one of the docs at CRGh explained it to me that basically stims and protocols is very much guess work trying to provide sufficient level of hormones for egg maturation but they do not always get it right cos everyone is different. Most women however do fine on any stims but high FSH/low AMH women are the ones where protocols need to be taylor made in each particular case. unfortunately it seems like it's up to us to work out what protocol works and then insist on it. I have these conversations almost every cycle when they see I have a few follicles they always want to stim me and it takes a lot of energy to persuade clinics to just let me get on with natural IVF because I just know even though natural IVF has low success rates stims are not going to make it better.

    One thing I have not tried though is long protocol but since natural IVF worked much better for me than anything else I am sticking with it for the time being. also because it's really easy on your body and you can do it every month back to back. logistic of doing it abroad is a nightmare though.

    Offline katkat2014

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    « Reply #156 on: 6/09/15, 19:40 »
    Everyone is just so different! Briss, it is really great you managed to work out the best for you and should stick with it. I know we talked before about you clinic abroad. You mention you haven't tried the long protocol...maybe better don't. I did once and I had the most eggs ever (13) but 11 were immature! To be shocked is an understatement. I was told I have an egg maturation problem and basically give up. But I researched that I would have needed some LH for maturation as only got gonal f, plus that maybe I needed a double trigger. So this may have worked on the long protocol, but am so scared of this protocol now, almost traumatised so didn't want to try it again.

    So the above is what I got instead on my next short protocol, here more eggs were mature and 4 out of 5 fertilised. But then my embryo quality was poor (3 out of 4 arrested, the good one didn't implant). But for some reason I was on crazy high dosages this time.

    So if I went for mild IVF with lower dosages of say 150iu, can I still take a 10,000 pregnyl or a double ovitrelle trigger? Just don't want to end up with immature eggs again. And is there any advantage of combining gonal f or menopur with chlomid or femara? I don't have any experience of these latter drugs and am so scared of all embryos arresting again.

    Sometimes I wonder if I am mad, stubborn or desperate that I keep on trying...but I think it is mainly the hope that for some strange reason I haven't found the right protocol for me yet nor the right drugs. Plus as long as there eggs there is a chance!

    Sorry for these ME-POSTS,  if anyone has any questions for me at all, am really happy to help and give you my input too!

    And not long to go for you now, crazyhorse!  :)

    Offline Briss

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    « Reply #157 on: 6/09/15, 22:30 »
    katkat, I am not sure it matters whether you have 5,000 or 10,000 of pregnyl or ovitrelle but again this is just my experience. I am usually on 5,000 pregnyl or one ovitrel but couple of times I got confused and injected 10,000 of pregnyl and basically it did not make any difference. larger follicles produce mature eggs and smaller ones immature eggs so I personally prefer they do not try to go after smaller follicles as i need to have ICSI which requires mature eggs. if you can have IVF instead of ICSi than it does not matter even immature eggs can still fertilise normally.

    I wonder if there is a connection between the trigger shot and maturation. I always thought the trigger was mainly to time EC to ensure the egg is ready to come off but even if it's immature it can still be collected after the trigger. I think maturation is the entire journey from CD 1 (or maybe even before that) up until the trigger. and the trigger/LH surge is just for the egg to prepare for valuation. I might be wrong though but again as you said everyone is so different it may matters to some ladies. Last time I had EC without the trigger shot at all just based on my natural LH surge and we got the egg and it was mature and fertilised.

    ladies seem to have very different experience with long protocol. i was always afraid of it cos i have heard various unfortunate stories but in the end unless you try you won't know for sure if it's going to work for you or not. I also like to think that I may still have one more option to explore.

    re chlomid, I am also scared of this because my lining is generally good so at least i know I can rely on it and would not want to compromise it with chlomid. but every now and then I come across ladies who failed on traditional stims and yet got pregnant on mild menopur/chlomid cycles. so this is definitely something to think about.

    sorry I've just realised you also have male factor. have you considered PICSI/IMSI? we also have male factor and I changed clinics mainly so we could have natural IMSI. It did make a difference to our embryos. unfortunately I miscarried so it cannot completely protect you but I strongly believe it helps.

    I think exactly as you are as long you have your cycle and you ovulate you can get pregnant and you will. it just takes a lot of effort to find the right protocol and the right clinic.

    Offline katkat2014

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    « Reply #158 on: 11/09/15, 07:34 »
    Hey Briss, many thanks for your input! I had a follow up with my current clinic and they will give me two different protocols to choose from (but recommend one). I think one will be high chlomid of 100mg for a few days then injectables (the not recommended one).  I have never read about anyone else doing this...then 10000 pregnyl.

    Yes we have MFI as well and the sperm was too bad for PICSI (you need good motility and we have just 25-30% motile, only 14 mil/ml count on the worst sample). IMSI was suggested as it is also the newer and better method but I have read somewhere that the time it takes between looking at the sperm and injecting it can damage sperm...Hmmm. ..only my clinic seems to believe in it, the 2 others I talked to didn't recommend it. May give it a try though

    Good luck with your next cycle!

    Offline MissMayhem

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    « Reply #159 on: 14/09/15, 01:55 »
    Hi everyone, glad to see thaCetrotide this thread has become active again, hope it's okay for me to join in. I feel the same as you kitkat, an not sure whether it's stubbornness, not finding the right protocol or foolishness that keeps me wanting to try with my own eggs

    My AMH is pitiful, 0.5 now that I've had one ovary removed. I so wish I'd insisted on stimming and freezing eggs before my op as Iit had been a quite respectable (for my age) 10.6 prior to that. I've had four failed cycles now:

    #1 Long protocol 300 Menopur, 3 mature eggs.
    #2 Long protocol 375 Menopur, 1 damaged  egg (though loads of follicles so have thought since just poor trigger timing/missed ovulation)
    #3 Short protocol Bravell, Menopur & Cetrotide, so called mild cycle. Cancelled due to dominant follicle so no EC converted to IUI
    #4 Short protocol Merional & Cetrotide, 1 egg, told it fertilised but arrested day 3 but also told it was immature.

    I respond so poorly and only ever have around four AFC. Went for high stims last time as was told that my third cycle was a complete waste as I would've responded in the same way without any medication

    I'm sending off for hidden C testing and 10 in 1 with Serum as last cycle was tandem and despite excellent lining, intralipids and steroids had no implantation from Grade A donor embryos.

    Don't know whether to go abroad and try mild/natural. Or try Create again where they've already told me I would have to be stimulated. I know it's so individual but anyone got any tips? Don't know whether to just give up and have donor frostie transfer first as last. Any advice welcomed.

    Good luck to you all, and hope you're doing ok crazyhorse! :) xx