There is no universal “best” protocol. However, there may be a best one for you.
You can run a natural start cycle, which simply means that you come in at the beginning of your menstrual cycle, say on day 3, and if there are no cysts, you start taking stimulating medication.
This simple approach is appealing because it is, well, simple. But there is a catch: it is quite likely that egg growth will be scattered across a variety of maturity levels. ”Scattered” maturation makes the ideal timing of egg retrieval difficult, and the cycle might suffer as a result.
To keep some eggs from developing too quickly, we like to suppress the ovaries before stimulation. Suppression also makes scheduling treatments easier for our clinic and our patients. Too many retrievals on the same day would compromise pregnancy rates for everyone.
The longest, deepest suppression is done with the long protocol. It is, as the name suggests, the longest of the protocols: several weeks on the birth control pill in most cases, overlapping with a GnRH Agonist (Lupron, Suprefact, or Synarel) which is even more suppressive. By the time you are done with this pre-treatment, your ovaries should be well-and-truly suppressed.
But there is the risk of going too far. When your ovaries are over-suppressed, the stimulating medications simply will not work. This means your estrogen starts off low – sometimes less than 50 pmol/l – and never climbs above 200 despite day after day of stimulation. This happens only about 5% of the time.
So why use the long protocol? Because when the long protocol works, we get the best pregnancy rates.
The long protocol isn’t the right choice for everyone.
If a woman has a low BMI (less than 21) or other reasons to suspect sensitivity to suppression, we usually opt for an OCP-antagonist protocol. In this case, we use the birth control pill (aka oral contraceptive pill or OCP) for a bit of suppression, then once the cycle starts, use a GnRH Antagonist (like Orgalutran or Cetrotide) to prevent ovulation. I like OCP-antagonist cycles, and have had a lot of success with them recently. It is a more pleasant protocol for patients, with fewer injections and side effects.
The challenge with using a birth control pill, for some women, is that even a low dose pill (Alesse, Yasmin) for a short period (2 weeks) is too suppressive. Natural start is one solution, but if the woman’s natural estrogen levels are not very high in the luteal phase, her FSH levels will drift up and…the ovaries will start to stimulate too early and egg growth scattering results. In these select cases, we can use estrogen-priming, in which an estrogen patch (0.1 q2d) or Estrace tablets (8mg daily) are used starting about day 21 in the cycle before stimulation. Estrogen priming is very successful in bringing down FSH levels, of real benefit to women of borderline ovarian reserve, and we have seen successful stimulations where none were possible before.
The catch (there is always a catch) is that estrogen primed cycles take a long time before we can see if they are going to work…..when we have to cancel them, it is usually quite late into a stimulation.
Estrogen priming is usually matched with an antagonist to prevent ovulation. But there is one more protocol to consider: a flare cycle. A flare cycle may involve OCP or estrogen-only pretreatment, but the key is that a GnRH agonist (Lupron, Suprefact, or Synarel) will be started at exactly the same time as the stimulating medication. The result is invariably rapid egg development. A flare protocol is the most “raw” of the protocols, sometime yielding difficult-to-interpret results. But we do use it in select circumstances.
Yes, there can always be hope. But that hope should be balanced with the reality that donor egg cycles will provide much higher success rates, for many clinics in the 50 to 60 percent range, and in some clinics, even higher.
The choice then becomes highly personal for you, as you weigh the relative odds of success against personal desires for a biological child. Your final answer will be highly personal, and I strongly recommend counselling as you consider your options.