Protocol Qs: EPP and MDL

BzeetyD

Hey gals -

We have our WTF appt this afternoon and I just need a little education before I go.

I'm familiar with long lupron and antagonist protocols as I've done them both.

Can someone enlighten me on and EP (estrogen priming) protocol and why a doc would use it? What are its supposed benefits? What problem does it attempt to solve?

Can someone enlighten me on a MDL (Micro-dose Lupron) protocol and why a doc would use it? What are its supposed benefits? What problem does it attempt to solve?

Also is there any other protocol that is semi-known that you want to share?

Many thanks

MandaS08

I've done both.  MDL for my first ivf and EPP for my second.  For me, we were using them b/c I am have DOR.  My RE feels like MDL is aggressive, but EPP is even more aggressive.  I don't know exactly what the other benefits are, but I know the MDL doesn't suppress you as much, and the EPP was to hopefully recruit a few additional follies.  I don't know though, if there are other benefit if you aren't DOR.

Edwina.McDunnough

I think everything I know about EPP is in the FAQ/LINKS.

Here is little gem for you: https://www.bioportfolio.com/resources/trial/91119/A-Comparison-Of-The-Microdose-Leuprolide-Protocol-Vs-Luteal-Phase-Ganirelix-Protocol.html 

And Advanced Fertility has a good descriptions of MDLF : https://www.advancedfertility.com/ivf-low-response.htm

EPP is a form of suppression whatever anyone wants to say about improving EQ or whatever, some people have horrible response to EP, others very good. I've had my best (13ER, 12fert norm) and worst (converted to IUI) cycles mirror images of each other at the same clinic on the same EPP protocol. Like LL the suppression keeps the cohort together. THere are many many ways to prime. SIRM has a conversion protocol I can send you the deets of and I've seen people on the board go for weeks on just estrogen prior to cycling, but the end result is : suppression.

Read the above and anything on the FAQ and I'm happy to discuss, though I've never done MDLF (though I've discussed it with my RE as an option). EPP is not rec'd for those with endo because of the blast of...estrogen. And because you're suppressed it can be a long stim on high doses which is very $$$. You can add EP to various stim protocols but it's most typically done with antagonist.

BzeetyD

Edwina.McDunnough:

I think everything I know about EPP is in the FAQ/LINKS.

Here is little gem for you: https://www.bioportfolio.com/resources/trial/91119/A-Comparison-Of-The-Microdose-Leuprolide-Protocol-Vs-Luteal-Phase-Ganirelix-Protocol.html 

And Advanced Fertility has a good descriptions of MDLF : https://www.advancedfertility.com/ivf-low-response.htm

EPP is a form of suppression whatever anyone wants to say about improving EQ or whatever, some people have horrible response to EP, others very good. I've had my best (13ER, 12fert norm) and worst (converted to IUI) cycles mirror images of each other at the same clinic on the same EPP protocol. Like LL the suppression keeps the cohort together. THere are many many ways to prime. SIRM has a conversion protocol I can send you the deets of and I've seen people on the board go for weeks on just estrogen prior to cycling, but the end result is : suppression.

Read the above and anything on the FAQ and I'm happy to discuss, though I've never done MDLF (though I've discussed it with my RE as an option). EPP is not rec'd for those with endo because of the blast of...estrogen. And because you're suppressed it can be a long stim on high doses which is very $$$. You can add EP to various stim protocols but it's most typically done with antagonist.

Thanks - I just grabbed the link that you posted (on IF) to the blog stuff - I've been looking for it for a few days and thought I was going crazy.

I might be able to get what I need to know from that. 

But I'm interested in anyone's thoughts about EQ protocols.

BzeetyD

I'm realizing that I'm in a really weird spot because I don't fit into any good category. I'm a high responder but OHSS isn't a concern. I don't have endo (confirmed by a lap). I don't have lead follicles. I make and they retrieve lots of eggs but the rate of maturity is low in comparison. Fert rate has generally been pretty good except for this last time.

It's frustrating.

nawlinsgrl

**TICKER**

FWIW, I am about to start MDL this cycle.  Last year I was successful with just antagonist (follistim, menopur, and ganirelix, with a novarel trigger).  Due to my AMA (which I was last time as well, but I'm now almost 15 months older and knocking on 40), RE wants me to try MDL to increase my eggs, and I believe the quality as well. 

I start MDL one week from today, and then begin stims 2 days later (follistim and menopur, but no ganirelix).  I know that doesn't help you make a decision on how to proceed today, but I'm happy to share my progress with you, if you'd like.  I'm a little nervous about deviating from what has already worked for me, but I trust my RE, so I'm hoping for good things.

Edwina.McDunnough

BzeetyD:

I'm realizing that I'm in a really weird spot because I don't fit into any good category. I'm a high responder but OHSS isn't a concern. I don't have endo (confirmed by a lap). I don't have lead follicles. I make and they retrieve lots of eggs but the rate of maturity is low in comparison. Fert rate has generally been pretty good except for this last time.

It's frustrating.

I'll put the link back into my sig, but I was going to phase it out since I'm not really posting or reading a lot (thus not adding links) anymore. If someone wants to help add new links we can discuss.

EPP is generally done with high stims. 600 FSH or SIRM starts around 750 which is why it's often done for low responders, but I don't think this is an absolute. Beyond the protocol are stim techniques that can help keep the cohort together as well, such as step-down stimming, and some women just respond better to different proportions of LH-FSH in the Rx. My C.ornell RE is of the mind that the stim protocol is less important than the expertise in administering it, and I tend to agree. But in the end it's just a guessing game because our bodies and our response are just a moving target.

I really think you can do better with maturation rate. I don't know if you've switched clinics so far but I've seen huge leaps with other women just because they need a different (not better per se) approach. Sometimes it's a mysterious bad match. Personally my previously acceptable response was much improved when switching for #4:

IVF 1 antagonist: ER : 9R : 6F : 5F normally
IVF 2 antagonist max stims: ER : 10R : 7F: 4F normally 

     (this was a crappy lead follie cycle)

IVF 3 EPP+antagonist: ER : 13R : 8F normally
IVF 4 EPP+antagonist +coculture : ER : 13R : 12F normally
     d3 embryos much much improved in grading. 

 

Just a note: with subsequent failed DE cycles I wouldn't say that all these IVFs were true failures because something else is going on with me...

 

BzeetyD

nawlinsgrl:

**TICKER**

FWIW, I am about to start MDL this cycle.  Last year I was successful with just antagonist (follistim, menopur, and ganirelix, with a novarel trigger).  Due to my AMA (which I was last time as well, but I'm now almost 15 months older and knocking on 40), RE wants me to try MDL to increase my eggs, and I believe the quality as well. 

I start MDL one week from today, and then begin stims 2 days later (follistim and menopur, but no ganirelix).  I know that doesn't help you make a decision on how to proceed today, but I'm happy to share my progress with you, if you'd like.  I'm a little nervous about deviating from what has already worked for me, but I trust my RE, so I'm hoping for good things.

Thanks for sharing and I am interested in your progress, if you're willing to share.

We're not making any decisions today, we're gathering info and going to marinade in it for awhile.

This is where we are too (bolded). Both our antagonist IVFs resulted in pregnancies but obviously they ended. Clearly something there is working. I'm hesitant to flip a different switch - but at the same time, we need a different total outcome.

nawlinsgrl

BzeetyD:

nawlinsgrl:

**TICKER**

FWIW, I am about to start MDL this cycle.  Last year I was successful with just antagonist (follistim, menopur, and ganirelix, with a novarel trigger).  Due to my AMA (which I was last time as well, but I'm now almost 15 months older and knocking on 40), RE wants me to try MDL to increase my eggs, and I believe the quality as well. 

I start MDL one week from today, and then begin stims 2 days later (follistim and menopur, but no ganirelix).  I know that doesn't help you make a decision on how to proceed today, but I'm happy to share my progress with you, if you'd like.  I'm a little nervous about deviating from what has already worked for me, but I trust my RE, so I'm hoping for good things.

Thanks for sharing and I am interested in your progress, if you're willing to share.

We're not making any decisions today, we're gathering info and going to marinade in it for awhile.

This is where we are too (bolded). Both our antagonist IVFs resulted in pregnancies but obviously they ended. Clearly something there is working. I'm hesitant to flip a different switch - but at the same time, we need a different total outcome.

I'm more than happy to share.  The reality of cycling again is starting to hit me this week.  Up until now I'd been chomping at the bit to get started, but the closer I get, the more I worry that it won't work.  I feel just like I did the first time, stressing about every little thing, which I will continue to do until beta at least.  I'm scared to be too optimistic, because I feel like the odds are more against me this time, due to my age and potentially reduced egg quantity/quality.  

I'm a researcher by profession, and I just found all my labs and u/s reports from last time to compare to this time (and give me more to stress about when the numbers are lower than last time).  I'm going to start putting these in a spreadsheet to have side-by-side data (yes, I'm a bit anal when it comes to this stuff--I call it being analytical--tomato, tomahto).  It might be helpful to show you as well, as an example of how the two protocols compare, despite the time gap. 

My starting doses of Menopur and Follistim will be higher this time, because I doubled my starting dose at my highest point last time, and I was a slow stimmer, so I know this will affect things too, hopefully for the better.

I hope your appointment goes well today.  Let me know what your RE has to say about everything.

 

MandaS08

Have you tried cycling with adding in human growth hormone?  We added it in this IVF-my RE wanted us to try it as we've had a failed IVF cycle.  It is supposed to help with the quality of embryos.

BzeetyD

MandaS08:

Have you tried cycling with adding in human growth hormone?  We added it in this IVF-my RE wanted us to try it as we've had a failed IVF cycle.  It is supposed to help with the quality of embryos.

Not yet. But it is on the table. 

My clinic is conservative but very good - so anything out of the norm isn't offered up. We'll see what she says today.

Thanks.

BzeetyD

Edwina.McDunnough:

BzeetyD:

I'm realizing that I'm in a really weird spot because I don't fit into any good category. I'm a high responder but OHSS isn't a concern. I don't have endo (confirmed by a lap). I don't have lead follicles. I make and they retrieve lots of eggs but the rate of maturity is low in comparison. Fert rate has generally been pretty good except for this last time.

It's frustrating.

I'll put the link back into my sig, but I was going to phase it out since I'm not really posting or reading a lot (thus not adding links) anymore. If someone wants to help add new links we can discuss.

EPP is generally done with high stims. 600 FSH or SIRM starts around 750 which is why it's often done for low responders, but I don't think this is an absolute. Beyond the protocol are stim techniques that can help keep the cohort together as well, such as step-down stimming, and some women just respond better to different proportions of LH-FSH in the Rx. My C.ornell RE is of the mind that the stim protocol is less important than the expertise in administering it, and I tend to agree. But in the end it's just a guessing game because our bodies and our response are just a moving target.

I really think you can do better with maturation rate. I don't know if you've switched clinics so far but I've seen huge leaps with other women just because they need a different (not better per se) approach. Sometimes it's a mysterious bad match. Personally my previously acceptable response was much improved when switching for #4:

IVF 1 antagonist: ER : 9R : 6F : 5F normally
IVF 2 antagonist max stims: ER : 10R : 7F: 4F normally 

     (this was a crappy lead follie cycle)

IVF 3 EPP+antagonist: ER : 13R : 8F normally
IVF 4 EPP+antagonist +coculture : ER : 13R : 12F normally
     d3 embryos much much improved in grading. 

 

Just a note: with subsequent failed DE cycles I wouldn't say that all these IVFs were true failures because something else is going on with me...

 

Yes. This has been my main concern since IVF#1. 

I did DHEA this last time and I had a better maturation rate but we had a dismal fert rate and good/medium grade embryos. I think it was an outlier as our other cycles had a very high fert rate with ICSI.

Sophistikitty

I?m a bit late to this thread (interrupted by work).  Both of my cycles were EPP.  The first was antagonist and the second was MDLF.  Mixing EPP with MDLF is considered extremely aggressive, so as you are a good responder that would be off the plate I would think. However, it is my understanding that EPP antagonist is used more broadly and like Edwina said, high dosages are not an absolute.  I know my clinic for instance does EPP with dosages as low as 300 FSH because they believe it improves egg quality.  EPP antagonist though is generally a long stim (I stimmed for 12 days but I have heard of people going longer).   Like Manda said, you may want to look into HGH.  My second cycle I had that option of adding Saizen but in the end we elected not to because there was concern that it might give a growth spurt to the fibroid I have that no one wants to touch.  Also there are varying opinions on its use in those with thyroid issues (I am hypothyroid).  Saizen may be something that is right for you though.  It would definitely be something I would look into more.