Estrogen Priming Protocols?

mtlaurel · September 2011

My dx and stats are in my siggy. I just did a microdose flare lupron cycle, and have my WTF next Tues. I think I responded pretty well to the MDFL, but I am trying to arm myself with knowledge about other protocols that may be appropriate.

So, can someone please help me understand how EP protocols work? My understanding is that the estrogen serves to block FSH so that during stims you pretty much completely rely on the injectables for follicle development. Also, I have read that EP protocols can help minimize lead follicle development, but I don't understand how. Is any of this correct? Anyone have links to good information on how EP works, or care to explain a little more to me?

Thank you!

UMichGirl · September 2011

Hi mtlaurel,

Our similar IF story continues. This is the protocol I'm currently doing. I don't know all the specifics of how/why it works, so I will be interested in hearing others' responses.

Not sure how your calendar will look, but I know that right now I'm taking doxycycline for 10 days, I'll be testing for my LH surge, then 10 days after the surge I'll start taking estrace and cetrotide for a couple days until I get my next AF. At that point I'll continue the estrace until I start my menopur and follistim again. Eventually I'll add back in the cetrotide (no idea why).

If all goes smoothly (and I know that is a lot to ask for) tentative ER would be early/mid-October.

GL!

mtlaurel · September 2011

UMichGirl:
Hi mtlaurel,
Our similar IF story continues. This is the protocol I'm currently doing. I don't know all the specifics of how/why it works, so I will be interested in hearing others' responses.
Not sure how your calendar will look, but I know that right now I'm taking doxycycline for 10 days, I'll be testing for my LH surge, then 10 days after the surge I'll start taking estrace and cetrotide for a couple days until I get my next AF. At that point I'll continue the estrace until I start my menopur and follistim again. Eventually I'll add back in the cetrotide (no idea why).
If all goes smoothly (and I know that is a lot to ask for) tentative ER would be early/mid-October.
GL!

Thanks, UMich. Do you know why you're taking the doxy?

I'm glad you were able to get right into another cycle, and I hope this one works for you. I'm not sure my RE will want to do EP, but I want to be able to discuss it intelligently with him.

Edwina.McDunnough · September 2011

I have written tons about this in previous posts, links HERE, including links to medical studies and posts from the developers of their version of the protocol. The most common types I have seen are SIRM's and the LPD Antagonist or Patch Protocols. If you have further Qs let me know.

The short answer is that your ovaries are suppressed, and like other suppression mechanisms, you start off your cycle with a clean slate and hopefully no leads. Basically, at the tail end of your cycle your body gears up to start making that one follicle, and a few AFs start developing. By suppressing this small surge in hormone production, you defeat these early developers and hopefully your cohort will develop with similarly sized follicles.

And because you are on massive doses of meds and don't get a jump start, the stim can be (but is not necessarily) long and slow, it's a very expensive protocol, and one that those that endo or those at risk for OHSS should be using.

That being said, there is a lot more to stimming than the protocol itself. I have done the "same" patch protocol at 2 different clinics with different approaches. For me this is my best protocol, but for others it is the absolute worst. And go figure, I did it 2x exactly the same meds and everything and had the best and worst response respectively, so sometimes you get unlucky and hit a fluke bad cycle, independent of whatever stim protocol you are on. Also, EP is priming, and most often done with an antagonist stim protocol, but it has been done with MDLF for instance. And there have been some other EP protocols on the board where the patient took estrogen for long periods, and no antagonist during their LP, so your clinic may have it's own technique.

Good luck.

ETA: I have a few relevant papers if you can deal with the technical lingo.

mtlaurel · September 2011

Edwina.McDunnough:
I have written tons about this in previous posts, links HERE, including links to medical studies and posts from the developers of their version of the protocol. The most common types I have seen are SIRM's and the LPD Antagonist or Patch Protocols. If you have further Qs let me know.
The short answer is that your ovaries are suppressed, and like other suppression mechanisms, you start off your cycle with a clean slate and hopefully no leads. Basically, at the tail end of your cycle your body gears up to start making that one follicle, and a few AFs start developing. By suppressing this small surge in hormone production, you defeat these early developers and hopefully your cohort will develop with similarly sized follicles.
And because you are on massive doses of meds and don't get a jump start, the stim can be (but is not necessarily) long and slow, it's a very expensive protocol, and one that those that endo or those at risk for OHSS should be using.
That being said, there is a lot more to stimming than the protocol itself. I have done the "same" patch protocol at 2 different clinics with different approaches. For me this is my best protocol, but for others it is the absolute worst. And go figure, I did it 2x exactly the same meds and everything and had the best and worst response respectively, so sometimes you get unlucky and hit a fluke bad cycle, independent of whatever stim protocol you are on. Also, EP is priming, and most often done with an antagonist stim protocol, but it has been done with MDLF for instance. And there have been some other EP protocols on the board where the patient took estrogen for long periods, and no antagonist during their LP, so your clinic may have it's own technique.
Good luck.
ETA: I have a few relevant papers if you can deal with the technical lingo.

Thank you. I was hoping you would respond, as I have read your posts about EP before. I know that I could respond differently to the exact same protocol, but part of this maddening process is obsessing about potentials, right?

I would love to read technical papers, if you don't mind sharing. Thanks again.

UMichGirl · September 2011

mtlaurel:
UMichGirl:
Hi mtlaurel,
Our similar IF story continues. This is the protocol I'm currently doing. I don't know all the specifics of how/why it works, so I will be interested in hearing others' responses.
Not sure how your calendar will look, but I know that right now I'm taking doxycycline for 10 days, I'll be testing for my LH surge, then 10 days after the surge I'll start taking estrace and cetrotide for a couple days until I get my next AF. At that point I'll continue the estrace until I start my menopur and follistim again. Eventually I'll add back in the cetrotide (no idea why).
If all goes smoothly (and I know that is a lot to ask for) tentative ER would be early/mid-October.
GL!
Thanks, UMich. Do you know why you're taking the doxy?
I'm glad you were able to get right into another cycle, and I hope this one works for you. I'm not sure my RE will want to do EP, but I want to be able to discuss it intelligently with him.

I'm not sure but both my husband and I are supposed to be on it 2x/day for 10 days at the start of the cycle. Even last cycle my husband was supposed to be on it as well (but not me).

Edwina.McDunnough · September 2011

YGPM. I also wanted to mention that I have always stopped E2 at the start of stims, but some protocols have you on E2 during stim. Hopefully someone doing these other protocols can chime in. I only have experience with the LPG/patch protocol and 3 out of the 4 clinics I have consulted with or cycle with use this method, the fourth being SIRM and their A/ACP which is well discussed esp on Dr S's blog and their BB.

https://www.ivfauthority.com/2009/07/ivf-ovarian-stimulation-gnrh.html

https://forums.haveababy.com/lofiversion/index.php?t865.html

https://estrogenprimingprotocol.blogspot.com/

Mrs.McIrish · September 2011

My EPP worked like this:

Check for LH surge. Start estrogen patch 10 days later and change every other day. Start ganirelix the day after the first patch and continue for 3 days total. Wait for AF. Leave final patch on when AF shows up until it falls off. Go for baseline on CD2. Start follistim 300 night of CD2 (after being cleared). Start menopur morning of CD3 with follistim 300 at night. I took the patch off the night I triggered.

This did not work well for me unfortuntately. I completely missed my LH surge as it must have happened prior to Cd8 when I started testing. I don't know if I started the estrogen patch too late and that messed things up? I also got AF the morning immediately after the 3rd ganirelix shot. Again, don't know if that was supposed to happen. I only used 2 estrogen patches due to the quick timing of AF following the ganirelix. My WTF is 9/13 so I don't know if I will be doing EPP again or something else.

Edwina.McDunnough · September 2011

Mrs.McIrish:
My EPP worked like this:

Check for LH surge. Start estrogen patch 10 days later and change every other day. Start ganirelix the day after the first patch and continue for 3 days total. Wait for AF. Leave final patch on when AF shows up until it falls off. Go for baseline on CD2. Start follistim 300 night of CD2 (after being cleared). Start menopur morning of CD3 with follistim 300 at night. I took the patch off the night I triggered.

This did not work well for me unfortuntately. I completely missed my LH surge as it must have happened prior to Cd8 when I started testing. I don't know if I started the estrogen patch too late and that messed things up? I also got AF the morning immediately after the 3rd ganirelix shot. Again, don't know if that was supposed to happen. I only used 2 estrogen patches due to the quick timing of AF following the ganirelix. My WTF is 9/13 so I don't know if I will be doing EPP again or something else.

I was told this is okay. As long as made it past the 3 injections. FWIW I know what my LP is and my start date takes that into account. If you are a little short, getting past the 3 injections is fine. If you go long, they may administer another ganirelix shot to keep your ovaries suppressed. I don't know if any of this impacts the cycle greatly, but it's hard to time it perfectly. Bodies do weird things.

Good luck with your WTF !

Mrs.McIrish · September 2011

Edwina.McDunnough:
Mrs.McIrish:

My EPP worked like this:

Check for LH surge. Start estrogen patch 10 days later and change every other day. Start ganirelix the day after the first patch and continue for 3 days total. Wait for AF. Leave final patch on when AF shows up until it falls off. Go for baseline on CD2. Start follistim 300 night of CD2 (after being cleared). Start menopur morning of CD3 with follistim 300 at night. I took the patch off the night I triggered.

This did not work well for me unfortuntately. I completely missed my LH surge as it must have happened prior to Cd8 when I started testing. I don't know if I started the estrogen patch too late and that messed things up? I also got AF the morning immediately after the 3rd ganirelix shot. Again, don't know if that was supposed to happen. I only used 2 estrogen patches due to the quick timing of AF following the ganirelix. My WTF is 9/13 so I don't know if I will be doing EPP again or something else.

I was told this is okay. As long as made it past the 3 injections. FWIW I know what my LP is and my start date takes that into account. If you are a little short, getting past the 3 injections is fine. If you go long, they may administer another ganirelix shot to keep your ovaries suppressed. I don't know if any of this impacts the cycle greatly, but it's hard to time it perfectly. Bodies do weird things.

Good luck with your WTF !

Thanks Edwina. My LP is very strange. It varies a LOT. Anywhere from 9-18 days, with an average of 15. Whenever someone says it shouldn't vary, I cringe since mine is all over the place. Even Fertility friend always comments on it (you have a variation in LP that we don't normally see...) Thanks FF..

Ginger71 · September 2011

I'm on my 3rd EPP. You have the info. correct.

Here's a good link

https://www.in-gender.com/cs/forums/t/36994.aspx

There is info. in my blog about timing and such if you are interested and if you have any specific questions,page me. I'm happy to help.

ETA: I didn't see what Edwina posted...excellent info. there as always Wink

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