Friday, July 19, 2024

Treatment Decision

Choosing the Right Treatment - An IVF Dilemma!

Choosing the right treatment can be very difficult unless a thorough infertility investigation has been carried out to identify your unique fertility needs and requirements. Even after a thorough investigation has been conducted, the IVF clinic and its team needs to make sure you are offered the most suitable treatment option which optimizes your chances of success. Choosing an IVF clinic abroad can also be overwhelming. While clinics may claim a number of things, the most important criterion must be how knowledgeable the clinical staff are and how much information you are being provided about your treatment options. As a unique patient, you need to be able to understand which treatment options are available to you and what can be done specifically to improve your chances of success. Each patient is different from the other, therefore, a single prescription will not fit everyone. This being said, while on this page we attempt to provide a general approach to treatment, you need to know that each patient needs a customized protocol. Please use the following information for reference purposes and contact us in order to get a more customized feedback.

Younger patients with no prior testing or infertility treatment history should start with Scenario 1 in the initial testing process described in our “Infertility Testing” section. Based on these test results, and the patients age, a less invasive treatment option such as IUI may be chosen as opposed to the more invasive IVF/ICSI procedure. However, older patients (aged above 32) are not recommended to lose more time with simple treatments such as IUI. This is because fertility tends to decline fairly rapidly after such age brackets and loss of time with non-invasive treatments such as IUI can mean missing your opportunity while you have the chance. Going straight for IVF/ICSI treatment will be a wise option.

Patients with a history of treatment failures will be subjected to further infertility investigation, as outlined in our “infertility testing” section. Should these test results indicate that the patients’ own eggs and sperm might be viable for treatment, then IVF/ICSI treatment will be recommended using own eggs and sperm. The protocol of treatment and the precise dose of medication to be administered will depend on your age, your unique hormone levels and previous treatment history. Additional supplements and methods can be used depending on your unique needs (as in the case of recurrent miscarriages or IVF failures due to immune-response related problems).

If there is any reason to suspect a genetic cause for prolonged periods of infertility and possibly repeated IVF failures, after the necessary testing has been performed, the couple might be advised to have PGD (Pre-implantation Genetic Diagnosis) testing on their embryos in order to separate the genetically healthy embryos from the genetically abnormal ones prior to the embryo transfer procedure. This is outlined in our IVF with Pre-Implantation Genetic Screening/Diagnosis section.

Should there be a serious defect with the eggs or the sperm that cannot be easily isolated via PGD testing, then using donor eggs or donor sperm may be the most appropriate course of action. IVF with Egg Donation is also recommended for couples with a female factor infertility where the female patient’s eggs do not allow for fertilization or pregnancy to occur for any reason. This can be due to premature ovarian failure and menopause. IVF using donor eggs is also the only option of treatment for patients in older age brackets, where the female patient no longer has an active ovarian function. While there is no specific cut-off for using donor eggs, pregnancy using own eggs after the age of 45 is almost non-existent, therefore, if you are aiming to have an IVF cycle after the age of 45, using donor eggs is usually a more suitable option.

IVF using donor sperm is recommended for couples with male factor infertility where the male partner is diagnosed with non-obstructive azoospermia. Before using donor sperm, a number of options can be explored to see if sperm cells can be obtained from within the testicles. Surgical sperm extraction can prove successful in obstructive azoosmpermia, but in some non-obstructive azoospermia cases, depending on the stage of sperm maturation, it can provide a desirable outcome. At North Cyprus IVF Center, we now also have started offering stem cell therapy for men diagnosed with non-obstructive azoospermia. You can visit our stem cell therapeutic study page for more information about this option. If all of these options fail, then using donor sperm becomes the only viable option.

-Patients in more advanced fertility ages, but who still ovulate may be recommended Mini IVF or a minimal stimulation protocol in order to obtain less number of eggs but without compromising the quality by subjecting them to higher doses of medication. In a higher age bracket, the ovarian reserve tends to have been severely depleted and the existing reserves are very delicate and sensitive to the IVF protocols. Alternatively, IVF using cytoplasmic transfer an be recommended for this age group in order to allow for a chance of pregnancy with own eggs. However, it should be noted that Mini IVF and Cytoplasmic transfer procedures still require a certain number of oocytes to be obtained with IVF stimulation. Therefore, if your ovarian reserves have been fully depleted and you do nor respond to standard IVF protocols, these treatment options are NOT for you.

Please keep in mind that these are only meant for guidance and we do not, in any way, aim to diagnose or recommend treatments on this website. For more accurate recommendations and guidance, we will need to review your test results as well as your history of infertility along with any details that might be relevant so that we can offer you customized recommendations.

IVF Protocols and Their Use

You may have heard various terms and jargons related to IVF treatment protocols and the medication regimen used during IVF treatments. Any couple going through IVF treatment is likely to hear about short versus long, Agonist versus Antagonist protocols. It is very easy to get lost in these jargons trying to identify which protocol is right for you and which medication to use during your treatment. Our purpose is to explain thoroughly what these terms mean and why different IVF treatment protocols are used for different groups of patients.

There are a number of IVF treatment protocols that can be administered depending on age, hormone profile, and any other factors that might be relevant. The general rule of thumb is, each woman receiving IVF treatment using her own eggs will receive a conrolled ovarian hyperstimulation (COH) protocol in order to obtain multiple good quality oocytes in order to increase chances of success with IVF treatment. The following protocols are examples of most popular IVF Protocols that are currently in use:

1- Natural Cycle IVF: The very first successful IVF treatment in 1978 was done through natural cycle without use of any medication to stimulate the ovaries. However, with the aid of science and technology, stimulation medication have become available as a means of increasing success with treatment, causing natural cycle IVF to lose its popularity. Natural cycle is often used for patients who are either very young and very fertile who are against the use of medication or patients who cannot use IVF medication due to health problems.

Sometimes Natural Cycle IVF can be combined with mild use of medication by incorporating clomiphene citrate, or even Gonadotropin-Releasing Hormone Agonist (GnRH-a). The degree to which medication use is incorporated into the natural cycle will be directly proportional to the likely success rate with treatment. Medication use will result in better stimulation of the ovaries, therefore, will generate a higher number of follicles. More follicles will translate into more eggs and that will necessarily increase the chances of success. We usually do not recommend natural cycles unless the patient has a very good reason for not wanting to use medication.

2- Gonadotropin-Releasing Hormone Agonist (GnRH-a) Protocols: There are a number of protocols that use the GNRH-a. The most common are the “Long Protocol” the “Short Protocol“. A Gonadotropin Releasing Hormone agonist works very much like the gonadotropin releasing hormone itself. This hormone is normally released in a pulsatile manner by the hypothalamus to enable production of gonadotropins (FSH and LH) by the pituitary. The FSH and LH hormones are involved in follicle recruitment and ovulation. Therefore, the hypothalamus-pituitary interaction is key in getting a good ovarian response. When a gonadotropin agonist is administered in a continuous fashion with daily injections or a one time depot injection, the larger dose and continuous flooding with the GnRH desensitizes the pituitary gland, and it stops secreting FSH and LH hormones. In other words, the GnRH agonist protocol puts the body in a menopausal state so that the following cycle can be better manipulated via ovulation induction.

There are two stages of IVF treatment in a GNRH-a protocol. These are the suppression (down-regulation) and the ovarian stimulation (controlled hyperstimulation) stages. In a “Long Protocol“, these are two distinct stages. Patients on the long protocol often begin their treatment on day 21 of their menstrual cycle. On day 21 of the menstrual cycle, a down regulation medication is to be started. These down-regulation medication include buserelin, lupron, lucrin, prostap, leuprorelin, triptorelin, cetrorelix, synarel, suprecur and ganirelix. The purpose of down regulation is to suppress the production of Follicle Stimulating Hormone (FSH) and the Luteinizing Hormone (LH) initially so that we can have a greater control over your IVF cycle when we reach the ovarian stimulation stage. Down regulation also makes sure that when we move onto the ovarian stimulation stage, your follicles will grow evenly and a premature luteinization and therefore, a premature ovulation will be avoided.

The second stage of treatment is your ovarian stimulation. Ovarian stimulation means stimulating your ovaries so that they produce more follicles than they normally would. Ovarian stimulation medication include Follitropin Beta, follitropin alpha, Menotrophin and follicle stimulating hormone – FSH. Different brand names are available. Our clinic often prefers to use Gonal-F and Menopur combined or independently depending on your age or hormone profile. Ovarian stimulation typically begins on day 2 or day 3 of your following menstrual period, about 6-7 days after your down-regulation begins. Once you use your ovarian stimulation medication, your follicles will start growing and once they reach the ideal size, you will receive a final shot of hCG (human chorionic gonadotropin) to trigger your follicles and prepare them for collection and later fertilization. Around 35 and a half hours are requried between the hCG shot and the “egg retrieval”.

A “short protocol” also has a down-regulation and an ovarian stimulation stage. However, in a short protocol, these two stages are simultaneous. In other words, down-regulation and ovarian stimulation begin at the same time. A short protocol is more suited for older patients with lowered production of FSH and LH, therefore, a shorter period of suppression will suffice. Once the ovarian stimulation stage makes sure follicles reach a desired stage of growth, just like in the long protocol, a hCG shot is administered and the follicles are prepared for collection. The main difference between a short protocol and the long protocol is the fact that the long protocol uses a longer down-regulation medication. This is ideal for women with optimal level of fertility and a good ovarian reserve. However, for women with lower ovarian reserve and a poor anticipated response for ovarian stimulation will be better candidates for the short protocol.

3- GnRH Antagonists: GnRH antagonists (e.g. Ganirelix, Cetrotide, Cetrorelix and Orgalutron) are used alongside with ovarian stimulation medication. The main difference between an agonist and an antagonist cycle is that, in both the short and long agonist protocols (see above), down-regulation is administered to suppress hormones and avoid premature Luteinization. However, this is usually a problem with older patients, or patients with lowered ovarian reserves. Using GnRH antagonist protocol will be favorable for women who have elevated baseline luteinizing hormone (LH) levels (e.g. those with polycystic ovarian syndrome [PCOS], women over 40 years of age, and poor responders who have diminished ovarian reserves). In such cases, the antagonist cycle will provide the IVF specialist more control over the cycle. Especially in the case of PCOS, antagonist protocols should be preferred as they give a much desired control over the risk of ovarial hyperstimulation.

The statements on this page and arguments about long/short agonist protocols or antagonist protocols should not be taken as guidelines for your IVF Treatment. This page only aims to inform you about different IVF protocols and why North Cyprus IVF Centre offers the protocols that they do. Before administering an IVF protocol, our IVF specialists will need to thoroughly investigate your unique needs and decide accordingly.

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