Different Protocols to Consider

June 16, 2005 - Thursday
2:00 PM to 3:00 PM (EST)
Guest Speakers: Carolyn R. Givens, MD, Pacific Fertility Center

Categories
Fertility • IUI • IVF • Pregnancy

	Lori_Masi_AFA_Patient_Advocate joined
	Hopeful joined
	Hopeful left
	Danielle joined
	Carolyn_Givens joined
Carolyn_Givens	Hi, Lori, are you there?
Lori_Masi AFA_Patient_Advocate	Hi Dr Givens! Welcome!
Carolyn_Givens	Hi, I just sent my short summary to your e-mail.
Lori_Masi AFA_Patient_Advocate	Good Evening! Welcome Everyone! Our Special Guest this evening is Carolyn R. Givens, M.D. of The Pacific Fertility Center and our topic is “Different Protocols to Consider”
Lori_Masi AFA_Patient_Advocate	Ok Thanks!
Lori_Masi AFA_Patient_Advocate	The last five years in the field of fertility care and treatment has seen some dramatic changes in our choices of medications. As our understanding of how the body regulates the recruitment of follicles from the ovary, we have been able to better manipulate this system for better results. This, coupled with the advent of new mediations that can control the reproductive hormone systems in women, has allowed us to come up with novel ways to control for the desired effects. Some new medications that have expanded the repetoire of what reproductive endocrinologists can use include GnRH antagonists (Ganirelix and Cetrotide), Letrozole (Femara), Metformin, low dose hCG, and low dose L
Lori_Masi AFA_Patient_Advocate	The above is dr Given's summary of our topic! I will re post it when we have more people log on!
Lori_Masi AFA_Patient_Advocate	Welcome Dr Givens and Danielle! We will begin in just a few minutes!
Danielle	Hello Everyone and thanks!
Carolyn_Givens	Lori, I just attended the AFA fundraiser last Saturday night at Dr. Mark Surrey's home in Beverly Hills. It was really a nice evening and very inspiring. But anyway, I'm here to answer any questions. If there aren't any right off the bat, I can give a little presentation of a protocol we are using for poorer responders that I presented at the Pacific Coast Reproductive Society meeting last month.
	Madh joined
Lori_Masi AFA_Patient_Advocate	That sounds great but let's wait a few minutes so everyone can hear it. I just got a few e mails from patients that are having trouble logging on due to a thunder storm here on the east coast.
Carolyn_Givens	Okay, strange thing, its raining here in the Bay Area today too. Very unusual for mid June.
Lori_Masi AFA_Patient_Advocate	Welcome Madh!
Madh	I am new to this today, so please excuse any problems that I may have
Lori_Masi AFA_Patient_Advocate	Do either of you have any questions for Dr Givens while we wait for the others
Lori_Masi AFA_Patient_Advocate	Madh please feel free to relax here - you are among friends who have all been thru this - me included!
Madh	thank you, i am not supposed to be hearing anything right, just reading and typing???
	Jenn joined
Jenn	Hi everyone
Lori_Masi AFA_Patient_Advocate	I will post a summary from Dr Givens on our topic tonight, it is as follows:
Lori_Masi AFA_Patient_Advocate	The last five years in the field of fertility care and treatment has seen some dramatic changes in our choices of medications. As our understanding of how the body regulates the recruitment of follicles from the ovary, we have been able to better manipulate this system for better results. This, coupled with the advent of new mediations that can control the reproductive hormone systems in women, has allowed us to come up with novel ways to control for the desired effects. Some new medications that have expanded the repetoire of what reproductive endocrinologists can use include GnRH antagonists (Ganirelix and Cetrotide), Letrozole (Femara), Metformin, low dose hCG, and low dose L
Lori_Masi AFA_Patient_Advocate	Madh this is correct Just type and hit send! Hi Jenn!
Carolyn_Givens	The last word should be Lupron
	Hopeful joined
Lori_Masi AFA_Patient_Advocate	Welcome hopeful!
Lori_Masi AFA_Patient_Advocate	Dr Givens where should the last word be lupron?
Lori_Masi AFA_Patient_Advocate	Due to a thunderstorm here in the east alot of people are calling and e mailing that they cannot log on, so why don't we begin and hopefully they can join us soon
	Rena joined
Carolyn_Givens	Here's the whole last paragraph, the last part of which I am not seeing:
Carolyn_Givens	Some new medications that have expanded the repetoire of what reproductive endocrinologists can use include GnRH antagonists (Ganirelix and Cetrotide), Letrozole (Femara), Metformin, low dose hCG, and low dose Lupron. I will be answering questions on how these medications, when used in certain patients for IVF stimulation, may help to improve egg and embryo quality and quantity and pregnancy outcomes.
Lori_Masi AFA_Patient_Advocate	Please post your questions now for Dr Givens!
Lori_Masi AFA_Patient_Advocate	Welcome rena
Rena	Hello.
Lori_Masi AFA_Patient_Advocate	Jenn why don't you begin!
Hopeful	I am in the 2ww from an IVF cycle that was converted to IUI. It is my 7th cycle since Jan 2004 - 4 converted, 2 cancelled & 1 to ER/ET. Made it to IVF last fall with 5 follicles/2 great embryos. After that failed, found out that I had developed a thyroid issue and that I have a clotting issue (double C MTHFR) and they think these could have been contributors to the failure. Done the protocols - antagonist, agonist, mdf, etc. The one that seems to work the best is a clomid + gonadatropin. This got us to IVF in Oct and was what I did this past cycle. I did respond well, this past cycle - faster than I ever have, but just too quickly and even after slowing things down, we lost a few follicles. Whenever
Lori_Masi AFA_Patient_Advocate	Dr Givens when I was going thru this not much could be done to improve egg and embryo quality - how has that changed?
Danielle	I am a low responder, what can be done?
Jenn	Sorry Lori- I didn't realize you were talking to me, I walked away for a sec. I do have a question...it's kind of basic though. Is famera (i believe that's the name) better than clomid? I hear a lot of people taking this drug instead of clomid
	slin joined
Lori_Masi AFA_Patient_Advocate	Welcome Slin! Good Evening! Welcome Everyone! Our Special Guest this evening is Carolyn R. Givens, M.D. of The Pacific Fertility Center and our topic is “Different Protocols to Consider”
Carolyn_Givens	I think we have come to better understand the importance of a little bit of LH hormone for egg and embryo quality. When some women are treated with OCPs and long Lupron suppression prior to stimulation, they really need a little bit of LH in the form of Repronex (one or two vials) or low dose hCG or the new recombinant LH, Luveris.
Rena	I'm a low responder too!! Please share what can be done. I'm 35, cancelled 1st IVF, retrieved 4 on second and transferred 3 great embryos, but no luck. On 3rd IVF, got two embryos that look great...time will tell.
Carolyn_Givens	As far as poor responders are concerned, I am using a new protocol in which a single dose of Cetrotide 3 mg is given in the luteal phase of the preceding natural cycle 10 days after ovulation.
Madh	my question is abour Gonal-F..last cycle 7-8 eggs were produced, i have read that too many eggs can also affect the IUI, is this true..and how many cycles of IUI with Gonal-F can i try before moving to IVF...i think my doc is rushing it
Danielle	what about egg quality, what can be done for that?
Carolyn_Givens	The idea is that the Cetrotide helps to suppress FSH levels in the late luteal phase of the preceding cycle because in many poor responders, it's this high FSH even before the menses starts that starts to recruit the smaller group of dominant follicles. This is especially true when the stim med doses are high and women are ready for hCG on day 7 or 8 of stim.
Carolyn_Givens	We saw that many of our patients on standard antagonist cycles who stimulated quickly with only a few follicles would grow follicles more slowly (10-13 d of stim) and get more follicles with better quality embryos.
Danielle	my fsh is low, but i am a poor responder, and I'm 43 with 1 miscarriage with IVF
Carolyn_Givens	There really isn't a protocol that is going to improve the age issue, I'm afraid. Because its the chromosomes of eggs that go bad with age. I doubt we can change that. All we can do is try to get more.
Rena	What if you don't stimulate quickly...follicles start showing up later. Would the Cetrotide still help?
Jenn	Is famera better than clomid? I hear a lot of people taking this drug instead of clomid.
Rena	I've gone to day 15 before egg retrieval.
Carolyn_Givens	Madh, I think 3-4 cycles of gonal-f + IUI is sufficient. Many studies show that chances of conceiving after that fall off. I ususally recommend IVF after 3-4 IUI attempts, depending on the age of the pt.
slin	My wife is 36, ttc 3 years, 2 IUI (chromid) and one canceled ivf early this month. She was under an aggressive ovulation induction protocol without lupron, taking bt pills, and 450 unit daily follistim. This resulted in only 4 grown follicles with normal fsh level from blood test. Our doctor recommended at least 6 to have reasonble chance of success and suggested we cancelled the ivf and proceeded as injectable iui. This failed to produce a pregancy unfortunately. Here are my questions for Dr. Givens: are there other protocols which might be helpful for my wife ? if so, are there tests (i.e. without going through ivf) available to guess which are the better ones ? Secondly, are there treatments (e.
Carolyn_Givens	Rena, if you are already taking a long time to stim, it may not help. For women that stim long, I like to use a microdose Lupron protocol.
	psmith joined
	psmith left
Madh	that was my problem, i did not stimulate quickly, so they were not seeing anything on the ultrasound, so they increased the doasage, and BOOM, she saw so many eggs..and now i am left with cysts and connot do anything till they go away..
Rena	Is that similiar to flare?
Lori_Masi AFA_Patient_Advocate	Good Evening! Welcome ! Our Special Guest this evening is Carolyn R. Givens, M.D. of The Pacific Fertility Center and our topic is “Different Protocols to Consider”. Please post your question for Dr Givens!
slin	Dr. Givens, my previous question has repeated typing, sorry about that ..
Carolyn_Givens	Jenn, Femara has some potential advantages over clomid, namely, fewer side effects and less of a anti-estrogen effect on the lining. It is possible that it can help women that don't express endometrial integrins to better express them.
Carolyn_Givens	Slin,
Rena	I mean 'Lupron Flare'.
Danielle	Dr Givens will these new protocols help me at all at age 43 or should I give up?
Carolyn_Givens	Slin, please see my abober replies about the Cetrotide protocol. I also think you need 450 IU of FSH with 150 IU daily of Repronex or 25 IU of low dose hCG. Go to retrieval on that if there are only 6, it could still work.
Carolyn_Givens	Rena, it is similar to a "flare" protocol, but with much less Lupron. It is diluted by the specialty pharmacy so you can take 40 micrograms twice daily starting on cycle day 2 with stim starting on cycle day 3. Has that been tried?
Carolyn_Givens	Danielle, it's hard for me to answer that question without having your entire history. You should discuss that with your RE.
Carolyn_Givens	Madh,
Carolyn_Givens	Madh, I think you sound like a good responder so your overall chances may be good. Did you previously use Clomid?
Rena	Thanks. I've done 2 cycles of .2cc of Lupron days 1-4, then switch to .05cc of Lupron 'til HCG. Follistim is started on day 1 - morning and night. I've done one with 150mg of F and then with 300mg of F. Both times - got about 7 Follicles - 5 mature. Ended up with 2 embryos to transfer - but good ones.
Madh	i am currently on metformin...i did use clomid, but it looked like it was not responding well...but i also wanted to ask, how many cycles of clomid and how much is the max dosage that they can try for clomid...my doc put me on 100 and then stopped..
Jenn	Dr Givens--I have hypothyroidism, and it seems like my tsh levels are constantly changing and my primary dr keeps increasing my thyroid meds. How is affecting me ttc? And should I put off ttc until we can get my thyroid numbers under control?
Carolyn_Givens	Rena, sounds like a standard Lupron flare protocol to me. The Microdose flare protocol is a little different. Much lower does of Lupron. Did you have any Repronex or source of LH?
Danielle	is it true that changing protocols can increase your response? Or should you stay with the same one?
Carolyn_Givens	Madh, I rarely use CC at 150 mg a day. Rather switch to Femara because the clomid thinning of the endometrium becomes more of a problem at the higher doses.
Jenn	(note: I just wanted to add also that I have been struggling with getting my thyroid numbers to stabilize for the last 2 years.)
Rena	I don't think so. Just the Lupron and Follistim.
Carolyn_Givens	Jenn, the issue with hypothyroidism for most women is one of miscarriage, not necessarily infertility.
Jenn	So then possibly my thyroid isn't affecting me actually getting pregnant?
Jenn	And there may be another underlying problem?
Carolyn_Givens	Danielle, if you are getting less than 8 eggs or if the embryo quality is poor, I would want to try a different protocol.
Carolyn_Givens	Jenn, unless you have true clinical symptoms of hypothyroidism, its unlikely that your ability to conceive is being affected by it. Have you been tested for anti-thyroperoxidase antibodies?
Danielle	I only had 3 to retreive but said was good quality PG 6 weeks w/ twins then no heartbeat!
Jenn	not that I am aware of- can you tell me what that is?
Carolyn_Givens	Rena, I would want to add some LH to your stim protocol.
Lori_Masi AFA_Patient_Advocate	I never heard of that either - what is it?
Jenn	Also do they test for anti-thyroperoxidase antibodies through a blood test?
Carolyn_Givens	Danielle, I'm so sorry to hear that. Sounds like the embryos were aneuploid (chromosomally abnormal). Probably not a stim protocol issue.
Rena	I'm sorry, but I'm not certain what you mean by "LH" and I want to make sure I don't miscommuncate to my Dr. Can you elaborate a bit? Thx!
Carolyn_Givens	Jenn, those are antibodies that are commonly associated with autoimmune thyroid disease and yes, they can be tested for in a blood test. They are associated with a higher risk of first trimester miscarriage.
Lori_Masi AFA_Patient_Advocate	Dr Givens what is the blood test called for this? I would like it myself....
Jenn	Dr Givens if I was to test positive to those anitbodies, what can be done to fix it?
Lori_Masi AFA_Patient_Advocate	BTW, I have had 6 unexplained miscarriages all 6-7 weeks - had some autoimmume blood tests but never heard about this - please elaborate for us thanks!
Carolyn_Givens	Rena, LH is the hormone made at the midcycle ("LH surge") and small amts of it are also made in the follicular phase. On standard lupron protocols, this gets shut down pretty profoundly. We know that women that do not make any LH, when stimulated with only FSH, will have low estradiol levels and poorer quality eggs. Most people are using one or two amps of repronex (75 IU of FSH + 75 IU of LH) or low dose hCG (25 iu) daily along with their Foll or Gonalf to help stim.
Madh	dr.givens,if a patient is responding well to gonal-f, how many times do you suggest they try that before moving on? all other factors are good, sperm count and motiltiy are good, the blue-dye test(i forgot the name of the test), actually we are using IUI with this also..
slin	Dr. givens, is there any medicine or treatment available to better prepare poor responder before IVF ? Under what circumstance would you recommend going through ivf if there are only 4 follicles ? THX
Carolyn_Givens	The test is Anti-Thyroperoxidase Antibodies. If a woman has high titers, her TSH may be harder to control. If the titer is >1000, I consider IVIG, something I normally strongly avoid.
	qpayton joined
Lori_Masi AFA_Patient_Advocate	Wecome qpayton! Good Evening! Welcome ! Our Special Guest this evening is Carolyn R. Givens, M.D. of The Pacific Fertility Center and our topic is “Different Protocols to Consider”. Please post your question for Dr Givens!
	qpayton left
Carolyn_Givens	Madh, I think 3-4 cycles of either Femara or Clomid + IUI then Gonal-f + IUI for 3-4 cycles is plenty. If not pregnant, move on to IVF. Statistically, its much much better.
Rena	Thanks for the help. One other quick question - a little off topic: I'm on prog. vaginal suppositories. Do I have to take this at the same time every evening.? I try to take and go straight to bed...just wondering if it must be at the same time every night.
Carolyn_Givens	Slin, yes, I recommend Cetrotide 3 mg.given 10 days after ovulation in the cycle preceding stimulation with an antagonist protocol. This shuts down late luteal phase FSH levels but wears off around the time of stim start so doesn't interfere with recruitment of follicles. Works well when pts respond poorly, especially when they stim quickly.
Carolyn_Givens	Rena, you should try to take the prog suppositories about the same time plus or minus one hour or so.
Jenn	Dr Givens- I have been charting my temps since I started ttc, and my temps usually range from 96.8 to about 97.5 throughout my cycle. Only when I was on clomid did they reach the 98.0 and higher. I recently read that if your temps are consistantly under 97.3 through your cycle (which mine are many times throughout my cycle) even if you do get pg, you will not be able to sustain the pregnancy. Is this true?
Rena	Okay. Thanks for your time!
Hopeful	Lori - Did my question post at the beginning of the session or should I repost? Thanks.
Carolyn_Givens	Jenn, low temps possibly indicate inadequate progesterone. Are they low on prog supp too?
Lori_Masi AFA_Patient_Advocate	Hopeful I did not see it - pls repost it for Dr Givens!
Jenn	I have never been on prog supps. I had my hormones checked by my primary dr, and my progesterone was very low. But she thought it may have just been because it wasn't properly scheduled at the correct time in my cycle.
Carolyn_Givens	Jenn, your prog level should definitely be checked 7 days after first detection of the LH surge by ovulation predictor kit. If it is less than 10 ng/mL, I would suspect inadequate progesterone.
Hopeful	I am in the 2ww from an IVF cycle that was converted to IUI. It was my 7th cycle since Jan 2004 - 4 converted, 2 cancelled & 1 to ER/ET. Made it to IVF last fall with 5 follicles/2 great embryos. After that failed, found out that I had developed a thyroid issue and that I have a clotting issue (double C MTHFR) and they think these could have been contributors to the failure. Done the protocols - antagonist, agonist, mdf, etc… The one that seems to work the best is a clomid + gonadatropin. This got us to IVF in Oct and was what I did this past cycle. I did respond well, this past cycle - faster than I ever have, but just too quickly and even after slowing things down, we lost a few follicles. I am typi
Jenn	my number was .76 NG/ML
Madh	i had severe cramps on the morning of mu iui, i could not even walk or go to the bathroom..is this pain from overstimulation or cysts that were seen later..
Carolyn_Givens	Jenn, that is not consistent with even having ovulated.
Jenn	So far I have only ovulated while on clomid and only 2 cycles out of the 5 cycles I took it. Other than that, I have annov. cycles.
Madh	usually how long does it take for cysts to go away?
Carolyn_Givens	Hopeful, I wasn't sure there was a question in your comments. I think the Cetrotide before menses protocol as I have described might be worth a try. By the way, I have quit testing for MTHFR mutations. So many people have them with no clinical consequences.
Carolyn_Givens	Madh, were the cramps before or after the IUI? If before, probably from the ovulation and the cysts. Cysts are almost always gone by the next natural menses.
Carolyn_Givens	Jenn, you need hCG and progesterone, I think.
Carolyn_Givens	Hopeful, you might also want to discuss Femara + gonadotropins with your RE.
Madh	the cramps were before the iui, and all day after the iui..lasted only 24 hours, the next morning i was okay...
Carolyn_Givens	Madh, that is not too unusual under your circumstances.
Danielle	i know it is not part of the subject but what do you think about the donor egg option?
Carolyn_Givens	Madh, overstimulation pain is usually worse several days after hCG.
Carolyn_Givens	Danielle,
	T_in_CA joined
Carolyn_Givens	Danielle, donor eggs are a terrific option, if you are ready to go there. Solves almost all the problems.
Jenn	What is hCG, and what does it do? And is there a way to take prog. orally, or only supps?
Lori_Masi AFA_Patient_Advocate	Welcome T
Madh	dr. givens, thank you for answering my questions....i wish all best of luck..bye
Lori_Masi AFA_Patient_Advocate	Ladies and Gentlemen we only have about 5 minutes left with our wonderful guest Dr Givens - please post your final questions!
	T_in_CA left
	Madh left
slin	Dr. givens, could you post your contact info ?
Carolyn_Givens	Jenn, hCG is human Chorionic Gonadotropin, the same hormone produced by the placenta during pregnancy. It is chemically very similar to LH and basically causes an LH surge in anovulatory women. It also can help the follicle to produce more prog after ovulation. Oral prog should be avoided. It's metabolites may be toxic to embryos. Use the oral tablets Prometrium once a day in the vagina after the ovulation.
Carolyn_Givens	slin, sure:
Rena	Is it common to see 3 good embyros transferred (everything else normal too) and it not work? I got discouraged.
Carolyn_Givens	Carolyn Givens, M.D.
Carolyn_Givens	55 Francisco St. #500
Carolyn_Givens	San Francisco, CA 94133
Carolyn_Givens	Phone: 888-834-3095
Carolyn_Givens	website: www.infertilitydoctor.com
Lori_Masi AFA_Patient_Advocate	Dr Givens you have done a wonderful job keeping up with all of our questions - thank you so very much for joining us tonight! I hope you will join us again soon! Please repost your contact info for everyone!
Jenn	Thank you so much for answering my questions Dr Givens. This has definatly been very informative. Thanks again for your time.
Lori_Masi AFA_Patient_Advocate	Folks we have 3 minutes left
Hopeful	Dr. Givens Thank you for your time.
slin	Dr. Givens, thank you for your help !!
Carolyn_Givens	Rena, yes, very common, sadly enough.
Carolyn_Givens	Bye everyone, nice chatting!
Lori_Masi AFA_Patient_Advocate	Good Night Everyone and again Thank you to Dr Givens!
Rena	Well - that is encouraging then! I'll just keep trying. THANKS AGAIN FOR YOUR TIME.
	Rena left
Carolyn_Givens	You are welcome. Good luck!!!
	Carolyn_Givens left
Lori_Masi AFA_Patient_Advocate	Good Night Dr Givens and thanks!
	Lori_Masi_AFA_Patient_Advocate left
	Hopeful left
	Jenn left
	Danielle left
	slin left

Different Protocols to Consider

Categories

Chat Archives