- Welcome to "Fertile Minds".
I'm professor Michael Chapman, I work with IVF Australia.
Today, we're gonna talk about the protocols we use
in an IVF cycle.
What we're trying to do is get you pregnant,
and this is the way we're gonna be doing it.
The commonest protocol used in Australia
and in about 85% of cycles, in fact,
is what's called the short protocol,
so let's go through that.
We start on day two, usually, giving injections of FSH.
That's the hormone that normally comes from your brain
to tell your ovaries what to do,
and what we give you is a synthetic version of that
at a much higher dose than your brain normally does
so we get lots of eggs.
So we start that on day two and in most cases,
that's a daily injection in your tummy,
like a diabetic does for their insulin injections,
with a little pen which has got a tiny little needle on it,
and that happens every day.
And then at day five or six, we start a second injection.
So the first one was to try
and make as many eggs as possible.
The second injection, which is on a daily basis,
called an antagonist, a GnRH antagonist,
cetrotide or orgalutran,
that is to stop you ovulating, stop you releasing the eggs
before we get to collect them.
Obviously, it would be a waste of a cycle
if you ovulated yourself
before we were able to harvest them.
So you're taking two injections a day,
usually at the same time,
it's recommended they're taken in the evening
but the time is not vital,
it doesn't need to be on the same hour every day,
but in the evenings on a regular basis.
From that point on,
you'll probably probably have one or two
or three blood tests and ultrasound scans,
transvaginal ultrasound scans,
to watch the follicles growing
and to measure the hormones
that are being produced by those follicles.
Then the specialist will see those results on a daily basis
and make decisions about whether to change the dosage
of the drugs that you're using,
or to make that final decision of it's time.
It's time to collect the eggs.
At that point, time is then set
for the egg collection to take place.
When the eggs are ready for collection,
they need a final maturing injection,
an injection that makes the eggs go
from 46 chromosomes to 23.
It's what happens in nature, just before ovulation,
so that your 23 chromosomes can meet up
with the 23 chromosomes of the sperm,
and that requires a trigger injection, it's called.
These days we use a synthetic version
of the pregnancy hormone hCG,
but we also can use hCG itself.
And that is given quite precisely,
and you will be told by your nursings
to be precise about taking that,
'cause once we give the injection,
we know the eggs are gonna be released
at about 40 hours after that.
So what we're doing is timing your egg collection
to be between 36 and 38 hours after the injection is given.
So if we've set a time, say tomorrow morning,
eight o'clock in the morning to do the egg collection,
you will have had your injection
at eight o'clock last night.
10 minutes, either way, is not important,
but if you forget it, it is a major problem,
because your eggs won't be ready.
Once you have had that injection, then as I say,
you're gonna be coming to the egg collection room
36 to 38 hours later, eggs are collected,
then we begin what is called luteal phase support.
In every IVF cycle,
to make sure the lining of the womb is good,
we need to keep progesterone levels high,
and that's done either with pessaries
or tablets in the vagina.
That's fairly uniform throughout cycles.
You can use hCG injections
instead of the progesterone pessaries,
but that has a risk of causing hyperstimulation,
so we rarely use it.
So that's the short protocol.
I'll just run it again.
Starts on day two, daily injections,
starting on day five, another set of injections,
the trigger injection, egg collection,
and then luteal phase support.
That's the majority.
That came to pass about a decade ago in Australia.
The previous regime, and that's what's used
by the other 10 or 15% of patients in Australia,
is called a long protocol.
It's called a long down-reg protocol.
That begins in the third week of the cycle
before the cycle that we're going to collect the eggs.
So 21 days on a normal cycle,
we will do a blood test to make sure you've ovulated,
and after that, we will be giving you
either a nasal spray or an injection
to switch off the ovaries,
so that when we get to the day of your period,
the ovaries are quiet, there's no activity,
and then we start the daily injections of the FSH.
Again, those injections will continue all the way through
until the day of the trigger injection.
That's about, usually, an average of 11 days of injections.
Could be 10, could be up to 14,
but the average is around 11 days.
Same injection as we talked about
in the short protocol at that point,
but we've already switched off your pituitary gland
with a nasal spray or the downregulation agonist injections.
Again, there'll be the same monitoring
with bloods and ultrasounds,
and a decision will be made by your specialists
that it's time to collect the eggs
and the trigger will be provided.
Again, it's the same trigger, 36 hours before the operation,
to collect your eggs.
The luteal phase support, again,
is identical to a short protocol.
Now, the reason why 85% do it that way,
it's not because it's any better,
it's just that it's easier for you,
the cycle is shorter.
Studies that I've personally done
have shown 99% of patients prefer the short protocol,
compared with the long one,
just because it's all over in the one month.
There are other protocols.
Some people would do natural cycles
where you only get one egg
and you don't need any medication.
In some countries around the world, Japan's one of them,
where the drugs aren't covered by Medicare,
natural cycles are done a lot,
but it means you gotta have lots of cycles
to get the same cumulative pregnancy rate
as we get in Australia,
so it's usually not the way to go.
Some people will start the injections later
to get one or two eggs only.
Again, it's a numbers game.
The more eggs you have,
the more chance ultimately you have of getting pregnant.
In some cases,
we even go as far as the long, long downregulation.
So we started on day one of a cycle, not in the cycle
that you're gonna be having the egg collection,
but a month later.
Some people do that
where there's endometriosis, for instance.
It may suppress endometriosis,
although in a month, it's unlikely to.
So there are multiple protocols.
The majority are pretty straightforward, short protocols
that, as I said earlier, much, much easier
and much less burdensome than in the past.
So when you sit down in front of your IVF doctor,
that's what they'll probably give you,
at least as your first cycle.
The dosing of those is dependent on your clinical situation,
age, weight and previous history.
I'm not gonna go into that today
but it will vary from patient to patient,
so don't necessarily compare my cycle
with your cycle (chuckles).
It can lead to confusion.
What you want is a specialist
who understands what the best is for you,
someone who's experienced,
and our doctors at IVF Australia are all in that category.
So thanks for watching, I hope that was useful,
and if you've got any questions or comments,
please make them, and please subscribe to The Fertile Minds.