High FSH Info

The approaches outlined below are based on a limited survey – there may be other protocols of which I am not aware. Note that the literature below focuses on IVF. The vast majority of the studies specifically addressing protocols for DOR focus on IVF rather than IUI. In terms of protocol, one of the primary differences between IUI and IVF is that with IUI the goal is to stimulate the ovaries, but not too much – otherwise there is a high risk of multiples. With IVF, the RE and the couple work together to determine how many embryos to transfer in order to control the risk of multiples. So with IVF, maximal stimulation is desired while avoiding hyperstimulation. Some RE’s will cancel IVF cycles that don’t create enough follicles, whereas other RE’s will pursue retrieval and transfer with few or only one follicle. This can be a very important issue for patients with high FSH because of the likelihood of producing a lower number of follicles.

• High-Stim Protocols.
  
  • Some RE’s theorize that patients who have demonstrated that they are poor responders (common with DOR, as explained above), may respond better to an extra-high dose of stim medications (e.g., 6 ampules). Anecdotal evidence seems to indicate that this approach is more successful with younger patients with high FSH.

• Minimal or Low Stim Protocols.
  
  • Some RE’s theorize that poor responders may respond better to an approach using minimal stimulation medications. Some RE’s even go so far as to say that minimal stimulation protocols are not only favored for poor responders but can provide a lower-cost, effective option for “normal” responders which is easier on the body than higher stimulation protocols. Although this approach results in fewer oocytes at retrieval, some RE’s contend that the pregnancy rates are comparable to a standard stimulation protocol.

  • Minimal-Stim protocols can utilize any of the stim medications described above – alone or in combination.
  • Some RE’s favor minimal-stim protocols primarily for those patients with “borderline” FSH – i.e., those patients close to (either just under or just over) the FSH cutoff for their clinic.

• Natural Cycle with Controlled Ovulation Protocols.
  
  • Since patients with DOR often do not respond to stim’s regardless of protocol used), some RE’s will perform “natural cycle IVF”. Most RE’s do not favor it because of the low probability of success since generally only one egg is produced.
  • The concept behind a natural cycle IVF is that in women who will probably not respond to stimulation medications, the actual procedure of an IVF – even if only
    one follicle is present – could potentially improve the chances for conception due to reduction of the steps in the conception process which are left to chance (and therefore subject to failure) in a cycle using intercourse only. A true natural cycle is very difficult, however, due to the need to know precisely when ovulation occurs in order to time the egg retrieval. Therefore, the few RE’s who attempt “natural cycle IVF’s” typically introduce some medication into the cycle in order to control the timing of ovulation (and to prevent a premature LH surge).
  • The few RE’s who do natural cycle IVF’s do so typically with those patients with very high FSH who have a proven track record of not responding to stimulation medications.

• Synthetic Estrogen.
  
  • Synthetic estrogen (including ethinyl estradiol (oral contraceptive), femtrace, estrace, gynodiol, etc.) can be used in two different ways for fertility. Note that RE’s will prescribe a specific type and dosage of synthetic estrogen based on where it is being used in your cycle – they are not all interchangeable. A good description of how synthetic estrogen can be used can be found in this article from Sher Institutes.
  • The two different ways that synthetic estrogen is used are:
    • In women w/ high fsh, the problem is not only that the fsh is high but that it starts rising before cd1. By having an fsh “head start”, it makes it difficult for stim meds to be effective because often one lead follicle takes the lead too early – possibly even before stims are started. By taking synthetic estrogen for some time prior to cd1 (e.g., 2 weeks), it keeps your fsh down and therefore “suppresses” your ovaries so that no follie gets an early head start. The objective is to keep the antrals at relatively the same size so that they all grow together in response to the stims.

    • The other related problem in women w/ high fsh is that sometimes ovulation happens too early (because of the head start) – before the egg has matured properly. Dr. Check says that ovulation before cd11 is bad. So in early ovulators, synthetic estrogen can be used in the first part of the cycle in order to slow down the maturation process so that the egg(s) has/have enough time to fully develop.

For more information on protocols, you should read this website from New Hope Fertility and this article from the Sher Institute.