wannababyIVF wrote:Also, can you explain what a flare protocol is?
There are three main protocols. They differ in how they control the pituitary gland. Controlling the pituitary during stimulation is important, to prevent a premature LH surge.
First, what causes the pituitary to release an LH surge? This happens when another gland, called the hypothalmus, releases a hormone called GnRH (gonadotropin releasing hormone). When GnRH hits the pituitary, the pituitary releases a surge of LH. So controlling LH from the pituitary is really about controlling the effect of GnRH.
There are two main ways to do this. You can use a drug that directly stops the effect of GnRH. These are called GnRH antagonists. One common example is ganirelix. They have been on the market for about 5 years or so, and are used in maybe 20% of cycles, plus or minus. Since these drugs directly shut down the pituitary, the are usually needed only when an LH surge is possible, for about 5 days or so, as stimulation approaches peak follicle development.
The other way is to use a drug that does what GnRH does, cause a surge. Yup. By causing a surge at one point, and then keeping the pituitary stimulated, it can prevent the pituitary from storing up enough for a surge at the wrong time. This is done with a GnRH agonist. Examples are Lupon or Buserelin. Also Synarel. These initially cause an LH surge, but continued use keeps the pituitary from saving up for a surge. So these are used in the "long protocol" because you must use them well before your cycle starts, and keep using them, is order to get this effect.
The agonists have been on the market since around 1990. Agonist cycles like the "long Lupron protocol" are the most common by far, maybe 3/4 of all cycles.
The least common is the flare protocol. In this protocol, the initial LH surge from the agonist is put to work "kick starting" ovarian stimulation. Note: An "LH surge" includes more than just LH, and releases a good deal of FSH as well. FSH, extracted from the urine of old nuns (yup) or the ovaries of Chinese hamsters, is the main active ingredient in the stimulation meds. Might as well use your own FSH, since you already have it sitting there, right? Makes sense. In this protocol, you start the agonist (like Lupron) later than in the long protocol. The initial surge of FSH and LH starts follicular development, and it's still augmented with more injectable stim meds.
From what I've read and the little I've seen, flare protocols work well, but may often be used as Plan B for patients who did not do well in one of the more common protocols.
While you are on either an agonist or an antagonist, you are "down regulated" or as they say on this board, "down regging". This refers to suppressing the pituitary.