endometriosis: Lupron vs. Birth Control Pills pre-IVF Treatment

There are patients coming from fertility clinics with either lupron and birth control pills for pre-ivf treatment.
While Lupron and birth control pill (BCP) help recruit multiple follicles by preventing natural selection of a single dominant follicle, each can suppress ovarian response, especially when used together during the pre-stimulation phase. Patients with low ovarian reserve will do better using regimens that minimize the inhibitory effects of Lupron and birth control pills (BCP). Following are different protocols,

1. Microdose Lupron Flare Protocol

In the regular IVF protocol, Lupron and BCP are used for at least 2 weeks before ovarian stimulation. In patients with low egg reserve, this combination may exert too much suppression on the ovaries. During the first few days of Lupron, the ovaries are stimulated by the natural pituitary hormones (the flare effect). Medications containing the same hormones are later added to augment the stimulation effect.

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Not all patients will benefit from the standard IVF protocols. While Lupron and birth control pill (BCP) help recruit multiple follicles by preventing natural selection of a single dominant follicle, each can suppress ovarian response, especially when used together during the pre-stimulation phase.

Patients with low ovarian reserve will do better using regimens that minimize the inhibitory effects of Lupron and birth control pills (BCP). At IVFMD we use a variety of aggressive protocols to optimize ovarian response. When choosing a protocol for patients with low egg reserve, the experience, creativity, and flexibility of the physician contribute greatly to the chance of success. Listed below are the protocols that we have used effectively over the years:

1. Microdose Lupron Flare Protocol

In the regular IVF protocol, Lupron and BCP are used for at least 2 weeks before ovarian stimulation. In patients with low egg reserve, this combination may exert too much suppression on the ovaries.

The Microdose Lupron regimen uses a very small dose of Lupron just 3 days before the start of stimulation medications to minimize the suppressive effect and to take advantage of a unique property of Lupron to release FSH and LH from the pituitary, which are the same hormones found in the stimulation medications. Thus during the first few days of Lupron, the ovaries are stimulated by the natural pituitary hormones (the flare effect). Medications containing the same hormones are later added to augment the stimulation effect.

Microlupron

The micro-Lupron protocol was one of the first aggressive protocols introduced and over the years has helped many patients with low ovarian reserve to conceive their own children without resorting to donor eggs. Its main disadvantage is that LH is also released along with FSH that can potentially impair egg development. There is also an increased risk of premature ovulation due to the light suppression of the pituitary. In addition, in patients with very low egg reserve (AMH <0.5 ng/ml), the use of BCP, though only for a short time, can still significantly suppress the ovarian response. 2. Estrogen Primed Antagonist Protocol This protocol is our favorite for patients with very low ovarian reserve, or those who have poor response after taking BCP. In this protocol, the pretreatment cycle is a natural cycle (no BCP). Estrogen is used to provides the young follicles an optimal condition to grow in the future. Stimulation medications are stated on day 3 of the next menses and the antagonist would be used again later to prevent premature ovulation. Following is only from one doctor's opinion. Also this patient did not have endo on ovary. Still need pre-IVF treat? anyway, here is the dialog. ---------------------- A: I can answer general questions on this forum; not give advice. The scope of your questions would really require a consultation. What I can tell you is that pretreatment before an IVF cycle in patients with endometriosis is the best way we know to bring their IVF results to the level of non-endometriosis patients. Of all your choices I would think the most recent evidence shows that pre-treatment with birth control pills and letrozole leading immediately into an IVF cycle seems to give the best results. Good luck. Arthur L. Wisot, M. D. Reproductive Partners Medical Group, Inc. --------------------- Question, Quick introduction: I am 39 years old and recently diagnosed with Moderate to Severe endo (I don’t have Endo on the ovaries or tubes-only on the uterus.) Chromotubation was also performed with prompt spillage of dye through both tubes, which did have good fimbriated ends. My uterus is free of fibroids and polyps and appears normal in width, length and depth. My pain level is mild and usually only on the 1st day of my menstrual period. I usually take 2 advils and the pain is gone. Based on our research on Endometrisos and speaking with other Endo patients it seems that ovarian suppression with GnRH agonists like LUPRON (3-months) or birth control pills (BCP) with Letrozole for two cycles pre-IVF treatment may help with some of the bad effects (i.e. uterine inflammation/beta 3 integrin) of the endometriosis and improve IVF pregnancy rates. Below are five (5) questions we have regarding Lupron and BCP and Endometrial biopsy: 1. In your opinion, please advise if you think that 3-month Lupron is more, less or equally effective to BCP with Letrozole pre-IVF treatment for moderate/severe Endo patients. What are the benefits/disadvantages/side effects of going with either one? 2. Does 3-month Lupron or BCP with Letrozole help with beta 3 Integrin and inflammation? Please explain which med is more effective and/or which one you’d recommend and why. 3. How soon after completion of 3-month Lupron or BCP with Letrozole should we start our IVF cycle? 4. There’s been a few times we’ve considered skipping taking Lupron or BCP prior to our IVF treatment due to my age but we think that taking Lupron or the BCP before our IVF treatment will help us increase the our odds of conceiving- Do you agree? 5. Finally, do you recommend doing an endometrial biopsy before moving forward with IVF? Below are some additional test details/results for your reference: Age: 39 (6-months away from 40) Laparoscopy/hysteroscopy surgery in Dec ’11 (note: Endo was not removed) I have never treated my endo with medication or surgery Diagnosis: Endometriosis (stage: moderate to severe. I don’t have Endo on the ovaries or fallopian tubes only on the Uterus) Tests: AMH (anti-mullerian hormone): 1.2 ng/ml E2 (Estadiol): 43 ( tested on 3rd day of cycle) FSH: 9 miU/mL (tested on 3rd day of cycle) My husband’s semen analysis is normal