• This procedure involve pituitary and ovarian suppression prior to gonadotropin administration, GnRH agonist starting in the mid luteal phase (cycle day 21 of an idealized 28 day cycle). In the next menstrual cycle from the 3 rd day gonadotropin administration starts, and the GnRH agonist dose is reduced to half. In case, the woman fail to respond to gonadotropin injections after 4 days, the dose can be increased. HCG is administered atleast two follicles reach 17 mm size. 35 hrs after the administration of HCG Oocyte harvestation is done. Fallicular recruitment, endimetrial preparation, good quality of oocytes (As LH surge is prevented), widenening of implantation window are the advantages with down regulation protocol.
“Short Protocol or Flare protocol”
• This protocol was developed for poor (ovarian) responders. With this protocol, the GnRH agonist is started early in the menstrual cycle (cycle day 1 or 2) to take advantage of the initial release of stored gonadotropins form the pituitary gland “flare” and are often then initiated on cycle day 2 or 3. This protocol reportedly results in fewer mature eggs at pick up, but has an important role in women who do not make mature eggs following ovarian suppression using the “long protocol”
“The high Responder”
• Women with PCOS produce very high estradiol concentration (over 4000pg/ml) in the presence of many small to midsized follicles, with few mature follicles. These group of women should optimally treated using a customized protocol, otherwise they are at a tremendous increased risk of OHSS, and success of IVF cycle is reduced since there are fewer good quality eggs and the very high estradiol concentration may interfere with embryo implantation.
High responders do well with a low dose GnRH agonist and only 1 or 2 ampules of gonadotropin at the onset of the stimulation portion of the cycle. Monitoring of cycle is must for these group of patients.