IVF Babble

What is a protocol and which one will you be put on?

Starting a round of fertility treatment can be incredibly overwhelming, as there is just so much to take in

The unfamiliar medical terminology that you will hear your consultant use, can make the experience seem even more nerve-racking too. However, once you understand what these unfamiliar words mean, you will see that it’s not that scary.

We turned to Michalis Kyriakidis, MD, MSc, Gynecologist in Assisted Reproduction, at Embryolab Fertility Clinic and asked him to explain more about a word that you will hear in your initial consultations – your protocol.

The term “protocol”

During the first steps of IVF, any couple will hear terms that may confuse them or even stress them out. One of the first words that they may hear from their fertility specialist is the term “protocol”. And they may wonder, is this something out of a James Bond movie or some secret government agency?

Well, no. The term protocol refers to the type and dose of fertility drugs you may need, the combination of different substances and the path of your fertility plan.

Controlled ovarian stimulation is a fundamental step of your treatment, during which the optimal number of eggs is recruited and later collected in order to be fertilised and produce embryos for transfer. Over time, assisted reproduction techniques have evolved to fulfill the needs of different types of patients.

Three main protocols

At this point, there are 3 different main protocols that your doctor may choose from, although several variations actually exist.

Their main difference lies with the type and timing of down-regulation. Keep in mind that down-regulation refers to the actions and medication taken in order to avoid premature ovulation and facilitate egg-collection.

The majority of couples globally will be treated with the antagonist protocol and a smaller portion will undergo an agonist protocol (long or short). In all protocols, there is routine monitoring of patients via trans-vaginal ultrasound scan and hormonal profiling. The criteria by which your doctor will choose include mainly age, medical history and characteristics, cause of infertility and previous fertility treatments.

The antagonist protocol

The antagonist protocol is the most commonly used IVF protocol worldwide and one of the most recent. It involves several advantages such as patient-friendly management, fewer days and doses of injections and a decreased risk of Ovarian Hyperstimulation Syndrome. This type of treatment starts on day 2-3 of your cycle with injectable Follicle-stimulating Hormones and lasts approximately 10-12 days.

After a few days of injections, the GnRH-antagonist is added to prevent premature ovulation. At the end, your doctor will provide a trigger to stimulate the final maturation of the eggs and proceed to egg-retrieval. This type of protocol is effective for the majority of patients and can be used in several different types of infertility.

The long GnRH-agonist protocol

On the other hand, the long GnRH-agonist protocol has been used for more than two decades as the standard in IVF since its discovery in the 1980s. This protocol starts on day 21 of the cycle prior to treatment with the introduction of the agonist daily injection for down-regulation. On day 2-3 of the following cycle, the patient starts with injectable follicle-stimulating hormones and continues with the agonist until the final maturation trigger. Consequently, this protocol involves side effects such as longer treatment duration, more ampoules of gonadotropin, ovarian cyst formation, and menopausal symptoms. As a result, it is usually reserved for normal responders and women with previous unsuccessful IVF-cycles or specific causes of infertility.

The short-agonist protocol

The third main protocol that your doctor may choose is the short-agonist protocol or Flare-up. This type of protocol uses the GnRH-agonist under a different concept in order to stimulate, rather than suppress, the body’s natural production of FSH. Although it is less common the past few years, the flare-up protocol is generally recommended when a patient had a poor response to other protocols or has tried them with no success.

Alternative protocols

Alternative protocols do exist and they can be an attractive option for many physicians and patients. These range from natural-IVF to minimal, mini or mild-IVF and may include priming or pre-treatment plans. These types of treatment can be considered a better option in patients with poor ovarian reserve and poor responders as they involve lower cost and medication doses as well as fewer monitoring visits. However, these protocols have the major disadvantage of limited egg recruitment for patients with normal ovarian function.

After several decades of medical and technological advancement, the debate on which protocol to choose is still ongoing. At EMBRYOLAB, we believe that the best protocol for each patient should be neither “maximal” nor “minimal” but instead, be “optimal”.

Ultimately, the correct protocol is based on the patient’s specific needs and characteristics as well as family goals. This is the reason we personalise our treatment plan to each individual couple. Every successful fertility journey starts with good planning!



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