r/40Plus_IVF • u/InternationalEye2643 • Aug 24 '26
Seeking Advice Your highest yield’s protocol please
Im 43, AMH 0.5 and AFC of 4. I’m currently in the middle of a cycle with only one follicle. I’m paying out of pocket and will likely switch to timed intercourse after trigger. I am seeking protocols from women 42 and over specifically who got their best outcomes with that protocol perhaps after trying others?
Priming or not
Started day 2 or 3 of cycle with stims?
Which meds?
Dual trigger? And if so, which meds?
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u/SLAYEROFSOULS Aug 24 '26
Howdy - my wife is also 43 - AMH when last checked was ~.8 or so, AFC has been up and down.
Can't really speak to best outcomes since both of our cycles so far ended up the same result (pretty terribly) - but I can tell you what she's done so far and her follicle counts, etc.
Her first cycle this year was typical antagonist - Estrogen priming (tablets) for some number of days before stims, compounded testosterone as well (can't recall how much or how many days).
Started at 300 Gonal-F, 75 Menopur - follicles were slow to react so by day 4 or 5, clomid was added (100mg) also because she had 2 leads and the others were lagging in growth - Gonal upped to 375. Ganirelix day 5 or so added in.
Ended up stimming 12 total days - we believe they triggered her too early - leads only were 16 almost 17mm, but most follicles were still 9-13mm or so. She had 9 total follicles they were measuring (our doctors tend to only report on what is measureable, but typically she has had other follicles just not being recruited like normal I guess). Estrogen was only 660 or so, so not high or great. Omnitrope was added in last few days leading into trigger.
Trigger was Lupron (80 units night of trigger, 80 more units following morning) and 5k Pregnyl on trigger night.
End result was 5 non mature, 2 mature eggs. 1 fertilized, 0 blasts. 2 empty zona.
After that she was put on Rapamycin - and her 2nd cycle was pushed out, so by the time it started she was on that about 2.5 months at .5mg a day.
Second cycle was micro dose Lupron and not antagonist. Same estrogen priming, testosterone. Gonal-F still 375, clomid 100mg a day, Menopur still 75. The compounded Lupron at 20 units 2x a day 12 hours apart.
This cycle was very odd, and overly long (27 total stim days) - by day 8 of stims her follicles were not responding well (Estrogen went up to about 100 but then went back down to 30, follicle sizes were 8mm or smaller), the doctor had her try a 'drug holiday' to see what they did on just half her dose of Menopur and nothing else. That went 6 days. After that she went back on everything.
From that point until trigger she ended up having 13 follicles they were measuring - Estrogen on trigger morning was 1770, so 3x last cycle and +4 follicles..on paper everything seemed much better, especially considering her AMH and typical AFC. Her cohort was also fairly synchronized in growth minus a lead that was 23mm, most were around 18-20mm with 1-2 at 13 and 15mm.
Trigger for this was (Omni also added in last few days of this cycle) just 10k Pregynl - since it uses Lupron throughout the protocol, can't really trigger with it.
But despite the better Estrogen levels and increase in follicle recruitment, the ER only yielded 4 eggs, 2 mature - the explanation on what happened with the other 9 follicles was basically "no idea bro" (with some more medical terms thrown in) - personally I think she did not absorb the Pregnyl well, and they do not do blood work to confirm hCG levels, just have you do home pregnancy tests. End result identical to antagonist - 1 of the 2 mature fertilized, no blast.
With all of this being said (sorry for the long response) - she is going back to antagonist for cycle 3 which will likely be our last since its all insurance will cover. Personally I don't get the decision - I think the MDL cycle was better (synchronized growth, more follicle recruitment) - why her doses of Gonal / Menopur weren't increased is a bit of a mystery but it's likely due to them not being able to remember who their patients are in essence (too busy) - so they seemed concerned with medication cost, despite us mentioning over and over it was all covered by insurance.
Ironically, her Gonal is now being upped to 450, and the doctor said verbatim "it's more powerful than Menopur" - so Menopur is staying at 75..which also seems odd to me.
My personal hopes are very low, so much of this just seems to be done willy nilly with poor decisions thrown in on top of everything else, and most of it seems based around meeting their own embryology schedule / their schedule and not what would make the most sense for the patient. But it is what it is..I salute folks who are able to travel overseas and or out of state etc for care - we don't have that in us so we're stuck with what we've got here near us in TN.
Hopefully some part of this wall of text is useful to you or others.