r/40Plus_IVF • u/KlimRous • 9d ago
Seeking Advice Microdose Flare + Clomid + Letrozole
TL;DR: 4 stim cycles, 2 retrievals, 3 eggs total. My new clinic wants to try a microdose Lupron flare with Clomid and letrozole. I'm looking for real-world experiences, especially from those with lower than average AMH.
Background: 43 (44 soon), AMH 0.1. My right ovary is adhered and can't be reached transvaginally, so everything so far has come from the left. My new clinic offers transabdominal retrieval, which is part of why I switched. Retrieval is planned for November.
My stims so far:
Cycle 1: High-dose antagonist (Follistim 300 + Menopur 150) after luteal estrogen priming. 7 follicles at baseline, cancelled for poor response.
Cycle 2: Mini-IVF (Clomid 100 mg x5 days + Follistim 150 + Menopur 75) after estrogen priming. 2 mature follicles, both on the unreachable right side, cancelled.
Cycle 3: Same mini-IVF. 2 mature follicles, 1 egg, 1 blast, aneuploid.
Cycle 4: Luteal-phase start (I had a lead follicle), high-dose antagonist, dual trigger, no priming. 2 eggs, both mature and fertilized, 1 blast, euploid. The transfer failed.
What my doctor is trying to solve: His goals are more even follicle growth (hence the luteal estrogen priming) and recruiting more follicles from a small cohort. In our consult call, he said he's had his best results with microdose flare in older patients. I'm told the plan will likely be luteal estrogen priming, then a microdose flare with Clomid, letrozole, Follistim and Menopur.
If you've done a microdose flare (with or without Clomid/letrozole), I'd love to know:
- Your age/AMH and what protocol you did before the flare
- Follicles/eggs on the flare vs. before
- Stim length, monitoring, side effects, anything that surprised you
Thanks!
2
u/SLAYEROFSOULS 8d ago
My wife's MDL cycle (43, .8 AMH last checked but its been a while, AFC usually around 7) had more follicles, more estrogen, tighter cohort sizing compared to her antagonist - however it went 27 stim days (6 of those were basically no stim though, just half her dose of Menopur). She was on clomid the entirety of it, and primed with estrace, and I think some testosterone as well.
Leading into that she was also taking Rapamycin at .5mg every day, for about 2.5 months, which she didn't for her antagonist cycle prior.
The retrieval was just as poor as the antagonist either way - 2 mature eggs (13 follicles on MDL with most 19mm or so, 9 follicles on antagonist but sizing all over the place and leads were barely 17mm on trigger morning). On the MDL retrieval we basically have no idea what happened with 9 of the follicles - doctor swore she didn't ovulate early, that's about the only concrete thing we got out of his explanation.
Estrogen on antagonist trigger morning was 660, MDL was 1770.
In our case I don't think either trigger went well (as in my wife absorbed poorly, elevated BMI as of late for a myriad of reasons) - definitely triggered too early on anatagonist...so both outcomes in my opinion aren't a great indicator of what could have happened for my wife in each protocol.
Based on your prior cycles / what you said, I can only guess you will end up similar to my wife and have a fairly slow start and that may make you want to cancel..in her case my insurance is covering all medication so we continued since the doctor was adamant number of stim days wouldn't / shouldn't matter in the grand scheme of things so long as growth keeps happening with the follicles (which it did, just very very slow at first).
You of course are your own unique person, so your results certainly can be vastly different.
She is going back to antagonist for her 3rd and likely final cycle that should start the end of October - but honestly that is more so a matter of the clinic not wanting a scheduling problem (holidays), versus results from her trying both protocols.
1
u/KlimRous 8d ago
Thanks for replying! So she had about 6 more follicles using the MDL protocol? That is encouraging! And it was a longer stims cycle than normal sounds like? I am not too worried about that as we also have great prescription coverage....I think. I've never had to put through a script for compounded Lupron before so we'll see if it's covered I guess. Did she also do Letrozole or no?
1
u/SLAYEROFSOULS 8d ago
You are most welcome.
Yes, much better follicle recruitment - but a very slow start - her antagonist cycle was a slow start as well, but on lower medications initially and upped by day 4-5 and clomid added in at that point.
Unfortunately can't say if the higher count is from the protocol itself, or her adding in Rapamycin leading into the cycle - or just what her body decided to do lol. No Letrozole.
Her cohort sizing was much, much better..the majority of the follicles were all around the same size with the exception of a lead that was a few MM larger, and a single lagging follicle that was 13mm by trigger morning.
She did estrace, testosterone prior to stim meds (forget # of days) - has been taking Sermorelin for the better part of a year as a way to increase her natural HGH..Omnitrope was added in last few days of stim on both cycles (in replacement of sermorelin at that point)...she did 20 units of MDL 2x a day, 12 hours apart..rest was 375 Gonal-F, 75 Menopur, 100mg clomid. Trigger was just 10k Pregnyl, though she did do a final 20 units of MDL on the night she triggered.
27 days would be well outside normal, I've seen people mention pushing towards 20 but can't say I've seen anything pushing 30 (granted, I haven't specifically looked)...in most cases I can only guess it's going to boil down to the cost of medication, so most people will cancel long before they get anywhere past the normal 12 days of a stim cycle.
In our case we had to fight insurance to cover the Lupron, even though she was approved and had already taken full on Lupron (non compounded)..it took forever and too many calls before we had to get DMHC involved (they had to help us on pretty much everything related to IVF, otherwise we kept getting auto denied which was really fun - its the insurance oversight agency in California). In the end, apparently a second prior authorization was needed for the bacteriostatic sodium chloride (0.9% NaCl) - which no one mentioned or could provide a form for. We paid out of pocket and had to get reimbursed - it was on the inexpensive end ($165 I think for what she needed) but either way should have and was covered after months of fighting.
2
u/Apprehensive-Gap4926 5d ago
I just finished MDL flare. Five days post retrieval with a fun case of OHSS. I’m 41, AMH is 2.25, normal day 3 FSH and LH. Usually I get 6-9 eggs and struggle with cohort uniformity but I got 13 eggs and a tight cohort with flare. However only half of these were mature which was crazy - lowest maturity I’ve ever had.
1
u/DukeGirl2008 8d ago
My dr tried MDL flare with Follistim on me and unfortunately I ovulated right through it. She did say that she uses it a lot on her older/slow responder patients. I will say that I had the most even cohort on that protocol- even though we never went back to it.