The Femara-Antagonist Protocol can be the last option for patients with extremely low egg reserve.
This is a protocol for patients who had failed to respond to all previous protocols due to extremely low egg reserve (AMH of < 0.3 ng/ml but with at least 3 antral follicles). In this protocol, there is no pre-treatment cycle. As soon as the baseline sonogram shows at least 3 antral follicles, ovarian stimulation begins immediately using a combination of Femara and high dose gonadotropins (FSH and HMG). Femara indirectly induces pituitary of FSH and LH release by blocking the synthesis of E2. The combination of pituitary and medication LH and FSH provides very potent ovarian stimulation. After 5-6 days of stimulation, an antagonist is added to prevent ovulation until the day of HCG trigger.
The disadvantage of this protocol is the delayed endometrial growth caused by 5 days of Femara but this effect can be overcome quickly with vaginal estrogen supplementation on the last day of Femara.
Another disadvantage is the lack of flexibility in cycle planning as there is no way to plan ahead the start of ovarian stimulation. However, for a patient who desires a last chance to use her own eggs, this protocol gives her a final opportunity before closure and moving on to donor eggs.