2014: How to stimulate your patient for IVF / ICSI
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it is important to know to basics of controlled ovarian hyperstimulation for IVF patients
Transcript of 2014: How to stimulate your patient for IVF / ICSI
IVF Steps• Pituitary desensitisation
• COH with gonadotropins;• Triggering with hCG• OPU• Fertilization by IVF or ICSI• Culture embryos• ET• Luteal support
Two ProtocolsGnRH AntagonistProtocols
GnRH AgonistProtocols
225 IU per day(150 IU Europe) Individualized Dosing of FSH/HMG
250 mg per day antagonist
Individualized Dosing of FSH/HMG
GnRHa 1.0 mg per day up to 21 days 0.5 mg per day of GnRHa
225 IU per day(150 IU Europe)
Day 6of FSH/HMG
Dayof hCG
Day 1 of FSH/HMG
Day 6of FSH/HMG
Dayof hCG
7 – 8 daysafter estimated ovulation
Down regulation
Day 2 or 3of menses
Day 1 FSH/HMG
OCP
Evaluation Before COH
• Liver & Kidney function• Basal Ultrasound (AFC)• AMH
Preparation
• Basal Ultrasonography• Antral follicle at day 3-5: 8-12 is optimum• Grow 1-3 mm/d
No OCP pretreatment Check patient cycle day 2 FSH 100-225 IU Antagonist earlier than later LH not necessary
Suggested GnRH Antagonist Protocol
Cycle day 2 Transvaginal US +
(if desired) hormonal profile
This suggested protocol represents a “best estimate” given current data and clinical experience. Further data are required before more
concrete recommendations can be made.
For regular IVF patients: 5-9 antral follicles per
ovary Age <35 years No PCOS No history of poor
responses No endometriosis
Duration of treatment based on clinical judgment in consultation with patient (usually 2 USs)
Cycle day 2/3 Start FSH 150-200 IU. Continue
Stimulation days 5-6Start GnRH antagonist
administered daily. Continue
Monitoring according to clinic practice US (+ blood test if required) FSH dose adjustments may be considered
3 follicles 17-20 mm
Day of triggering Ensure interval between antagonist and hCG does not exceed 30 h hCG 5000-10,000 IU
Oocyte retrieval
36 h
YES
NO
US = ultrasonogram; OCP = oral contraceptive pill. Devroey et al. Hum Reprod. 2009;24:764.
Lucrin 0.1
• Long luteal phase protocol
Day 15 21 281
GnRHa
10-14 day
hMG 225-300 IU*
Thin endometrial thicknessEstradiol < 30 pg/ml
Most frequent protocol
Which Gonadotropin?
• Human menopausal gonadotropin(hMG)• Purified FSH• Highly purified FSH• Recombinant FSH (r FSH)
Which Gn? Which Dose?
• Any type of Gn• If below 28yrs : 150IU• If 28-35yrs: 225IU• >35 yrs : 300IU• >40: 450IU
• Monitoring – Estradiol– Follicle size
Endometrium
• endometrial thickness more than 8 mm on day of hCG
How to determine Dose
• Aim is to get between 8-12 MII
• Between 37.5-600 IU/d• Depends on Age
BMIPrevious history
