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  • 1. HCG timing Prof Aboubakr Elnashar Benha university Hospital, EgyptAboubakr Elnashar
  • 2. Ovulation trigger The end point of any ovulation induction protocol is to indentify the best time for triggering ovulation.  Most crucial step Critical timing for HCG administation depends on the criteria for follicular maturity 1. Follicular diameter 2. Serum E2 3. Endometrial thickness  Always time HCG with follicle size Gnt follicles mature at 15-18 mm CC follicles mature at 18-20 mm (Sperof,f 2005) Aboubakr Elnashar
  • 3. HCG ovulation triggers substitute for LH surge seen in spontaneous menstrual cycles Control the timing of ovulation Timing of SI. Timing of IUI Timing of OR HCG has a half-life of about 35 h: support the initial part of the luteal phase. Aboubakr Elnashar
  • 4. HCG similar activity to LH and binds to its receptor.  capable of inducing luteinization and ovulation. Ovulation: 38 to 40 h after HCG injection.  2 types: urinary and recombinant Urinary HCG dose: 5000-10,000 IU, IM. Recombinant HCG: Dose: 250 mcg, SC. similar pharmacokinetics as the u HCG: ovulation is expected following a similar time interval. Aboubakr Elnashar
  • 5. Preparation Trade name Route U.pr Price Company Urinary HCG Pregnyl Profasi IM 95% Organon Serono H.P.HCG Choriomon SC, IM <5% Ibsa Recombinant HCG Ovitrelle Choriogonadotropi n SC - Serono LH Luveris lutotropin SC - Serono Types of HCG Aboubakr Elnashar
  • 6. I. Timing SI  Rationale:  Viable spermatozoa should be present in the female genital system at the time of ovulation.  Sperms retain their fertilizing capacity for 40-80 h, oocyte have life span of 12-24 h after ovulation.  SI  between 2 days before & the day of ovulation: Highest conception rate  On the day after ovulation: conception is zero. ≥24 h after ovulation then oocyte has already degenerated. Aboubakr Elnashar
  • 7. CC: Spontaneous ovulation can be expected when the lead follicles 18-20 mm. HCG trigger: when 1-2 follicle(s) is at a mature size (18-20) It is very important to avoid stimulation of too many mature (or close to mature) follicles because of the OHSS ovulation can be induced with HCG) or (GnRHa). Aboubakr Elnashar
  • 8. Cochrane Database of Systematic Reviews 2013 Evidence is inadequate to recommend or refute the use of u hCG as an ovulation trigger in anovulatory women treated with CC No trials evaluating the use of ovulation triggers in anovulatory women treated with other ovulation-inducing agents. Aboubakr Elnashar
  • 9. II. Timing IUI  IUI should be performed around the moment of ovulation. Since spermatozoa and oocytes have only limited survival times correct timing is essential.  Methods for timing of ovulation: 1. Urinary LH surge: In natural cycles: Follicular rupture occurs 36 h after the onset of serum LH rise. A positive urine result is often found only 12 h after the onset of LH surge in the serum (around the point of serum LH peak). Serum LH surge >25mIU/ml  ovulation must be expected to occur on average as early as 24 h, after a positive urine test. If one adds a fertilizing life span for the ovulated ovum of only 12 h to be on the safe side, IUI 36 h after positive urine test is very satisfactory.Aboubakr Elnashar
  • 10.  Serum LH surge: 12 h Urine LH surge (serum LH peak): 24 h Follicular rupture lunch-time (11.0-15.00) is the best time to check for the LH surge using urine dipsticks and insemination at any time between 18 and 53 h after the onset of the surge will produce optimal results (Khattab et al, 2005). A spontaneous LH surge was noted in a variety of follicular sizes (14 to 35 mm) (Vlahos et al, 2005) Aboubakr Elnashar
  • 11. 2. U/S and HCG triggering a. Follicles: The exogenous HCG mimics the endogenous LH surge & offers the advantages that the onset of LH surge is known precisely. • HCG is given when the leading follicle is 17-20 mm. • HCG should be withheld if > 3 follicles > 16 mm: (Macklon et al, 1999). >4 follicles ≥ 14 mm (Kamrava et al., 1982; Hugues et al., 2006). Aboubakr Elnashar
  • 12. b. Endometrial thickness: <6 mm: No pregnancies 9-10 mm or more: The chance of pregnancy is great (Isaacs et al, 1996). Aboubakr Elnashar
  • 13. 3. E2 peak (pg/ml): <200 pregnancies are rare 500-1500 optimal 1500-2000 risk of OHSS is significant >2000 pg./ml: hCG is not given Cyle is cancelled (Speroff et al, 2006). Aboubakr Elnashar
  • 14. Chochrane. 2010 Cantineau et al No significant differences between different timing methods for IUI expressed as live birth rates: hCG Vs LH surge uhCG Vs rec hCG hCG Vs GnRHa The choice should be based on hospital facilities convenience for the patient medical staff Costs drop-out levels. Since different time intervals between hCG and IUI did not result in different pregnancy rates, a more flexible approach might be allowed. Aboubakr Elnashar
  • 15. 24 0r 36 H after HCG IUI 36 h after hCG has marginally better pregnancy rates than 24 h. Timing of insemination may be kept at 24 or 36 h after hCG injection to suit the convenience of the clinic or care provider. (Rahman et al, 2011) Aboubakr Elnashar
  • 16. HCG 34-36 h before or after IUI HCG after IUI: more closely resembles the fertilization process in natural cycles. PR were 10 and 12 % (P = 0.85), respectively. HCG administration after IUI brought about no improvement in PR. HCG can be administered either before or after IUI. (Firouzabai et al, 2013, Aydin et al, 2013) Aboubakr Elnashar
  • 17. III. Before OR Ovulation occurs 35-42 h after the onset of LH surge which trigers resumption of meiosis inside the oocyte: OR is scheduled for at least 35 h after HCG HCG: 3 or more follicles of size ≥17 mm Aboubakr Elnashar
  • 18. Timing of hCG in IVF/ICSI protocols using GnRH agonist or antagonists: a systematic review and meta-analysis Chen et al, 2014 1295 participants were included. Early Vs 24 –h late HCG The prolongation of follicular phase by delaying hCG administration could increase E2, P levels and oocyte retrieval, which will not influence PR per oocyte pick-up, miscarriage rate and live birth rate. Postponing hCG may enable increased flexibility of cycle scheduling to avoid weekend procedures. Aboubakr Elnashar
  • 19. Devroy et al, 2009 Aboubakr Elnashar
  • 20. Thank You Face book Aboubakr Elnashar Lectures Aboubakr Elnashar

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