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

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How to stimulate your patient for IVF / ICSI

  1. 1. How To Stimulate Your Patients For IVF/ICSI Cycle • Hesham Al-Inany, PhD • kaainih@yahoo.com
  2. 2. IVF Steps • Pituitary desensitisation • COH with gonadotropins; • Triggering with hCG • OPU • Fertilization by IVF or ICSI • Culture embryos • ET • Luteal support
  3. 3. Two Protocols GnRH Antagonist Protocols GnRH Agonist Protocols 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 6 of FSH/HMG Day of hCG Day 1 of FSH/HMG Day 6 of FSH/HMG Day of hCG 7 – 8 days after estimated ovulation Down regulation Day 2 or 3 of menses Day 1 FSH/HMG OCP
  4. 4. Evaluation Before COH • Liver & Kidney function • Basal Ultrasound (AFC) • AMH
  5. 5. Preparation • Basal Ultrasonography • Antral follicle at day 3-5: 8-12 is optimum • Grow 1-3 mm/d
  6. 6.  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 5-6 Start 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.
  7. 7. Lucrin 0.1 • Long luteal phase protocol Day 15 21 281 GnRHa 10-14 day hMG 225-300 IU* Thin endometrial thickness Estradiol < 30 pg/ml Most frequent protocol
  8. 8. Which Gonadotropin? • Human menopausal gonadotropin(hMG) • Purified FSH • Highly purified FSH • Recombinant FSH (r FSH)
  9. 9. Which Gn? Which Dose? • Any type of Gn • If below 28yrs : 150IU • If 28-35yrs: 225IU • >35 yrs : 300IU • >40: 450IU
  10. 10. • Monitoring – Estradiol – Follicle size
  11. 11. Endometrium • endometrial thickness more than 8 mm on day of hCG
  12. 12. How to determine Dose • Aim is to get between 8-12 MII • Between 37.5-600 IU/d • Depends on Age BMI Previous history

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