Presentation given in 2016 on protocols used for ovarian stimulation when undertaking in vitro fertilization (IVF) for management of infertility when using assisted reproductive technologies.

2. Dr. Anuradha Katragadda
ANU TEST TUBE BABY CENTER

3. IVF REGIMENS
 Different approaches to ovarian
stimulation
 Oocytes collected in Natural and
Stimulated cycles

4. I - IVF BABY
 Birth of Louis Brown – July, 1978
‘Steptoe & Edwards’, the pioneers
of In-Vitro-Fertilization (IVF)
 Result of a single oocyte
retrieved in a natural cycle

10. REVOLUTION / EVOLUTION –
OVARIAN STIMULATION DRUGS
 Ovarian stimulation
 An integral part of ART
 Each phase had -
 Own ‘gold standard’
stimulation
 A large armamentarium of
pharmaceutical agents
 To utilise in treatment
protocols
The initial regimens:
clomiphene citrate.
Urinary gonadotropins were later
added to the ovulation induction
regimen alone or in combination
with clomiphene citrate.
In the late 1980s- early 1990s:
addition of a GnRH agonist to
achieve pituitary modulation.
1990s-
Development of Recombinant
Gonadotrophins, GnRH
antagonists.

11. STIMULATION REGIMENS –
‘WHAT TERMINOLGY’
 ‘International society for mild
approaches in Assisted
Reproduction’(ISMAAR)
Revised definitions & terminology
for natural cycle & different
protocols for stimulation

12. TERMINOLOGY

13. DEFINITIONS

14. MODIFIED / NATURAL CYCLE IVF
 Aim – to collect a naturally selected
single oocyte at the lowest possible cost
LH surge
DF OR
0 10 14 28
Days
0 10 14 28
HMG / FSH
± GnRH-ant.
OR
15 mm
HCG
Days

15. ‘PROS’ & ‘CONS’ OF NATURAL CYCLE IVF
ADVANTAGES : DISADVANTAGES :
• simple
• Less invasive
• Less stressful
• Can be repeated
every month
• No risk of
OHSS
• Higher
cancellation rates
• Lower pregnancy
rates
• Need for
monitoring LH
surge

16. HMG
GnRH ant.
CC
MILD IVF
0 7 14
Days
3
OR
HCG
F – 14 mm
‘ This method is likely to increase and possibly
even replace the current conventional protocol
in future’.

18. ‘WHY-CONVENTIONAL PROTOCOLS’
(to tackle premature LH Surge)
Gonadotropins used to stimulate follicle growth
1
Stimulation of many follicles results in higher E2 levels
2
LH surge occurs before complete follicle maturation
3
Developmental arrest of oocytes and cycle cancellation
4

19. CONVENTIONAL IVF
(GnRH – analogue cycles)
PROTOCOL
i. GnRH-agonist - used for pituitary
downregulation followed by
conventional doses of stimulation with
FSH or HMG
ii. GnRH-antagonist - With conventional
doses & early start of FSH / HMG

21. Schematic graph showing first treatment protocol for IVF

22. GnRH ANALOGUES
Generic Dose
Goserelin 3.6 mg/mth
Buserelin 6.6 mg/6wks
300 mcg tds
Leuprorelin 3.75 mg/mth
1 mg/ml
Triptorelin 3.75 mg/mth
0.1 mg/day
Nafarelin 400 mcg/day

23. GnRH–a PROTOCOLS
FSH / HMG
GnRH agonist
GnRH agonist
HCG
D - 2
D - 21
D - 3
SHORT PROTOCOL
LONG PROTOCOL

24. GnRH – a PROTOCOLS
ML GnRH–a
 Suppression more
prompt
 Fewer cystic
follicles
Flare Protocol
 Shorter duration
 Fewer injections
 Lower gonadotrophin
dose

25. ALTERNATE REGIMENS
 ‘Ultralong’ GnRH-a
 3-6 m. depo-agonist in stage III – IV
endometriosis before IVF
 PR higher
 ‘Mini dose’ GnRH-a
 For poor responders
 Lupron 0.25mg/d followed by 0.1 mg/d
from stimulation
 OC / GnRH-a
 For high responders
 OC for 25 days and 1mg Lupron from last 5
days

26.  Third generation decapeptide
 GnRH agonist with amino acid
modifications at 1,2,3,6 & 10
2 Compounds 2 Regimens
Cetrorelix Flexible
Ganirelix Fixed
GnRH ANTAGONISTS

29. COS - Complications
Multiple Pregnancy
Increased incidence of heterotopic
pregnancies
OHSS

30. ECTOPIC & HETEROTOPIC
PREGNANCIES
 Incidence of ectopic – 1.5 - 2 %
 With Ovulation Induction - 3 %
 With ART - 5 %
 Incidence of Heterotopic Pregnancies –
1 in 30,000
 With Ovulation Induction & ART – 1 %
 Surgical treatment – viable option
 1/3rd spontaneous miscarriages
 A high index of suspicion required

32. OHSS
‘ Loss of control over COH ’
 Only after overstimulated ovaries
‘ exposed to hCG inj ’
C U L P R I T
HMG HCG

33. OVARIAN HYPERSTIMULATION
 An iatrogenic complication
 Significant increase globally
 Incidence of moderate cases ≈ 5 %
 Incidence of cases requiring admission
hospitalization ≈ 2 %
Devastating consequence of OHSS is a serious
threat to life –
3 maternal deaths 100,000

34. BEFORE STIMULATION
PREDICTING RISK PREVENTION STRATEGY
RISK FACTOR THRESHOLD
1. Age < 33 yrs
2. BMI < 19
3. Previous moderate / severe
H/o OHSS & H/o Hospitalization
4. PCO ≥ 12 AF 2-8 mm
diam.
5. High AFC > 14
6. High Basal AMH > 8 mg / ml
1. Exposure to mild stimulation
gonadotrophins low dose protocols
No FSH on
day of hCG
2. GnRH antagonist risk
protocol
3. Metformin / Glucocorticoids

35. DURING STIMULATION
PREDICTING RISK PREVENTION STRATEGY
RISK FACTOR THRESHOLD
1. No. of follicles on > 14 follicles with
day of hCG diam. Of 11mm.
2. Levels & rate of > 3,000 pg / ml
of E2
3. Elevated inhibin levels
on d 5 of gonadotrophins
& 3 d before OPU
1. hCG for trigger requires large RCT
2. Coasting appears to reduce
but does not
eliminate
3. Alternative agents
for trigger GnRH-a
4. Dopamine Agon- reduced incidence
ists
5. Unilateral ovarian
follicular aspiration
6. ‘ cycle cancellation’.

36. OHSS - FUTURE
 Design individualized treatment
protocols
 In-Vitro maturation of oocytes
Artificial ovary
 ‘ Mild ’ stimulation for IVF
 Single embryo transfer (SET)

37. IN-VITRO-MATURATION (IVM)
 Collecting immature oocytes from hormonally
unstimulated or minimally primed
follicles to achieve a live birth
 Immature oocytes are collected from small
antral follicles before spontaneous
ovulation,
Matured in lab. For 24 – 48 hrs. using
culture medium with added small quantities of
hormones. Routine IVF / ICSI
 IVM reduces risks & costs associated with COS

38. IVM - INDICATIONS
 PCOS – most widely used indication
 Young women with high AFC
 Overresponders to Gonadotrophins
 Poor responders
 Empty follicle syndrome
 Oocyte donation
 Fertility preservation

39. CONCLUSIONS - IVM
 Not a competitor of IVF; a
complementary ART
 Simplest & least invasive option
 With further improvements can be
come – ‘Ultimate’ patient-
friendly protocol

40. AN OHSS – FREE CLINIC
Segmentation –
of –
IVF treatment

41. Segmentation of IVF
OHSS can be ‘erased’ by applying ovarian
stimulation using a combination of
GnRH-antagonist with
GnRH-agonist trigger
- freeze all

42. AGONIST - TRIGGER
 Possibility of luteal phase defect
Reduced pregnancy rates
1. Rescue of luteal phase
2. ‘Freeze all’ – a safe alternative

43. THE PATIENT-FRIENDLY
PROTOCOL
Segmentation of IVF –
- Freeze-all &
Frozen embryo cycle
‘The balance between the desire for pregnancy
and patient’s safety is a top priority’.

46. Is antagon protocol-
a universal protocol
NO-ONE-SIZE FITS ALL

48. ENDOMETRIOSIS

49. ENDOMTRIOSIS – IVF PROTOCOLS
 ART most effective therapy
 Inferior outcomes may result from
Decreasing no of retrieved oocytes
Reducted oocyte/embryo quality
Impaired uterine receptivity

50. ENDOMTRIOSIS – IVF PROTOCOLS
 3-6 months of GnRH-a treatment
-increased pregnancy rates
 Risk of pelvic infection
Resulting infected endometrioma or
pelvic abscess necessitate
surgical intervention

51. FERTILITY PRESERVATION
INDICATIONS –
 Cryopreservation of Oocytes / embryos
 Young women with cancer, before chemo /or
Radiotherapy
 Women who wish to circumvent the
advancing age

52. FERTILITY PRESERVATION
Controlled ovarian stimulation (cos) is a
preferred method- higher success rates
CONVENTIONAL PROTOCOL –
 Initiated at beginning of follicular phase
 Requires 2-6 wks. Depending on menstrual phase
May cause significant delay of cancer
treatment
‘potential for increased stress for patient
& physician’

53. RANDOM – START – COS
(FERTILITY PRESERVATION)
‘Stimulation on presentation regardless
of menstrual phase’
COS in follicular / Luteal phase –
i. Initiating Luteolysis followed by COS
with menses
ii. Initiating Luteolysis with
simultaneous COS

54. ESTROGEN SENSITIVE MALIGNANCY –
FERTILITY PRESERVATION
(i.e. endometrial or ER – positive breast ca)
 2.5 – 5 mg Letrozole started with
stimulation & continued until trigger
 Letrozole titrated upto 10 mg/d
depending on E2 levels

55. RANDOM – START COS
Late follicular phase :
i. Before spontaneous LH surge;
i. If follicle cohort following lead follicle < 12 mm. –
start ovarian stimulation with out GnRH – ant.
ii. If follicle cohort ≥ 12 mm – OS with GnRH-ant.
ii. After LH surge ;
GnRH–ant. When secondary follicle cohor reach 12 mm
Periovulatory phase :
- when DF 18 mm; GnRH-a or hcg trigger
stimulation started 2-3 after trigger
Luteal phase :
- ovarian stimulation started in absence of GnRH-ant.

56. FERTILITY PRESERVATION

57. DOUBLE STIMULATION

58. FERTILITY PRESERVATION
 Creates an opportunity to attempt
fertility preservation
 A prompt referral may allow embryo or
oocyte cryopreservation without a
delay in chemotherapy

59. LOW RESERVE

60. POOR RESPONDERS :
Is There Any Thing New ?
 Estimated incidence 9-24 %
 Recent reviews, shows slight increase
 Limitation in quantifying incidence
 Difficulty of a clear definition
 Substantial lack of literature that
identifies an ideal protocol

61. AGE – ‘POR’
 Single most important determinant factor
 Women under 35 yrs - 32.3 %
 35 – 37 yrs - 27.7 %
 38 – 39 yrs - 19 %
 40 – 42 yrs - 11.9 %
 43 – 44 yrs - 4.6 %
 44 + yrs - 4 %

62. DECREASE IN OVARIAN RESERVE
- CAUSES
 Ov. Surgery (especially endometrioma)
 Genetic defects
 Chemotherapy
 Radiotherapy
 Autoimmoune disorders
 Single ovary
 Ch-smoking &
 Unexplained infertility
 Diabetes mellitus Type I
 Transfusion dependent β- Thallasemia

63. ‘THE BOLOGNA ESHRE
CRITERIA’: POOR RESPONDER
 At least 2 of the following criteria:
i. Previous episode of POR (≤ 3 oocytes
with standard dose)
ii. An abnormal ov. Reserve;
 AFC < 5 – 7 follicles
 AMH < 0.5 – 1.1 ng/ml
 Women > 40 yrs. Age or
 Presence of other risk factors for POR

64. IS THERE AN IDEAL
PROTOCOL ?
GONADOTROPINS
 Higher doses of Gonadotropins
 Conflicting data reported
 Recent studies
 Increase of FSH starting dose does not result
in higher PR
 No diff. between starting dose of 300, 450 &
600 IU.

65. GnRH-a PROTOCOLS - POR
 Decrease the length of suppression
 Decreasing duration of GnRH-agonist
Short or ultrashort
Microdose protocols
 To lower or to stop (after pit. Suppression)
the dose of initiated GnRH-a.
 To use GnRH-antagonist
May induce excessive ov. suppression

66. ALTERNATIVE APPROACHES - POR
Addition of estradiol in luteal phase
 Decreases risk of cycle cancellation &
increases chance of preg.
 Luteal E2 priming could improve
synchronization of pool of follicle
available to COS
Addition of Rec. LH
 Recent meta-analysis of 40 RCT –
 Significantly more oocytes with r-hFSH plus r-
hLH vs r-hFSH treatment in POR

67. ALTERNATIVE APPROACHES
 Addition of growth hormone (GH)
 Modulates the action of FSH on
granulosa cells by upregulating local
synthesis of IGF-1
 No recent or robust data suggesting
routine addition

68. ALTERNATIVE APPROACHES
 Addition of Androgens
 Inadequate levels of endogenous androgens –
associated with decreased ov. Sensitivity to FSH
lower PR
 Oral administration of DHEA
 Before ovarian stimulation could improve response
 Recent meta-analysis of 4 RCT
 Significantly higher PR
 Needs large multicentre RCT
 Addition of Aspirin
 No substantial positive effect

69. ALTERNATE APPROACHES - POR
 Natural cycle IVF with or without
minimal stimulation
 Easier & cheaper approach
 50 % cancellation rate
 Contradictory reports

71. POR remains one of the most
challenging tasks in
reproductive medicine.
Oocyte / embryo donation - POR

72. OOCYTE / EMBRYO DONATION
Gamete donation
- The first sperm donor insemination-
Philadelphia, in 1884
- First oocyte donation-
Monash IVF centre, 1983
‘Cross –Border Reproductive care’.
- gametes & embryos moving across borders
- individuals travelling to different countries

74. THE END OF DONOR ANONYMITY
 Genetic testing
 Direct-to-consumer (DTC)
 Formation of large international genetic
geneology databases
 DTC genetic testing- (commercial co.)
 ‘Family tree DNA’-
 Offers Y-DNA matching database
 ‘The 23 and Me’-
 Autosomal DNA test for males & females
-to solve unknown parentage cases

75. END OF DONORY ANONYMITY
 ‘uncovering secrets’
 Donor anonymity not guaranteed
 May drive gamete donation out of business

76. ‘Fertility industry needs a critical self-
analysis to strike an ethical balance
which can allow autonomoUs informed,
decision-making for patients’

77. FUTURE – OVARIAN
STIMULATION PROTOCOLS
 To develop novel treatment protocols to
Reduce risk of OHSS, multiple preg
Improve oocyte & endometrial quality
Reduce emotional stress & financial
burden