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How To Stimulate Your Patients For
IVF/ICSI Cycle
• Hesham Al-Inany, PhD
• kaainih@yahoo.com
IVF Steps
• Pituitary desensitisation
• COH with gonadotropins;
• Triggering with hCG
• OPU
• Fertilization by IVF or ICSI
• Culture embryos
• ET
• Luteal support
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
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 5-6
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.
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
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
BMI
Previous history

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How to stimulate your patient for IVF / ICSI

  • 1. How To Stimulate Your Patients For IVF/ICSI Cycle • Hesham Al-Inany, PhD • kaainih@yahoo.com
  • 2. IVF Steps • Pituitary desensitisation • COH with gonadotropins; • Triggering with hCG • OPU • Fertilization by IVF or ICSI • Culture embryos • ET • Luteal support
  • 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. Evaluation Before COH • Liver & Kidney function • Basal Ultrasound (AFC) • AMH
  • 5. Preparation • Basal Ultrasonography • Antral follicle at day 3-5: 8-12 is optimum • Grow 1-3 mm/d
  • 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. 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. Which Gonadotropin? • Human menopausal gonadotropin(hMG) • Purified FSH • Highly purified FSH • Recombinant FSH (r FSH)
  • 9. Which Gn? Which Dose? • Any type of Gn • If below 28yrs : 150IU • If 28-35yrs: 225IU • >35 yrs : 300IU • >40: 450IU
  • 11. Endometrium • endometrial thickness more than 8 mm on day of hCG
  • 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