This document describes various ovarian stimulation protocols for infertility treatment, including oral medications, injectable medications, and monitoring techniques. It summarizes protocols for natural cycles, mild stimulation, conventional stimulation, antagonist protocols, and protocols for poor responders. Key points include the use of clomiphene citrate, gonadotropins like hMG and rFSH, protocols with and without downregulation, monitoring with ultrasound and hormones, and tailoring the protocol based on ovarian reserve and previous response. The goal is to recruit multiple follicles for retrieval while avoiding overstimulation and maintaining endometrial receptivity.

1. Stimulation Protocols
Prof Dr. Mohammed Hussein

5. Oral medications:
• Clomiphene citrate (clomide)
• Tamoxifene (Nolvadex)
• Cyclophenil
• Aromatase inhibitors
( Femara)

6. Intact
hypothalamic
pituitary ovarian
axis

7. Dose:( Clomid )
• 50- 150 mg/day
• 5-7 days
• Days 2-5 of the cycle.

8. Adjuvant drugs:
• Metformin
• Acetyl cysteine
• Oestrogen
• hMG

9. Advantages:
• cheap
• rare side effects & complications:
blurring of vision
OHSS
Multiple pregnancy

10. Disadvantages:
• Cervical mucous
• Endometrium
• No. of follicles

11. Injections:
Urinary:
hMG
uFSH
Both have LH activity
IM or subcutaneous depending on degree of
purification.
75 IU- 150 IU/ amp.

12. Recombinant:
• rFSH
• No LH activity
• Subcutaneous
• 75,100,150 IU/amp

13. Ovaries with good ovarian reserve
• FSH & E2 cycle day 3
• AFC antral follicle count cycle day 3
• AMH any day
• Ovarian volume

14. Regimens

15. No Down Regulation
• Start day 2-3 of the cycle
• Dose: 75-300 IU/day depending on:
Ovarian reserve
Age
Previous response
PCOs

16. Monitor by:
• TVUS
• Serum E2
Usually
• 8-10 days
• one or more follicle >17 mm
• hCG 10,000 IU
Luteal support:
• No need.
• Or micronized progesterone.

17. Down regulation:
• COH for ART: IUI, IVF, ICSI
• Benefits:
– Prevent premature LH surge.
– Better quality of oocytes.
– Scheduled oocyte pickup.
• Starts at least 5 days before expected date of
menses.( Long Luteal )
• 1st day of menses.( Long Follicular )
• Long acting GnRh agonist
• Short acting GnRh agonist daily dose till hCG day.

18. Down regulation:
• E2<50 pg/ml
• Dose: 225-300 IU/day
• Monitor with TVUS & serum E2
• Adjust the dose: ↑or ↓ after 4- 5 days.
• 3 follicles or more > 17 mm
• Stop agonist
• hCG 10,000 IU
• OPU 34-36 hours after hCG
• IUI 36-48 hours after hCG.
• Luteal Support

20. OOCYTE RETREIVAL

21. 0
10
20
30
40
50
1 4 7 10 13 16 19 22 26
FSH,LH
Days
P
LH
FSH
E2
Selection
Dominance
Ovulation
Corpus Luteum
Recruitment
E2,P

22. Long protocol:
Stimulation day 6
tripple line endometrium 7 mm

23. Long protocol:
Stimulation: day hCG
tripple line endometrium 9 mm

24. Long protocol:
Stimulation: day hCG
early secretory endometrium

25. Long luteal protocol

26. Antagonist protocol:
• Start hMG on day 3 of menses.
• Antagonist when follicle reach 14-15 mm
– Long acting ( single injection )
– Short acting (Daily usually 3-4 injections).
• hCG 10,000 when 3 or more follicles > 17mm
• OPU 34-36 hours
• Luteal Support

27. Antagonist protocol

28. Short Protocol( Flare up )
• Agonist 2nd day
• hMG 3rd day
• Usually 9 – 10 days
• 3 0r more follicles > 17 mm
• hCG 10,000
• Luteal Support.

29. Short ( flare up ) protocol

30. Poor Responders
• 3 or less follicles
• What to do?
1- short protocol (flare up protocol)
2- Antagonist protocol.
3- No down regulation
4- COCpills + short protocol
5- Comiphene citrate

31. Protocol for poor responders

32. 4- Adjuvant treatment:
• Growth hormone
• Combined oral contraceptive pills
• Clomiphene citrate.

33. Ovarian HyperStimulation
Syndrome:
• Pridection
History
PCOS
High AMH

34. During monitoring:
–E2 > 4000 pg/ml
–No of follicles.

35. What to do:
–Soft protocols.
–Coasting
–Metformine
–Cabergolin
–Antagonists
–Cancellation (no hCG)
–No ET

36. • Ultra short, highly economic and effective
protocol for ICSI patients.
• El Deeb M.W, Sami S, Sallam A, Ismail E,
Mohsen E, Darwish Y, El Sharaki A.
• INTEGRATED FERTILITY CENTER,
ALEXANDRIA, EGYPT.

37. • Keeping things simple without altering success rate
of ICSI is the idea behind our novel protocol. This
simple protocol aims to reduce the burden of ICSI
procedures and its related complications, thereby
giving a couple the chances to conceive using
procedures less costly in terms of physical,
emotional, social and financial costs. We had 65
cases underwent ICSI, their age ranges from (23-47)
years. Clomiphene citrate (CC ),3 tablets daily
started from the second day of the cycle for 5 days,
In the last day of CC administration HMG was
given in the form of 2 amps of Menegon 75
(Ferring) or Merional 75 (Ibsa) + 2 amps of Gonal F
75 ( Merck Serono) , till we reach one or more
follicles > 16 mm. E2 is measured. Next day early
morning one amp. Of Cetroide 0.25 mg. and the full
HMG dose was received… HCG 10,000 was
administrated when one or more follicles > 18 m.m
as usual.

38. • Average number of oocytes retrieved
ranges from (2-25) oocytes, number of
embryos transferred (ET) ranges from (1-
5) embryos, only one case had no ET. We
had 25 pregnant cases 38.4 % five of them
had blastocyst transfer. These
encouraging results of this highly
economic protocol should be put in
consideration as a simple and successful
ICSI protocol.

39. Thanks for your attention