it is important to know to basics of controlled ovarian hyperstimulation for IVF patients

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

10. • Monitoring
– Estradiol
– Follicle size

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