IVF stimulatiion protocol

1. Protocols in ART
(Long Agonist and
Antagonist)
Dr Payal Agrawal

2. Concept
Initial studies: Premature LH peak used to occur in 20-
50% of the cycle due to positive feedback activity by high
serum E2 level

3. 5-20%
Premature LH surge
• Poor quality
• No fertilization or very poor pregnancy rate
• Cancel egg retrieval
So to compensate for changes induced by stimulation, GnRH analogue
cotreatment is usually added.

4. GnRH
Agonist
GnRH
Antagonist
GnRh
Anlogues

5. Agonist protocol in ART

6. Mechanism of action

7. GnRH agonist
.
‘Flare effect’
‘Down regulation’

8. • Within 12 hrs of administration Upregulation
Liberation of FSH and LH , and also increase in the no. of
receptors
(5 fold increase in FSH,10 fold increase in LH,and 4 fold increase in
estradiol)
• Continuous delivery Downregulation
Supression of the gonadotropic pitutary function and desensitsation
of the receptor

9. Action of GnRH agonists
LH + FSH
post-receptor-cascade
GnRH - receptor
GnRH
GnRH - agonist
flare up effect
Down
regulation
pituitary suppression

10. Structure of GnRH agonists
Modifications of natural GnRH
to have GnRH agonistic properties
1 2 4
3 6
5 9
8 10
7
Pyro (Glu) – His – Trp – Ser – Tyr – Gly – Leu – Arg – Pro – Gly – NH2
Activation of the
GnRH receptor
Regulation
of GnRH
receptor
affinity
Regulation of
biologic activity

11. Advantages
• Prevents premature LH rise decreases cycle cancellation
• Synchronizes follicular development
• Decreases intrafollicular androgen concentration  decreasing
atresia  higher no of follicles obtained (filicori et al)
• Helps in programming ovum pickups

12. Disadvantages
1.Formation of cysts
• Initial transient flare up effect of the GnRH agonist on gonadotropins
• Direct effect of GnRH agonist on the ovaries and steroidogenesis
2.Long duration of t/t
3. Direct inhibition of ovarian steroidogenesis
(Dor 2000)

13. Various preparations and routes
Generic
name
Trade name Half life Relative
potency
Route Recommended
dose
Nonapeptides
Leuprolide Lupron 90 min 50-80
20-30
SC
IM depot
500-1000mcg/day
3.75-7.5mg/mth
Buserelin Suerfact 80min 20-40 SC
Intranasal
200-500mcg
300-400*3-4/day
Histerelin Supprelin <60min 100 SC 100mcg/day
Goserelin Zoladex 4.5hr 50-100 SC Implant 3.6mg/month
Decapeptides
Naferelin Synarel 3-4 Hr 200 Intranasal 200-400*2/day
Triptorelin Decapeptyl 3-4.2 Hr 36-144 SC
IM depot
100-500mcg/day
3.75mg/day

14. Issues with use of GnRH Agonist
• Best route of administration???
• Which agonist should be used???
• Optimal scheme???
• Otimal dose???

15. Various routes
• Nasal sprays
• Intramuscular
• Subcutaneous

16. Nasal sprays
• Require 2-4 administrations per day to maintain effective drug
concentration
•Unpredictable absorption
•Fluctuating desensitization level due to considerable losses of the
peptide occur by proteolysis and swallowing
Various routes…..

17. Subcutaneous daily injections
•Once daily
•Most stable effect deserve preference
•Rapid absorption and elevated blood concentrations for many hours
Various routes…..

18. Intramuscular depot preparation
•Long duration of action not first choice of treatment in ART
Various routes…..
•Disadvantage:
– Longer stimulation phase
– More ampules needed
– Lower implantaion and delivery rates

19. Optimal Scheme and Dose

20. Various agonist protocol
• Three main protocols
1. Ultrashort
2. Short and
3. Long protocol

21. Various types of long protocols
TYPE Day of adm duration advantage disadvantage
Long follicular D2 till hcg
adm
28-35 Program
Good PR
Long duration
Long luteal D21 till
HCG adm
21-28 same same
Long
follicular(depot)
D2 once Patient
comfort
Too long
duration
Long
luteal(depot)
D21 once Patient
comfort
Too long
duration
Ultra long D2 or D21 8-12 weeks Special cases Estrogen
deficiency

22. Long Luteal Protocol
• D2-D5 of the previous
cycle start oc pills
• D18-21 of the same cycle 
start GNRH agonist for 12 to
14 days
• Pituitary desensitisation
usually takes 2-3 weeks

23. Stimulation
• CHECK
Adequate desensitization
Endometrium<5 mm
No functional cysts
• DOSE
Age, BMI, AMH, AFC,
previous response to stimulation
• Dose of agonist reduced to half
and contined till day of OCR

24. When to start ????
Luteal phase Vs follicular phase
• Live birth rate
• Clinical pregnancy rate
• Cycle cancellation rate
• No of oocytes retrieved
• Gonadotrophin dose
Kondaveeti gordan 1996,
Pellicer 1989,
Ron –El 1990
Increased
requirement in
lplp
No difference

28. Same dose vs reduced dose?
• Clinical pregnancy rate
• No of oocytes
• Gonadotrophin dose
• Cycle cancellation rate
Simon 1994,
Fabregues 2005
Dal Prato 2001
No difference

29. Effect of reduced of triptorelin at the start of ovarian stimulation on
the outcome of IVF: randomized study
Aim: to investigate the effect of reduced daily dose of triptorelin,
at the start of ovarian stimulation, on the results of IVF and ICSI
L.Dal Prato et al, Hum reprod,16:7,1409-1414,2001
Group 1:
•66 pts
•3.75mg of triptorelin
Group 2:
• 66 pts
•100 mcg of
triptorelin
• Reduced to 50 mcg
at the start of
stimulation

30. Group 1 Group 2
Pregnancy rate 38% 34.9% NS
Implantation rate 20.2% 18% NS
Abortion rate 8.3% 9.1% NS
FSH Amp 46.6+/-25.3 41+/-26 P<0.003
Days of stimulation 11+/-1.3 11.8+/-1.5 P<0.005
Conclusion: Reduced dose of triptorelin is sufficient for pitutary desensitization during
ovarian stimulation. The possibility of shorter treatment protocol with lower amount of
gonadotropins should be considered in view if its economic advantages

31. GnRh agonist dose dependency of Pitutary
desensitization during COH in IVF
Janssens et al, Hum Reprod,13;9,2386-91,1998
Study design: RCT double blind
Study population:
48 ivf pts  devided into four group as per dose of triptorelin,
5mcg,15mcg,50mcg,100mcg
Conclusion: Daily dose of 100 mcg appears to be too high, since
adequate pitutary desensitisation can be achieved with doses as
low as 15mcg and 50mcg

32. Continued Vs stop protocol
• Clinical pregnancy rate
• Ongoing pregnancy rate
• Cycle cancellation rate
• No of oocytes
• Gonadotrophin dose
Dirnfeld 1999
Garcia- Velasco 2000
Simons 2005
No difference

33. Early cessation of triptorelin in in vitro fertilization: a
double-blind, randomized study
Arnold H.M.Simon et al,fertil Steril 2005;83:889 –96
• Double-blind, randomized, multicenter study
• N : 178 patients divided into three groups
• Midluteally started triptorelin administration was continued
Group S : until the first day of hMG treatment
Group M : up to and including the fourth day of hMG treatment
Group L : the day of hCG injection

34. •Early cessation of triptorelin on day 1 of hMG treatment in a
midluteally started IVF protocol is as effective as the traditional long
protocol in preventing a premature LH surge and results in similar
fertility effects

35. Depot Versus Daily
Administration

37. Why this review
• Advantage of depot preparartion:
Single dose  More comfortable
• Disadvantages of depot preparation
– More intense corpus luteum inhibition  increasing miscarriage rates
(Herman 1992)
– More gonadotrophin for ovarian stimulation (Vauthier 1989)
– Lower estradiol levels and lower cleavage rates of preembryos

38. GnRHa depot versus GnRHa daily injection
Outcome: Live birth/ongoing pregnancy rate per woman

39. Depot versus daily injections
• Live birth rate
• Clinical pregnancy rate
• Miscarriage rate
• OHSS incidence
No statistically
significant
difference

40. Number of gonadotropin (FSH) units employed
• More gonadotrophin units
needed
(SMD 0.26
95% CI 0.08 to 0.43)
Significant heterogeneity in
comparison
Eleven studies
Dada 1999
Dal Prato 2001
Ferrari 2004
Gianaroli 1994
Harrison 1994
Hsieh 2008
Isikoglu 2007
Safdarian 2007
Tapanainen 1993
Tehraninejad 2010
Tsai 1995

41. Number of days of gonadotrophin treatment
• Significantly longer duration of
ovarian stimulation
(MD 0.66
95% CI 0.41 to 0.92)
Statistically significant heterogeneity
in this comparison
Six studies
Dada 1999
Dal Prato 2001
Ferrari 2004
Gianaroli 1994
Harrison 1994
Tapanainen 1993

42. Which Agonist to be used???

43. • Total 60 patients
• Analogue started in follicular phase
Group A
n: 20
Drug : Buserelin
acetate
Dose: 0.5 mg daily,
s.c.
Group B
n : 20
Drug :Nafarelin
Dose :100 mg 8-hourly
Intranasal spray
Group C
n : 20
Drug: depot injection
of leuprorelin acetate
Dose: 3.75 mg single
dose, S.C.

46. However, after 3 weeks there was no significant difference between the three analogues
Leuprorelin, nafarelin and buserelin are equally effective in pituitary suppression,
ovarian stimulation and IVF outcome
Satisfactory suppression with nafarelin and leuprorelin occurred after 2
weeks, buserelin required an additional week to achieve equivalent results

47. Formation of Cysts

48. How cyst affect IVF outcome???
Passive diffusion of E2 from the cyst into the circulation 
increased serum levels of E2 level
Imperfect pituitary suppression of bioactive gonadotropins, with
subsequent effects on oocyte quality and implantation (Penzias et al.,
1994)
• Mechanical reduction of the space for growing follicles or by
impairing the ovarian blood supply
(Fiszbajn et al., 2000)

49. • METHODS: A prospective study
• N : 1317 IVF patients who developed one or more functional
ovarian cysts of 15 mm following GnRH agonist treatment was
performed
• RESULTS: The incidence of follicular cyst formation was 9.3%.

51. Management of Cyst

52. • Objective: To assess the effect of pretreatment with an oral contraceptive (OC) on ovarian
cyst formation during pituitary suppression with buserelin acetate.
• Design: Prospective randomized trial.
• Patient(s): 83 patients who were undergoing IVF-ET treatment.
• Intervention(s):
Study group
•Pretreated with an OC for
14 days on D1 of
menstruation.
• SC buserelin acetate
initiated on the last day of
OC administration
Control group
• Buserelin acetate on day 2
of menstruation

53. Conclusion(s):
•Pretreatment with an OC abolishes ovarian cyst formation
•Shortens the time required to achieve pituitary suppression
•Decreases gonadotropin requirements

54. Progestogen pretreatment
Statistically significant less ovarian cyst formation in the group pre-
treated with a progestogen
OR 0.21; 95% CI 0.12 to 0.35, P < 0.00001

55. Antagonist protocol in ART

56. Colin M Howles et al,Vol 4. Suppl. 3. 64–71, Reproductive BioMedicine Online;
March 2002
Promising alternative to the long-established GnRH agonist regimens for
prevention of a premature LH surge

57. Mechanism of action

58. Action of GnRH antagonists
LH + FSH
post-receptor-cascade
GnRH - receptor
GnRH
GnRH - antagonist
pituitary suppression

59. Comparison: mode of actions

60. Outline
• Advantages
• Protocol: Fixed Vs Flexible
• Single dose Vs Multiple dose
• Cetrorelix Vs Ganirelix
• Dose increament of gonadotropin at the start of antagonist
• Trigger (Hcg Vs GnRh Agonist)
• Cycle schedulling

61. Advantages of antagonist
• Avoids the initial ‘flare-up’ of LH
• Shortens the overall treatment period (which in turn has possible cost
implications)
• Not associated with hypo- estrogenemia
• Reduced risk of OHSS( 54% reduction in risk compared to agonist)
• Reduced distress due to shorter protocol
Colin M HowlesVol 4. Suppl. 3. 64–71 Reproductive BioMedicine Online; March 2002

62. Preparations available
Colin M HowlesVol 4. Suppl. 3. 64–71 Reproductive BioMedicine Online; March 2002

63. Optimal scheme and Protocol

64. Human Reproduction, Vol.24, No.4 pp. 764–774, 2009

65. Multiple Vs Single daily dose

66. Multiple daily dose
• Available for cetrorelix and
ganirelix
• Minimal effective dose in
multiple dose protocol- 0.25 mg
Single dose
• Available for cetrorelix
• The single-dose protocol
(cetrorelix, 3 mg) prevets
premature LH surge for about 3 - 4
days
• If more days of stimulation needed
beyond 72 hours, then daily
0.25mg till HCG is introduced

67. Multiple dose
Single dose

68. Tsung-Hsien Lee et al,2005
Fertil Steril 2005;83:1700 –7
The MD and SD GnRH antagonist protocols were effective for
preventing LH surge and appear to elicit an equivalent pregnancy
rate to that corresponding to a LP GnRH agonist

69. When to start antagonist????

70. Fixed Vs Flexible dose

71. Fixed protocol:
Antagonist started on D6 of
stimulation
Flexible protocol
Antagonist started when
•Lead follicle size of 14-15 mm
size
•E2 level : 400 -500 pg/ml

72. Fixed group
• N – 102
• Daily 0.25mg GnRH
antagonist ganirelix
(Orgalutran) from the 6th
day of stimulation onward
Flexible group
• N – 103
• Daily 0.25mg GnRH
antagonist starting on the
day that the dominant
follicle had reached a
diameter of $15mm

73. Fixed versus flexible

74. Fixed group
• GnRH antagonist cetrorelix
(0.25 mg/d) started either on
day 6 of stimulation
Flexible group
• LH was >10 IU/L,
• Follicle with mean diameter
>12 mm was present
• Serum E2 was >150 pg/mL
Fertil Steril 2011;95:558–62.

76. Conclusion(s): Flexible antagonist administration from day 3 onward does not appear to
reduce the incidence of LH rises compared with fixed antagonist administration on day
6 of stimulation.

77. • Antagonist administration was initiated according to at least one of the
following patient-specific criteria:
(i) At least one follicle measuring >14mm
(ii) Estradiol levels >600 pg/ml
(iii) LH levels >10 IU/l
Group D6:
n - 70
Group D5:
n - 98
Group D4:
n – 40

79. Delayed start of GnRH antagonist  relatively high LH concentrations
negative effect on pregnancy rate, through prolongation of oestradiol/LH
exposure to the endometrium

80. Fertil Steril 2013;100:867–74

81. Early initiation of GnRH-a cotreatment  more stable endocrine profile, with more
physiological levels of E2 and LH during the follicular phase
The effect on clinical outcomes must be established in larger trials

84. Early initiation of GnRH antagonist treatment does not improve clinical outcomes of
IVF treatment compared with midfollicular initiation of GnRH antagonist.
The currently used GnRH antagonist protocol starting on CD 6 remains the best choice
at present

85. N: 60 women divided into two groups

86. Administration of GnRH antagonist on d 1 (compared with d 6) of
stimulation is associated with a lower exposure to LH and estradiol,
which does not seem to affect follicular development

87. Luteal Antagonist

88. GnRH antagonists
• Luteolysis
• Prevent FSH rise

89. Luteal phase estradiol versus luteal phase estradiol and
antagonist protocol for controlled ovarian stimulation
before in vitro fertilization in poor responders
Elassar et al,Fertil Steril 2011;95:324–6.
Synchronization of follicular growth in the luteal phase using E2 and a GnRH
antagonist is not superior to E2 alone in low responders undergoing ovarian
stimulation before IVF
.

90. Cetrorelix Vs Ganirelix
• N: 185 patients
• No statistically significant differences between treatments for any
IVF/intracytoplasmic sperm injection (ICSI) or ET outcomes, including
pregnancy rate (PR).
• Cetrorelix required significantly fewer injections than ganirelix.
John Wilcox, M.D.,et al, Fertility and Sterility Vol. 84, No. 1, July 2005

91. Whether to increase the dose of
gonadotropins???

92. N : 30
Dose 150–300 IU of
rFSH
Step-up group:
N: 30
An additional 75 IU of
rFSH after starting a
GnRH antagonist
Fertil Steril 2006;86:58–63

93. Increasing the dose of rFSH after starting a GnRH antagonist does not
alter the estradiol response or improve the implantation and pregnancy
rates.

94. Trigger

95. • .
Oocyte maturation triggering is the final differentiation process of an immature female
egg cell before fertilisation, either in normal or stimulated ovarian cycles in assisted
reproductive techniques
There are two hormones:
Human chorionic gonadotropin (HCG) (Standard treatment)
Gonadotropin-releasing hormone agonist (GnRH agonist)
It is like the final ripening of a seed or the attainment of full functional capacity by a
cell

96. Criteria for trigger
• The physiologically ideal criteria for administration of hCG in
GnRH antagonist IVF cycles has not been conclusively
determined.
• In most studies, hCG is administered when ≥3 follicles ≥17 mm are
present
Borm and Mannaerts, 2000
Fluker et al., 2001
Kolibianakis et al.,2002

97. Delay of trigger
K.P. Tremellen et al,Human Reproduction, Vol.25, No.5 pp.
1219–1224, 2010

98. Conclusion: It is possible to safely avoid weekend ORs during GnRH
antagonist cycles by simply advancing and delaying without adversely
impacting on IVF live birth outcomes

99. HCG Vs GnRH Agonist

100. • Standard triggering agent : HCG
Sustained luteotrophic effect  increased chances of
OHSS
(Cerrillo 2009),

101. • Gonadotropin-releasing hormone (GnRH) antagonist protocols
allow the use of GnRH agonists for triggering final oocyte
maturation
• Due to the specific mode of action of the antagonist, the pituitary
remains responsive to a GnRH agonist
(Felberbaum 1995; Orvieto 2006)

102. Advantages
• Reduce the risk of OHSS due to quick and irreversible
luteolysis
(Kol 2004)
• More physiologic LH and FSH surge resulting in better
oocyte and embryo quality
(Humaidan 2005)
• May improve endometrial quality due to lower luteal phase
steroid levels
(Forman 1998; Simon 1998)

103. A total of 122 normogonadotrophic patients following a flexible
antagonist protocol

105. .
The poor results were attributed to a luteal phase insufficiency despite
standard luteal phase support (LPS) with progesterone and estradiol

106. GnRH agonist versus HCG for oocyte maturation triggering,
outcome: Live birth rate per women randomized

107. GnRH agonist Vs HCG for oocyte maturation triggering,
outcome: OHSS incidence per women randomised

108. Analysis according to the regimen of luteal phase support, outcom
Ongoing pregnancy rate

109. Conclusion
Recommended that GnRH agonists should not be routinely used due to
significantly lower live birth rate, ongoing pregnancy rate and higher
early miscarriage
Only indication to use GnRH agonists as the final oocyte maturation
trigger may be in women with a high risk of OHSS

110. Scheduling

111. • Antagonist protocol : the absence of synchronization of the
follicular cohort  slight reduction in the number of retrieved
oocytes
(Al-Inany and Aboulghar, 2002)
• Hence - attention to the potential interest of steroid pre-
treatments to program cycles and therefore to synchronize the
follicular cohort before stimulation

112. • Two issues :
1. Negative control exerted by steroid administration on the
endogenous gonadotrophin secretion.
2. Timing and intensity of the gonadotrophin secretory rebound that
usually follows pre-treatment discontinuation

113. • BACKGROUND: This prospective study assessed hormonal and ultrasound data
collected during the free period after the discontinuation of three different pre-
treatments to provide information on the optimal time interval required before
starting stimulation.

116. According to our results, a 5- day wash-out period seems to be optimal
for patients pretreated with progestogens and OCP, whereas FSH
stimulation should be started early, 1 or 2 days after stopping natural
estrogen pre-treatment

117. Fertil Steril 2011;96:590–3.
N: 115 patients
Ocp for 14-16 days
Stimulation after 5
days of ocp
N : 113 patients
Luteal phase triptorelin
from luteal phase of
previous cyclefrom day
20

118. Conclusion: Comparable outcomes can be obtained using OCP
containing 0.030 ethinyl E2/0.15 desogestrel to schedule patients
undergoing the antagonist protocol

119. .
• No significant difference in ongoing pregnancy rates between
patients who received OCP pretreatment and those who did not (OR:
0.74, 95% CI: 0.53 to 1.03)
• Dose and duration of Gn were significantly increased after OCP
pretreatment.
Fertil Steril 2008;90:1055–63.

120. Updated Metanalysis
Griesinger et al FS 2010
• 6 RCT, 1343 pts, OPR worsens with OCP

121. Cycle scheduling for in vitro fertilization with oral
contraceptive pills versus oral estradiol valerate: a
randomized, controlled trial
Erik E Hauzman et al, Reproductive Biology and Endocrinology 2013, 11:96

123. Agonist Vs Antagonist

124. Agonist Vs antagonist: Meta analysis
Daniel Bodri et al, Fertility and Sterility Vol. 95, No. 1, January 2011

126. Among patients treated for IVF with gonadotrophins and
GnRH analogues, is the probability of live birth dependent on
the type of analogue used?
• Metanalysis
• No significant difference was present in the probability of live
birth between the two GnRH analogues [odds ratio (OR), 0.86;
95% confidence intervals (CI), 0.72 to 1.02]
• Non significant diff of 2.7%
Kolibianakis et al, Human Reproduction Update, Vol.12, No.6 pp. 651–671, 2006

127. GnRH agonist versus GnRH antagonist in assisted
reproduction cycles: Oocyte morphology
Reproductive Biology and Endocrinology 2012, 10:33
Total Agonist Antagonist

128. In terms of the quality of oocyte morphology, there is no difference
between the antagonist multi-dose protocol and the long-term agonist
protocol

129. Agonist Vs antagonist: role of endometrial
receptivity (Fertil Steril 2008;90:1294–6)
• The GnRH agonist group showed significantly higher
endometrial thickness and higher pregnancy rate, suggestive of a
higher endometrial receptivity
• Higher human integrin beta 3 subunit and leukemia inhibitory
factor expressions  higher implantation rate after COH using
GnRH agonist

130. Reproductive BioMedicine Online (2012) 24, 6– 22
N: 966 women were included in nine randomized controlled trials

131. The antagonist protocol was associated witth significantly lower risk of
OHSS (relative risk 0.60; 95% CI 0.48–0.76; P < 0.0001).

133. • Objectives:
To evaluate the effectiveness and safety of gonadotrophin-releasing
hormone (GnRH) antagonists compared with the standard long
protocol of GnRH agonists for controlled ovarian hyperstimulation
in assisted conception cycle

134. • Live birth rate
• Ongoing pregnancy rate
• Miscarriage rate
• Cycle cancellation rate
• Statistically significant lower incidence of OHSS in the GnRH
antagonist group
(29 RCTs; OR 0.43, 95% CI 0.33 to 0.57)
No stastically
significant
difference

135. The GnRH antagonist protocol is a short and simple protocol with a
comparable live-birth rate to longer protocols with GnRH agonists
It is associated with a highly significant reduction in the incidence of the
ovarian hyperstimulation syndrome compared to the GnRH agonist long
protocol
Therefore justifies a move away from the standard GnRH agonist long
protocol to a GnRH antagonist protocol

136. • Think Preparing the Ovary for Egg Collection
• Think Patient Oriented Treatment
• Always Minimise Trauma to Patients

137. Here comes your footer
 Page 137