This document discusses various methods for ovarian stimulation in IVF treatment. It begins by describing the early history of IVF and the move away from using fertility medications to a more natural approach. It then outlines different protocols for ovarian stimulation preparation including natural cycles, minimal stimulation, in vitro maturation, and various FSH stimulation methods with and without agonists/antagonists. The majority of the document focuses on comparing the use of GnRH agonists versus antagonists, including their modes of action, individualization of protocols, studies comparing outcomes, and the ability of antagonists to reduce OHSS risk. It notes some problems with ovarian stimulation methods including costs, side effects, and long-term risks.

1. Individualization of Cycle Control
Dr. Milton Leong
MDCM DSc (McGill)
Director, IVF Center, HKSH
Specialist in Reproductive Medicine
Adjunct Professor, OBS-GYN, McGill University

2. The first IVF Baby
Drs. Steptoe and Edwards decided to
abandon the use of fertility medications
and try aspirating a single egg in a
natural menstrual cycle. On their
second attempt, Louise Brown was
conceived

3. Preparation for Ovum Collection
• Natural Cycles
• Minimal stimulation (clomiphene/FSH)
• IVM
• FSH stimulation with agonists
• FSH stimulation with antagonists

4. Ovulation Stimulation
WHAT GOES AROUND COMES AROUND
*American idiom

5. Stimulated ovary

6. Technology and product development
timeline: gonadotrophins
1930 1940 1950 1960 1980 1990 1995 2003
Adapted from: Lunenfeld. Reprod Biomed Online 2002;4:11
Horse
PMSG
Pig
FSH
Pituitary
FSH
u-hMG u-FSH u-FSH r-hFSH
(HP)
r-hFSH
FbM
Local reactions
Potential side-effects
Consistency
Quality
Antibodies Local, systemic
reactions
Creutzfeldt–
Jacob disease

7. Premature LH surge
• Poor quality
• No fertilization or very poor pregnancy rate
• Cancel egg retrieval
5-20%
All cycles treated in early 1980’s
5-20%

8. GnRHa Long Protocol vs No Suppression
meta-analysis IVF cases
Odds ratios for IVF clinical pregnancy after GnRH-a versus
clomiphene/FSH/hMG ovulation induction protocols

9. GnRHa Long Protocol vs No Suppression
meta-analysis GIFT cases
Odds ratios for GIFT clinical pregnancy after GnRH-a versus
clomiphene/FSH/hMG ovulation induction protocols

10. Results of first application of GnRH-agonists
in the long protocol
• 11 patients eligible for IVF
• GnRH agonists s.c. (busereline) started at day of
menstruation of one day before
• Ovarian stimulation started with HMG or purified
FSH when all ovarian follicles and the
endometrial lining has disappeared on
ultrasound (average 15 days)
• One ongoing pregnancy achieved
Porter et al., 1984

11. OVARIAN STIMULATION
• FSH with agonist down regulation
• FSH with antagonists
• Low dose clomid/FSH stimulation
• Delayed stimulation
• IVM
• Natural cycles

12. Structure of GnRH agonists
Modifications of natural GnRH
to have GnRH agonistic properties
1 2 3 4 5 6 7 8 9 10
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

13. Action of GnRH agonists
LH + FSH
GnRH
GnRH - receptor
post-receptor-cascade
GnRH - agonist
Down
regulation
Flare up effect
Pituitary suppression

14. Schematic representation of different protocols
using GnRH agonists in combination with
gonadotrophins for ovarian stimulation in IVF

15. 22nd day
of previous
cycle
14 days
1st day
of gonado-tropins
gonadotropin administration
in an individualized dosage
ovulation
induction
oocyte
pick up
embryo
transfer
luteal phase support
start of
GnRH agonist
The long luteal protocol

16. Individualizing protocols
• Our contribution to
1. low dose short term agonist down
regulation using decapeptyl
2. flexible low dose antagonist
• Aims: - to simplify treatment
- to minimize drug usage

17. Agonist Studies
2000 - 2001
Deca Long Luc Long Bus
<40 <40 <40
Number of OPU 69 76 61
Number of Eggs Retrieved 881 885 726
Number of MTII 647, 73% 642, 73% 552, 76%
Number of MTI 136, 15% 44, 5% 101, 14%
Fertilization Rate 74% 76% 71%
Mean # of Embryos Transferred
3.1 3.2 2.8
per ET
Pregnancy Rate per ET 51% 49% 44%
Implantation Rate 20% 22% 18%
Average Age 34.4 33.2 34.9

18. Decapeptyl Down Regulation
2000-2002
Total < 40 ≥ 40
# of patients 90 76 (32.9) 14(40.8)
# of pregnancy 42 40 2
Pregnancy % 46.7 52.6 14
# of twins+ 10 10 0
# of babies 43 42 1
Miscarriage rate 16% 50%

19. Decapeptyl Down Regulation 2000-2003
Laboratory Data
# of eggs 831 MTII 539 (67%)
MTI 139 (16.7%)
# of eggs ICSI 551
# of fertilized 427 Fert. % 76.4
# of E.T. 244 Mean transferred 2.7
# of preg. (F.H.) 46 Implantation rate 21%

20. Down Regulation

21. GnRH agonists
Undesirable effects:
• Over-suppression:
– LH becomes so low that it affects the production of
estrogen, and possibly progesterone in the luteal phase
– Leads to poor response, poor pregnancy outcome due to
early abortion.
Also it is:
• Too long and too much drug use, cost, cancelled
cycles and it is unnatural.

22. Structure of GnRH antagonists
to achieve antagonistic properties of natural GnRH more
modifications than only in position 6 and 10 are necessary
1 2 3 4 5 6 7 8 9 10
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

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

24. Characteristics of GnRH antag
Ganirelix
• Fully effective
within 4 hours, with
a half-life of about
13 hours
Cetrorelix
• Fully effective
within 8 hours, with
a half-life of about
36 hours
R.E. Felberbaum and K. Diedrich, 1999.

25. The Cetrotide® 0.25 mg
multiple dose protocol
gonadotropin administration
in an individualized dosage
1st day
of gonado-tropins
ovulation
induction
oocyte
pick up
embryo
transfer
luteal phase support
1st day
of menstruation
Cetrotide® 0.25 mg administration
daily s.c. starting on day 6 of stimulation

26. Possibilities to individualize the
multiple dose protocol
• To avoid a premature LH rise the
administration of cetrotide® 0.25 mg on day 6
of stimulation should be the standard
procedure
• Using the standard procedure, a mean of 6.3
injections are necessary
• This is in accordance with the package size
of 7 ampoules cetrotide® 0.25 mg per patient

27. Possibilities to individualize the
multiple dose protocol
• Individualized administration of Cetrotide®
0.25 mg can be done
– According to follicle size:
only if leading follicle is ³ 14 mm
• Thereby, the multiple dose protocol can
also be adapted to patients with a lower
response

28. Cetrorelix 0.125mg
Flexible Dose Trial
Selection Criteria:
1. Previous over-suppression with
agonist
2. Previous poor response
3. Previous LH surge if no agonist

29. 10
0 1 2 3 4 5 6 7 8 9
BMI Distribution
<20 20 21 22 >25
Mean = 21.8 (range 19-30)

30. 10
0 1 2 3 4 5 6 7 8 9
# Days Cetrorelix Used
1 2 3 4
Mean = 2.2 days (range 1-3)

31. LH and Cetrorelix 0.125mg/day
• Range mIU/ml
• Pre 1.2 - 7.8
• Day 1 post 0.9 - 4.9
• Day HCG 1.8 - 6
1.2
0.9
1.8
2.4
2.1
2.5
7.8
4.9
6
9
8
7
6
5
4
3
2
1
0
Pre-CET Day 1 Post Day HCG
Low
Average
High

32. Cetrotide 0.125 mg vs 0.25 mg, 2004 – Sep 2006
0.125 mg/day 0.25 mg/day P
Cycles 121 331
Average age 37.1±4.0 37.5±4.2 NS
Days of stimulation 9.3±1.7 9.4±1.8 NS
Total dose of FSH used
(amp)
31.4±14.4 36.0±14.5 0.004
E2 on HCG day (pg/ml) 1943±941.8 2028.0±1376.0 NS
LH on HCG day (IU/L) 3.5±3.9 2.1±1.9 0.001
Oocytes collected 1160 (9.6) 3198 (9.7) NS
MTII 902 (77.75%) 2503 (78.26) NS
Fertilized oocytes
770 (85.4%) 2085 (83.3%) NS
(fertilization rate)
Embryos transferred 2.8±0.8 2.9±0.8 NS
Pregnancy rate/ET 50/121 (41.3%) 106/331 (32.0%) NS (P=0.066)
Implantation rate 17.3% 13.4% NS (P=0.081)

33. Cetrotide 0.125 mg vs 0.25 mg, 2004 – Sep 2006
(age <40)
0.125 mg/day 0.25 mg/day P
Cycles 86 215
Average age 35.1±3.1 35.2±2.9 NS
Days of stimulation 9.4±1.7 9.3±1.8 NS
Total dose of FSH used
(amp)
29.6±11.9 33.2±11.6 0.016
E2 on HCG day (pg/ml) 2081.5±977.6 2040.6±1300.2 NS
LH on HCG day (IU/L) 3.7±4.4 2.1±1.8 0.002
Oocytes collected 941 (10.9) 2240 (10.4) NS
MTII 732 (77.78%) 1742 (77.76) NS
Fertilized oocytes
623 (85.1%) 1448 (83.1%) NS
(fertilization rate)
Embryos transferred 2.8±0.6 2.8±0.7 NS
Pregnancy rate/ET 43/86 (50.0%) 84/215 (39.1%) NS (P=0.083)
Implantation rate 21.8% 17.4% NS (P=0.144)

34. Cetrotide 0.125 mg vs 0.25 mg, 2004 – Sep 2006
(age ≥40)
0.125 mg/day 0.25 mg/day P
Cycles 35 116
Average age 41.6±1.7 42.0±2.3 NS
Days of stimulation 9.1±1.8 9.4±1.9 NS
Total dose of FSH used
36.0±18.6 41.1±17.7 NS
(amp)
E2 on HCG day (pg/ml) 1602.2±756.1 2003.9±1517.8 NS
LH on HCG day (IU/L) 3.0±2.4 2.2±2.1 NS
Oocytes collected 219 (6.26) 958 (8.25) NS
MTII 170 (77.6%) 761 (79.4%) NS
Fertilized oocytes
147 (86.5%) 637 (83.7%) NS
(fertilization rate)
Embryos transferred 2.9±1.1 3.0±1.0 NS
Pregnancy rate/ET 7/35 (20.0%) 22/116 (19.0%) NS
Implantation rate 6.9% 6.6% NS

35. Antagonist vs Agonists
Cet Agonist
<40 ≥40 <40 ≥40
Number of OPU 371 184 171 23
Number of Eggs Retrieved 3994 1388 2126 199
Number of MTII 2984(75%
)
1055(76%) 1575(74%) 152(76%)
Number of MTI 526
(13%)
160 (12%) 205 (10%) 25 (13%)
Number of ICSI’d 3269 1131 1729 173
Number of 2PN 2472 870 1303 126
Fertilization Rate 76% 77% 75% 73%
Total # of Embryos Transferred 1039 521 532 62
Mean # of Embryos Transferred per
2.8 2.8 3.1 2.7
ET
Number of Pregnancy 145 25 82 5
Pregnancy Rate per ET 39% 14% 48% 22%
Implantation Rate 17% 5% 20% 10%

36. Comparison: Mode of Actions
Antagonists Agonists
•Immediate onset of
actions (shortens
treatment durations)
•Prevents hormonal
withdrawal
symptoms
•No recovery time of the
pituitary
•long pre-treatment
•Hormonal (estrogen)
withdrawal symptoms
through desensitization
of pituitary
•Recovery of the
pituitary gonadotrophin
secretion, after
stopping the treatment
takes about 2 weeks.

37. Reduction of OHSS using Cetrotide®
• Multiple dose protocol
– rate of OHSS: 6.5% vs. 1.1% (agonist vs. antagonist protocol)
– RR 6.2, 95% CI: 1.4 - 27.1, p = 0.03
• Single dose protocol
– rate of OHSS: 11.1% vs. 3.5% (agonist vs. antagonist protocol)
95% CI: - 18.4 to 3.2
– patients requiring hospitalisation: 5.6% vs. 1.8%
– (agonist vs. antagonist protocol)
95% CI: - 11.7 to 4.1
• With both Cetrotide® protocols a clear reduction of
OHSS was achieved

38. The GnRH Antagonists
• Conclusions:
• Why treat 100% of patients when we are
trying to prevent 5-10% LH surge
• Avoid over-suppression and poor
response
• Effective in preventing LH surge
• Reduction of hyper-stimulation
• Lower costs

39. Ovum Preparation for IVF
• FSH/GnRH Down Regulation
• FSH/GnRH Antagonists
• Clomid, Clomid/FSH
• Minimal Stimulation
• IVM
• Natural Cycles

40. Problems with Ovarian Stimulation
• Drug Costs
• Side effects: immediate and delayed
• Future long term risks
• Not “User Friendly”

41. Problems with Ovarian Stimulation
• Waste of Human Resources
• Excess eggs ? how to deal with
• Excess embryos - even worse
• Multiple pregnancies and their
associated complications

42. Individualized stimulation

43. Individualized Stimulation

44. Individualizing Stimulation

45. Individualized Stimulation

46. Over responders
• Risk of OHSS
• Treatment options
a) Cancel cycle
b) Coasting
c) No embryo transfer
d) Convert to IVM

47. Individualizing protocols
• For over responders
• For low responders

48. Over responders
Prolonged Coasting
• Aim: To prevent hyperstimulation
• Practice: Coast till E2 ≤ 3000 pg/mL
• Sher, 1995 Start when 30% follices > 15 mm
• Nilsson, 1999 When 3 follicles > 17mm

49. IVM stimulation

50. Poor responders
• Age (average age of ML patient 38.7 yrs)
• Decrease ovarian reserve (↑D2 FSH)
• Decrease preantral follicles
• Previous ovarian surgery
(Laparoscopic ovarian cystectomy)

51. Poor responders
• High dose
• Microdose flare
• Low dose clomid/FSH stimulation
• Delayed stimulation
• IVM

52. Microdose Flare Regimen (1)
• Oral Contraceptive
• 20 mcg leuprolide cs bd x 2 d
• uFSH for ovarian stimulation
• Results:
↑oocytes
Less ampoules FSH
Source: Scott et al, 1994

53. Microdose Flare Regimen (2)
• Oral Contraceptive
• 40 mcg leuprolide sc bd
• 4 IU/d growth hormone IM
• Followed by uFSH 2 days later
• Results:
↓Cancellation rate
↑E2 levels, number of oocytes
Source: Schoolcraft et al, 1997

54. Microdose Flare Regimen (3)
• Oral Contraceptive
• 40 mcg leuprolide sc bd
• uFSH starting 2 days later
• Results
↓Cancellation rate
↑E2 levels, number of oocytes
Source: Surrey et al, 1998

55. Poor responders
• High dose
• Microdose flare
• Low dose clomid/FSH stimulation
• Delayed stimulation
• IVM

56. Minimal stimulation

57. Poor responders
• High dose
• Microdose flare
• Low dose clomid/FSH stimulation
• Delayed stimulation
• IVM

58. Delayed Stimulation

59. Poor responders
• High dose
• Microdose flare
• Low dose clomid/FSH stimulation
• Delayed stimulation
• IVM

60. IVM stimulation

61. IVM results
2004 Aug to 2007 Jun
<38 ≥38
Patients (n) 33 16
Average age 32.6 40.0
Total eggs 420 (12.7 ) 160 (10.0)
MTII stage 314 (74.8%) 123( 76.9%)
Fertilization rate 254 (80.9%) 107 (87.0%)
Pregnancy rate 33.3% 37.5%
Embryos
84 34
transferred
Implantation
rate
14.3% 17.6%

62. Modern Trend in ART
• Minimize multiple pregnancies
• Minimize number of embryos transfer
• Minimize patients’ load and stress
• Physiological
• Psychological
• Financial

63. Question
• Is it time to revisit the aim and clinical
practice of so called Controlled Ovarian
Hyperstimulation. Should we be
heading towards a modified direction

64. Answer
• We should look at the clinical aim of
“Preparing Eggs for the treatment of
IVF” rather than Ovarian Stimulation

65. Preparation for Ovum Collection
• Natural Cycles
• Minimal stimulation (clomiphene/FSH)
• IVM
• FSH stimulation with agonists
• FSH stimulation with antagonists

66. Conclusions:
1. It is possible to choose stimulation procotol
according to: age
Ovarian status
Previous history
2. We should aim for minimal stress (in all
senses) for the patients provided similar
result can be obtained.
3. Individualization of stimulation should be
considered for every case.

67. Stimulated ovary

68. Stimulated ovary