2. CONTENTS
1. TYPES OF OVARIAN STIMULATION FOR IVF
2. DRUGS
3. GNRHa PROTOCOLS
4. GNRHan PROTOCOLS
5. TRIGGERING OF OVULATION
6. CYCLE CANCELLATION
7. INDIVIDUALIZATION OF COS
Aboubakr Elnashar
3. MethodsAimPrevious
terminology
Recommended
terminology
No medicationSingle
oocyte
Unstimulated,
spontaneous
cycle
1. Natural cycle
hCG only
GnRHan and FSH/HMG
add-back
Single
oocyte
Semi-natural,
controlled natural
cycle IVF
2. Modified
natural cycle
Low dose FSH/HMG,
oral compounds and
GnRHan
2-7
oocytes
Soft, minimal
stimulation,
‘friendly’ IVF
3. Mild
GnRHa or antagonist
conventional
FSH/HMG dose
> 8
oocytes
Standard, routine,
COS
4. Conventional
International Society for Mild Approaches in Assisted Reproduction
(ISMAAR), 2007
1. TYPES OFOVARIAN STIMULATION FOR IVF
Aboubakr Elnashar
4. GnRHa GnRHan No GnRH
analogue
long Short Ultra
short
Standard Mild Modified
natural
Mini Natural
Protocols of ovarian stimulation in IVF
Aboubakr Elnashar
14. Effects of GnRha
Flare effect: Within 12 h and lasting 24-48 h
: 5 fold increase of FSH
10 fold rise in LH &
4 fold elevation in E2.
Continuous administration
: opposite effects:
internalization of the agonist /receptor complex & decrease in
the number of receptors
(down-regulation).
: paradoxical suppression of the pituitary Gnt synthesis &
liberation
(desensitization).
Aboubakr Elnashar
15. The decreased levels of FSH & LH:
1. Arrest of follicular development
2. Decrease in sex steroid levels to castrate levels.
The pituitary blockade persist during agonist tt but it
is reversible after therapy.
Aboubakr Elnashar
16. (a)action of native GnRH on a gonadotroph;
binding of GnRH to the receptor results in FSH
and LH secretion. FSH and LH, in turn, stimulate
the gonads to produce steroid hormones.
(b) Binding of a GnRH agonist to the
gonadotroph receptor produces an initial
stimulation of FSH and LH, but subsequently
suppression of gonadotropins occurs, with the
resulting suppression of gonadal steroid
production.
(c) Binding of a GnRH antagonist to the
gonadotroph receptor stimulates an immediate
downregulation and desensitization, with
resulting suppression of gonadotropin secretion
and gonadal steroid
Aboubakr Elnashar
17. Protocols
Ultra-short (sequential):
Based on
initial stimulatory effect of GnRHa on Gnt secretion
[flare- up effect]
lasts for 1-2 days
promotes simultaneous maturation of several
follicles.
GnRHa: from the 1st to 3rd day of the cycle.
Gnt: from the 3rd day of the cycleAboubakr Elnashar
18. No evidence of a difference in the outcome of LBR
in a comparison of GnRHa long, short or ultrashort
protocols.
PR was significantly higher in Long vs short
protocols
(Maheshwari A et al 2011. Cochrane , 2011)
Aboubakr Elnashar
19. Short (Flare):
GnRHa: from the 1st day of the cycle until the day of
ovulation induction.
Gnt: from the 3rd day of the cycle.
Aboubakr Elnashar
20. Leuteal support
FSH 75-300 IU
Ovulation
5.000-10.000 IU
hCG
Short GnRHa protocol
75-
300/day
IU /FSH
34 h.
OPU
TVS > 18 ml
E2
Cycle
ay 1
GnRHa 0.1mg/day
3rd day
TVS
E2
Aboubakr Elnashar
21. Long:
GnRHa:
From:
1st day (follicular) or
middle of the luteal phase (D19-21)
{1. inhibition of the pituitary function can be achieved earlier.
2. Higher fertilization & PR than therapy started on the 1st day
of the cycle}.
until a sufficient inhibition of Gnt release (10-14
days)
Gnt while GnRHa therapy is maintained.
Aboubakr Elnashar
23. Luteal support
hCG
5-10000 IU
75-300 IU / FSH/day
Long GnRHa Protocol (luteal phase)
TVS
E2
34 h.
OPU20th day
previous
cycle
TVS >18 ml
E2
GnRHa 0.1mg/day
< 50 pg/ml
TVS
E2
FSH
2 weeks
Aboubakr Elnashar
24. -Criteria of suppression:
Hormonal: E2 <50 pg/ml
Progesterone < 1 ng/m
LH <5 IU
US: No ovarian cysts
Endometrial thickness <6 mm
predicts down regulation in 95% of cases
Aboubakr Elnashar
25. Advantages:
long protocol Vs Short & ultrashort
(Cochrane review, 2000)
superior in terms of
1. follicular development &
2. fertilization rate
3. number of embryos suitable for transfer
4. PR
5. more units of GN were needed
Midluteal is the optimal Gnt suppression & oocytes
(Roman et al 1992,Huirne et al,2004) Aboubakr Elnashar
26. ,rFSH Vs other GN (HMG, hp-FSH, p-FSH), no
evidence of difference in LBR or OHSS
42 trials, 9606 couples
Further research on these comparisons is unlikely
to identify substantive differences in effectiveness or
safety
(Cochrane Database Syst Rev. 2011, Wely et al)
Use either u or rec Gnt for ovarian stimulation
(NICE, 2013)
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27. Depot Vs daily
No differences PR.
Depot:
longer duration
higher doses of Gnt
more luteal support depot
(Cochrane review 2002)
Aboubakr Elnashar
28. 4. GNRHan PROTOCOLS
GnRHan
Produced by
Modification at 6, 10, & 1, 2, 3, 8 positions
Effects
Inhibition of LH & FSH immediately without the initial
flare up effect of the Gnta.
Mechanism of action
Competitive receptor blockade.
The suppression of LH is dose related.
Larger doses of antagonist is associated with marked
reduction of pregnancy rate in IVF cycles
Aboubakr Elnashar
30. Protocols
1. Small daily dose (LubecK):
HMG or FSH:
From day 2 or 3 of the cycle &
Cetrorelix or Ganirelix: 0.25 mg daily SC: from
stimulation day 5 or 6 (fixed protocol) or
leading follicle14 mm (Flexible protocol) onwards until
the day of HCG (Diedrich et al,1994).
Advantages:
1. Prevents premature LH surge
2. effective in terms of CPR/cycle & /ET (22% &
27%).
3. safe in terms of a low incidence of patients
hospitalized due to OHSS. Aboubakr Elnashar
32. 2. Single dose(French):
HMG or FSH:
from day 2 or 3 of the cycle
Cetrorelix:
single dose, 3 mg SC, on stimulation day 7
(Olivennes et al,1998).
HCG is given when the follicles are mature by U/S
&/or E2.
GnRha single dose can be given instead of HCG to
reduce incidence of OHSS {shorter half life of the
agonist compared to HCG}.
Aboubakr Elnashar
34. Single Vs multiple (Olivennes et al,2003)
Similar efficacy & safety
Recommendations of GnRHan Consensus
Workshop Group)
No increase starting dose of Gnt
Fixed antagonist appears superior to flexible.
Optimal timing for HCG administration
Agonist for triggering
Luteal phase supplementation is required
Aboubakr Elnashar
35. Agonists Vs Antagonists
LBR after COS for IVF does not depend on the
type of analogue used for pituitary suppression
(SR: Kolibianakis et al,2006)
Antagonist protocol:
short, simple with significant decrease in severe
OHSS & amount of GN.
CPR, OPR/LBR were lower in antagonist group
(Cochrane Database Systematic Review Al-Inany et al., 2006)
No evidence of a difference in LBR
(Cochrane Database Syst Rev. 2011, Al-Inany et al, 2011)
Aboubakr Elnashar
37. 5. TRIGGERING OF OVULATION
1. HCG
Rational:
The structure & action of HCG are very similar to
those of LH.
HCG induces final follicular maturation.
Ovulation follow:
IM injection of HCG at 37 h.
Accordingly follicular puncture is performed earlier i.e.
32-34 h or 35 h after hCG administration.
Aboubakr Elnashar
38. Usual dose:
10,000 IU administered 34-36 h before the scheduled
time of oocyte retrieval.
When:
. At least 3 follicles >18 mm
. E2: 150 pg/ml per >15mm follicles.
. Endometrium: Thickness >8mm, Triple line
Aboubakr Elnashar
39. Risk: OHSS
long half life (30 H) with serum hCG detectable up
to 14 days after the injection.
:prolonged luteotrophic effect:
multiple corpora lutea and
supraphysiologic levels of VEGF
(McClure et al., 1994).
development of OHSS via the enhancement of
capillary leak
(Lesterhuis et al., 2009).
Aboubakr Elnashar
40. Do not trigger ovulation with the intention of fresh
ET in women who have:
E2>3500 pm/l or
>20 follicles on US
(NICE, 2013)
Aboubakr Elnashar
41. 2. GnRHa in antagonist cycles
: pituitary endogenous LH surge which is enough to
cause a trigger but does not last enough to result in
OHSS.
Itskovitz-Eldor et al., 2000
8 patients: an increased risk for OHSS
(>20 follicles 11 mm and/or E2 3000 pg/ml).
0.2 mg triptorelin (Decapeptyl) to trigger ovulation
None of the patients developed OHSS.
Four clinical pregnancies
A new treatment option
reducing
risk of developing OHSS in high responders
cycle cancellation. Aboubakr Elnashar
42. 6. CYCLE CANCELLATION
Define:
discontinuation of ovarian stimulation prematurely
without oocyte retrival.
Incidence
12% of all IVF cycles are cancelled before egg
collection.
Womens age Cancellation rate
Less than 35 7.7-10%
35-37 11.6-14.7%
38-40 14.6-19.5%
Over 40 19.1-24.6%Aboubakr Elnashar
43. The main reasons
1.No or poor egg production (83%)
2.Patient’s personal reasons (10%)
3.Excessive response to ovarian stimulation and
risk of developing OHSS (5%)
4.Medical illness (1%).
(SART 2005 and HFEA 2006 Reports).
Aboubakr Elnashar
44. Indications
1. Follicular growth is delayed:
ovarian stimulation over 10 days:
< 3 follicles > 16 mm & E2 < 600 pg/ml.
2. Basal LH is elevated:
LH > 10 IU/l or a premature LH surge occurs
3. Elevated serum P4:
>1.5 ng/ml is detected prior to ovulation induction.
4.OHSS is suspected:
each ovary contains > 10 follicles < 16 mm &
E2 > 3500 pg/ml
Aboubakr Elnashar
45. 7. INDIVIDUALIZATION OF COS
What?
I. Selection of protocol
II. Selection of Gnt starting dose.
cCOS
Repeated cycle
Outcome of previous cycles: If good: same protocol.
1st cycle:
a. Empirical:
based on either the clinician’s or a centre’s
preference.
b. Clinical criteria:
Age, BMI, PCOS
(Homburg and Insler, 2002; Arslan et al., 2005).
Aboubakr Elnashar
46. FSH starting dose (IU/day)
(Tronson & Gardner, 2000)
1st cycle
<37 yr old: 150= 2 amp
& PCOS: 112.5= 1.5 amp
37-39 yr: 225= 3 amp
>40 yr: 300= 4 amp
BMI>30 Kg/m (PCO excluded):
increase by 75= 1 amp
Severe endometriosis:
increase by 75= 1 amp
Previous
Normal response(>4 follicles):
same
OHSS: 75= 1 amp
Poor response: 450= 6 amp
Adjust dose
as cycle monitoring proceeds
with U/S & E2.
Do not use a dose of
FSH>450 IU/d
Aboubakr Elnashar
47. I. Individualization of stimulation protocol
Correct prediction of ovarian response
(especially extremes: poor and hyper
response).
By most sensitive markers of ovarian reserve.
Ovarian reserve testing before the first IVF cycle
categorize patients (NICE, 2013)
High responseLow
response
16 or more4 or lessTotal AFC
3.5 or more0.8 or less
AMH
ng/ml
4 or less8.9 or moreFSH IU/L Aboubakr Elnashar
48. A. Expectant low responder: Antagonist protocol
1. No evidence of superiority of one approach
over another (Pu et al., 2011; Sunkara et al., 2013).
2. Antagonist is associated with
Reduced discomfort and treatment burden
(Nelson et al. ,2009)
Fewer days of Gnt stimulation (10 Vs 14 d)
(Pandian et al., 2010): improve patient compliance.
Lower Gnt consumption: lower cost
Drop in cycle cancellation
Prognosis remained poor, with CPR 16% with
GnRHan Vs 11% with the GnRHa
(Nelson et al., 2009).
Aboubakr Elnashar
49. B. Expectant high responders: Antagonists
Reduction of: high response {OHSS, cycle cancellation
{risk of OHSS} (Al-Inany et al., 2007, 2011; Hosseini et al., 2010; Lainas
et al., 2010; Tehraninejad et al., 2010).
La marca et al,
2013
Aboubakr Elnashar
50. II. Individualization of Gnt Starting Dose:
A. Simple models
One or 2 parameters
1. AMH
2. AFC and age
3. AFC
B. Complex models: > 2 parameters
Aboubakr Elnashar
51. SELECTION OF PROTOCOL ACCORDING TO
OVARIAN ReserveReserve ‘Low’ ‘Average’ ‘High’
AFC <7 7-14 >14
AMH <1.1 ng/ml 1.1-3.5 >3.5
Starting FSH
dose IU
Amp
375
5
225
3
150
2
Protocol - Antagonist
-Microdose flare
-Agonist stop
-GH
-Natural
-Modified natural
-Long
protocol
-Antagonist
-Long
protocol
-Antagonist
Aboubakr Elnashar