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Aboubakr Elnashar
3. Contents
1. Types of anovulation
2. Types of ovarian stimulations
3. Types of Gnt
4. Patient selection
5. Indications
6. Contraindications
7. The starting dose
8. Protocols
9. Monitoring
10.Results
11.Complications
Conclusion
11
Aboubakr Elnashar
4. 1. Types of Anovulation
% Type Hormonal profile
5-10%
WHO type I
(Hypogonadotropic
Hypoestrogenic)
E2
FSH
75-80%
WHO type II
Normogenadotrophic
Normoestrogenic
Normal E2
Normal FSH
10-20%
WHO type III
(Hypergonadotropic
Hypoestrogenic)
E2
FSH
5-10%
WHO type IV
(Hyperprolactinemia) prolactin
WHO Scientific group, Geneva 1976, Report 514, Rowe et al, 1993
Aboubakr Elnashar
10. CHOICE OF GONADOTROPINS
No difference in outcome between ovarian stimulation with
hMG preparations or urinary derived FSH, in studies using
the long protocol of GnRH desensitization.
(MA: Agrawal et al. 2000)
No significant clinical differences between hMG and rFSH.
(Nugent et al., Cochrane Data base Syst Rev 2000; van Wely et al, 2003)
hMG, uFSH, and r-FSH: equally effective for achieving
pregnancy in PCOS.
(Al-lnany et al.,2005)
Rec FSH make no difference to the incidence of OHSS.
The particular FSH formulation used for ovarian stimulation
does not affect the incidence of OHSS.
(SOGC, (I)
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11. ,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)
Aboubakr Elnashar
12. 4. Patient selection
I. Basic investigations of infertility
1. Semen analysis
2. HSG
3. Midluteal P
II. If amenorrhea &/or galactorrhea:
Workup
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13. 5. Indications
I. Induction of ovulation
1. Hypogonadotropic Hypogonadism (5-10%)
(hypothalamic amenorrhea, WHO Group I)
Gnt secretion:
extremely low
HMG:
only effective Gnt {contains both FSH and LH}.
LH-containg Gnt if LH <3 IU/L
(Speroff, 2009)
CC& related medications:
ineffective
{their actions require an intact& functional hypothalamic-
pituitary-ovarian axis}.
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14. 2. CC resistance or failure
Resistance (No ovulation) or
Failure (No pregnancy)
PCOS(WHO Group II)
Gnt: normal
LH: may be high
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15. 2nd line tt after CC resistance/failure
(The Thessaloniki ESHRE/ASRM workshop)
{1. Lack of an oral formulation.
2. Expensive
3. Serious side effects: multiple pregnancy and OHSS
4. Close monitoring with ultrasound}.
If AFC≤7: CC+ Gnt
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17. Weight reduction
Oral anti-estrogens (CC)
Obese &overweight
Normal weight &No weight loss & No ovulation
LODGnT
No ovulation after 3 cycles.
No pregnancy after 6 cycles.
No pregnancy
after 6 cycles.
No pregnancy after spontaneous,
CC, FSH ovulation
IVF
Other surgical indication
Difficult follow up
Less aggressive
No desire for
surgery
Add metformin
IGT &IR
Aboubakr Elnashar
18. Clomiphene Citrate Resistance
Incidence:
20%
Define
No ovulation after tt with CC, {100 mg, for 5 days in 3 cycles}
(Coelingh Bennink, 1998).
Causes:
Hyperandrogenic
Obese
Severe insulin resistance
(Murakawa et al.,1999; Speroff et al., 1999).
Aboubakr Elnashar
19. Clomiphene citrate failure:
Define:
No pregnancy despite of ovulation with CC
Causes:
long half-life& peripheral anti-estrogenic effects on
endometrium& cervical mucus.
low fertilization rate
variable implantation rate
deficient corpus luteum function
(Speroff et al., 2005)
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20. Dosage:
Minimum: single dominant follicle.
{Response can vary greatly from individual to
individual& from cycle to cycle}
Monitoring:
Adjust dosage
Timing of ovulation.
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21. Luteal-phase support
seldom necessary
{endogenous LH levels typically are more than
sufficient to support normal luteal function}.
Indication
1. GnRHa used
2. Evidence of poor luteal function after otherwise
successful ovulation induction
How:
progesterone
{higher risk of OHSS associated with hCG}
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23. CC Vs EM
No better (and even inferior) LBR than EM
(14% vs 17%).
(Bhattacharya et al., 2008)
NNT: 40 for one additional pregnancy compared with
placebo
(ASRM, 2006).
No evidence that CC was more effective than no tt or
placebo for CPR or LBR
(SR by Hughes et al.;2010)
Do not offer oral ovarian stimulation agents (such as
CC, or anastrozole, letrozole).
{no increase CPR, LBR}
(NICE, 2013)
Offer IVF after 2 ys
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24. HMG Vs CC
significantly higher CPR: 25% Vs 8%
(Karlstro¨m et al., 1993; Echochard et al., 2000 Balasch)
FSH plus Letrozole:
improved response to FSH:
lower FSH dose
higher number of mature follicles UI
(Mitwally & Casper, 2003)
Aboubakr Elnashar
27. IUI with Gnt
ESHRE, 2009
PR: 12%/cycle but multiple birth rates13%.
IUI in stimulated cycles may be considered
1. while waiting for IVF or
2. when in women with patent tubes and IVF is not
affordable
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28. Cochrane, 2012
IUI with HMG:
increases CPR compared to IUI alone
increases CPR compared to TI in stimulated cycles
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29. NICE, 2013
IUI with stimulation was better than EM in all groups
of women, but it was clear that it significantly
increased the risk of multiple pregnancies.
IUI (with or without stimulation) should not be
routinely offered for couple with UI
Exceptions:
Social
cultural or
religious objections to IVF
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30. Monitoring:
{avoid obviously excessive stimulation}.
Risks
Multiple pregnancy: > in CC resistant anovulatory
women
Luteal support:
Not required
(Speroff et al, 2005)
{combined contributions of two or more corpora
lutea may be reliably expected to yield
supraphysiologic luteal-phase serum progesterone
concentrations}
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31. LPS in IUI
vaginal progesterone: higher LBR compared with
no progesterone support
(Up todate, 2015)
(OR 2.11, 95% CI 1.213.67;three trials, 1196 cycles) (SR of RCT)
In subgroup analysis, the benefit was restricted to
Gnt stimulated cycles.
Indicated:
1. history of unexplained RM
2. luteal phase <10 days.
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32. CompanyPrice
(LE)
FormMgGeneric
name
FormTrade name
Abbott20 tab10DydrogesteroneOralDuphaston
Ibsa82.510 amp100ProgesteronIMProntogest
Ibsa7230 vag pessaries200ProgesteronVag or
rectal Ibsa10230 vag pessaries400
Actavis9015 vag pessaries200ProgesteronVag or
rectal
Cyclogest
Actavis12515 vag pessaries400
Ferring20021 vag tab100ProgesteronVagEndometrin
Serono236jell15 tube8 %ProgesteroneVagCrinon
October2430 caps100ProgesteroneVag or oralUterocare
Pharco1824 caps100ProgesteroneVag or oralProgest
Aboubakr Elnashar
33. III. COS
IVF or ICSI
Aim:
induce multifollicular growth.
maintaining a subthreshold level of Gnt during the
time of follicular recruitment: overriding the process of
selection of a single dominant follicle.
How:
GnRHa, or antagonist to block endogenous LH
production& LH surges.
Gnt
HCG
When an appropriate follicular size is observed: final
maturation of the follicles Aboubakr Elnashar
34. 6. Contraindications
Rare:
1. Hypersensitivity to Gnt or to any of
the excipients.
2. Ovarian, uterine, or breast cancers.
3. Tumors of the hypothalamus&
pituitary gland
4. Ovarian enlargement or cyst not
due to PCOS
5. Pregnancy& lactation.
6. Gynecological hemorrhages of
unknown origin.
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35. 7. The starting dose of Gnt
Depend on:
1. The intended goal:
unifollicular ovulation or superovulation
2. Age
3. BMI
4. PCOS
5. Ovarian reserve:
baseline FSH, ACF, AMH
6. Previous response.
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40. 8. Protocols
I. Step-up:
1. Conventional=Standard
2. Low dose
3. Chronic low dose
II. Step-down
III. Step-up, step-down
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41. I. Step up
Principle:
Stepwise increase in FSH
{determine the FSH threshold for follicular
development}
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42. 1. Conventional:
Starting dose: 150 IU/d:
Duration of starting dose: 5 d
Increased by: 75 IU/3-5 d
Excessive follicle development
Increased OHSS
(Thompson and Hansen, 1970; Dor et al., 1980; Wang and Gemzell, 1980).
No longer recommended
(Buvat et al., 1989; Brzyski et al., 1995)
Aboubakr Elnashar
43. Starting dose: 150 IU/d
2 FSH/hMG/day
Day 3Day 3 Day 7Day 75 days5 days
If
Follicle > 12 mm
E2 > 400U
Continue
2 FSH/d
No response® 3 FSH/day
for 3 more days
Endocrine Rev. 1997; 18: 71
Aboubakr Elnashar
44. 2. low-dose
•Stating dose: 75 IU/d
(White et al., 1996; Hayden et al., 1999; Balasch et al., 2000; Calaf et
al., 2003).
•Duration of starting dose: 5-7 d
-No follicle development: increase the dose by
100%
-Follicle growth: maintain same dose until
follicular selection is achieved.
-Mono-ovulation: 69%
- MP: 5.7%
- OHSS: 0.14%
(Homburg & Howles, 1999. Hum. Reprod. Update 5:493-499).
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45. Starting dose:75 IU/d
If
mm12>Follicle
E2 > 400
Continue
1 FSH/d
No response 150 FSH/d
for 1 more w (max. 3 amp.)
Endocrine Rev. 1997; 18: 71
75 FSH/hMG/day
Day 3 Day 75 days
Aboubakr Elnashar
47. 3. Chronic low-dose
•Starting dose: 37.5-75 IU
•Duration of starting dose:14 d
•The weekly dose increment: reduced from 100%
to 50% or 37.5 IU
(Seibel et al., 1984; Polson et al., 1987; Sagle et al., 1991; Dale et al.,
1993).
:Markedly ↓excessive ov stimulation
Marked ↓OHSS.
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48. 0 14 21 28 35
75 iu
112.5 iu
150 iu
187.5 iu
225 iu
Days
7
37.5 iu
½ Amp.
One Amp.
42 49
2 Amp.
3 Amp.
White et al. J Clin Endocrinol Metab 1996;81:3821–4
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51. 9. Monitoring
1- TVS:
Baseline D2 or 3 of the cycle
ovarian cyst:
30 mm: decreased fecundity
(Akin and Shepard, 1993).
: postpone Gnt.
AFC:
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52. Serial
D5-7 of stimulation
Repeat /2-3 d depending on the size of
leading follicle, until it is 18 mm
a. Follicles:
number & size
Documentation of all follicles >10 mm {predict the risk of
multiple pregnancies}.
1 or 2 follicles 18-20 mm: HCG
Daily SI on the day of HCG& for the next 2 days
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53. > 3 follicles > 16 mm:
(Macklon et al, 1999).
>4 follicles ≥ 14 mm
(Kamrava et al., 1982; Hugues et al., 2006).
Stop stimulation& hCG withheld
Gnt follicles mature at 15-18 mm
CC follicles mature at 18-20 mm
(Speroff et al, 2005)
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55. b. Endometrial thickness:
<6 mm: No pregnancies
9-10 mm or more: The chance of pregnancy is great
(Isaacs et al, 1996).
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56. 2-E2 peak (pg/ml):
<200
pregnancies are rare
500-1500
optimal
1500-2000
risk of OHSS is significant
>2000 pg./ml:
hCG is not given
Cyle is cancelled
(Speroff et al, 2006). Aboubakr Elnashar
58. II. Pregnancy
Low:
1. hyperandrogenic chronic anovulation group
2. Above 35 y
CC resistant
anovulatory
Hypogonadotropic
hypogonadism
5-15%25%Cycle fecundity
30-60%90%Cumulative PR after up to 6 cycles
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59. III. Miscarriage
20-25%
moderately higher than is generally (15%).
1. advanced maternal age
2. obesity
Low in
hypogonadotropic hypogonadism
Higher in
clomiphene-resistant anovulatory women
Aboubakr Elnashar