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Anatomy of Ovarian Stimulation Protocol for IVF

Anatomy of Ovarian stimulation Protocol for IVF

Understanding the anatomy of ovarian stimulation Protocol for IVF or how is the ovary stimulated to produce multiple eggs, helps you understand different medications you are administering prior to IVF. Understanding the endocrine make up of a woman is essential before selecting and optimizing a protocol including

i. ovarian reserve (and predicting before starting treatment if she is a high, average or low responder)

ii. Age and what is a reasonable response for a pregnancy to ensues

iii. Differentiating between PCOS, hypothalamic amenorrhea and normal ovulatory women.

iv. Other gynecologic problems e.g endometriosis

v. other factors that may lower the response : prior ovarian surgery, medical disorders, chemotherapy exposure ..

vi. What are the specific aims of IVF in addition to pregnancy e.g PGD..

After evaluating these factors for each woman, different options are selected for stimulation prior to IVF. There is o place for one protocol fits all. Its a diligent thinking of what works best, one patient at a time.

Adjuvants

These are medications given prior to menses or during the cycle to improve response to gonadotropins

Estradiol: oral or vaginal to synchronize the follicles, so that they are equal before starting stimulation so that they end the cycle close to each other at the time of egg retrieval

Antagonist: to prevent a premature growth of follicles prior to starting stimulation so that we obtain a synchronized group of follicle.

Oral contraceptive pills: we do not use birth control for timing of the cycle most of the time but sometimes to obtain a regular group of follicles before starting stimulation

Testosterone: testosterone gel for 2-3 weeks has been shown in randomized clinical trials  likely because of of sensitizing the ovary to the effects of stimulation medication. No other androgen preparation has been demonstrated to improve pregnancy outcome including DHEA.

Clomid or letrozole: these oral medications may improve response through release of internal FSH from the master gland.

Other medications suggested to improve response with week evidence that they actually improve the pregnancy rates e.g Growth Hormone

Prevention of premature ovulation

One landmark improvement in stimulation protocols is the addition of medicine that prevents the master gland in the brain from triggering ovulation prematurely. Two options are available agonist or antagonist

Agonist in a short protocol (flare lupron) or long protocol

Antagonist starts during the cycle when the largest follicle reach 14mm and estardiol level 300pg/mL

Each have its advantages and merits and they are generally used for women with different endocrine environmwnt. Antagonist protocols gained more dominance in the past decade.

Gonadotropins

Two main types of gonadotropins exist in the US; Pure FSH and a mixed FSH + LH preparation. FSH is the main stimulating medicine but in some women the addition of LH improves the response. Many women receive mixed FSH and LH ptotcols.

The dose of such medicine starts at the highest dose then is drops gradually, the step down protocol. The initial dose depends on egg reserve, weight and expected response. Usually the maximum starting dose is a total of 450 units.

Some reproductive endocrinologists recommend Minimal stimulation IVF   in select patients. There is no proof that the concept one healthy egg is correct. As a matter of fact many women produce many healthy eggs in the same cycle. There is no evidence that cycle for cycle they produce comparable pregnancy rate. Proponents of multiple stimulation recommend multiple cycles to produce multiple embryos.

Ovulation Trigger

When your reproductive endocrinologist perceive that the eggs are close to maturity, she or he employs a triggering agent to finalize follicle maturity and prepare the eggs for retrieval. Two agents age available

hCG given in muscle or under the skin. Its associated with higher incidence of ovarin hyperstimultion.

Agonist (Lupron) trigger given under the skin and has a short duration of action. It prevents ovarian hyperstimulation syndrome.

The Length of Stimuation

In general, shorter the stimulation the better the outcome. The earlier the the trigger shot is administered the better the quality of the eggs. Longer stimulation increases the exposure of eggs to gonadotropins and likely lower the quality of eggs.

Luteal phase Support

Every woman stimulated for IVF require luteal phase support as progesterone production after retrieval is defective. Two preparations exist

Progesterone in the muscle. This is the classic way of supplementing progesterone. Its very stable but require injections and also can cause allergy.

Vaginal progesterone. Recently introduced, used twice a day using an applicator in the vagina.

Many aspects of stimulation protocol need to be considered in each patient to ensure optimal stimulation of the ovaries, best possible egg yield and subsequently the highest number of good quality embryos and highest pregnancy rate. Sometimes changing the protocol is better for women than to continue with a protocol that is less productive and associated with low pregnancy rate. The talent, care and experience of reproductive endocrinologist is central to selection appropriate stimulation regimen

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Fertility Treatment Options

Fertility Treatment Options

Fertility Treatment Options: What Are Infertility Treatments?

 

 

Following detailed fertility investigation of the male tubal and ovarian factors, patient and her reproductive endocrinologist decide together on the optimal fertility treatment options.

Factors to consider in selecting the best fertility treatment options include:

Sperm source

  1. Is there a male partner: if so what is the ejaculate volume, sperm concentration, motility and shape? if >10 million moving sperm then pregnancy through intercourse or IUI is possible. Lower numbers indicates IVF or ICSI. If azospermia (no sperm in the ejaculate) then surgical sperm retrieval may be needed (TESE) or donor sperm can be used.
  2. If there is no male partner: anonymous or known donor sperm is used

Tubal Factor

  1. Open fallopian tubes allow for natural conception or IUI.
  2. Blocked fallopian tubes require IVF. Sometimes tubes can be fixed using tubal surgery.
  3. Blocked and dilated fallopian tubes (Hydrosalpinx) require surgical removal of the dilated tubes followed by IVF. Dilated tubes are very difficult to fix and can leak fluid into the uterine cavity and prevent implantation of the embryo.

Ovarian Factor

  1. Women who do not ovulate due to polycystic ovary syndrome  (PCOS): ovulation can be induced using oral medications (clomid or letrozole) or injection medications  (gonadotropins). This is usually combined with IUI.
  2. Women who do not ovulate due to defect in the master gland in the brain (Hypothalamic amenorrhea): ovulation can be induced using injection medications  (gonadotropins). This is usually combined with IUI.
  3. Women diminished ovarian reserve and unexplained (idiopathic) infertility commonly have lower quality eggs and may benefit from inducing multiple ovulation followed by IUI or IVF, to increase the chance that one of the eggs is healthy (chromosomally normal).

Donor Eggs

  1. Donor eggs are needed in women with low egg reserve that fail multiple IVF cycles after menopause or those who carry some genetic abnormalities.
  2. Donor eggs can enable same sex male couples parent a child (together with a gestational carrier).

Gestational carriers

  1. Gestational carriers enable women to parent a child if the uterus is absent or was removed due to a disease e.g endometrial cancer or if the lining of the uterus is damaged e.g intrauterine scarring due to prior scrapping.
  2. Gestational carrier enable women who cannot get pregnant to parent a child e.g history of breast cancer
  3. Gestational carriers enable same sex male couples to parent a child.

Genetic analysis of the eggs or embryos (PGD)

  1. Women and men with risk of conceiving a child with a specific genetic disorder e.g cystic fibrosis, sickle cell anemia should consider testing their embryos before transfer into the uterus (PGD)
  2. PGD can also be used for selecting the sex of the baby for family balancing.
  3. PGD can be used to test the chromosomes of the embryo to increase the chance for pregnancy in women select women but its efficacy for that purpose is still being investigated.

Fertility Preservation

  1. Women at risk for diminished fertility due to a medical problem or treatment e.g breast cancer can freeze their eggs or embryos to use later
  2. Men at risk for azospermia due to genetic factors, cancer and cancer treatment can freeze sperm for use later
  3. Many other techniques for fertility preservation can also be applied to adults and children to preserve reproductive organs and tissue.

 

Many fertility treatment choices exist to help women and men conceive a child. One or more of these methods can be tailored to each

i. individual circumstances:

singles women or men,

heterosexual couples or

same sex couples.

ii. reproductive aim:

wants to get pregnant now versus later,

wants one child only or accepts twins,

wants to conceive a child of certain sex,

will use own uterus or a gestational carrier,

will use own gametes- sperm or egg or donor gametes.

 

To learn more about  fertility treatment options please visit nycivf.org

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