Taking The Birth Control Pill Prior to IVF: Does It Compromise Outcome?

16 Jul
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It is often stated that it is not a good idea to take birth control pills (BCP) before starting controlled ovarian hyperstimulation (COH) for IVF, the reason being that it will suppress follicle development, prolong the cycle of stimulation and compromise egg/embryo quality. This is not accurate because it is only half of the story.

It is a fact that if a woman goes directly from a BCP to COH, without overlapping the last few days on the pill with a GnRH agonist (GnRHa) such as Lupron, Nafarelin, or Buserelin, the stimulation will very often be compromised. However, this is NOT the case if GnRHa is given for the last 4-6 days on the BCP prior to commencing ovarian stimulation with gonadotropins….and here is why:

Towards the end of a natural ovulatory cycle, starting a few days prior to menstruation, the corpus luteum (the structure that produces estrogen and progesterone after ovulation) starts to fail. This is associated with a rise in blood levels of follicle stimulating hormone (FSH) which in turn triggers the final process of egg recruitment and development of antral follicles, in preparation for use in the upcoming cycle. Without such FSH triggering, egg and follicle preparation is more likely to be compromised.

Administration of a birth control pill (BCP) suppresses FSH release by the pituitary gland, blocks ovulation and thus prevents formation of the corpus luteum. Accordingly, when a woman is on BCP and immediately begins COH with gonadotropins upon menstruation following discontinuation of the pill, she would be initiating ovarian stimulation without having completed egg recruitment and antral follicle development. As a result, follicular response to COH will usually be delayed and blunted. In the process, follicle and egg development is often compromised and the length of the ovarian stimulation cycle is prolonged significantly. Perhaps now it will be appreciated why starting ovarian stimulation coming directly off the BCP is less than ideal.

In my view, it is not only acceptable, but even ideal to take the BCP for at least one cycle prior to starting COH in preparation for IVF. Doing so allows one (without prejudice) to better plan and time cycles of IVF. Furthermore, since the BCP also suppressed LH, it is often especially advantageous in older women, in women with diminished ovarian reserve and in those with PCOS (in whom high LH levels can compromise egg/embryo quality). However, when women undergoing IVF launch their treatment cycles with a BCP, it is imperative to overlap the BCP with GnRHa for several days prior to menstruation and initiation of COH. The reason for this is that preceding GnRHa administration, the pituitary gland expunges FSH, which upon reaching the ovaries, serves to prepare eggs and antral follicles for the upcoming ovarian stimulation with gonadotropins. Simply stated, the combined use of BCP/GnRHa prepares the ovary for COH by supplanting the natural stimulus for FSH release that would otherwise occur with a failing corpus luteum.

The message is that the use of a BCP to set up a cycle of IVF should always include overlapping with a GnRHa for a few days before the stimulation begins. If this is done the BCP will NOT suppress or compromise response to COH.

211 Comments

  • Laura says:

    Dear Dr Sher,

    First of all thank you for your clear and insightful information. I’ve been reading on your website with great interest and find so much information that I was looking for, and more. I’m following a long down regulation protocol: 21 days of BCP, last 7 seven days overlapping with Decapeptyl, on 3rd day of menses start Menopur 225 ie a day and continuing Decapeptyl. My AMH is 3, FSH 7, LH 5 and i’m 38 years old. I have one failed IVF/ICSI (flare protocol), with 11 eggs, 4 fertilised, 3 made it to day 5, but 2 of them were not viable, one was transferred, but was still pre-stage blast. All 4 embryo’s were slow growers. Since if been reading on the negative effect of the flare protocol on egg quality i’ve requested a long down regulation protocol, and because my eggs weren’t evenly growing we started the cycle with bcp. Today i’m on day 14 of my bcp and I should be starting with Decapeptyl (according to the schedule i found on the internet, i didn’t get one from my hospital), but unfortunately I fell asleep early yesterday when i was reading in bed, and because of that i forgot my bcp. This morning as soon as i remembered i took the missed pill, 10 hours late. My question is: do the the fluctuating levels of hormones due to the late intake of the bcp have an effect? Especially since I’m supposed to start the decapeptyl tonight. And is it advisable to take another week of bcp so the hormones are in balance again, and start then with the decapeptyl? I’m a bit afraid that taking the BCP longer than 21 days will over supress my ovaries. I hope you can help me with my questions. Since the hospital isn’t very familiair with the protocol i’m in doubt what to do. Thank you so much for your time and interest!! Have a lovely day, kind greetings from the Netherlands.

    • Geoffrey Sher says:

      Thank you for connecting! I am updating my entire blog, so kindly-go to http://goo.gl/4hvjoP and re-post your question/comment there, and I will respond promptly. Henceforth I will be responding on that site.

      Thank you.

      Geoff Sher

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