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      • Use of the Birth Control Pill Prior to IVF Ovarian Stimulation: Does it Suppress Response and/or Compromise Egg/Embryo Quality?

      Dr. Geoffrey Sher Recommends

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      All too often, I hear of women (even young ones) who are prescribed the birth control pill (BCP) or receive prolonged estrogen therapy as a “lead in” to controlled ovarian stimulation (COS) for IVF that go on to experience slow and/or poor follicular development, and low numbers /poor quality eggs / embryos. In many cases, this is ascribed to the BCP having a suppressant (dampening) effect on ovarian response to stimulation. But that is an erroneous assumption; it is not the whole story.

      In fact, in most such cases further inquiry will reveal that the woman went directly from such hormonal treatment into a cycle of ovarian stimulation without having first received a GnRH agonist (GnRHa) such as Lupron or Superfact for 4-6 days prior to menstruation. Herein usually lies the root of the problem.

      You see, in non-pregnant ovulating women, a physiologic rise in blood FSH takes place about 4-6 days prior to menstruation. This is an essential prerequisite for proper recruitment of antral follicles (AF), without which subsequent FSH-induced follicle growth and development might be delayed, or may not occur in an orderly fashion. The BCP or prolonged premenstrual estrogen administration invariably suppresses pituitary production of FSH (and also LH). As a result, antral follicle development is often compromised. This problem can only be overcome by withholding use of the BCP/estrogen or by causing FSH to be released while on the BCP by administering GnRHa (overlapped with the BCP) for several days prior to menstruation.

      In my opinion, the overlooking of this important consideration is what has led to the erroneous belief that the BCP suppresses response to COS. Unfortunately too many women (often to their own detriment) are taken directly from menstruation that follows withdrawal of the BCP/prolonged estrogen treatment, to COS without such a GnRHa overlap, only to end up with slow and disorderly follicle growth, compromised egg development and poor embryo quality.

      Notably, this concern does not apply in cases where, coming off regular non-hormonally treated ovulatory cycles, GnRHa down-regulation is initiated about 5 days prior to menstruation or COS. In such cases, the physiological premenstrual rise in FSH will promote orderly antral follicle development.

      Thus the adage that use of the BCP or sustained premenstrual estrogen therapy hinders follicle and egg development is completely erroneous. In fact, quite to the contrary, it can offer distinct advantages to patients as well as to the treating IVF team. Here is how :

      By lowering LH prior to COS, it reduces sustained stromal (thecal) production of androgens (testosterone and androstenedione). The latter, if produced in excess (as in often the case with older women, women with diminished ovarian reserve, and those with PCOS) might otherwise compromise follicular growth and egg quality.
      By shortening or lengthening the cycle prior to COS, it allows for precise timing of the IVF cycle. This, without any real negative effects, allows cycles to be conducted and, at the same time, facilitates proper cycle “batching” to the convenience and cost-effectiveness of the IVF program.
      There are certain situations where use of the BCP might increase risk to the patient. These include a history of thromboembolism, a hereditary clotting defect (i.e., thrombophilia), obesity, severe diabetes, lupus erythematosus etc. Such conditions might either preclude use of the BCP altogether or necessitate that antithrombotic drugs (e.g., aspirin, coumadin’s etc.) be added to the treatment regimen. Clearly this decision requires a very careful assessment of the risk/benefit ratio.

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      25 Responses to “Use of the Birth Control Pill Prior to IVF Ovarian Stimulation: Does it Suppress Response and/or Compromise Egg/Embryo Quality?”

      1. Tina says:
        April 15, 2012 at 5:33 am

        Hi, If I ovulated while taking the pill and lupron will this lessen the effect on outcome of my cycle? Does this change anything at all.

        Thanks,
        Tina

        Reply
      2. Tina says:
        April 15, 2012 at 10:30 pm

        Thanks:)

        Reply
      3. Maria says:
        September 21, 2012 at 8:31 pm

        So what happens to people who want to do IVF and are not able to take pills for whatever reason?

        Reply
      4. Kristy says:
        October 13, 2012 at 11:39 am

        If I was Rx’d BCP without the pre-menstruation Lupron, but was put on antagonist protocol, could that have affected my previous cycles? I am 40 and have had 2 IVF cycles this year and my doctor said I was a poor responder. The BCP was Rx’d to coordinate timing of my menstruation cycle since travel was included.

        Reply
        • Geoffrey Sher says:
          October 14, 2012 at 10:27 pm

          It could well, but I would need much more information to comment properly.

          Consider calling 800-780-7437 or 702-699-7437 to arrange a telephone or Skype consultation (free of charge to those who reside in the United States or Canada). While an audiovisual (Skype) interaction is much more personable and preferable than a discussion by telephone, either will suffice.

          Please go to http://www.IVFauthority.com and when you get to the home page find the “search bar” in the right hand column. Type in the following subjects into the bar and it will take you to all the relevant articles I posted there.

           “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
           “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
           “Agonist/Antagonist Conversion Protocol”
           “Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)
           “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
           “A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)

          Please consider calling 800-780-7437 or 702-699-7437 to arrange a telephone or Skype consultation (free of charge to those who reside in the United States or Canada). While an audiovisual (Skype) interaction is much more personable and preferable than a discussion by telephone, either will suffice.

          Geoff Sher

          Reply
      5. lana2020 says:
        October 14, 2012 at 7:55 pm

        I am a low responder. My fsh is 8 and I am 33 years. When I use BCPs my FSH went to 10 or 12 and last cycle I was on BCP for three months and my FSH went to 18!!!!
        When I stop taking any medicine and my period come my FSH was 10 then 8!!!
        AMH is 1.77. Stay always the same.
        I only get 5 to 7 eggs mature when I went with short protocol without BCP but If they used long protocol I had 4 to three mature eggs.. The qualiy always good.
        I am claim BCP for being bad responder. What do you think?

        Reply
        • Geoffrey Sher says:
          October 14, 2012 at 10:19 pm

          Hi lana,

          i would need a great deal more information to comment constructively. I can tell you that the BCP cannot increase your FSH. It will lower it. Also the highest FSH is the one we look at and quite frankly the way you have responded suggests that this is the case with you too. Your AMH is the outlying result. I would like to know what the normal AMH range is in the lab that measured it. Either way I would repeat the AMH. I strongly suspect that the protocol for ovarian stimulation needs to be strategically individualized in your case. Given that you likely have diminished ovarian reserve (which is gets progressively worse over time) you should seriously consider “Staggered IV” with Embryo banking” (see below).

          Please go to http://www.IVFauthority.co and when you get to the home page find the “search bar” in the right hand column. Type in the following subjects into the bar and it will take you to all the relevant articles I posted there.

           “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
           “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
           “Agonist/Antagonist Conversion Protocol”
           “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
           “A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
           “IVF success: Factors that influence outcome”
           “Staggered IVF”
           “Embryo Banking”

          Consider calling 800-780-7437 or 702-699-7437 to arrange a telephone or Skype consultation (free of charge to those who reside in the United States or Canada). While an audiovisual (Skype) interaction is much more personable and preferable than a discussion by telephone, either will suffice.

          Geoff Sher

          Reply
          • lana2020 says:
            October 16, 2012 at 9:21 am

            THanks so much. My AMH level was 1.74 in US standard. I had problem with FSH which is always change from month to month between 8 to 16!!
            I did long protocol on 2009 with 300IU and I get 7 eggs and 5 embryos. Short protocol on 2010 I had same result but more follicles!!!
            last month I did Gainrelex protocol and 13 follicles and 8 mature but bad quality and I was on 450 IU gonal F and 375 Menapoure.
            Now my RE need to try MIcroflare protocol. Can I have natural cycle with this protocol without BCP ?!
            However, I had three natural pregnancy witout any problem. I am trying IVF with PGD for gender selection because all three kids are girls with C-section.

            What do you think?

            Reply
            • Geoffrey Sher says:
              October 16, 2012 at 2:37 pm

              I personally am not very enthusiastic about microflare protocols. This is explained in the article “An Individualized approach to Ovarian Stimulation for IVF”, elsewhere on this site.

              Geoff Sher

              Reply
      6. Birdy says:
        October 17, 2012 at 11:34 am

        Hi,
        thank you for your artcle. I am just getting prepared for IVF and now I am wondering… my doctor put me on progesteron on day 20-27 of previous cycle, and planned to start with hormon injections on day 2 of the IVF cycle. No Lupron in between or overlapping with hormon injections is planned…my first trial with this approach (premesntrual progesteron) resulted in no follicles at day of menstruation (first time ever!). After reading your article, could this be due to reduced follicle development due to permenstrual progesteron treatment? I would be not surprised….

        By the way, I am 40, and have low AMH (0.6), but regular cycle and good response to stimulation. Usually a good amount of follicles develop..

        Thanks for your answer in advance!

        Reply
        • Geoffrey Sher says:
          October 17, 2012 at 3:37 pm

          You could be correct. However, I would much prefer to review your medical records with you in order to provide a more informed opinion.Consider calling 800-780-7437 or 702-699-7437 to arrange a telephone or Skype consultation (free of charge to those who reside in the United States or Canada). While an audiovisual (Skype) interaction is much more personable and preferable than a discussion by telephone, either will suffice.

          Might I suggest that you go to the home page on this blog (www.IVFauthority.com) and when you get to there, look for a “search bar” in the upper right hand column. Type in the following subjects into the bar and it will take you to all the relevant articles I posted there.

           “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
           “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
           “Agonist/Antagonist Conversion Protocol”
           “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
           “A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
           “IVF success: Factors that influence outcome”
           “ Use of the birth control pill in VF”

          Sincerely,

          Geoff Sher

          Reply
      7. Corry Bleath says:
        October 31, 2012 at 5:45 pm

        Thanks much for this article because I too felt like BCP slows the floicle growth. And I greatly appreciate you diligently responding to questions.

        My doctor, has recommended me to take BCP after the menstruation for 10 days before I start my medication leading to egg retrieval (because one of my blood test result will not arrive on time and I don’t want to wait for another two months). Will BCP after menstruation before medication be a problem?

        Reply
        • Geoffrey Sher says:
          October 31, 2012 at 9:35 pm

          Please go to http://www.IVFauthority.com and when you get to the home page find the “search bar” in the right hand column. Type in the following subjects into the bar and it will take you to all the relevant articles I posted there.

           “Use of the birth control pill in IVF””
           “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
           “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
           “Agonist/Antagonist Conversion Protocol
           “Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)
           “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
           “A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)

          Consider calling 800-780-7437 or 702-699-7437 to arrange a telephone or Skype consultation (free of charge to those who reside in the United States or Canada). While an audiovisual (Skype) interaction is much more personable and preferable than a discussion by telephone, either will suffice.

          Geoff Sher

          Reply
      8. 2girls says:
        January 9, 2013 at 10:01 am

        Hi i have a question.my amh came back really high at 14.i am 27 years old mother of two kids going for ivf for boy.

        my DR has put me for bcp for 43 days then lupron 10 units for 5 days and 5 units for 15 days.dexa 0.75 mg for 20 days and gonal f 150 units for 3 days and gonal f 75 units for 4 days.

        what do you think about my protocol

        Reply
      9. saanya21 says:
        February 20, 2013 at 9:54 pm

        If somebody has an AMH of 14 .no infertility two kids .going for sex selection.

        how long should i take bcp prior to cycle.i will be cycling after 3 months (for my protocol i have to take for 40 days for sure) but.my nurse is suggesting to continue it for 3 months but i am afraid of continuing for so long.what do you suggest?

        Reply
      10. lucy says:
        April 30, 2013 at 8:43 am

        Hi Dr Sher,

        I have a diminished ovarian reserve and am going to IVF#2.
        My Dr. prescribed BCP + growth hormone (seizen)to be taken at the same time, does this make any sense?
        My question is if the follicles that I have when starting the BCP will be the same to be stimulated by hormones later? Or once I have my menses after the BCP will it be a new group of follicles?
        Thank you in advance for any insight.

        Reply
      11. alma says:
        May 3, 2013 at 7:11 pm

        Hi Doctor Sher,

        If you take BCP for 3 weeks what is supposed to see at an ultrasound on day 3 after stopped BCP? I mean do you need to see the follicles or not ?
        Thank you

        Reply
      12. UpNorth says:
        May 13, 2013 at 2:23 pm

        Hi there,

        Thank you so much for your amazing & insightful articles. I’ve spent days reading your publishings and am much more educated thanks to the time spending posting this info. However, I am now a bit concerned with my first upcoming IVF cycle!

        I am 33 and TTC #1 since 2010 with no known issues. We recently lost our first son (natural pregnancy) in the 2nd trimester due to chromosomal issues and are now moving to IVF with PGS even though that was thought to be a “fluke”. My highest FSH has been 8.23 (back in early 2011), AMH last July was 5.57. My LH was double FSH once but typically is about 1:1 with LH (e.g. LH 8-FSH 6.89 last September).

        Anyway, I am ready to get the ball rolling and just received my IVF calendar last week but all of my new “knowledge” has me a bit worried and I’m wondering if it is justified. I’m waiting for my cycle to start later this week and then I will go in for day 3 bloodwork and start BCPs. My schedule only has me on BCPs for about 8 days (assuming my cycle starts on time) ending on 5/25, baseline 5/28, 225 IU Follistim & 150 IU Menopur starting 5/30. They will tell me when to start Ganirelix. No Lupron. My clinic obviously batches cycles.

        I haven’t seen this “fast” of a cycle before but of course I am very new to all of this. I have never had a hard time stimulating to clomid and my BMI is about 18.5 (5’7″, 115lbs). My concern is will this type of protocol decrease my egg quality before they really have a shot? After what happend to our son, I am very nervous about egg quality and have been taking various supplements since mid-March to improve any issues (e.g. CoQ10, L-Arginine, Inositol, etc). I would hate for all of this to go to waste if the protocol is not a good one! Does that protocol seem OK?

        Reply
        • Geoffrey Sher says:
          May 13, 2013 at 6:18 pm

          My only concern is going on to stimulation coming directly off the BCP. Please read the article entitled “Use of the Birth Control Pill in IVF” elsewhere on this blog and you will see why…..

          Geoff Sher

          Reply

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      Why Did My IVF Fail? Part 2 – Uterine Receptivity and Transfer Technique
      This is the second part of a two-part post on IVF failure. In my January 22nd post, I discussed what I often refer to as the “seed” variable in the “seed/soil” relationship – the embryo. This week’s post will address the “soil” variab... more
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      My IVF Cycle Failed – What Went Wrong? Question #19: Why Do I Keep Having Chemical Pregnancies and Miscarrying?
      This is the 19th in a series of answers to common questions about failed IVF. Early pregnancy loss – whether due to miscarriage or chemical pregnancy – is due to two major factors. In more than 70-80% of cases the cause is attributable to... more
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      My IVF Cycle Failed – What Went Wrong? Question #18: My Fertility Clinic Reports a High Success Rate – How Could I Have 2 Failed Cycles In A Row?
      This is no. 18 in a series of answers to common questions about failed IVF. While it is true that IVF failure can be due to preventable factors, it is as important to understand that optimal medical care does not always equate with an optimal outcome... more
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      My IVF Cycle Failed – What Went Wrong? Question #17: Why Didn’t I Get Pregnant When I Used a Young Egg Donor and Had Good Quality Embryos?
      This is #17 in a series of answers to common questions about failed IVF. For women whose advancing age and/or ovarian resistance make having a baby with their own eggs unfeasible or unlikely, IVF using donated eggs from a young donor (under 35 years)... more
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      My IVF Cycle Failed – What Went Wrong? Question #16: Why did my hCG levels stop rising properly?
      This is the 16th in a series of answers to common questions about failed IVF. Immediately following implantation, the root system (trophoblast) of the embryo begins to release the pregnancyhormone, human chorionic gonadotropin (hCG) into the surround... more
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      My IVF Cycle Failed – What Went Wrong? Question #15: Might My Mental State Have Played a Role?
      This is the 15th in a series of responses to common questions about failed IVF There is little doubt that stress and emotional lability plays a role in the normal physiological/hormonal regulation of the menstrual cycle.After all, Eskimos often stopp... more
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      My IVF Cycle Failed – What Went Wrong? Question #14: Could it Have Been Due to Inadequate Hormonal Support After the Egg Retrieval & Embryo Transfer?
      This is the 14th in a series of answers to common questions about failed IVF. In vitro fertilization establishes an abnormal hormonal environment in the uterus.In some cases (especially older women and those with a diminished ovarian reserve), high o... more
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      My IVF Cycle Failed – What Went Wrong? Question #13: Did the Number of Embryos I Had Transferred Play a Role?
      This is the 13th in a series of answers to common questions about failed IVF. Virtually everyone recognizes that pregnancy with multiples (especially triplets or greater) is associated with a high incidence of premature delivery that has serious cons... more
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      My IVF Cycle Failed – What Went Wrong? Question #12: Might the Timing of Embryo Transfer – Day 2-3 (Cleaved) vs. Day 5-6 (Blastocyst) Play a Role?
      This is the 12th in a series of answers to common questions about failed IVF. (Note: I’ll be hosting a live video chat on Aug. 2 on the topic of Failed IVF where I’ll discuss the issues addressed in this series of posts and take your ques... more
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