Treatment: Undergoing Controlled Ovarian Hyperstimulation
Treatment: Undergoing Controlled Ovarian Hyperstimulation
IVF success rates are dependent upon the number eggs which can be coaxed to maturity and fertilized in order to become healthy embryos available for transfer. While undergoing IVF, you’ll be given fertility drugs for two reasons: (1) to enhance the growth and development of ovarian follicles in order to produce as many healthy, mature eggs as possible and (2) to control the timing of ovulation so that your eggs can be surgically retrieved before they are ovulated. If you have previously been treated with fertility drugs, your regimen will be largely based upon your most recent response to treatment. If however you are going to be receiving gonadotropins (fertility promoting hormones) for the first time, the dosage and regimen will be determined by tests for “ovarian reserve” including FSH and E2 levels, and sometimes other tests like Inhibin-B concentrations on the 3rd day of a preceding menstrual cycle. Another test which is gaining popularity is Anti-Müllerian Hormone (AMH).
In most cases, you’ll begin your treatment cycle by taking oral contraceptive birth control pills (BCP) for 6 to 30 days before initiating daily injections of GnRHa (e.g. Lupron, Nafarelin, Buserelin, Synarel). Think of this as a resting period for your ovaries – like a runner before a big race. Both the BCP and Lupron are administered together for an additional 4 to 6 days, whereupon the BCP is withdrawn while daily Lupron injections are continued. Alternatively, Lupron may be supplanted with a GnRH Antagonist (Ganirelix, Cetrotide, Cetrorelix, Orgalutron), 125mcg IM daily, from the onset of menstruation up to the day of hCG administration. Menstrual bleeding will usually follow about 3 to 7 days after stopping the BCP. In this way, it is possible to accurately plan the onset of your menstruation by varying the length of time on the BCP. We are then able to schedule your cycle of IVF effectively. Additionally, the combined use of BCP and Lupron reduces the risk of Lupron-induced ovarian cyst formation, minimizing the chance of cycle delay or cancellation.
Soon after menstruation begins, your plasma E2 will be measured to confirm that it is less than 70 pg/ml; this will confirm that you’re ready to initiate ovarian stimulation with gonadotropins. If your E2 level is greater than 70 pg/ml, Lupron therapy will be continued at the same or possibly an increased dosage for a few more days, and a follow up blood test will be performed. Failure of the E2 to fall below 70pg/ml is an indication for a pelvic ultrasound to check for an ovarian cyst. If present, an ovarian cyst needle aspiration may be needed before the cycle can proceed.
Daily suppression of ovulation will be continued while you begin a specified regimen of hormones to stimulate your ovaries with gonadotropins. The goal will be to promote egg development while also preventing egg release. There are a host of other ancillary treatments that may be added to support the success of your cycle. These include:
- A prenatal vitamin to give the developing egg, and later the embryo, all of the nutritional support necessary for growth
- Dexamethasone, a hormone to suppress your immune system, is given to improve the survival of an embryo after it is transferred
- Estradiol (injected, administered vaginally, or applied transdermally) may be recommended if you’ve got a history of poor response to gonadotropins
- Viagra (and similar medications) may be used to improve blood flow to the uterus if there is a history of certain uterine factors contributing to your infertility
- Folgard (folic acid) is a medication often prescribed to women with certain inherited risk for blood clot
- Heparin and/or intravenous immunoglobulin (IVIG) may be prescribed for immunologic factors that could be contributing to your infertility
- Progesterone may be prescribed to support embryo implantation
- Antibiotics are often prescribed to prevent infections following the embryo transfer
- Human chorionic gonadotropin (hCG) is the hormone used to trigger your eggs to complete their maturing process-the last step before egg retrieval
- Intralipid infusion is a relatively inexpensive synthetic substance that suppresses NKa and, pending outcome of ongoing trials, could ultimately replace IVIG.
More about individualized protocols for Controlled Ovarian Hyperstimulation (COH)
For an in-depth discussion of various types of fertility medications and an overview of basic protocols, refer to our book, IVF: The SIRM Way or contact your nearest SIRM office for a consultation with an SIRM physician
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