How to Prepare for Ovarian Hyperstimulation
The process of controlled ovarian stimulation is a typical part of the IVF journey. Like any trip however, it requires careful planning and preparation. The steps taken before you begin promoting egg development are as important to your success as any other aspect of your IVF treatment. Here are some of the variations of preparatory steps.
Use of the Birth Control Pill With Ovarian Hyperstimulation
We virtually always start patients on a combined, low dose BCP for 7-21 days, to put their ovaries in a resting state. In fact, in older women (>40 yrs.), poor responders and women who have PCOS, we sometimes recommend that they take the BCP for 2-3 months before launching into a cycle of Controlled Ovarian Hyperstimulation. The purpose is to suppress endogenous LH as well as promote regular turnover of the endometrial cells. Contrary to popular belief, the use of the BCP does NOT diminish ovarian response to COH with gonadotropins, provided the BCP is synchronized with a GnRHa (e.g. Lupron) for a few days before initiating the stimulation. The GnRHa causes a brief surge in FSH release by the pituitary gland, thereby setting up the recruitment of follicles to be available in the stimulation cycle ahead.
When you are cycling naturally, a rise in FSH takes place as the corpus luteum begins to atrophy a few days before menstruation. This serves as a trigger that recruits follicles taking them to the antral stage in which form they become available for the ensuing cycle. Without an FSH trigger, no follicles are recruited in which case stimulation is more likely to fail. The BCP blocks ovulation and suppresses FSH and thus if a patient comes directly off the BCP and goes on to gonadotropin stimulation, she does so without optimally recruiting follicles – an invitation for a stimulation cycle to become a disaster. A proper response to stimulation with gonadotropins requires that recruited antral follicles be available and ready by the time COH commences.
Controlled Ovarian Stimulation of the Egg Provider
Controlled Ovarian Hyperstimulation is used to maximize the number of retrievable eggs for fertilization. The goal is to optimize the chances of a viable pregnancy. For women that do not have menstrual cycles (due to hysterectomy or endometrial resection), approximately 14 days after spontaneous ovulation occurs (as assessed by home ovulation test kit), she starts taking a birth control pill (BCP). About 8 to 20 days later a GnRHa is administered daily to prepare the ovaries. After 5 days of GnRHa, the BCP is stopped and the woman providing the eggs continues on the GnRHa for another few days, at which time daily blood estradiol (E2) measurements are done. Once the E2 is found to be less than 70pg/ml, the she is ready to receive gonadotropins. The exact timing is dependent upon when the surrogate (whose cycle has been synchronized) starts menstruating and reaches an E2 level of less than 70 pg/ml as well.
The female partner’s first day of gonadotropin injections is referred to as cycle day 2. On cycle day 9, the program would likely begin intensive daily monitoring by means of blood hormone measurements and ultrasound examinations. Usually, one-to-three additional days of gonadotropin therapy will be required. Once monitoring confirms that the female partner’s ovarian follicles have developed optimally, she is given an injection of the ovulatory trigger, hCG, at which time daily injections of GnRHa are discontinued. Her eggs are retrieved 34 to 36 hours after the HCG injection, by transvaginal ultrasound needle guided aspiration. This procedure is performed under anesthesia.