Stimulation Protocols

Dr. Mohammed Walaa ElDeeb

Oral medications:

• Clomiphene citrate (clomide)

• Tamoxifene (Nolvadex)• Cyclophenil• Aromatase inhibitors ( Femara)

Intact hypothalamic

pituitary ovarian

axis

Dose:( Clomid )• 50- 150 mg/day• 5-7 days• Days 2-5 of the cycle.

Adjuvant drugs:• Metformin• Acetyl cysteine• Oestrogen

Advantages:• cheap• rare side effects &

complications: blurring of vision OHSS Multiple pregnancy

Disadvantages:• Cervical mucous• Endometrium• No. of follicles

Injections:Urinary:hMGuFSHBoth have LH activityIM or subcutaneous depending on

degree of purification. 75 IU- 150 IU/ amp.

Recombinant:• rFSH• No LH activity• Subcutaneous• 75,100,150 IU/amp

Ovaries with good ovarian reserve

• FSH & E2 cycle day 3

• AFC antral follicle count cycle day 3

• AMH any day

• Ovarian volume

Regimens

No Down Regulation• Start day 2-3 of the cycle• Dose: 75-300 IU/day depending on:

Ovarian reserveAgePrevious responsePCOs

Monitor by:• TVUS• Serum E2Usually • 8-10 days • one or more follicle >17 mm • hCG 10,000 IU Luteal support:• No need.• Or micronized progesterone.

Down regulation:• COH for ART: IUI, IVF, ICSI• Benefits:

– Prevent premature LH surge.– Better quality of oocytes.– Scheduled oocyte pickup.

• Starts at least 5 days before expected date of menses.( Long Luteal )

• 1st day of menses.( Long Follicular )• Long acting GnRh agonist• Short acting GnRh agonist daily dose till hCG

day.

Down regulation:• E2<50 pg/ml• Dose: 225-300 IU/day• Monitor with TVUS & serum E2• Adjust the dose: ↑or ↓ after 4- 5 days.• 3 follicles or more > 17 mm• Stop agonist• hCG 10,000 IU• OPU 34-36 hours after hCG• IUI 36-48 hours after hCG.• Luteal Support

OOCYTE RETREIVAL

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 26 27 280

10

20

30

40

50

Days

FSH,

LH P

LH

FSH

E2

Sel

ectio

n

Dom

inan

ce

Ovu

latio

n

Corpus LuteumRec

ruitm

ent

E2, P

Long protocol:Stimulation day 6

tripple line endometrium 7 mm

Long protocol:Stimulation: day hCG

tripple line endometrium 9 mm

Long protocol:Stimulation: day hCG

early secretory endometrium

Long luteal protocol

Antagonist protocol:• Start hMG on day 3 of menses.• Antagonist when follicle reach 14-15 mm

– Long acting ( single injection )– Short acting (Daily usually 3-4 injections).

• hCG 10,000 when 3 or more follicles > 17mm

• OPU 34-36 hours • Luteal Support

Antagonist protocol

Short Protocol( Flare up )

• Agonist 2nd day• hMG 3rd day• Usually 9 – 10 days• 3 0r more follicles > 17 mm• hCG 10,000• Luteal Support.

Short ( flare up ) protocol

Poor Responders

• 3 or less follicles• What to do?1- short protocol (flare up protocol)2- Antagonist protocol.3- No down regulation4- COCpills + short protocol5- Comiphene citrate

Protocol for poor responders

4- Adjuvant treatment: • Growth hormone• Combined oral contraceptive pills

• Clomiphene citrate.

Ovarian HyperStimulation

Syndrome:• Pridection History PCOS High AMH

During monitoring:

–E2 > 4000 pg/ml–No of follicles.

What to do:–Soft protocols.–Coasting–Metformine–Cabergolin–Antagonists–Cancellation (no hCG)–No ET

• Ultra short, highly economic and effective protocol for ICSI patients.

• El Deeb M.W, Sami S, Sallam A, Ismail E, Mohsen E, Darwish Y, El Sharaki A.

• INTEGRATED FERTILITY CENTER, ALEXANDRIA, EGYPT.

Keeping things simple without altering success rate of ICSI is the idea behind our novel protocol. This simple protocol aims to reduce the burden of ICSI procedures and its related complications, thereby giving a couple the chances to conceive using procedures less costly in terms of physical, emotional, social and financial costs.

We had 65 cases underwent ICSI, their age ranges from (23-47) years. Clomiphene citrate (CC ),3 tablets daily started from the second day of the cycle for 5 days, In the last day of CC administration HMG was given in the form of 2 amps of Menegon 75 (Ferring) or Merional 75 (Ibsa) + 2 amps of Gonal F 75 ( Merck Serono) , till we reach one or more follicles > 16 mm. E2 is measured.

Next day early morning one amp. Of Cetroide 0.25 mg. and the full HMG dose was received… HCG 10,000 was administrated when one or more follicles > 18 m.m as usual.

Average number of oocytes retrieved ranges from (2-25) oocytes, number of embryos transferred (ET) ranges from (1-5) embryos, only one case had no ET. We had 25 pregnant cases 38.4 % five of them had blastocyst transfer.

These encouraging results of this highly economic protocol should be put in consideration as a simple and successful ICSI protocol.

Thanks for your attention