Latest Protocol for IVF stimulationDr. Priyanka Rani

• We need a large number of good-quality eggs from the female in order to maximize success rates with in vitro fertilization. During the egg retrieval procedure, we usually strive to collect between 10-18 eggs.

• The number of eggs retrieved correlates with IVF success rates.

• Several ovarian stimulation drug procedures are used to "pump up" the ovaries so that they produce adequate follicles and eggs. Without hormonal stimulation, the ovaries produce and release only one mature egg per menstrual cycle (month).

• Injections of follicular stimulating hormone - FSH - are routinely used in stimulation regimens.

• Luteal Lupron treatment, often known as "long Lupron" or "agonist downregulation."

• Antagonist procedures including the use of GnRH antagonist drugs

• Flare and micro-flare protocols, also known as short Lupron protocols or short protocols are utilized for patients who are likely to respond poorly to ovarian stimulation.

One to suppress the LH surge and ovulation until the developing eggs are ready, another to suppress the LH surge and ovulation, and a third to suppress the developing eggs.

• Lupron is a GnRH-agonist (gonadotropin releasing hormone agonist).

• GnRH antagonists, such as Ganirelix or Cetrotide, are used toinduce the formation of numerous eggs.

HCG (human chorionic gonadotropin) (Gonal-F, Follistim, Bravelle, Menopur) to cause ultimate egg maturation

The ovaries are stimulated for 7-12 days with injectable FSH medicines until numerous mature size follicles have been produced.

The goal of ovarian stimulation for in vitro fertilization is to obtain 8 to 15 quality eggs during the egg retrieval procedure.

We do not want ovarian hyperstimulation, which can cause substantial discomfort for the lady and, in rare situations, result in ovarian hyperstimulation syndrome, or OHSS.

We have utilized a Lupron trigger in recent years to lessen or eliminate the risk of ovarian hyperstimulation syndrome.

Our 2014 study on the use of Lupron triggers to maintain high success rates while lowering the danger of hyperstimulation

We also don't want the ovarian stimulation to be insufficient, giving us only a few eggs when we could have gotten more by using larger pharmaceutical doses, etc.

In vitro fertilization can be effective even with a small number of eggs recovered, although success rates increase significantly when more eggs are recovered.

The infertility specialist doctor's job with ovarian stimulation is to:

• Choose an appropriate drug plan and dosing regimen.

• Keep track of the patient's stimulation progress so that drug dosages can be changed as needed.

• At the perfect time, trigger with hCG. Triggering too soon or too late diminishes success and can occasionally increase the risk of ovarian hyperstimulation (if triggered late).

• In vitro fertilization requires strict quality control throughout the entire process. We have increased quality control in our program by using highly specialized ultrasound technology.

• GE Voluson E8 ultrasound machine with a built-in computer to outline and precisely measure growing follicles is used.

• We discovered that this method is more precise and trustworthy than the traditional method, which is typically two-dimensional hand measurements.

• The machine's computer traces the follicular edges (in three dimensions). It then computes a volume for each of them. It computes an average diameter for each follicle based on the volume (as if it was a sphere).

• This technology provides us with more accurate and trustworthy measurements than we previously had.

• The three planes in a volume of data from one ovary are depicted in an ultrasound image. This patient is nearing the end of the stimulation, as evidenced by the presence of multiple follicles in the ovary. The higher left represents the sagittal plane, the upper right represents the transverse plane, and the bottom left represents the coronal plane. A 3-D view of the follicles can be found in the lower right corner (generated by the computer).

• We strive to induce the woman to produce at least four follicles measuring 14-20mm in diameter.

• Ideally, there should be at least 8 follicles ranging in size from 13 to 20 mm.

• The goal is to collect a sufficient number of high-quality eggs (8-15).

• Blood hormone levels and the size of developing follicles are measured.

• The follicles are measured by ultrasound (discussed above on this page)

• Blood levels of the oestrogen hormone are critical. Estrogen (actually estradiol) levels are typically less than 60 pg./ml at the start of a cycle and rise dramatically when numerous follicles form.

• Peak estradiol levels during IVF are typically between 1000 and 4000 pg./ml.

• The stimulation procedure typically takes 8-10 days. 

• When the oestrogen level and follicle measures appear to be optimal for a good outcome, the HCG injection is administered. The HCG injection is required to induce ultimate egg maturation.

• The egg retrieval is scheduled for 34-35 hours following the HCG injection, just before the woman's body begins to release the eggs (ovulate).

It is usually not difficult to obtain enough follicles to develop. However, the ovaries' reaction can be weak at times, resulting in a low number of developing follicles. The ability of the ovaries to stimulate well and produce a large number of eggs can be reasonably accurately predicted by an ultrasound test called the antral follicle count.

The minimum number of follicles required to proceed with in vitro fertilization
treatment is determined by several factors, including their size, the woman's
age, the results of previous stimulations, and the couple's and the doctor's
willingness to proceed with egg retrieval when there will be a low number of
eggs obtained.

In our experience, IVF success rates with fewer than three developed follicles are extremely low.

Some doctors would advise you to have at least 5 follicles that are 14mm or larger, while others may perform the egg retrieval with only one follicle. Most IVF programs in the United States require at least 3-4 mature (or close to mature) follicles.

Women with low antral counts, women over the age of 37, women with elevated FSH levels, and women with other symptoms of diminished ovarian reserve are more likely to respond poorly to ovarian stimulation.