Ovarian Stimulation An overview BY Mohammad A. Emam Prof. of Obstetrics and Gynecology Mansoura Faculty of Medicine Mansoura Integrated Fertility center (MIFC) EGYPT

Indications Some cases of primary amenorrhea. Some cases of POF. Some cases of delayed puberty. Infertility ( anovulatory or ovulatory cycles).

Objective To highlight the rationale, philosophy and different protocols of ovarian stimulation in cases of infertility

First child, Louise brown 1978 was the product of ovulation in a sopontaneous cycle (Steptoe & edwards) First I.V.F pregnancy using ovarian stim. Was ectopic. Introduction

- Advantages of spontaneous cycle ovulation: Avoidance: - Endocrine abnormalities - Luteal phase defect (LPD) - Advantages of ovarian Stimulation : – Avoidance Low pregnancy rate (single pre - ovulatory follicle. –Avoidance Difficulty of monitoring a spontaneous cycle(need 24hs) –  oocytes   embryo  pregnancy. Ov. Stim. Vs Spontaneous cycle

Advances in Ov. Stim. Major advances in understanding of ovarian physiology. New medical technologies for management of infertility(GNRH analogue, self administered). New Monitoring techniques( TVS replace Laparoscopy). Simplifying procedure + improving results. Over the past decade (Triad):

Ovarian physiology Ovarian physiology Two roles – gametogenic – endocrine The gametogenic potential is established early in the fetus Endocrine role of the ovary is not realized until puberty

Physiological Key Points Each Month: 600 – 650 occytes are destroyed (Atresia)= (Apoptosis). Only one oocyte ovulate HOW?

Physiological Key Point Normally : A cohort of primordial follicles Continuously intiating follicular growth (Independent of Gn stim. = intrinsic mechanism) Preantral stage Need FSH in appropriate level Pre- ovulatory stage  E + FSH  FSH receptor content Dominant follicle  E  FSH  atresia of less developed foll.s Ov.Stim Disturb mechanism Many follicles

Philosophy of Ovarian Stimulation 1.Induction of a single dominant follicle. 2.Induction of small number of follicles (1-4). 3.Multiple follicular development (IVF&ICSI)

Factors guiding Ovarian Stimulation 1.Clinical circumstances( age,wt …..). 2.Aim: Office therapy + timed Sex.I. IUI IVF or ICSI. 3.Number of eggs needed.

Types of Ov. Stimulation 1.Induction of ovulation. 2.Superovulation. 3.Controlled ovarian hyperstimulation (COH).

Induction of Ovulation Use of medications to stim. Development of one (?) or more mature follicles in anovulatory cycles.Use of medications to stim. Development of one (?) or more mature follicles in anovulatory cycles.

Superovulation Production of many mature follicles in one cycle triggered by medication that stim. Ovaries early in follicular phase. Intentional

Controlled Ov. Hyperstim. (COH) Regulated Superovulation by turning off the patient’s own Hs (down regulation) followed by stim. 1.Multiple follicles growth. 2.Control timing of ovulation eggs can be surgically retrieved before they are ovulated. 3.Prevention of premature LH surge. Aim:

Drugs for Ov. Stim. cc Gonadotrophins: HMG highly purified ur FSH Rec. FSH Rec LH GnRH (pulsatile). GnRHa (intranasal-S.C- I.M) GnRHa (intranasal-S.C- I.M) GnRH ant (involved in final steps of oocyte maturation). GnRH ant (involved in final steps of oocyte maturation). HCG & Bromocripitine (!?) HCG & Bromocripitine (!?)

CC Competitive inhibitor of E2 blocks E receptor in hypothalamus. GnRH FSH & LH. Follicles After last tablet by one W: Freeing of hypothalamus receptors from blockage. Trigger LH surge (response to E2).

till day of cycle 1- long lasting(till day of cycle) 2-  subclinical pregnancy loss compared to normal population 3-  LH sec > FSH   miscarriage unexplained infertility 4-  (LUF)syndrome(unexplained infertility) cx &endometrium 5- Anti E(cx &endometrium) 6-  ectopic (tubal transport) nausea-vomiting-flush skin- hair loss 7- side effect : -Minor (nausea-vomiting-flush skin- hair loss) OHS Multiple pregnancy. Problems with (cc)

Unlike CC – Gn acts directly on the ovaries. Gonadotropins

Better batch-to-batch consistency. Steady supply. A purified compound. Well tolerated. No antibodies formation. Advantages of Recombinant Human Gonadotropins

-Is a deca peptide ( ten AA ). -Half life time is 8 min (10 min bursts every 60 min) -By selective A.A or ethylamide substitutions at 6 and/or 10 (Gly) postions. - -  affinity for GnRH receptors ( times). -  1/2 life to 5 hours. GnRH Synthetic Natural

Advantages Prevent the possibility of premature LH surges (as a result of  E in response to Gn)  cancealed cycles. Suppression of endogenous basal LH levels  recruitment of a larger cohort of follicles. Decrease LH stimulation of ovarian androgen production (may interfere with follicular development) Allow better timing of oocyte retrival &synchronise follicular growth. GnRHa

Routes: - Intranasal. - S.C. (Longer period + need higher doses Gn+ need more luteal support) - Depot (Longer period + need higher doses Gn+ need more luteal support) (Devreken et al,1996).Effect: - Agonistic (flare up) phase  LH & FSH. on continuous administration) - Down regulation (on continuous administration) Within two weeks). GnRHa

Chemically it is also a decapeptide with changing the aminoacid sequense at positions 1,2,3,6 and 10. When GnRH antagonist is applied for short period it leads to abortion of LH peak, diminished E2 production and impairment of follicular growth. GnRH Antagonist

How to induce a single dominant follicle?

Induction of a Dominant Single Follicle?! Induction ovulation protocol which mimic more closely the FSH threshold and window of the natural cycle?!. Low dose step down Gn. Stim. Regimen.

Low dose Step-down regimen Day 3 2 FSH/d 1½ FSH/d 1 FSH/d 3-4 amp. U/S & E2 Foll>11 mm U/S & E2 Foll>11 mm 2-3 days U/S hCG D7 FSH dose may be high or low: Need to dose. Need to dose. Need to dose by one ampoule.Need to dose by one ampoule. FSH dose may be high or low: Need to dose. Need to dose. Need to dose by one ampoule.Need to dose by one ampoule.

How to Obtain Small Number of Follicles (1-4)

1.CC. 2.CC ± FSH or ± HMG. 3.Gn. Standard step-up protocol. 4.Gn. Low dose step-up protocol. 5.Gn. Low dose step-up, step- down protocol. protocols

Unripe follicle Ripening follicle OvulationCorpus luteum Regression of Corpus luteum Clomiphene 100 mg day2 for 5 days Gonadotrophin stimulation from day 4 to day of HCG HCG Leading follicle > 18mm Oocyte mature 38 hrs

Standard Step-up Protocol Starting dose = 150 IU/day IfIf Follicle > 12 mm E2 > 400U Follicle > 12 mm E2 > 400U Continue 2 FSH/day Continue U/S and E2   3 FSH/day for 3 more days U/S and E2   3 FSH/day for 3 more days Endocrine Rev. 1997; 18: 71

Complications : Multifetal pregnancy (36%) OHSS (14%) Standard Step-up Protocol cont…

Low dose Step-up regimen It allows the FSH threshold to be reached gradually, minimizing excessive stimulation decreasing the risk of multifollicular response.

Low dose Step-up regimen Starting dose = IU/day IfIf Follicle > 12 mm E2 > 400US Follicle > 12 mm E2 > 400US Continue 1 FSH/day Continue no response  1.5 FSH/day for 1 more week (max. 3 amp.) no response  1.5 FSH/day for 1 more week (max. 3 amp.) Endocrine Rev. 1997; 18: FSH/hMG/day Day 3 Day 7 5 days

Low dose Step-up Step-down regimen one FSH/day Day 3 step-up till 14 mm foll. step-downstep-down hCGhCG

Multiple Follicular Development

Rationale of COH:Rationale of COH: FSHFSH To disturb the normal relationship between FSH&E  by increase FSH available to follicles other than the dominant follicle  increase total number of follicles that reach the pre ovulatory stage.

(transfer 2-3 embryo\ cycle)Production of sufficient number of very high-quality embryos (transfer 2-3 embryo\ cycle) Placement >3 :(  multiple pregnancy not  pregnancy rate)Placement >3 :(  multiple pregnancy not  pregnancy rate) for 2nd use & decrease number of stim. CyclesFreeze remaining embryos (for 2nd use & decrease number of stim. Cycles) Aim of (COH)

Complication of GnRHa (COH) Programes Transient neurological disturbances (6%). Ovarian cysts (14-29%). Multiple pregnancy. OHSS. Hypoestrogenic effect?! Short luteal phase.

suppressionLong (suppression):utilizes pituitary desensitiz. Short (flare –up) sequentialUltrashort(sequential): Modifications Shorter duration Lower doses difficult timing and program Protocols for Multiple Follicular Development - Microdose flare up. - Stop over technique (Norfolk protocols) - Step down regimen. GnRH antagonist.GnRH antagonist.

hCG 2 Luteal phase Downregulation 211 Embryo Transfer Oocyte Retrieval Cycle day hMG Ultrashort Protocol hMG G n RH-a hMG Flare Protocol Follicular phase Downregulation hMG G n RH-a

Pattern of Response to COH: FSH on cycle day3 (provided E2 < 50pg/ml)  Low responder (FSH>15 miu/ml)  Intermdiate responder (FSH miu/ml).  High ( FSH <10). Pre-Requisites for COH

Selection of Protocol According to Responders Long (luteal):  Good in intermediate & high responders. Short: (Flare up) protocol:  Good in poor responder. Winslow, 1991

Long Protocol Criteria of Pituitary Suppression  Serum LH< 2.  Serum Estradiol < 50 pg/ml.  Absence of ovarian cyst.  Transvaginal sonographic measurement of endometrial thickness of <6mm predicts pituitary down- regulation in over 95% of cases.

Directprogesterone substitutions Direct: (progesterone substitutions) 2x100 mgm supp. or micronized 3-6x100 (from day of embryo transfer). Indirect(HCG) Indirect: (HCG) - Hyperstim - False pregnancy test. Support of Luteal Phase

Protocols of GNRH Antagonist

Lubeckmultiple doses Lubeck ( multiple doses) (0.25mgS.C - 7th day of the cycle till the day of HCG). French: Single dose French: (Single dose) ( 2-3 mg as single or dual around day 9). NB: Another “soft protocol”= FSH + GnRH ant. HMG or FSH on day 2-3 of the cycle Two Protocols of Antagonist +

Advantages of GnRH antagonist 1.Immediate suppression of endogenous FSH and LH without flare up phenomenon. 2.Shortening treatment period with relief of physical, psychological and financial burdens. 3.Decreased number of HMG ampoules per cycle (Diedrich et al, 1994 and 2000).

Lubeck ( multiple doses)

Antagonist (Lubec) Vs GnRH-a Metaanalysis Cycle Day 6Day of Day 2-3of FSHhCG Cycle Down Day of Day Regulation hCG 2-4 Weeks FSH GnRH antagonist GnRH agonist FSH

Antagonist (Lubec) Vs GnRH-a Metaanalysis “Inany, 2002 ” No significant difference in prevention of LH surge. Lower number of oocytes retrieved. Lower pregnancy rate in spite of transfer of an equal number of embryos. No significant difference in prevention of severe OHSS.

PCOS HCG (Exo/Endo). High serum E2. Multiple follicles. Younger age < 32. GnRH-a protocols Patients at Risk OHSS

Prevention of OHSS Withholding HCG administration. Reduced dose of HCG. Administration of rec-LH. Freeze the embryos. coasting

Conclusions You should know what is you need from ov stimulation before selecting a certain protocol

Conclusions 1.Long protocols: they are the golden standard for all ART candidates especially those with young age, normal base line pituitary hormones, average size ovaries (more than 3ml) and normal BMI. 2. Short protocols: they are used in ART candidates with previous poor response, older women with relatively high FSH.

Conclusions cont… 3. Cases of poor response with short protocols, ovaries are stimulated either without analogues (ie HMG alone) with the usage of antagonist. OR

Telfax &