Ovulation induction in IUI Dr.Shiuli Mukherjee MBBS,MD,FNB(Reproductive Medicine) Infertility & IVF consultant

35 years old lady suffering from primary infertility, husband normozoospermic, HSG-B/L spillage positive, AMH- 1.5, had 6 cycles of ovulation induction with clomiphene citrate and timed coitus (unmonitored cycle), not conceived. Now planned for IUI (AIH). How to stimulate? CC + Gonadotrophin Anestrazole Continuous Gonadotrophin Continuous Gn + antagonist

Learning Objectives At the conclusion of the presentation participants should be able to answer: Why we need ovulation induction? How to stimulate ovary? How to monitor?

Controlled ovarian stimulation in IUI cycle OBJECTIVE: To produce more than one egg for better chance of pregnancy

Different drugs and stimulation protocols used for IUI 3 TYPES OF DRUGs Clomiphene citrate Letrozole/anestrazole GONADOTROPIN – FSH or HMG GnRH AGONIST or ANTAGONIST 6 TYPES OF PROTOCOLS 3 CONVENTIONAL 3 NON CONVENTIONAL

Why different drugs and protocols? All patients are not equal responders to a particular type of stimulation Response basically depends on : OVARIAN RESERVE - 3 A Age AFC (Antral follicle count) AMH (Anti Mullerian Hormone) PELVIC PATHOLOGY BMI

AFC and AMH AFC – follicles between 5-10 mm diameter on day 2 – 3 AMH secreted by early antral follicles Both predict ovarian response accurately. Jayaprakasan K, et al. Fertil. Steril. 93(3), (2010), La Marca A,et al. Hum. Reprod. Update 16(2), 113–130 (2010).

Different protocols of stimulation CONVENTIONAL: Cc with or without adjuncts Cc with ‘soft’ gonadotropin stimulation Scattered d3, d5, d7, d9 with cc Sequential after completion of cc d5 or d7  Fixed d3 & d8 with cc Continuous low dose gonadotropin stimulation

Our publication…. Mukherjee Shiuli, Sharma Sunita, Chakravarty BN, JHRS, 3;2 ,2010

And result…… Significant improvement in pregnancy rate in CC + gonadotrophin group particularly in anovulatory patients. Miscarriage rate remain same.

Protocols …. contd NON CONVENTIONAL: Low dose GnRHa followed by soft protocol CC + FSH/HMG stimulation – Amenorrhoeric PCOS Recent case study on Mrs.N.Saha with very high LH and resistant PCOS Cc / HMG  antagonist When lead follicle is 14mm In the morning of day of hCG Recent recFSH / LH protocol for competent monofollicular development

CC with or without adjuncts CC– 100 mg daily from d3 – d7 Adjuncts: eltroxin, bromocriptine, metformin, dexamethasone as & when necessary

Cc with soft protocol gonadotropin (d3/d8) Cheap – as well as effective Gonadotropin on d3 – why ? to recruit one or two additional co-dominant follicles Gn on d8 – why ? to counteract antioestrogenic effect of CC and to enhance preovulatory oestradiol level for effective LH surge Mukherjee et al, Journal of Human Repro Sci, 2010

Continuous low dose gonadotropin OBJECTIVES: To compensate low levels of FSH compared to LH in early follicular phase as in PCOS To recruit additional codominant follicles in early follicular phase Antioestrogenic effect of CC is avoided

LOW DOSE GnRH-A FOLLOWED BY SOFT PROTOCOL CC-FSH AMENORRHOEIC PCOS WITHDRAWAL OC PILL D5 - D25 LUPRIDE 0.5-1 ML SC DAILY D16 – D25 or D21 till bleeding WITHDRAWAL CC (100mg) D3 – D7 + GN (75 IUI) 1 amp. INJ. D3 , D5 & D7 IUI Also applicable in non amenorrhoic PCOS (to down regulate LH)

Soft protocol stimulation with CC /HMG + antagonist CC (D3-D7) + rFSH / HMG (75IU) Daily Or On Alternate Days From D5 Flexible Multiple Dose Of Cetrorelix When Lead Follicular Diameter Is 14mm – 1 Or 2 Doses Mukherjee et al, Journal of Human Reprod Sci, 2012

Literature review- our publication…. Significant improvement in pregnancy rate No OHSS

Soft protocol + antagonist …. contd OBSERVATION : Dose of cetrorelix may have to be increased from 0.25mg to 0.5mg in order to decrease number of LH surges COMMENT: Antagonist with CC for soft protocol should be cautiously used (Engel et al, 2002)

Gn ANTAGONIST & IUI CYCLE STIMULATION WITH GONADOTROPIN (HMG) RATHER THAN WITH CC AND ANTAGONIST FOLLOWED BY IUI – RESULTS ARE BETTER THAN WITH GONADOTROPIN ALONE PREVENTS PREMATURE LH RISE AND LUTEINISATION (Allegra et al, 2007) IN MONOFOLLICULAR DEVELOPMENT EARLY DECLINE OF E2 AND ONSET OF BLEEDING

Recent protocol for monofollicular development Addition of hCG/rLH instead of HMG in late follicular phase (under trial) rFSH(150IU) daily for 7 days Decrease FSH dose (50, 25, 0 IU) Start increasing dose of hCG (50, 100, 200 IU)

ADVANTAGES Support development of larger follicles Expedite regression of small follicles Low risk of OHSS Hcg is less expensive than lh; longer half life, therefore more effective No risk of leutinization (Fillicori 2002)

RECENT PROTOCOL … CONTD CONCEPT IS BASED ON NORMAL PHYSIOLOGY OF OVULATION EARLY FOLLICULAR PHASE (D1 TO D4) MORE FSH IS ESSENTIAL – SMALL AMOUNT OF LH IS AVAILABLE FROM ENDOGENOUS SOURCE MID FOLLICULAR PHASE (D5, D6) DOMINANT FOLLICLE IS SELECTED – HAS BOTH FSH, LH RECEPTORS

OVULATION – PHYSIOLOGY …. CONTD LATE FOLLICULAR PHASE (D6 TO D12) DOMINANT FOLLICLE IS LH DEPENDANT – PRODUCES ENOUGH E2 ABSENCE OF FSH AND DOMINANCE OF LH CAUSES FOLLICULAR ATRESIA – MONOFOLLICULAR DEVELOPMENT

MONITORING OF OVARIAN RESPONSE SERIAL FOLLICULOMETRY CERVICAL MUCOUS STUDY FERNING PATTERN 1ST ORDER BRANCHING 2ND ORDER BRANCHING SERUM E2 & SERIAL URINARY LH ESTIMATION  NOT PERFORMED NOW-A-DAYS ENDOMETRIAL THICKNESS LH Kit assessment

2ND ORDER BRANCHING OF FERN - E2 PEAK - hCG

TIMING OF hCG ADMINISTRATION NOT TOO EARLY, NEITHER TOO LATE HOW TO DETERMINE ? DOMINANT FOLLICLE – 17-19mm CERVICAL MUCOUS – 2ND ORDER BRANCHING; CLEAR TRANSPARENT MUCOUS E2 – 100-150 PG/FOLLICLE IN CASE OF 3RD ORDER BRANCHING (BREAKAGE OF BRANCHES, DARK BACKGROUND) LH SURGE STARTED – NO hCG (SPONTANEOUS OVULATION) P4 SHOULD BE LESS THAT 1.2ng/ml

LH Kit Preferably to done when dominant follicle reaches 18mm with ET >7 mm, isoechoic, trilayered. IUI ideally to be done on the same day preferably by evening if LH kit become positive by morning. Speroff et al, 2010

USG PREDICTION OF FAVOURABLE/UNFAVOURABLE RESPONSE NO IN COHORT DAILY INCREASE IN DIAMETER PERIFOLLICULAR BLOOD FLOW FOLLICLES

USG PREDICTION OF FAVOURABLE/UNFAVOURABLE RESPONSE…contd. ENDOMETRIAL THICKNESS, TEXTURE & BLOOD FLOW > 7 mm ON HCG DAY ISOECHOIC WITH TRIPLE LINE S.E. BLOOD FLOW

Gonadotrophins !!!!!!!!!! Why use? When/where to use? What to use?

HISTORY 1978 !! Early 1980- CC+uGn Late 1980- uGn

First extracted from pig pituitaries or pregnant horses. 1950, extracted from human cadaver pituitary glands or urine of postmenopausal women. hMG 1964, purified hMG 1982, HP hMG 1992. Late 1990s-: Recombinant Gonadotrophins Genetically engineered Chinese hamster ovary - Follitrophin alpha & Follitrophin beta. Late 1980s – GnRH agonist Late 2000 - GnRH antagonists

3 GENERATIONS OF GONADOTROPHINS Urinary gonadotrophins (FSH & HMG) Purified/ Highly purified Urinary gonadotrophins [ virtually no LH & < 5% proteins ] Recombinant FSH , 99% pure FSH, No LH, high consistency Recombinant LH

Why ? Gonadotrophins are the cornerstones of ART treatment More follicles, more gamets, more embryos - enhancing pregnancy rate In specific situation like hypogonadotrophic hypogonadism (HH) WHO group I

Paradise lost .. Paradise regained Premature LH surge Poor quality No fertilization or very poor pregnancy rate Cancel egg retrieval 5-20% All cycles treated in 1980’s

Paradise regained………

GnRH agonist-antagonist CETRORELIX-.25 mg GANIRELIX-.25 LEUPROLIDE-.5 ,1 mg. BUSERELIN-.2,.5 mcg GOSERELIN-3.6 MG TRIPTORELIN-.1,.05 mg

Action of GnRH agonists downregulation Action of GnRH agonists 1. Binding of GnRH leads to a post-receptor-cascade and this consecuitively to the release of LH and FSH 2. Adding of GnRH agonists will lead - because they have a higher affinitiy to the receptors and have a higher biologic potency - to binding of the agonists to the receptors instead of the natural GnRH. 3. Initially, this will lead to an increase in the receptor action, number and post-receptor-cascade with a consecutive increase in the release of LH and FSH (flare up effect). 4. After that, however, receptors are internalized, lysed, the number of receptors decreases, the post-receptor-cascade is downregulated and the stimulus to release LH and FSH will also be suppressed. 5. Downregulation and pituitary suppression will result. GnRH LH + FSH GnRH - receptor post-receptor-cascade pituitary suppression flare up effect GnRH - agonist

Action of GnRH antagonists 1. Binding of GnRH leads to a post-receptor-cascade and this consecutively to the release of LH and FSH 2. Adding of GnRH antagonists will lead to a competitive action of GnRH and GnRH antagonists - which do not have any intrinsic activity. 3. A sudden downregulation of the post-receptor-cascade is the result with a consecutive decrease in the stimulus to release LH and FSH. 4. Pituitary suppression is achieved within a few hours without any initial flare up effect. GnRH LH + FSH GnRH - receptor post-receptor-cascade pituitary suppression GnRH - antagonist

Where / When ? In specific situation like hypogonadotrophic hypogonadism (HH) WHO group I CC resistant or CC failure - WHO group II POF - WHO group III IVF stimulation as a routine

Proceed step by step Protocol selection agonist(long,short,ultrashort) vs antagonist Dose calculation –ovarian reserve -3 A AFC, Age, AMH Monitoring

The long luteal protocol ovulation induction oocyte pick up embryo transfer gonadotropin administration in an individualized dosage start of GnRH agonist In the long luteal protocol a GnRH agonist depot preparation is administered during the mid-luteal phase of the preceeding cycle, or a GnRH agonist is started with a daily administration at that time. Two weeks later, in between menstruation will start, pituitary suppression is achieved. At that time point a transvaginal ultrasound should be done to exclude cyst formation, since the flare up effect of the agonist may lead to ovarian cyst formation. If pituitary suppression has been achieved and the ovaries do not show cysts, gonadotropin stimulation can be started at that day. It will go on until hCG can be administered for ovulation induction. Luteal phase support is necessay for these protocols. 22nd day of previous cycle 1st day of gonado- tropins STOP GnRH luteal phase support

The Cetrotide® 0.25 mg multiple dose protocol ovulation induction oocyte pick up embryo transfer gonadotropin administration in an individualized dosage 1st day of menstruation In the multiple dose antagonist protocol ovarian stimulation is started with the second or third day of the menstrual cycle. Cetrotide® 0.25 mg is started on the 6th day of ovarian stimulation in the morning or on the 5th day in the evening. And is administered up to and including the day of hCG, if given in the morning. 1st day of gonado- tropins luteal phase support Cetrotide® 0.25 mg administration daily s.c. starting on day 6 of stimulation

Ovulation Induction – r/u FSH hCG 5000 Dosage STEP DOWN 150 IU/d 100 IU/d 50 IU/d D1 D7 D14 Days

STEP UP Dosage hCG 5000 150 IU /d ø foll > 10 mm 100 IU / d Days

What to use? Urinary ? P / HP Urinary / Recombinant? FSH vs HMG vs LH Agonist vs antagonist

Advantages of Rec. FSH Recombinant DNA technology: unlimited supply Batch to batch consistency  allergic reactions,  potential risk of infection High specific activity: less acid isoforms Sub-cutaneous administration Increased % of mature eggs. Enhanced embryo cleavage Increased implantation rate More embryos for freezing, better quality embryos Is the use of r FSH cost effective?

Literature review R-FSH – 16% increased chance of having a baby. 40% more U-HMG needed to have a baby compared with r FSH. Cochrane review - No statistical significant difference in live birth rate between rFSH and HP FSH. Choice depend on availability, convenience and cost

Advantages of GnRH-antagonists Fits into the normal cycle - patients friendly Less side effects in comparison to the long protocol: Ø cysts Ø hormonal withdrawl Significant reduction of OHSS Simple No significant difference in the probability of live birth between GnRH-agonists and antagonists Al-Inany et al, 2012

The future of ovarian stimulation FSH CTP s.c. GnRH-Antagonist p.o. 1 2 3 4 5 6 7 8 9 10 11 12 cycle day

The future of ovarian stimulation Oral LH Mimetic Depot FSH s.c. GnRH-Antagonist p.o. 1 2 3 4 5 6 7 8 9 10 11 12 cycle day

The future of ovarian stimulation Oral LH Mimetic Oral FSH mimetic GnRH-Antagonist p.o. 1 2 3 4 5 6 7 8 9 10 11 12 cycle day

Lets hope for a new beginning Thanks