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

2. 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

3. 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?

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

5. 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

6. 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

7. 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).

8. 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

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

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

12. 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

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

14. 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

15. 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

16. LOW DOSE GnRH-A FOLLOWED BY SOFT PROTOCOL CC-FSH
AMENORRHOEIC PCOS
WITHDRAWAL
OC PILL D5 - D25
LUPRIDE 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)

17. 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

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

19. 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)

20. 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

21. 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)

22. 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)

23. 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

24. 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

25. 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

26. 2ND ORDER BRANCHING OF FERN - E2 PEAK - hCG

27. 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 – 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

28. 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

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

30. 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

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

32. HISTORY
1978 !! Early CC+uGn Late uGn

33. 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 GnRH antagonists

34. 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

35. 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

36. 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

37. Paradise regained………

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

39. 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

40. 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

41. 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

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

43. 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

45. 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

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

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

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

49. 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?

50. 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

51. 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

52. 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

53. 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

54. 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

55. Lets hope for a new beginning
Thanks