IVF Stimulation Protocols...cooking eggs with DrG

Many of the questions that I answer on the INCIID bulletin board revolve around issues of stimulation. High responders, low responders, unusual responders…you name it. Of course, making pronouncements on cycles that I have never seen, from clinics that I have never heard of and with REs that I personally have never met represents a difficult proposition.

IVF is really an art on some level and we need to carefully pick stimulation protocols and make trigger shot decisions after careful consideration of all the data. We sometimes really agonize over these decisions and that is why we prefer to do our own sonograms so we can get a real feel for whether the follicles are ready….and yet sometime it just doesn’t work out the way you thought that it would….

So after much delay, here is another question from the book that every fertility patient should buy or borrow or steal (OK, not steal) although we have yet to see a dime from our publisher…


62. Which types of drug protocols are used in IVF, and how is the most appropriate protocol selected?

Although several drugs and protocols are available to stimulate the ovaries to produce extra eggs for IVF, most clinics The first method, called luteal suppression, involves suppression of the ovaries using a GnRH-analog (Lupron) during the luteal phase of the menstrual cycle preceding the planned IVF treatment cycle. Once the ovaries are suppressed, ovarian
stimulation is accomplished with daily injections of gonadotropins (e.g., Gonal-F, Follistim).



In the second method, called flare stimulation, the woman does not take any medications until the second day of her menstrual cycle. At that time, a microdose (most commonly) of Lupron is used to “flare” the pituitary gland and induce it to release its store of FSH and LH. Simultaneously, gonadotropins are started, producing a “one–two punch” in terms of ovarian stimulation. Premature ovulation of the eggs rarely occurs despite the low dose of GnRH agonist utilized in this protocol.

A third, more recent option is GnRH-antagonist stimulation, in which GnRH antagonists are added later in the stimulation to prevent premature ovulation. In this method, the gonadotropins are started on cycle day 2 of a normal menstrual period. Once the follicles have reached a specific size (usually 12 to 14 mm), the woman begins the GnRH-antagonist medication, which almost instantaneously prevents the pituitary gland from generating an LH surge.

Some reproductive endocrinologists prescribe oral contraceptive pills to their female patients prior to beginning the actual ovarian stimulation drugs, but this practice varies between patients and fertility clinics. We have found that the use of birth control pills often results in oversuppression of the ovaries and cycle cancellation except in those patients known to be high responders (women with PCOS, in particular).

The type of protocol selected for any patient (i.e., luteal suppression, flare stimulation or GnRH antagonist) depends on the individual patient and the philosophy of the fertility clinic. Factors that may influence the type of stimulation protocol selected include the patient’s age, her day 3 hormone levels, her follicle antral count as determined by ultrasound, and her previous responses to any other attempts at ovarian stimulation.