IVF Protocols

During an IVF cycle certain medications are used to superovulate the ovaries in order to produce numerous of eggs. These medications may be given in a variety of combinations called protocols. In conventional IVF two types of protocols are commonly used; the long protocol and the short protocol. The drugs used in both protocols are the same; however the dosages and the period administered are different. The physician reviews the patient’s records (woman’s age, response to the medication and the outcome of previous attempts) and determines which protocol will be used for the upcoming treatment cycle.

Long Protocol

Ovarian Suppression

In order to optimize the stimulation of the ovaries, certain drugs (Superfact, Daronda, Avercap, Cetrotide and Orgalutran) are given starting approximately 1 week before the expected period day 21 of a 28-day cycle. Alternately, patients can start taking these drugs on day 2 of the cycle. These medications act by suppressing two hormones made in the pituitary gland, which normally cause your ovary to make eggs and ovulate. By suppressing these two hormones called follicle stimulating hormone (FSH) and luteinizing hormone (LH), the ovaries become suppressed so that they do not make eggs nor produce the ovarian hormone called estradiol. Women take these drugs for approximately 10-15 days. At the end of this period an ultrasound scan of the uterus and the ovaries and blood estradiol test are performed. If down regulation is not complete, at approximately 10% to 15% of all cases, patients extend the same medications for another week. A second ultrasound scan and blood estradiol test are then performed. Occasionally, an ovarian cyst aspiration is required. Down regulation or ovarian suppression (the ovaries do not contain follicles that are greater than 15 mm in size, and the blood estradiol level is less than 50 pg/ml) allows the physician to have greater control over the ovarian stimulation which provides for an even growth of ovarian follicles, and prevents a condition known as premature luteinization defined as the premature attempt of the body to ovulate.

Ovarian Stimulation

After ovarian suppression has been achieved, ovarian stimulation using gonadotropin fertility medication, (Puregon, Gonal-F, Menogon and Altermon) may commence at a scheduled time referred to as the cycle start. On the cycle start day, you may be instructed to reduce the initial dose, which will be continued throughout the stimulation phase of the cycle until hCG is administered.

The dose of the medications is based upon the woman’s age, weight, number of ovaries, FSH and estradiol levels and response to previous stimulation cycles. Patients take this initial dose of medication for 2 days before returning on the morning of gonadotropin Day 3 for an estradiol blood test. The dose may be changed then based upon the level of estradiol. Women take medication for 2 more days before returning on medication Day 5 for an estradiol blood test. Ultrasound scans are conducted starting on Day 7 of the stimulation period. In general, patients return for follow-up ultrasounds and estradiol blood tests usually every 1 to 3 days in order to monitor the growth of the follicles. Towards the end of ovarian stimulation patients are asked to return to the clinic more frequently for observation. Most women require 8 to 12 days of ovarian stimulation, and 4 to 6 sonograms and/or estradiol levels during this period of time. During ovarian stimulation the drugs for down regulation (phase 1) are continued. Monitoring of ovarian stimulation (ultrasounds and blood tests) is conducted at our clinic.

Follicle Triggering (hCG)

When the growing follicles have met the criteria that indicate that the eggs are mature patients are instructed to take hCG (Pregnyl). In general, at least two follicles with a mean diameter of at least 18 mm and an appropriate estradiol level (150-200pg/ml for each follicle) must be present before hCG is administered. Patients are instructed to inject hCG (5,000 - 10,000 units) approximately 36 hours before the oocyte retrieval. For example, if Pregnyl is injected at 7:00 p.m. Monday evening, oocyte retrieval will occur at 7:00 a.m. Wednesday morning. In addition, patients stop administering gonadotropins and GnRH analogues after they have received hCG. Administration of hCG is commonly called follicle "triggering." The purpose of this medicine is to induce the final stages of oocyte maturation and the release of the eggs by the ovary. Timing administration of this medication is important and patients must carefully follow the physician's and nurse’s instructions.

Short Protocol

The short protocol generally matches in with the normal cycle and is therefore over a timescale of approximately 4 weeks (rather than the long protocol of 6 weeks). The short protocol is usually used when a woman has a poor ovarian response in previous cycles under the long protocol or where the woman is a bit older than average.

The main difference between the short protocol and the long protocol is that unlike in the long protocol where there are 2 distinct stages – down regulating and stimulating, in the short protocol patients go straight to the stimulating stage. What usually happens is that on day 3 of the cycle patients go to the clinic for a scan and/or blood test to make sure that the womb lining has thinned out after their last period. Assuming that it has they then start the stimulation injections described above and at the same time start to take the down regulating nasal spray or injection. Patients are then asked to return to the clinic after a few days and thereafter will have regular scans and blood tests (daily, every 2 days or every 3 days) until the doctor decides that they are ready for egg collection.

Once the physician has made that decision the process is exactly the same as under a long protocol as described above (hCG injection, egg collection). The advantages of the short protocol are that there are fewer drugs to take as you miss out the initial down regulating stage, which is part of the long protocol, and as a result it is also a faster treatment cycle. Most women who have not had a very good response under the long protocol find that they produce more eggs under the short protocol but this is not always the case.

FSH INJECTIONS

These injections are administered as a single subcutaneous injection in either the abdomen or thigh of an evening

GONAL F

Comes in pen form. Either 300iu, 450iu&900iu. When using a new pen, remove sheath from needle and twist needle onto end of pen. Dial to 37.5, pull out end of pen and press end of pen. This is to prime a new pen to ensure you then receive your full daily dose of Gonal F. Once the pen is primed, dial up your daily rose of Gonal F (FSH), pull the end of the pen out, pierce the skin and press down end of pen to inject. Hold needle in skin for a couple of seconds before removing. Remove needle and place in sharps container for disposal. Only when opening a new pen do you need to prime it. There may be a small amount of overfill left in the pen once the full amount is dispensed, it is not advised that you administer this.

PUREGON

Comes in pen form. Either 300iu, 600iu& 900iu. Remove outer cover of pen and cartridge from packaging. Untwist the pen so cartridge can be inserted and replace. Remove sheath from needle an twist onto end of pen. If you don not see a drop on the end of the pen then twist one click of the dosage dial then press the injection button. Dial up your daily dose of Puregon (FSH), pierce the skin and press down end of pen to inject. Hold needle in skin for a couple of seconds before removing. Remove needle and place in sharps container for disposal. There may be a small amount of overfill left in the cartridge once the full amount is dispensed, it is not advised that you administer this.

MENOPUR

• 75iu 1 powder to be mixed with 1ml of solvent (one ampoule)
• 150iu 2 powders to be mixed with 1ml of solvent (one ampoule)
• 225iu 3 powders to be mixed with 1ml of solvent (one ampoule)
• 300iu 4 powders to be mixed with 1.5ml of solvent (one and a half ampoules)
• 375iu 5 powders to be mixed with 1.5ml of solvent (one and a half ampoules)
• 450iu 6 powders to be mixed with 1.5ml of solvent (one and a half ampoules)

Please note: Some people will continue to experience bleeding whilst taking the FSH injections. Continue your injections and please inform your ultrasonographer and nurse at your first appointment.