Standard Ovarian Stimulation

For the procedure of egg pick up, patient is completely investigated by taking a detailed history and doing base line blood testing and ovarian reserve testing. Underlying medical problem like diabetes (HBA1C > 7) or hypothyroid(TSH > 2.5 miu/ml) or hyperprolactinaemia (prolactin > 20) needs to be addressed before starting the procedure. Body mass index BMI needs to be calculated and if patient is obese she needs to be sent to a weight loss specialist. Ideally the BMI < 29, preferably < 25 , will yield the best results . If the BMI is > 35 with comorbidities or > 40 , she needs to undergo Bariatric surgery to correct her weight , prior to IVF . If patient is > 40 years of age, we advise a medical fitness by doing a Blood pressure test, biochemistry including a GTT, X ray chest, ECG, 2 D echo and stress test. The antral follicular count AFC on day 2/3 is done using the vaginal ultrasound is. The Anti Mullerian hormone AMH testing can be carried out at any time of the menstrual cycle. Based on these two tests, the patients are classified into three groups :1)the normal responders: AFC : 8-15 and AMH: 2-3.5 ng/ml ;2) the hyper responders: AFC >15 and AMH>3.5 ng/ml ;3) The poor responders : AFC < 8 and AMH < 1.5 ng/ml. The patients are given supplements prior to starting the cycle. These are in the form of iron, calcium, vitamins and proteins. In patients with poor ovarian reserve appropriate supplements (DHEAS, coenzyme q, zinc, melatonin, anti-oxidants and whey proteins) are given to the woman. In males with low counts or motility, clomiphene, co enzyme, carnitine, antioxidants may be given.

Ovarian stimulation for egg pick up is started usually on day 2 of the menstrual cycle. In patients who need urgent fertility preservation, the patient can be started on stimulation on any day of the menstrual cycle. This is called the random start stimulation. Based on the type of patient (poor/normal/hyper responder), past history of ovarian response and BMI, the type and starting dose of gonadotrophins is selected. In general, normal responders can be given rec FSH or highly pure HMG from second day for 9 to 11 days, till the day of HCG /gnrh trigger. The patient is called for follicular monitoring by vaginal ultrasound on Day 2, day 7 and Day 10 of the cycle for checking growth of eggs on ultrasound and adjusting doses of injections. Most of the hormone injections which are used now a days are patient friendly and patients usually self-administer them subcutaneously. After the eggs are ready as per ultrasound findings of two leading follicle of > 17 mm diameter, the patient is given a HCG/Gnrh trigger injection following which 35 to 36 hours later egg pick up is done under short general anaesthesia. The trigger may be a urinary HCG injection 5000/10000 units subcutaneously or recombinant HCG injection 250/500 units subcutaneously or GnrH trigger 0.2 mg of Triptorelin subcutaneously or a combination of HCG and Gnrh injection. The oocyte retrieval takes about 10 to 30 minutes. Usually most of the patients are discharged within 2-4 hours of procedure and can resume their normal activity.