OVARIAN STIMULATION AND ULTRASOUND AND/OR HORMONAL MONITORING

OVARIAN STIMULATION AND ULTRASOUND

AND/OR HORMONAL MONITORING

The treatment requires the use of drugs aimed at achieving multiple follicular growth. Depending on the stimulation protocol used, the duration of the entire ovarian stimulation cycle can vary from 10 to 20 days.

The different protocols, chosen according to the characteristics of the ovarian reserve, age and clinical history of the patient are classified in:

  • Protocol with GnRH agonists (used in less than 10% of cases) 
  • Protocol with GnRH antagonists (used in more than 90% of cases)

These protocols, although with important differences, are based on three fundamental points: stimulation of multiple follicular growth, prevention of premature peak LH and final induction of oocyte maturation.

New ovarian stimulation protocols have recently been implemented aimed at a more efficient management of patients with poor prognosis and exposed to negative outcomes with conventional approaches. The DuoStim appears among these as one of the most promising. It combines two consecutive stimulations in the follicular and luteal phases of the same ovarian cycle, with the aim of increasing the number of oocytes retrieved and embryos produced in a short interval of time. This protocol is indicated for the treatment of all conditions that require optimization of the ovarian reserve, such as cancer patients and older women. Currently, data from independent studies have highlighted the consistency and reproducibility of this approach, which could also reduce dropout between consecutive cycles of failed IVF in patients with poor prognosis.

Follicular growth is monitored by serial ultrasound investigations for a total of 3-5 controls and by hormonal dosages. These controls allow to modulate the pharmacological dosage according to the response obtained. In selected cases, monitoring can take place following the growth of the only follicle produced spontaneously during the patient’s natural cycle (spontaneous cycle). Spontaneous cycle may be indicated in patients with reduced ovarian reserve or who have undergone several cycles of IVF without obtaining results. However, it should be noted that, in these cases, embryo transfer occurs in 40-50% of the cycles initiated. When one or more follicles with a diameter greater than 17-18mm are displayed, the final maturation of the oocytes contained in the follicles is induced (35-36 hours before the oocyte collection).

 

The final induction of ovulation was obtained for many years exclusively by the administration of hCG (chorionic gonadotropin of placear origin) extracted from the urine of pregnant women (u-hCG). HCG is able to simulate the peak of endogenous LH, due to its structural analogy with this hormone. There is also the possibility of using recombinant extraction hCG (r-hCG). With the introduction of GnRH antagonists and recombinant gonadotropins, other possibilities to achieve final oocyte maturation have opened up. The choice of the GnRH agonist trigger depends on the age of the patient, the AMH value, the antral follicle count, the ovarian response (number of follicles displayed on ultrasound) and the oestradiol value on the day of the trigger. The use of the agonist trigger also finds a potential role in all cycles in which no fresh embryo transfer is performed because the couple decides to perform pre-implantation genetic screening or when they decide, in agreement with the treatment manager, to perform double stimulation (DuoStim).

IVF and ICSI steps

OVARIAN STIMULATION AND ULTRASOUND

AND/OR HORMONAL MONITORING

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OOCYTE

RETRIEVAL

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SPERM COLLECTION

AND PREPARATION

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IN VITRO OOCYTE

INSEMINATION (IVF OR ICSI)

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EMBRYO CULTURE UP

TO THE BLASTOCYST STAGE

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EMBRYO TRANSFER (ET)

AND CRYOPRESERVATION OF EMBRYOS

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