IVF CYCLE >> Controlled Ovarian Hyper Simulation

This  can be done using urinary gonadotropins or recombinant FSH. At the onset of menses HMG or FSH is started in the dose of 2-8 ampoules and the GnRH agonist continued  in the dose of 2ml.on the fifth day of  the treatment transvaginal sonography is done to asses the adequacy of the stimulation .Ideally the patient should have at least 5- follicles developing in both the ovaries and there should be no dominant follicle .

If no follicles develop the dose of HMG/ FSH is increased and serum prolactin level done .Sonography is generally repeated 3 days later .The follicles noramally develop at the rate of 2mm day.HMG/FSH with GnRH against is continued until the leading follicle reaches 18-20mm and 2 follicles are 17mm endometrium at least 8mm thick and E2 level should be 150 pgm/ follicle > 15mm. Once these
criteria are met the patient is given HCG 10000 iu or LH one ampoule:

a) Flare up and stimulation :- In patients with poor ovarian response the GnRH against is not used to suppres  the pituitary but is used to cause a flare up action.It is given in the dose of.%ml subcutaneously twice a day for the first three days followed by the HMG / FSH injection. b) GnRH antagonist:- With the advent ofGnRH antagonist ,the down regulation step in IVF cycle is done.GnRH antagonist cause immediate suppression of pituitary gonadotropins ie. FSH + LH. Thus the Premature LH surge is prevented .HMG / FSH is started on day 2 or 3 of the cycle and when the lead follicle reaches 14mm ie.usually day 6-7 GnRH antagonist is given subtaneouslly until the day of HCG injection. The two protocols are shown in the fig