CONTROLLED OVARIAN HYPERSTIMULATION AND

OOCYTE RETRIEVAL : CLINICAL INPUTS

DR Priyanka Sinha

MD OB-GYN

MUMBAI, INDIA

LEARNING OBJECTIVE

Introduction

Ovarian stimulation protocols

Comparison of different protocols

Ovulation Trigger

Oocyte retrieval

Challenges and complications of oocyte Retrieval

Take home Message

INTRODUCTION

Controlled ovarian hyperstimulation is an important step in Assisted Reproduction.

Controlled ovarian hyperstimulation is a technique used in assisted reproduction

involving the use of fertility medication to induce multifollicular development

CONTROLLED

OVARIAN

HYPERSTIMUL

ATION

GnRH

agonist or

GnRH

antagonis

Prevents

premature

LH surge

GONADOTROPINS

(FSH or HMG)

Stimulates

development of

multiple ovarian

follicles l

HCGOvulation trigger

TYPES OF PROTOCOL

1. GnRH agonist - 1984 Conventional

- GnRH agonist Downregulation - The Long Protocol

- GnRH agonist UltraShort

- GnRH Agonist Flare

2. GnRH Antagonist - 1999

MODE OF ACTION AGONIST

AGONIST PROTOCOL

GnRH agonist 1 mg per day

LONG PROTOCOL GnRH agonist 0.5 mg \day

MENSES

GONADOTROPINS 225 IU HCG

CYCLE DAY

21 22 23 24 25 26 27 28 1 2 3 4 5 6 7 8 9 10

Individualised dosing of FSH \HMG

SHORT PROTOCOL

GnRH AGONIST “FLARE” PROTOCOL

MICRODOSE GnRH AGONIST 40 mcg

twice daily

MENSES

GONADOTROPINS 225 IU HCG

CYCLE DAY

1 2 3 4 5 6 7 8 9 10

OCP

Individualised dosing of FSH \HMG

MODE OF ACTION GnRH ANTAGONIST

GnRH ANTAGONIST SHORT PROTOCOL

GnRH ANTAGONIST

250 mcg\ day . fixed

\flexible

Single or multiple

doses

MENSES

GONADOTROPINS 225 IU HCG

CYCLE DAY

21 22 23 24 25 26 27 28 1 2 3 4 5 6 7 8 9 10

Micronized Estradiol 2 mg twice d

OCP - scheduling,

synchronising follicle

Griesinger et al, 2008

Estrogen doesn’t

affect cycle outcome,

used for programming

cedrin et al 2012

Gnrh agonist (eldor et al

2000). OHSS and CPR

reduced ( Cochrane

review 2011)

Individualised dosing of FSH \HMG

COMPARISON AGONIST (LONG) AND ANTAGONIST

AGONIST ANTAGONIST

Action Downregulation of pituitary Immediate blocking of Gnrh

receptors

Time to blockage of pituitary 2-4 weeks 8 hrs

LH level Stable low LH level High in early stage, fluctuates

Synchronisation of follicle Yes Ocp for synchronisation

Scheduling flexibility Yes Ocp \ Estradiol for Flexibility

Hypoestrogenemia symptoms Common Not seen( varney et al 1993)

CONTINUED……...

Cyst formation ** Possible (Ron et al 1989) No

OHSS Higher incidence( Rizk et al 1992)

Lower incidenceAl- Inani et al 2011

Consumption of

gonadotropins

Higher Ben Rafel et al 1991

Lower

Pregnancy rate (result of meta

analysis cochrane review 2011)

Equal Equal

Oocyte retrieval is the process of collecting

mature eggs directly from ovary prior to

their release from ovary

TIMING : 34-36 hrs after HCG injection

OOCYTE RETRIEVAL

APPROACH

LAPAROSCOPY- technique of choice in 1st 10 years

ULTRASOUND

1 . TRANSVAGINAL Wikland et al in 1985

Simple , rare complication, gold standard

2. TRANSABDOMINAL

When ovaries not accessible transvaginal

Safe and effective comparable with the result of TVOR

Bortan et al 2011

MATERIAL CHECKLIST

USG MACHINE WITH TVS PROBE

NEEDLE GUIDE

ASPIRATION NEEDLE

CONNECTING TEFLON TUBINGS

SUCTION PUMP

DRY BLOCK HEATERS AND WARM BLOCKS

HEATED LAMINAR TABLE

TEST TUBE, PETRI DISHES, PIPETTE

PREPARATION AND TECHNIQUE

CHALLENGES AND COMPLICATIONS

Ovaries stuck behind cervix and uterus

Endometrioma

Intra Abdominal bleeding

Cervical and Vaginal bleeding

Empty follicle syndrome

Postoperative pelvic infection

Rupture of dermoid cyst , lumbosacral osteomyelitis

TAKE HOME MESSAGE

Ovarian stimulation is a critical step in Assisted Reproduction .

Antagonist protocol is short , simple and safe with pregnancy rate comparable to

Agonist protocol.

Oocyte retrieval is Simple and efficient procedure

A variety of controlled ovarian hyperstimulation regimens are available and

efficacious, but individualization of management is essential and depends on

assessment of the ovarian reserve.

Priyanka Sinha

THANK YOU