BIOMATERNITY Fertility Specialsts-EGG RETRIEVAL-OVULATION INDUCTION-Hypothalamus_Anterior Pituitary. GnRH. LH. FSH

Ovulation Induction

During regular menstrual period, an egg matures within a follicle (a fluid-filled cyst in the ovary that contains the egg) and is released from the follicle (ovulated).

Ovulation induction is the use of specific fertility medications to stimulate the female reproductive system to produce mature eggs in the ovaries and release them.

It is used in women:

  • who are likely to have ovulatory dysfunction presented by irregular menstrual (oligo-ovulatory) cycles or no menstrual periods (amenorrhea or anovulation),
  • without ovulatory dysfunction, so as to stimulate the ovaries to produce more than one egg per cycle leading to the release of multiple eggs (Controlled Ovarian Stimulation – COS) in order to increase pregnancy rates with various assisted reproduction treatments. COS is also an important part of most IVF treatment.

 

Classification of oligo/amenorrhoea, common causes, and hormonal profiles
NameCommon causesHormonal profile
Hypothalamic– pituitary failure

Hypogonadotrophic hypogonadism

Weight,
exercise,
stress related
Kallmann’s syndrome Sheehan’s syndrome Hypophysectomy/ radiotherapy
Tumours
Idiopathic
Very low FSH, LH, E2
Hypothalamic– pituitary dysfunctionPCOS (PolyCystic Ovary Syndrome)Low or normal FSH
High or normal
LH High or normal testosterone
CAH (Congenital Adrenal Hyperplasia)High 17-OH prog.
Cushing’sHigh cortisol
Androgen- producing tumoursVery high testosterone
Ovarian failureAutoimmune Infections Surgery/irradiation
Gonadal dysgenesis Idiopathic/familial
High FSH, LH (LH may be normal in early stages).
Low E2
HyperprolactinaemiaPituitary adenomaHigh prolactin
MedicationLow FSH, LH
Stress
HypothyroidismHigh TSH
Outflow tract defectImperforate hymen Transverse vaginal septum Asherman’s syndrome

Absent uterus
Cervical stenosis

Normal
Androgen insensitivityTestosterone

Egg Retrieval

Oocyte retrieval is performed about 34-36 hours after hCG has been administered.
An anesthesiologist usually administers intravenous medications (sedatives and pain relievers) in order to minimize the discomfort that may occur during the procedure. Most patients sleep through the procedure.

Ovulation Induction

Step 1 - Prestimulation treatment
  • Initiation of Oral Contraceptives
    Some patients will receive oral contraceptives in the cycle prior to the ART cycle. This ensures that GnRH analog therapy will start at the proper time if you have irregular cycles. There is also evidence that oral contraceptives can help prevent ovarian cysts, which sometimes develop during GnRH analog therapy. Provera® or progesterone may be prescribed for patients who ovulate irregularly or not at all.
  • Suppression of Ovulation
    There are two principle ways that physicians ensure ovulation does not occur before egg retrieval. One involves pre-treatment of a patient with a GnRH agonist. The other involves treatment after six or so days of stimulation with a GnRH antagonist.
  • GnRH Agonist Administration
    GnRH agonist: (This medication is taken by injection. There are two forms of the medication: A short acting medication requiring daily injections and a long-acting preparation lasting for 1 month. The primary role of this medication is to prevent a premature LH surge, which could result in the release of eggs before they are ready to be retrieved. Since GnRH-agonists initially cause a release of FSH and LH from the pituitary, they can also be used to start the growth of the follicles or initiate the final stages of egg maturation.A GnRH agonist might be prescribed sometime after taking oral contraceptive pills. This dose may be reduced when ovarian stimulation is begun. Agonist is often discontinued on the day of hCG (human chorionic gonadotropin) administration.

Some protocols also might begin GnRH agonist sometime after ovulation in the cycle preceding stimulation in the “mid-luteal” protocol, after the start of menses in the “flare” or “micro-flare” protocol.

  • GnRH-antagonists (ganirelix acetate or cetrorelix acetate) (Antagon®, Cetrotide®):
    These are other classes of medications used to prevent premature ovulation. They are typically administered several days after stimulation and require fewer injections.
  • Baseline Pelvic Ultrasound
    Around the time of your expected period, your physician will perform an ultrasound scan to examine the ovaries. If your physician detects a cyst, they may withhold further therapy until the cysts resolve spontaneously (usually in about a week). Occasionally, cyst aspiration (drainage) is recommended. This is a procedure in which your doctor inserts a fine needle connected to a syringe, guided by ultrasound, into the cyst. They may also perform a blood test (serum estradiol measurement) to confirm that the ovaries are properly suppressed.
Step 2 – Ovarian Stimulation

In general, ovarian stimulation begins after menstrual bleeding starts. Several similar medications may be used to stimulate follicle development: Bravelle®, Repronex®, Lupron®, Gonal-F®, Repronex® Follistim® Follistim AQ pen and Gonal-F RFF Pen. GnRH-antagonists (ganirelix acetate or cetrorelix acetate) (Antagon®, Cetrotide®) are another class of medications used to prevent premature ovulation and, in combination with an antagonist trigger, they may offer protection from severe ovarian hyperstimulation syndrome. They tend to be used for short periods of time in the late stages of ovarian stimulation. There are several different types of stimulation protocols. Although all protocols more-or-less employ the same types of medications, specific protocols may help certain types of patients to have a better response than other types. It is, however, unrealistic to think that switching from one protocol to another will dramatically change a poorly responding patient to a highly responding patient.

Step 3 – Monitoring of Follicle Development

Follicular development is monitored with the combination of vaginal ultrasound and hormone measurements (blood tests). These tests are performed frequently during the ART cycle, and the dose of medication might be adjusted in an effort to improve follicular development. The amount of medication prescribed also depends upon the results of the blood tests and ultrasound exams.

Step 4 – Final Oocyte Maturation and hCG Administration

Human chorionic gonadotropin (hCG) (Profasi®, Novarel®, Pregnyl®, Ovidrel®) is a hormonal drug that stimulates the final maturation of the oocytes. Determining the proper day for hCG administration is critical. The time of the injection determines when the egg retrieval will be scheduled. Some protocols using GnRH antagonists use GnRH agonists to trigger the final maturation of oocytes.

Egg Retreival

Step 5 – Transvaginal Oocyte Retrieval
  • Eggs are removed from the ovary with a needle under ultrasound guidance.
  • Anesthesia is provided to make this comfortable.
  • Injury and infection are rare.

Oocyte retrieval is performed about 34-36 hours after hCG has been administered. An anesthesiologist usually administers intravenous medications (sedatives and pain relievers) in order to minimize the discomfort that may occur during the procedure. Most patients sleep through the procedure. A transvaginal ultrasound probe is used to visualize the ovaries and the egg-containing follicles within the ovaries. A long needle, which can be seen on ultrasound, can be guided into each follicle and the contents are aspirated. The aspirated material includes follicular fluid, oocytes (eggs) and granulosa (egg-supporting) cells. The physician will collect the oocytes and follicular fluid into a test tube and the embryologist will search the follicular fluid and locate the oocytes using a microscope.

After the retrieval, patients recover from anesthesia where they will be observed while the intravenous medication wears off. It is not uncommon to have some vaginal spotting and lower abdominal discomfort for several days following this procedure. Generally, patients feel completely recovered within 1 to 2 days.

The number of oocytes retrieved is related to the number of ovaries, their accessibility, and the number of follicles that develop in response to stimulation. Ultrasound provides only an approximation of the number of oocytes that one can expect to recover. On the average, 8 to 15 oocytes are retrieved per patient.

BIOMATERNITY Fertility Specialsts-EGG RETRIEVAL-OVULATION INDUCTION-Procedure
BIOMATERNITY Fertility Specialsts-EGG RETRIEVAL-OVULATION INDUCTION-Hypothalamus_Anterior Pituitary. GnRH. LH. FSH

Ovulation Induction

During regular menstrual period, an egg matures within a follicle (a fluid-filled cyst in the ovary that contains the egg) and is released from the follicle (ovulated).

Ovulation induction is the use of specific fertility medications to stimulate the female reproductive system to produce mature eggs in the ovaries and release them.

It is used in women:

  • who are likely to have ovulatory dysfunction presented by irregular menstrual (oligo-ovulatory) cycles or no menstrual periods (amenorrhea or anovulation),
  • without ovulatory dysfunction, so as to stimulate the ovaries to produce more than one egg per cycle leading to the release of multiple eggs (Controlled Ovarian Stimulation – COS) in order to increase pregnancy rates with various assisted reproduction treatments. COS is also an important part of most IVF treatment.

 

Classification of oligo/amenorrhoea, common causes, and hormonal profiles
NameCommon causesHormonal profile
Hypothalamic– pituitary failure

Hypogonadotrophic hypogonadism

Weight,
exercise,
stress related
Kallmann’s syndrome Sheehan’s syndrome Hypophysectomy/ radiotherapy
Tumours
Idiopathic
Very low FSH, LH, E2
Hypothalamic– pituitary dysfunctionPCOS (PolyCystic Ovary Syndrome)Low or normal FSH
High or normal
LH High or normal testosterone
CAH (Congenital Adrenal Hyperplasia)High 17-OH prog.
Cushing’sHigh cortisol
Androgen- producing tumoursVery high testosterone
Ovarian failureAutoimmune Infections Surgery/irradiation
Gonadal dysgenesis Idiopathic/familial
High FSH, LH (LH may be normal in early stages).
Low E2
HyperprolactinaemiaPituitary adenomaHigh prolactin
MedicationLow FSH, LH
Stress
HypothyroidismHigh TSH
Outflow tract defectImperforate hymen Transverse vaginal septum Asherman’s syndrome

Absent uterus
Cervical stenosis

Normal
Androgen insensitivityTestosterone

Egg Retrieval

Oocyte retrieval is performed about 34-36 hours after hCG has been administered.
An anesthesiologist usually administers intravenous medications (sedatives and pain relievers) in order to minimize the discomfort that may occur during the procedure. Most patients sleep through the procedure.

BIOMATERNITY Fertility Specialsts-EGG RETRIEVAL-OVULATION INDUCTION-Procedure

Ovulation Induction

Step 1 - Prestimulation treatment
  • Initiation of Oral Contraceptives
    Some patients will receive oral contraceptives in the cycle prior to the ART cycle. This ensures that GnRH analog therapy will start at the proper time if you have irregular cycles. There is also evidence that oral contraceptives can help prevent ovarian cysts, which sometimes develop during GnRH analog therapy. Provera® or progesterone may be prescribed for patients who ovulate irregularly or not at all.
  • Suppression of Ovulation
    There are two principle ways that physicians ensure ovulation does not occur before egg retrieval. One involves pre-treatment of a patient with a GnRH agonist. The other involves treatment after six or so days of stimulation with a GnRH antagonist.
  • GnRH Agonist Administration
    GnRH agonist: (This medication is taken by injection. There are two forms of the medication: A short acting medication requiring daily injections and a long-acting preparation lasting for 1 month. The primary role of this medication is to prevent a premature LH surge, which could result in the release of eggs before they are ready to be retrieved. Since GnRH-agonists initially cause a release of FSH and LH from the pituitary, they can also be used to start the growth of the follicles or initiate the final stages of egg maturation.A GnRH agonist might be prescribed sometime after taking oral contraceptive pills. This dose may be reduced when ovarian stimulation is begun. Agonist is often discontinued on the day of hCG (human chorionic gonadotropin) administration.

Some protocols also might begin GnRH agonist sometime after ovulation in the cycle preceding stimulation in the “mid-luteal” protocol, after the start of menses in the “flare” or “micro-flare” protocol.

  • GnRH-antagonists (ganirelix acetate or cetrorelix acetate) (Antagon®, Cetrotide®):
    These are other classes of medications used to prevent premature ovulation. They are typically administered several days after stimulation and require fewer injections.
  • Baseline Pelvic Ultrasound
    Around the time of your expected period, your physician will perform an ultrasound scan to examine the ovaries. If your physician detects a cyst, they may withhold further therapy until the cysts resolve spontaneously (usually in about a week). Occasionally, cyst aspiration (drainage) is recommended. This is a procedure in which your doctor inserts a fine needle connected to a syringe, guided by ultrasound, into the cyst. They may also perform a blood test (serum estradiol measurement) to confirm that the ovaries are properly suppressed.
Step 2 – Ovarian Stimulation

In general, ovarian stimulation begins after menstrual bleeding starts. Several similar medications may be used to stimulate follicle development: Bravelle®, Repronex®, Lupron®, Gonal-F®, Repronex® Follistim® Follistim AQ pen and Gonal-F RFF Pen. GnRH-antagonists (ganirelix acetate or cetrorelix acetate) (Antagon®, Cetrotide®) are another class of medications used to prevent premature ovulation and, in combination with an antagonist trigger, they may offer protection from severe ovarian hyperstimulation syndrome. They tend to be used for short periods of time in the late stages of ovarian stimulation. There are several different types of stimulation protocols. Although all protocols more-or-less employ the same types of medications, specific protocols may help certain types of patients to have a better response than other types. It is, however, unrealistic to think that switching from one protocol to another will dramatically change a poorly responding patient to a highly responding patient.

Step 3 – Monitoring of Follicle Development

Follicular development is monitored with the combination of vaginal ultrasound and hormone measurements (blood tests). These tests are performed frequently during the ART cycle, and the dose of medication might be adjusted in an effort to improve follicular development. The amount of medication prescribed also depends upon the results of the blood tests and ultrasound exams.

Step 4 – Final Oocyte Maturation and hCG Administration

Human chorionic gonadotropin (hCG) (Profasi®, Novarel®, Pregnyl®, Ovidrel®) is a hormonal drug that stimulates the final maturation of the oocytes. Determining the proper day for hCG administration is critical. The time of the injection determines when the egg retrieval will be scheduled. Some protocols using GnRH antagonists use GnRH agonists to trigger the final maturation of oocytes.

Egg Retreival

Step 5 – Transvaginal Oocyte Retrieval
  • Eggs are removed from the ovary with a needle under ultrasound guidance.
  • Anesthesia is provided to make this comfortable.
  • Injury and infection are rare.

Oocyte retrieval is performed about 34-36 hours after hCG has been administered. An anesthesiologist usually administers intravenous medications (sedatives and pain relievers) in order to minimize the discomfort that may occur during the procedure. Most patients sleep through the procedure. A transvaginal ultrasound probe is used to visualize the ovaries and the egg-containing follicles within the ovaries. A long needle, which can be seen on ultrasound, can be guided into each follicle and the contents are aspirated. The aspirated material includes follicular fluid, oocytes (eggs) and granulosa (egg-supporting) cells. The physician will collect the oocytes and follicular fluid into a test tube and the embryologist will search the follicular fluid and locate the oocytes using a microscope.

After the retrieval, patients recover from anesthesia where they will be observed while the intravenous medication wears off. It is not uncommon to have some vaginal spotting and lower abdominal discomfort for several days following this procedure. Generally, patients feel completely recovered within 1 to 2 days.

The number of oocytes retrieved is related to the number of ovaries, their accessibility, and the number of follicles that develop in response to stimulation. Ultrasound provides only an approximation of the number of oocytes that one can expect to recover. On the average, 8 to 15 oocytes are retrieved per patient.

FREE
CONSULTATION

CONSULT FOR FREE OUR FERTILITY SPECIALISTS

*Any and all information will be kept completely private.