TREATMENT CYCLE PROCEDURE
Ovarian Stimulation (Standard Protocol) :
Medications used to supraovulate the ovaries may be given in a variety of combinations called protocols. Your physician will review your records and determine which protocol will be used for your upcoming cycle. The following information describes the initial protocol used for the majority of patients. In a standard protocol, there are three key steps.
Down Regulation With Lupride :
In order to optimize the stimulation of your ovaries, Lupride, is given starting approximately 1 week before your expected period (day 21 of a 28 day cycle). Alternately, if you have been instructed to initiate oral contraceptive pills (OCPs), then Lupride is started around day 15 (out of the 21 days of active pills) of the OCPs. Lupride suppresses both the pituitary gland and ovaries and allows for greater pharmacologic ovarian stimulation.
Lupride is administered subcutaneously (underneath the skin, not into the muscle). This medicine is typically injected into the thigh or hands and is easily self-administered. Alternately, you may have your husband or a friend administer this medication. This medicine is usually given for at least 10 days before ovarian suppression occurs, but may also be given longer (for several months) without affecting your ovarian stimulation. Usually the Lupride dose will be reduced (1/2 does) once the stimulation phase of the cycle begins.
Ovarian Stimulation :
You should experience a menstrual period within 7 to 14 days from starting the Lupride injections. Please notify the clinic when you start your period so that we may schedule a baseline sonogram and blood estradiol test. The purpose of these tests is to confirm that the Lupride has, in fact, suppressed your ovaries to a baseline state. This means that your ovaries should contain no follicles which are greater than 15 mm in size, and your blood estradiol level should be less than 50 pg/ml.
In approximately 10-15% of patients, one or both of these conditions are not met and may need further evaluation. Occasionally a persistent ovarian cyst may need to be aspirated. After ovarian suppression has been achieved, stimulation using gonadotropins will begin on a specified date (cycle start).
The initial dose of your medications will be based upon multiple factors (age, weight, FSH level, previous history) and be given subcutaneously once or twice a day. You will take this initial dose of medication for 5 days before returning for an estradiol blood test. Sonogram are performed starting on Day 6/7 of your stimulation.
Further doses of gonadotropins may be modified based on estradiol levels or sonogram results. In general, you will return for follow-up sonograms and estradiol blood tests usually every 1 to 3 days in order to monitor follicular growth and endometrial development. Usually visits are more frequent at the end of a stimulation cycle. Most people require approximately 10 days of ovarian stimulation.
Follicle Triggering (HCG) :
When your follicles indicate that your eggs are mature, we will instruct you to take HGC. In general, at least two follicles with a mean diameter of at least 18 mm and an appropriate estradiol level must be present before HCF is administered. Also, at least 2 mature follicles should be present in order to receive HCG.
You will be instructed to inject HCG 36 hours before the oocyte retrieval. For example, we may tell you trigger at 9:00 a.m. Monday evening, so that oocyte retrieval can occur at 9:00 a.m. Wednesday morning. This will be your last injection prior to the egg retrieval. Timing of this medication is extremely important!
Oocyte (Egg) Retrieval :
You should have nothing to eat or drink in the eight hours prior to your retrieval. The procedure is conducted under intravenous sedation, administered by an anesthesiologist, so that you will be comfortable during the egg collection. Most patients are candidates for vaginal sonogram to guide a needle through the posterior wall of the vagina into an ovary. Each follicle is then aspirated under direct visualization. The procedure usually last about 20 minutes.patients are allowed to go home after recovery. If you experience pain, bleeding (more than a period), temperature >101 degrees,or other side effects following the procedure, please notify your physician as soon as possible.
Collection of Semen Specimens :
A semen specimen will be required on the day of egg retrieval, and is usually collected at the ART center. Abstinence from intercourse is required for approximately 2 days prior to egg retrieval. We recommend that ejaculation occurs the same evening when HCG is given to assure better quality sperm for the IVF procedure.
If a significant male factor is present, you may be asked to prolong the period of abstinence prior to the day of the oocyte retrieval. If you anticipate any collection difficulties, please notify your physician.
Oocyte Culture :
After the egg retrieval, you will be given the preliminary results on the number of oocytes retrieved. Please realize that the quality, number, and maturity of the eggs may not be evident because the eggs are surrounded by follicle cells (granulose cells) which prevent quick evaluation. Supraovulation yields various types of eggs, including mature, immature, post mature, and nonviable eggs.
you will be contacted by an embryologist one day after your egg retrieval and given the status report on the number of oocytes that fertilize. At this time, fertilization is seen in most cases, but viability can only be confirmed when the fertilized egg divides normally, usually after another day. As you know, one risk of IVF is lack of fertilization. Sometimes a reason for this is understood, but many times no reasons are evident.
A hospital representative will review your hospital financial obligation with you at that time. Your cycle may stop at any stage where your physician believes that successful completion of the treatment cycle is unlikely. Credit or refund will be given for services that were not performed.
Embryo Transfer :
We will ask you to arrive 02 hours prior to your scheduled embryo transfer time. The procedure is similar to having an intrauterine insemination. Sedation and pain medications are usually not necessary. Usually this procedure will be done under (transabdominal) ultrasound guidance. You will rest on your back at the ARTS Center for approximately thirty minutes. You should have someone with you to drive you home after embryo replacement.
Luteal Phase Support :
On the day after your oocyte retrieval, you will be instructed to start progesterone injections. Progesterone is a hormone produced by the ovaries only during the post-ovulation, or luteal phase, of your ovarian cycle. Progesterone develops the endometrial lining of your uterus to support and maintain pregnancy.
Although your ovaries are producing progesterone, supplementation is required because some of the cells which produce progesterone in the ovary are removed during the egg retrievel, and some of the medications you received may contribute to a progesterone deficiency after the oocyte retrieval.
