Ovarian Stimulation Protocols

Ovarian stimulation protocols have been introduced for controlled ovarian hyperstimulation of patients undergoing in vitro fertilization treatment. Protocols are individualized based on ovarian reserve testing and the results inform responder classification types.

Classification

• Anticipated Low Responder characteristics:

  • Advanced age (≥ 37 years)

  • High basal cycle day 3 FSH (≥ 10 mIU/mL) or high basal E2 levels (≥ 90 pg/mL)

  • High FSH:LH ratio and low LH levels in basal cycle day 3, and/or low ovarian volume and/or a reduced AFC

• Poor Responders: are subjected to stimulation with one of two protocols. In both regimens recombinant FSH is used at doses higher than in intermediate responders, either in a micro flare GnRH agonist protocol or with a GnRH antagonist protocol.

  • GnRH antagonists and GnRH agonists are equally recommended for predicted poor responders.

  • Other stimulation options include patch protocol or minimal stimulation protocol.

• Anticipated Normal Responder: The GnRH antagonist protocol is recommended for predicted normal responder women, with regards to improved safety. A long-luteal protocol can also be used.

• Anticipated High Responder: A significant proportion of patients who have an exaggerated ovarian response to ovulation induction include women who have overt polycystic ovary syndrome (PCOS) or have an elevated baseline LH:FSH ratio.

  • The classic morphological appearance of PCOS is that of enlarged, polycystic ovaries characterized by a white, thickened capsule, multiple follicles at various stages of development and atresia, a hyperplastic stroma, and rare or absent corpora lutea and corpora albicans.

  • The GnRH antagonist protocol is recommended for women with polycystic ovary syndrome (PCOS), with regards to improved safety and equal efficacy.

Protocol Types

• Antagonist: You will start stimulation medications after your period and after 5-7 days, you will start another medication called a GnRH antagonist, which prevents you from ovulating.

• Long luteal: You will start a GnRH agonist (Lupron) after you ovulate then start stimulation medications after your next period.

• Microflare: You will start dilute Lupron and stimulation medications after your period.

• Minimal Stimulation: You will start clomid or letrozole after your period then start injectable stimulation medication after ~5 days. A few days after that, you will start a GnRH antagonist.

Note: Based on how you respond in the first cycle, your doctor may change the protocol to try to improve outcomes

Reference

https://academic.oup.com/hropen/article/2020/2/hoaa009/5827574

Last updated - 2/14/24