controlled ovarian hyperstimulation and oocyte … fileovulation trigger. types of protocol 1. gnrh...
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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