Ovarian Stimulation (Stimulating Follicles)
Baseline Assesment & Evalulation of Patient
An office visit is scheduled on day 2 or day 3 of menstrual cycle to begin a baseline evaluation for the couple. The initial step in the IVF process is to undertake a transvaginal ultrasound scan. This scan is utmost determining factor on the treatment protocol. The imaging of the ovaries allows us to assess ovarian reserve by counting the small growing follicles which are called antral follicles. We also check for cysts in the ovary which might affect fertility. Also, the uterus is examined to see whether the cavity where the embryo will implant is normal and the endometrium is healthy.
It is very important to have proper baseline. The basic parameters for a proper baseline evaluation are as below
- Uterine lining is thin
- Hormone levels of E2, progesterone, LH are all low
- Neither of the ovaries have any large cysts
If there are any cysts detected by our doctor, the treatment protocol might change. For example, cysts aspiration is recommended or to wait until the cysts resolve on its own.
In general, ovarian stimulation begins on second or third day of the menstrual cycle and the treatment lasts about 8-12 days. Ovarian stimulation is started with injectable fertility medications on the day that is chosen by our physician. There are several different types of stimulation treatment protocols.
- First group of medications, FSH and LH Analogues, are for the Follicle development
- Second group of medication, GnRH-Antagonists and GnRH-Agonist, are for preventing early ovulation.
- Third group of medication, HCG (Human Chorionic Gonadotrapin) or Chorriogonadotropin Alpha is used for timely induction of ovulation.
Although all protocols more-or-less employ the same types of medications, we provide patient specific protocols based on our evaluations of the patient.
Development of Follicles and Monitoring
Follicular development is monitored with a combination of vaginal ultrasound and hormone measurements such as estradiol (E2) are performed. Regardless of the treatment protocol the patient would be monitored every other day by vaginal ultrasound and every day towards end of treatment cycles as follicle grow. These tests are performed frequently during the 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.
Oocyte Maturation and hCG Administration
When at least three follicles have reached 18mm or more and if the endometrium is satisfactory then an injection of a hormone called hCG is given to mature the eggs in the ovary and cause ovulation to occur 36 hours later. The timing of the egg collection has to be very precise so that it is collected before ovulation occurs. Therefore the injection of hCG also needs to exactly on time.
Egg(Oocyte) Retrieval 36 Hours After hCG
Egg retrieval is performed about 36 hours after hCG has been administered. Before the procedure an 8-hour fasting is required. An anesthesiologist administers intravenous 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 aspirated. The aspirated material includes follicular fluid, eggs and egg-supporting cells. The physician will collect the eggs and follicular fluid into a test tube and the embryologist will search the follicular fluid and locate the egg using a microscope.
After the retrieval, patients recover from anesthesia where they will be observed while the intravenous medications wear off. Patients are observed at our center for about 2 to 3 hours after the procedure. It is not uncommon to have some vaginal spotting and lower abdominal discomfort for several days following this procedure.