Ovarian stimulation protocols
There are three (3) key protocols for ovarian stimulation, the “long”, the “short” and the “antagonist’ protocol”. The personalization and selection of the protocol will be done by Dr. Ioannidis, having thoroughly studied and investigated your medical history as well as the medical history of your partner.
The long protocol starts on the 2nd or the 21st day of the cycle using the class of drugs called GnRH-analogues (e.g. Daronda, Arvecap, etc.) that will have to be administered for 10-14 days. These drugs are intended to prepare and suppress your ovaries by temporarily stopping their biological clocks. Then, after your period comes, you should have a blood test to verify the level of your hormones. It is necessary to establish whether ovaries have ben suppressed or not. Then, while continuing with the GnRH analogue, you initiate the follicle stimulating preparation (Gonal-F, Puregon, Menopur, Altermon, Merional), which helps the ovaries produce many follicles. Proper follicular development is checked via a combination of blood tests and vaginal ultrasound scan. When more than 3 follicles are larger than 17mm, a chorionic gonadotropin (Pregnyl or Ovitrelle) injection (night injection) is administered, which is necessary for the final maturation of the eggs. Egg retrieval is scheduled to take place 34-36 hours after the administration of chorionic gonadotropin.
The short protocol includes administration of GnRH-agonists from the 2nd day (as in the long), with concomitant administration of drugs that stimulate follicular production from the 3rd -4th day. Proper follicular development is followed-up via a combination of blood tests and vaginal ultrasound scan (as in the long protocol). The same applies to the final administration of chorionic gonadotropin.
The antagonist protocol is the most recent of the other two, as it involves newer drugs called GnRH-antagonists (Cetrotide, Orgalutran). Follicle stimulation medicines are initiated on the 2nd period and the antagonist is added on the 5-7th day of the cycle. Proper follicular development is followed-up via a combination of blood tests and vaginal ultrasound scan (as in the long protocol). The same applies to the final administration of chorionic gonadotropin.
Weekly ovarian stimulation with corifollitropin alfa (Elonva)
In all of the above protocols, ovarian stimulation to produce eggs is performed by daily injections of the appropriate drugs. In 2011, a new formulation (corifollitropin-α or Elonva) was released, which can replace the first 7 injections in a single “concentrated” form. This may have an indication for people who can not inject themselves and stay away, so they avoid daily travel. However, the activity and efficacy of this drug requires further documentation
In all protocols, during stimulation, we aim at producing and then retrieve a satisfactory number of eggs (between 4 and 15). However, the use of these drugs requires experience and attention to prevent ovarian hyperstimulation [link]. Conversely, if a lower dose is administered than the one required, fewer ova are produced and then the success rates of IVF are reduced.
The minimum number of eggs required to proceed with an IVF cycle depends on factors such as the size of the follicles, the age of the woman, the results of previous stimulations, and the will of the couple and the physician to proceed to egg retrieval even if only a small number of eggs is retrieved. If, despite the stimulation, the ovaries produce less than 3 mature follicles, then it is advisable to advise the woman, if this cycle fails, to proceed in the future to natural IVF cycles.
The role of reproductive gynecologist in all protocols is to personalize and select the appropriate protocol, with the appropriate drugs, at the appropriate dosages and to administer them for the appropriate period of time.