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Stepwise Approach to IVF
by Geoffrey Sher, M.D.
1. CONTROLLED OVARIAN HYPERSTIMULATION (COH)
IVF success rates are dependent upon the number of the mature eggs and healthy embryos available for transfer. A woman undergoing IVF is given fertility drugs for two reasons: (1) to enhance the growth and development of her ovarian follicles in order to produce as many healthy eggs as possible and (2) to control the timing of ovulation so that the eggs can be surgically retrieved before they are ovulated, with as many of them being mature as possible. In cases where the woman has previously received fertility drugs, the subsequent treatment regime is largely based upon her most recent response to such treatment. For a woman receiving gonadotropins for the first time, the dosage and regimen is determined by her blood FSH, E2, and Inhibin-B concentrations on the 3rd day of a preceding menstrual cycle (see above), medical history and body habitués.
In most cases, the woman begins her cycle of treatment by taking oral contraceptive birth control pills (OCP/BCP) for 6-30 days before initiating daily injections of leuprolide acetate (Lupron). Both the OCP/BCP and Lupron are administered together for an additional 4 to 6 days where upon the BCP is withdrawn while daily Lupron injections are continued. Menstruation will usually follow about 3 to7 days after stopping the BCP. In this way it is possible to accurately plan the onset of menstruation by varying the length of time on the BCP. In this way we are able to schedule each cycle of IVF to the convenience of the patient and the medical team. Additionally, the combined use of BCP and Lupron reduces the risk of Lupron-induced ovarian cyst formation, thereby largely avoiding the need to delay or cancel the cycle of treatment.
As soon as menstruation begins, blood is taken and if the plasma E2 concentration is less than 70 pg/ml, the patient is ready to initiate ovarian stimulation with gonadotropins. If the E2 level is greater than 70 pg/ml, Lupron therapy is continued at the same (or at an increased) dosage for a few more days, whereupon the E2 concentration is re-measured. Subsequent failure of the E2 to fall below 70 pg/ml is an indication for a pelvic ultrasound for the detection of an ovarian cyst, the presence of which usually mandates the performance of an ovarian cyst needle aspiration.
2. THE EGG RETRIEVAL
3. SPERM PROCESSING
5. SELECTING THE MOST “COMPETENT” EMBRYOS FOR TRANSFER
6. THE EMBRYO TRANSFER
7. POST-EMBRYO TRANSFER MANAGEMENT
8. EMBRYO/BLASTOCYST CRYOPRESERVATION