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The IVF Process: Ovarian Stimulation Basics

My Post (3).jpgStudies have shown that approximately 40% of patients will abandon the IVF process after a single cycle. The most common cause of dropout is the physical and psychological burden of the treatment, which accounts for 35% of dropout.

But another common cause is an inadequate response to ovarian stimulation, which is unexpected in most cases, with 10% of couples quitting the IVF process simply because of an inadequate response in the first cycle.

Ovarian stimulation protocols are the means by which a patient's ovaries are stimulated to produce eggs. Fertility clinics can and should optimize their ovarian stimulation protocols so that the patient's response in the first cycle is adequate. By doing so, they can not only decrease dropout, but reduce failed IVF, cancellation of IVF cycles, and complications such as ovarian hyperstimulation syndrome (OHSS).

Individualizing Ovarian Stimulation

For many years, we have known that every IVF patient is different, and it does not make sense to use one “standard” stimulation protocol for everyone. A qualified fertility specialist will individualize their IVF stimulation protocols. At InVia Fertility Specialists, we do this by using a set of clinical parameters and ovarian reserve markers:

Ovarian Reserve Markers

We look at the following ovarian reserve markers in each patient in order to individualize ovarian stimulation:

  • Antral follicle count (AFC) is the number of antral follicles (2 – 5 mm in diameter) present in the ovaries and detectable by transvaginal ultrasound scanning. These are the small follicles that will respond to gonadotropins and form large follicles (that contain the microscopic eggs). The higher the AFC, the more the number of eggs that will be retrieved.

  • Anti-mullerian hormone (AMH) level is now commonly used to assess the number of eggs (oocyte pool) that remain in the ovaries. The higher the AMH level, the larger the oocyte pool. There isn’t a definite value identified in the literature that will by itself predict ovarian response. Using the old DSL assay, the cut off was 0.7 ng /ml (5 pmol/l). With the new Gen II AMH assay the cut off value is about 40% higher and closer to 1 ng/mL.

  • Day-3 Follicle stimulating hormone (FSH) level is a better predictor of pregnancy. Ovarian response cannot be predicted based on day-3 FSH levels. However, if there is diminished ovarian reserve (day-3 FSH level > 10 mIu/mL), one can expect poor ovarian response to stimulation.

Other Clinical Parameters

We also look at these clinical parameters in each patient in order to individualize ovarian stimulation:

  • Previous ovarian stimulation response: It is very helpful to be able to review (if available) a previous stimulation. Based on the ovarian response and number of eggs retrieved, we can increase or decrease the dose of medications used.

  • Menstrual cycle characteristics: Patients with irregular cycles will often benefit from starting birth control pills so that we can then better time start of stimulation. Irregular or absent menses can be associated with polycystic ovarian disease. Concurrent hot flashes or vaginal dryness can be suggestive of ovarian failure.

  • Features suggestive of polycystic ovary syndrome (PCOS): These include once again irregular or absent menses, increased hair (hirsutism), signs of androgen (male hormone) excess like acne, temporal balding etc. Obesity is not a diagnostic feature of PCOS. PCOS patients can be a challenge clinically. They often have high AMH levels and are high responders. At the same time, if they are obese, they may require high doses of gonadotropins for a satisfactory ovarian response.

  • Age: Age is an independent variable that must be considered when assessing ovarian reserve. Older women generally require a higher dose of medications to respond. However, there are exceptions to this rule, such as patients with PCOS.

  • Body mass index (BMI): Obese patients will often require a higher dose of gonadotropins for a satisfactory response. It is well-established in the literature that IVF success rates are lower in obese patients. In fact when the BMI is > 35, IVF pregnancy rates are 67% lower! Currently, at InVia, we will have patients with high BMI lose weight till it is < 35 before they are accepted in our IVF program.

  • Smoking: Smokers will require a higher dose of medications than their non-smoking counterparts. We do not accept smokers as anonymous egg donors at InVia.

    Using these markers and parameters, we can categorize the patient as either a poor responder, a normal responder, or a high responder, and provide ovarian stimulation in a way that is most likely to produce success for her based on that categorization.

To see a fertility specialist with a strong success rate diagnosing and treating fertility issues, make an appointment at one of InVia’s four Chicago area fertility clinics.

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Dr. Vishvanath Karande

Dr. Vishvanath Karande

Dr. Karande is Board Certified in the specialty of Obstetrics and Gynecology as well as the subspecialty of Reproductive Endocrinology and Infertility. He is a Fellow of the American College of Obstetricians and Gynecologists and Member of the American Society for Reproductive Medicine.

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