Ovulation Induction Protocols/Stimulation Protocols
The success of any Assisted Reproductive Technology (ART) procedure improves if multiple mature oocytes are available for retrieval. To achieve stimulation of the ovaries, the fertility specialist administers hormonal injections of Gonadotropins daily. The most commonly used Gonadotropins are Gonal – F, Menopur, Repronex etc.

The Long Protocol
This is the most common protocol used in ART in which GnRH analogues (Lupride, Decapeptyl, Suprefact) are started subcutaneously 7 days prior to the expected day of her period and then continued daily till the day of her HCG in a fixed dose (1/2ml equivalent to 20 units of an insulin syringe.)

Alternatively, a single shot of Zoladex or Lupride depot may be given on the 21st day of her previous cycle.

A day 2 Estradiol (E2) helps to confirm suppression (value should be less than 50). An ultrasound examination rules out any cyst in the ovaries and helps to assess the uterine lining (thickness should be less than 4mm). Once done, actual stimulation is started with Gonadotropins.

The stimulation of ovaries starts from D2 of the menstrual cycle. Stimulation starts with one of these drugs:

• Recombinant FSH (Gonal F or Recagon)

• FSH (Metrodin HP, Metrodin, Fostine, Gonotrop)

• HMG (Menogon, GMH, Pergonal)

• Normally Recombinant FSH or FSH is started first on D2 and is continued for 4-6 days followed by HMG for another 7-9 days. The Dosage depends on age and the response of ovaries to injections
  

The Short Protocol:
This protocol is similar to the long protocol except that suprefact is to be started from the second day of menstrual period and continued till the day of HCG.

The Ultrashort Protocol:
In this protocol, suprefact is given from day 2 to day 5. This protocol is used for patients with very low egg reserve and elderly patients.

Ultrasound Monitoring-
The baseline ultrasound is done on Day 2 and if it is normal, stimulation is started. This allows about 8-12 follicles to develop simultaneously but the number may vary from 3-4 to 20-25 follicles depending on the age, baseline FSH & E2 and the dosage of the medication.

During the period of ovarian stimulation, strenuous physical work should be avoided as it may interfere with follicular development.

HCG Timing:
Once the follicles are ready for retrieval, injection HCG is given so as to make the eggs ready for retrieval.

D. Ovum Pick UP –
The retrieval is usually scheduled 34-36 hours following HCG injection. The patient is generally called empty stomach so that short sedation could be given for the procedure. A needle is inserted through the vagina into the ovaries under ultrasound guidance but the patient does not feel the pain due to sedation. The follicles are punctured one by one and the fluid containing the eggs is collected in test tubes and quickly given to the embryologists in the IVF laboratory. The procedure takes about 15-20 minutes to complete. Simultaneously husband is asked to give his semen sample. An abstinence of 2-5 days is recommended before the scheduled day of retrieval. After the procedure is over, the patient is allowed to rest for some time and then sent home. The patient might have some pelvic pain or soreness and heaviness with some amount of spotting on that day. She is advised rest and abstinence on the day

Fertilization-
Once the eggs are retrieved, they are placed in special culture media inside special carbon dioxide incubators for a few hours during which time the semen sample is prepared. The best quality sperms are then placed in the same dish as the eggs so as to allow them to fertilize the eggs. Alternatively, fertilization can also be achieved by injecting the sperms directly into the eggs by performing ICSI (Intracytoplasmatic sperm Injection)

Normally an embryo starts to cleave first into two then into 4 cells after 36-48 hours. The best quality embryos are then transferred back into the uterus on D3 to D5 depending on several factors.

Embryo Transfer
This procedure is scheduled either on D3 or D5 of the retrieval depending on the number and the quality of embryos. The number of embryos to be transferred would depend on the age, previous IVF history, quality, number of embryos available etc. The embryologist loads the embryos into a thin catheter and the specialist passes the tip of catheter through the cervix into the uterus and transfers the embryos under ultrasound guidance. This procedure totally painless and does not require sedation. The additional good quality embryos, if available, are frozen and kept for future use.

On the day of transfer there is no need of fasting and the patient is asked to come with a partially full bladder will allows transfer to happen easily and gives a better picture ultrasonographically. Thereafter the patient is advised rest for a couple of hours and should be completely relaxed. It is pertinent to mention here nothing that the patient does such as walking, going to washroom etc would dislodge the embryos from the uterine wall. The main factors that determine whether implantation would take place or not are the receptivity of uterine living and the viability of embryos.

Luteal Support-
Following Embryo transfer, progesterone support is started to enhance the chances of a successful IVF pregnancy. Progesterone is the natural hormone which the body produces to support the endometrium and maintain an early pregnancy.

Pregnancy Test-
The pregnancy test is usually scheduled two weeks after the embryo transfer. This might be the most difficult time for the patient but she needs to be relaxed. She might experience a feeling of heaviness or cramping in the lower abdomen. Sometimes there might be some spotting as well but the medication should not be discontinued.

On the day of the test, if it is positive, a repeat test is done after 2-3 days to ascertain the growing levels of BHCG. If unfortunately the test is negative, the patient is instructed to stop the medicines and then counselled for her next step. Another cycle of treatment can be started as soon as one month after the failed cycle.

Do's and Don'ts after and IVF cycle

• Avoid heavy work and vigorous exercise

• Use the steps sparingly and with caution

• Avoid vaginal creams or lubricants other than those prescribed by your specialist

• Avoid intercourse until advised. Avoid hot baths, Jacuzzis

• Travel slowly and avoid jerks

• Avoid stress

Intracytoplasmic Sperm Injection (ICSI) – We provide affordable ICSI treatment which consists of:-

• Ovarian Stimulation with injections to produce multiple eggs which are monitored using transvaginal ultrasound and hormone (Estradiol) levels

• Administering injection HCG when at least two leading follicles reach a diameter of 18 mm

• Ovum pick up under short general anaesthesia usually 34-36 hours after HCG injection.

• Isolation of eggs in the laboratory from the fluid.

• Sperm collection and processing. In case of azoospermia (no sperms present in the semen), the sperms are collected directly from the testis using PESA/MESA/TESE/TESA or FTNB

• Dissecting the eggs by using an enzyme (Hyaloronetis) which are then placed into small droplets of culture media under oil.

• Placing sperm into small droplets of PVP under oil immobilizing the sperm with a microinjection needle and then aspirating immobile sperm into the needle (tail first).

• Holding the egg with the holding pipette and injecting the immobilized sperm into the egg

• Placing these eggs into the incubator

• Embryo transfer on D3 or D5 of retrieval

Indications

• Males with very low sperm count (less than 5 million), poor motility or higher percentage of abnormal sperms

• Males with azoospermia (when no sperms are present in semen). In case of obstructive or non obstructive types, sperms can be retrieved directly from testis using PESA/TESA/TESE.

• Males with antisperm antibodies

• Males with ejaculatory dysfunction or retrograde ejaculation

• Patients with repeatedly failed cycles of IVF.

• The success rate of ICSI at our unit is about 30-40% which is comparable to those of best centres in the world.

Dolphin IVF & laparoscopy Centre.