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rFSH is preferred in IVF cycles because these are:

  • Highly purified products of specific activity, free of contamination.
  • Reliable unlimited supply with batch to batch consistency without adverse immune reactions.
  • Ovarian response to gonadotrophins is consistent with no risk of variability.
  • Can be self administered subcutaneously. Total dose of Gonadotrophins required is lower.
  • More effective resulting in higher pregnancy rates per started IVF cycle. 5.4% more pregnancies. For every 19 women treated with Recombinant there was one extra pregnancy.

The timing, dosage, and administration of the hormonal medications are critical to the success of the cycle.

Standard IVF Schedule It is essentially a regimen of controlled ovarian hyperstimulation aiming to develop multiple follicles. Recombinant Follicle Stimulating Hormone (rFSH) 225 to 300 units is administered daily starting on Cycle Day (CD) 4 for 5 days after which first monitoring is done. Usually step down regime is followed, starting with higher dosage and then lowering it after seeing the response. In some cases step up, starting with low dose and then increasing it and in others sequential dosage is used.

Careful monitoring is necessary to adjust dosages and ensure an optimal stimulation period. Excessive amounts may result in ovarian hyperstimulation syndrome (OHSS), whereas insufficient quantities of the drugs may result in an unsuccessful cycle leading to cancellation. The woman is monitored with vaginal ultrasounds and blood tests. TVS provide actual image of the ovaries and aid in the assessment of follicular growth. These ultrasounds begin around the ninth day of the cycle. The follicle diameter (FD), their number, growth and any signs that require alterations in treatment is checked. TVS probe is gently introduced into the vagina and through it ovaries are identified. The follicles are counted, their size measured. Endometrium thickness is also noted. > 9 mm or more Follicular diameter indicates recruitment.

Depending on the response, the dose is maintained, increased or reduced. The woman revaluated after another 5 days (10 days since start). If required the dose is readjusted. The woman is now monitored after every 2/3 days.

When follicles are > 17 mm, it is an indicator of maturity and approaching ovulation. The multiple follicles developed are of variable diameters. While some grow to > 20 mm, many may be < 15 mm. In such cases the stimulation is to continue until FD of 50 % follicles is > 18 mm. 9 mm thick triple line Endometrium reflects that the uterus is ready for implantation.

A minimum of 3 follicles need to develop to maturity to proceed to egg retrieval. If this is not achieved, cycle is cancelled and we do not proceed to egg retrieval. About 90 % of women under 40 with normal FSH and normal antral follicle counts will develop at least this minimum number.

In women not at risk of OHSS, or poor responders (normally identified before the treatment cycle), the visits can be limited. Only one TVS performed on stimulation day 9 or 10 can be enough. If the patient on that day had three follicles of 18 mm (means of two diameters), fewer than 15 follicles and an endometrial thickness of 7 mm or more, hCG is given. If the follicle did not fulfill these criteria on the day of the scan, a follicular growth of 2 mm/24 hours is predicted and hCG given accordingly. Egg retrieval is scheduled 36 hours after hCG administration.

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