IVF and Egg Freezing Flashcards
Controlled Ovarian Stimulation–Phases
Suppression/Priming: (prior to ovarian stimulation)
Birth Control pills
Aygestin (progesterone)
Estrace (estrogen)
Testosterone
Stimulation of the Ovaries:
FSH/LH by injection
Clomid/Letrozole w/injections
2a. Suppression of ovulation - we don’t want pt to ovulate on their own
Agonist (Lupron) or Antagonist (usually started around 5th day until trigger day - )
2b.“ Trigger”
Egg Retrieval
usually after suppression, the pt will get to baseline - then started on FSH and LH by injection for about 8-10 days. The egg will then be mature and we can retrieve it.
Lifestyle Modifications/Restrictions…- how long after retrieval to obstane from sex?
Exercise
Ovaries will enlarge to accommodate growing follicles
Activities that involve bouncing or twisting, are discouraged since there is risk of ovarian torsion due to the increase size/weight of the ovaries.
Patient can stay active by continuing to engage in walking, cycling, or using an elliptical. These restrictions apply for 1-2 weeks following your retrieval. Can begin as early as day 5-7 of stimulation if there is an expectation of a high egg count.
Hot tub/sauna/Hot yoga
Not recommended to engage in activities in which body temperature cannot be regulated
Heat can affect both growing eggs and sperm
Sexual Activity - need to use condoms - pull out does not work
Use barrier contraceptives and spermicide (use condoms) if you are having intercourse with a male partner.
This rule should start with the first day of the period before treatment and continued until the period following retrieval.
After retrieval, you should abstain from any vaginal intercourse for 1 week.
Chronic Medications -
All medications prescribed elsewhere should have been recorded in your new patient questionnaire so that the physician can determine if they are compatible with your treatment medications.
Important to ask patient is any new medications/supplements have been added prior to IVF/EF or Embryo transfer
Herbal supplements/Adjuncts
Unless SPRING has advised the addition of supplements, it is best for a patient to discontinue due to possible interference with test results and outcome
Ovarian Torsion
blood supply of ovary compromised, rare/emergent condition, stimulated ovary at risk, signs/symptoms - severe pain, N/V
Egg Freezing
Freezing eggs (oocyte cryopreservation) is an important option for those wishing to delay childbearing or diagnosed with a disease in which a lifesaving treatment may affect future fertility (Cancer)
Success rate is based on age & number of eggs frozen
Egg Calculator available to help with expectations (Spring Fertility website)
IVF Stimulation protocols
Goal:
Retrieve the optimal number of eggs required to obtain enough healthy embryos to allow reasonable chance to attain future family building goal.
Stimulation protocol chosen by MD:
Ovarian reserve testing (AFC/AMH)
Previous stimulation
MD experience/previous outcomes
IVF Protocols
MD will recommend protocol based on:
Patient history
Diagnosis
Previous treatment
Test results (AMH/AFC)
Every fertility clinic develops their own protocols based on science/experience
Spring has ~ 15 protocols they can utilize
Suppression/Priming
Prior to starting stimulation medication, often the patient is advised to begin a medication to assist in suppressing endogenous hormones
This can begin in the follicular or luteal phase
Why use priming prior to ovarian stimulation??
Follicle synchronization
Planning
Decrease the chance of early follicular recruitment in patients with DOR
(or PCOS)
Priming protocol using GnRH agonist..(the less popular option)
(the lupe is agonizing)
Lupron (Leuprolide Acetate) is a GnRH agonist- SQ injection (this prevents GnRH binds with lupron - so no bonding to LH and FSH receptors - no eggs growing, then no LH surge - this gives us full control over HPO axis - and we can use meds to get eggs to grow. this is DOWN REGULATION.
when given in small doses over an extended period of time (10-15 days)-GnRH agonists desensitize the pituitary gland (GnRH receptor downregulation).
Once downregulated, the pituitary cannot respond to GnRH pulses and therefore will not secrete FSH/LH
After stopping the agonist, the effects last for approx. 12 days, therefore no LH surge will occur either. If stim 12+days, best to add antagonist to avoid premature ovulation.
This issue w/ using this med is if we use it before the stimulation, we can’t use it during the surge and the pt is at risk for OHSS
Priming protocols using hormones..(this option is more common)
Increased E2/P4
E2=Estrogen
P4=Aygestin
(E2 and P4 is basically a birth control pill - this is usually low during follicular phase, which is why LH and FSH get high)
Suppresses FSH/LH
Helps to decrease the possibility of endogenous FSH being secreted early which can cause early follicular recruitment
minimal stimulation
instead of using injections, pt will do combo of oral meds, and then shots to finish
Fewer eggs available for stimulation
Decreased medication cost
Multiple cycles often completed to reach desired outcome
Cancellation rate—high
Egg Retrieval
Outpatient procedure
Under Anesthesia (conscious sedation)
Diprivan/Fentanyl/Versed
Pre-anesthesia consult required for some patients (completed prior to ovarian stimulation):
Co-morbidities
BMI >40
Patient advised to take day off of work
Most can return to work next day
safe, 20 min
pt is with us for about 2 hrs
each egg is carefully aspirated
Ovarian Hyperstimulation Syndrome (OHSS)
Ovarian hyperstimulation syndrome (OHSS) is an excessive response post trigger, from the gonadotropins that encourage multiple eggs to grow.
Most at risk are those that have an increased number of eggs and high estradiol at time of trigger.
Rarely, OHSS can result from taking other ovulation induction medications, such as clomiphene citrate.
The cause is not fully understood however having a high level of HCG plays a role. When we trigger using HCG, this can lead to OHSS syndrome in those at high risk.
HCG hormone high Vascular Endothelial Growth Factor (VEGF) secretion from the follicles VEGF cause vascular permeability loss of fluid to third spacing
Symptom’s peak ~3-5 days after the retrieval.
Pregnancy worsens and can prolong the syndrome.
can affect 1 out of 3 pts - mild
OHSS
this is just excess fluid in the abdomen - ascites - 3rd spacing
OHSS can be classified as : mild, moderate, or severe.
One out of three has symptoms of mild OHSS
Worse in the evening…
Peak 3-4 days following egg retrieval
Prolonged/more severe if pregnancy in same cycle (i.e.. Fresh embryo transfer)
Those with severe OHSS need to be monitored closely and may need support/intervention
Usually have vomiting/cannot keep down liquids.
Experience shortness of breath without exertion
At risk for pleural effusion & blood clots in lung/extremities..
May need vaginal paracentesis to drain fluid in the pelvis, may need multiple
Severe cases may need IV hydration and possible hospitalization
OHSS Patient Education..
Advised to contact clinic or provider on call if they have:
Rapid weight gain (>2.5lbs within 24 hours)
Severe persistent pain that is not managed w/ Tylenol and/or Ibuprofen
Persistent vomiting
Decreased urine output, despite maintaining proper hydration
Shortness of breath at rest
How to avoid:
Lower doses of gonadotropins (LH and FSH)
Minimal or no hcg for trigger injection (depends on protocol, etc) (you can give lupron instead, but lupron doesn’t work for everyone
Addition of medications following egg retrieval:
Dopamine agonist (cabergoline) to decrease vascular permeability
Additional antagonist (Cetrotide/Ganirelix) to help decrease E2 and expedite recovery from stimulation
