CONTROLLED OVARIAN HYPERSTIMULATION AND OOCYTE RETRIEVAL : CLINICAL INPUTS DR Priyanka Sinha MD OB-GYN MUMBAI, INDIA
LEARNING OBJECTIVE Introduction Ovarian stimulation protocols Comparison of different protocols Ovulation Trigger Oocyte retrieval Challenges and complications of oocyte Retrieval Take home Message
INTRODUCTION Controlled ovarian hyperstimulation is an important step in Assisted Reproduction. Controlled ovarian hyperstimulation is a technique used in assisted reproduction involving the use of fertility medication to induce multifollicular development CONTROLLED OVARIAN HYPERSTIMUL ATION GnRH agonist or GnRH antagonis Prevents premature LH surge GONADOTROPINS (FSH or HMG) Stimulates development of multiple ovarian follicles l HCG Ovulation trigger
TYPES OF PROTOCOL 1. GnRH agonist - 1984 Conventional - GnRH agonist Downregulation - The Long Protocol - GnRH agonist UltraShort - GnRH Agonist Flare 2. GnRH Antagonist - 1999
MODE OF ACTION AGONIST
AGONIST PROTOCOL SHORT PROTOCOL GnRH agonist 1 mg per day LONG PROTOCOL GnRH agonist 0.5 mg \day Individualised dosing of FSH \HMG GONADOTROPINS 225 IU HCG MENSES 21 22 23 24 25 26 27 28 1 2 3 4 5 6 7 8 9 10 CYCLE DAY
GnRH AGONIST FLARE PROTOCOL OCP MICRODOSE GnRH AGONIST 40 mcg twice daily Individualised dosing of FSH \HMG GONADOTROPINS 225 IU HCG MENSES 1 2 3 4 5 6 7 8 9 10 CYCLE DAY
MODE OF ACTION GnRH ANTAGONIST
GnRH ANTAGONIST SHORT PROTOCOL OCP - scheduling, synchronising follicle Griesinger et al, 2008 Micronized Estradiol 2 mg twice d Estrogen doesn t affect cycle outcome, used for programming cedrin et al 2012 MENSES GONADOTROPINS 225 IU GnRH ANTAGONIST 250 mcg\ day. fixed \flexible Single or multiple doses Individualised dosing of FSH \HMG HCG Gnrh agonist (eldor et al 2000). OHSS and CPR reduced ( Cochrane review 2011) 21 22 23 24 25 26 27 28 1 2 3 4 5 6 7 8 9 10 CYCLE DAY
COMPARISON AGONIST (LONG) AND ANTAGONIST AGONIST ANTAGONIST Action Downregulation of pituitary Immediate blocking of Gnrh receptors Time to blockage of pituitary 2-4 weeks 8 hrs LH level Stable low LH level High in early stage, fluctuates Synchronisation of follicle Yes Ocp for synchronisation Scheduling flexibility Yes Ocp \ Estradiol for Flexibility Hypoestrogenemia symptoms Common Not seen( varney et al 1993)
CONTINUED... Cyst formation ** Possible (Ron et al 1989) No OHSS Consumption of gonadotropins Pregnancy rate (result of meta analysis cochrane review 2011) Higher incidence ( Rizk et al 1992) Higher Ben Rafel et al 1991 Equal Lower incidence Al- Inani et al 2011 Lower Equal
OOCYTE RETRIEVAL Oocyte retrieval is the process of collecting mature eggs directly from ovary prior to their release from ovary TIMING : 34-36 hrs after HCG injection
APPROACH LAPAROSCOPY- technique of choice in 1st 10 years ULTRASOUND 1. TRANSVAGINAL Wikland et al in 1985 Simple, rare complication, gold standard 2. TRANSABDOMINAL When ovaries not accessible transvaginal Safe and effective comparable with the result of TVOR Bortan et al 2011
MATERIAL CHECKLIST USG MACHINE WITH TVS PROBE NEEDLE GUIDE ASPIRATION NEEDLE CONNECTING TEFLON TUBINGS SUCTION PUMP DRY BLOCK HEATERS AND WARM BLOCKS HEATED LAMINAR TABLE TEST TUBE, PETRI DISHES, PIPETTE
PREPARATION AND TECHNIQUE
CHALLENGES AND COMPLICATIONS Ovaries stuck behind cervix and uterus Endometrioma Intra Abdominal bleeding Cervical and Vaginal bleeding Empty follicle syndrome Postoperative pelvic infection Rupture of dermoid cyst, lumbosacral osteomyelitis
TAKE HOME MESSAGE Ovarian stimulation is a critical step in Assisted Reproduction. Antagonist protocol is short, simple and safe with pregnancy rate comparable to Agonist protocol. Oocyte retrieval is Simple and efficient procedure A variety of controlled ovarian hyperstimulation regimens are available and efficacious, but individualization of management is essential and depends on assessment of the ovarian reserve.
THANK YOU Priyanka Sinha