1. OVULARIAN STIMULATION PROTOCOLS

12. So what do we use in Practice? Clomiphene Citrate Antagonists TI AIH hMG or FSH ______________________________________________ hMG or FSH

16. IVF ICSI Gonadotrophins hMG, FSH, rec-FSH + GnRHa - long -short -u-short Antagonists +GnRH antagonist Always LP++

17. Protocols for IVF GnRH Antagonist Protocols GnRH Agonist Protocols 225 IU per day (150 IU Europe) Individualized Dosing of FSH/HMG 250  g per day antagonist Individualized Dosing of FSH/HMG GnRHa 1.0 mg per day up to 21 days 0.5 mg per day of GnRHa 225 IU per day (150 IU Europe) Day 6 of FSH/HMG Day of hCG Day 1 of FSH/HMG Day 6 of FSH/HMG Day of hCG 7 – 8 days after estimated ovulation Down regulation Day 2 or 3 of menses Day 1 FSH/HMG OCP

22. The protocol was criticized for being unphysiological, and increases the LH levels in the early stages of the follicular phase, which might be harmful to the growing follicles.

25. A meta analysis of 22 randomized trials comparing long and short protocols demonstrated the superiority of the long protocol of GnRH agonist regarding clinical pregnancy rate. (Daya 1999)

29. Type of Gonadotropin / / / 3% glycoproteins 97% other proteins FSH 75 I.U LH 75 I.U. + detectable amounts of hCG

37. Live Birth / Ongoing Pregnancy rate O.R.: 1.21 (95% CI 0.95-1.54)

38. Significant result with Long Protocol O.R.: 1.26 (95% CI 1.00-1.60)

42. Agonist vs antagonist

44. Pregnancy per woman O.R = 0.80, 95% CI = 0.69 to 0.92

47. Incidence of OHSS R.R. = 0.61, 95% CI = 0.42 to 0.89

54. Complications of Ovulation Stimulation Drugs. OHSS Multiple Gestation

56. Complications of Ovulation Stimulation Drugs. OHSS Prevention of TI/IUI withhold hCG use “coasting” use Antagonist IVF

60. Novel protocol 75 IU/HMG CD3 CD7 150 mg CC hCG IUI DF ≥ 18 mm 34-36h

61. Control group 75 IU/HMG CD3 hCG IUI DF ≥ 18 mm CD7 34-36h

62. Results (cont.) Variable HMG/CC (n=110) HMG (n=107) P value LH on day of hCG (miu/ml) for cases with no premature LH surge 7.3 ± 1.8 7.8 ± 2.2 NS Number of Follicles ≥ 16 mm 2.4 ± 0.97 1.3 ± 1.1 P < 0.05 * Number of patients with premature LH surge 6 (5.45%) 17 (15.89%) P<0.001 * End. Thickness (mm) 5.9 ± 0.7 4.9 ± 1.9 NS Clinical Pregnancy 11 (10%) 9 (8.41%) NS

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