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DR Frank Quinn Clinical Director IVF Australia
DR Frank Quinn Clinical Director IVF Australia
DR Frank Quinn Clinical Director IVF Australia
Clinical Director
IVF Australia
Definition
Advanced age
Ovarian surgery
Pelvic adhesions
High body mass index
Reflecting early ovarian aging
Clinical significance
Interventions
Modifying stimulation protocols
Adjuvant therapy
Modifying stimulation protocols
Letrozole
Aspirin
RecombinantLH
Human growth hormone
Short vs. long GnRH agonist
Malmusi 205
N=152
Short GnRH agonist
Decapeptyl 0.1mg day 1 of cycle
rFSH 450iu daily start day 2 for 6 days, then ?600iu/d
Antagonist
rFSH 450daily from day 2 for 6 days, then ? 600iu/d
Orgalutran 0.25mg/d when lead follicle >14mm
GnRH antagonist vs. short GnRH
agonist
GnRH antagonist vs. short GnRH
agonist
No difference in pregnancy rate
Antagonist 21.4%
Short GnRH agonist 25%
GnRH antagonists may be associated with
- simpler stimulation protocols,
- lower gonadotropin requirements,
- reduced patient costs,
- shorter downtimes between consecutive cycles.
Greatest advantage of GnRH antagonists is the ability to
assess ovarian reserves immediately prior to starting
gonadotropin stimulation.
The ability to respond to cycle-to-cycle variation in antral
follicle counts may allow the optimization of oocyte yield and
reduce cycle cancellation rates.
Long GnRH agonist vs.
'stop'protocol
single embryo
?better quality and
?more receptive endometrium
Morgia 2004
N=70 low dose arm and n=59 in natural cycle
No difference in cancellation or miscarriage rate
Natural cycle vs. low dose GnRHa flare
protocol
Natural cycle vs. low dose GnRHa flare
protocol
CONCLUSION
Modifying stimulation protocols
Schoolcraft et al
GnRH antagonist and letrozole 2.5mg daily
Goswami et al
Long GnRH agonist protocol n=38
No difference in FSH dose, oocytes retrieved or
pregnancy rate (23.1% vs. 24.0%)
Letrozole and poor responders
Letrozole and poor responders
Addition of pyridostigmine
Addition of pyridostigmine
Addition of L-arginine
Addition of L-arginine
Addition of testosterone
Addition of aspirin
Addition of aspirin
Addition of aspirin
LH receptor formation
5 RCT’s
Berg et al, Fertil Steril 1994;62:113-20.
Dor et al, Hum Reprod 1995;10:40-3.
N=138
Poor response
At least 2 failed IVF cycles with <5 eggs
E2 <500pg/mL on day hCG and <3eggs prev. cycle
No difference in
no. eggs retrieved
duration of ovarian stimulation
Owen’s study showed reduction in total FSH
Difference in
live birth rate (95% CI close to unity, ?clinical
significance may be small)
Addition of human growth
hormone
Addition of human growth
hormone