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Standard IVF Protocol
Medications used
to superovulate the ovaries (cause the production of numerous
eggs) may be given in a variety of combinations called protocols.
Your physician will review your records with you and will determine
which protocol will be used for your upcoming treatment cycle.
The following information describes the standard or initial protocol
used for the majority of patients. Each patients protocol is individualized
and may vary from the standard protocols.
With the standard protocol, four (4) types of medications
may be given:
- Lupron,
a gonadotropin-releasing hormone (GnRH) agonist, which acts
on the pituitary gland to inhibit gonadotropin (FSH and LH)
secretion which prevents premature ovulation or
- Progesterone
to support endometrial development.
- Gonadotropins,
medications consisting of a combination of FSH alone or combined
FSH/LH preparations, which act on the ovaries directly to stimulate
development and maturation of the eggs, and
- hCG,
or human chorionic gonadotropin (known commercially as Pregnyl
or Ovidrel), which acts directly on the ovary causing the release
of the eggs from the ovarian follicle.
In order to optimize the stimulation of your ovaries,
a medication called
Lupron, is given starting approximately 1 week before your
expected period, i.e., cycle day 21 of a 28-day cycle. Alternately,
if you have been instructed to initiate oral contraceptive pills
(OCPs), then Lupron is administered beginning on day 14 (out of
the 21 days of active pills) of the OCPs. Lupron acts by  suppressing
two hormones made in your pituitary gland, which normally cause
your ovary to make eggs and ovulate. By suppressing these two
hormones called follicle stimulating hormone (FSH) and luteinizing
hormone (LH), your ovaries will become suppressed so that they
do not make eggs nor produce the ovarian hormone called estradiol.
Down regulation or ovarian suppression with Lupron allows your
physician to have greater control over the ovarian stimulation
which provides for an even growth of ovarian follicles, and prevents
a condition known as premature luteinization defined as the premature
attempt by your body to ovulate.
Lupron is administered subcutaneously (underneath
the skin, not into the muscle). This medicine is typically injected
into the thigh and is easily self-administered. Alternately, you
may have your husband or a friend administer this medication.
Lupron is given usually 10 to 14 days before ovarian suppression
occurs, but may also be given longer (for several months) without
affecting your ovarian stimulation. Approximately 10% of patients
require longer than 10-14 days of Lupron to completely suppress
the ovaries. Please note that your Lupron dose will be reduced
be half once the stimulation phase of the cycle begins.
Ganirelix Acetate
and Cetrotide are both GnRH (gonadotropin releasing hormone)
antagonists that suppress pituitary gland LH secretion directly
by binding to the GnRH receptor. These act immediately to suppress
pituitary LH-secretion to prevent premature LH surges. Depending
on your situation, your physician may decide to use one of these
medications in place of Lupron .
Ganirelix Acetate or Cetrotide will be started after ovarian
stimulation has begun, typically around stimulation day 6, or
when the lead follicles are approaching 12 mm in mean diameter.
Ovulation 'triggering' is handled similarly to a Lupron cycle.
You should experience a menstrual period within 7
to 14 days from starting the Lupron injections. Please notify
the clinic when you start your period so that we may schedule
a baseline ultrasound and blood estradiol test. The purpose of these
tests is to confirm that the Lupron has, in fact, suppressed your
ovaries to a baseline state.
"Suppression" means that your ovaries should
contain no follicles that are greater than 15 mm in size, and
your blood estradiol level should be less than 50 pg/ml. In approximately
10-15% of patients, one or both of these two conditions are not
met. Depending upon the results of these tests, we may extend
the Lupron medication for another week and ask you to return for
another sonogram and blood estradiol test, or occasionally may
perform an ovarian cyst aspiration (performed in the office).
After ovarian suppression has been achieved, ovarian
stimulation using gonadotropin
fertility medication, ( FSH ) may commence at a scheduled
time referred to as the cycle start. On the cycle start day, you
may be instructed to reduce the initial dose, which will be continued
throughout the stimulation phase of your cycle until
hCG is administered.
The dose of your medications will be based upon your
age, weight, number of ovaries, cycle day 3 FSH and estradiol
levels, and your response to previous stimulation cycles. You
will take this initial dose of medication for 2 days before returning
on the morning of gonadotropin Day 3 for an estradiol blood test.
Your dose may be changed based upon the level of estradiol. You
will take medication for 2 more days before returning on medication
Day 5 for an estradiol blood test. Sonograms are conducted starting
on Day 7 of your stimulation. In general, you will return for
follow-up sonograms and estradiol blood tests usually every 1
to 3 days in order to monitor the growth of your follicles.
You will be asked to return more frequently towards the
end of your ovarian stimulation. Most people require 8 to 12 days
of ovarian stimulation, and most people require 4 to 6 sonograms
and/or estradiol levels during this period of time. Monitoring is conducted at our Dallas, TX fertility clinic location.
If you are participating in our Dallas donor egg program, we have a separate site devoted to this topic.
When your follicles have met the criteria that indicate
that your eggs are mature, we will instruct you to take
hCG (Pregnyl or Ovidrel). In general, at least two follicles
with a mean diameter of at least 18 mm and an appropriate estradiol
level must be present before hCG is administered. You will be
instructed to inject hCG (5,000 - 10,000 units) approximately
36 hours before the oocyte retrieval. For example, we may tell
you to inject Pregnyl or Ovidrel at 7:00 p.m. Monday evening,
so that oocyte retrieval can occur at 7:00 a.m. Wednesday morning.
You do not need to administer gonadotropins or Lupron after you
have received hCG.
Administration of hCG is commonly called follicle
"triggering." The purpose of this medicine is to induce
the final stages of oocyte maturation and the release of the eggs
by the ovary. Timing administration of this medication is important
and you must carefully follow your physician's/nurses's instructions.
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