Controlled ovarian stimulation is key in IVF/ICSI cycles.

As it is step one upon receiving the results and confirming the possibility of IVF/ICSI, the same used not only for getting pregnant but also when a woman decide to freeze her eggs, this will help maximizing the number of oocytes produced to increase the chances of getting pregnant and/or freezing for future use.

We also encourage maximizing the number of produced oocytes when Gender selection and preimplantation genetic diagnosis is required, as it will increase the probabilities of required gender / healthy embryos.

The 2 most commonly used protocols for stimulation are the Short Antagonist protocol and the Long Agonist protocol.

The Long Agonist protocol is typically started on day 21 of the cycle in a regular 28 days cycle or simply a week before the anticipated cycle.

• Young age group ( <35 years)
• Recurrent failures.

• Start 5-7 days before the expected period if regular period, if irregular period you can start any time after at least 3 weeks from the LMP.
• Do base line TVS US to check for ovarian collection cyst > 25 mm, ovarian endometrioma, or obvious endometrial polyp
• Give Promulot N 10 mg or Duphastone 2 Tab for 5 days in cases of irregular periods or if the patient gives history of variable periods or there is a need to design and delay the cycle of treatment.
• Start Decapeptyl 0.1 µg subcutaneous daily at the same time of the day (preferably in the evening) either immediately after finishing Pogesteron tab or as detailed in the previous point. Continue the injections for at least one week, until day 3 of the period. One may need to extend the Deca injection for 2 weeks if the period did not start. Remember to do Pregnancy test if delay of period >7 days.
• On Day 3 of the period do TVS US (Down Regulation scan). It could be on D2-D5 as far as the patient continued the Deca injections. The scan is to check thin endometrium (ET) < 5mm and no collection cyst > 20mm. If any of the previous two points persist need to wait few days and continue on Decapeptyl injection and then repeat the scan. If thick ET persists consider to cancel the cycle and the need of Hysteroscope. If collection cyst > 20 mm persists consider cyst aspiration.
• Start stimulation according to the suitable dose and reduce to decapeptyl to 0.05µg (1/2 injection) subcutaneously for 5-7 days.
• At day 6-8 of stimulation TVS US to check ET and folliclometry. ET is expected 6-8 mm and the leading follicle 12-15 mm. Adjust the stimulation dose accordingly and repeat the scan as need. Expected growth of recruited follicle 1-1.5 mm per day.
• When reaching 3 follicles ≥ 17 mm consider the patient for egg collection. There is no need for the patient to receive stimulation or Decapeptyl on the day of the HCG injection however if the patient already received the injection one can proceed with treatment as planned.
• Triggering of ovulation 10,000 iu HCG IM or 5000 iu HCG if more that 10 follicle >16mm or more than 15 follicle in total. HCG injection 36 hours before the egg collection procedure. Example HCG injection on 10pm Saturday the egg collection at 10 am Monday.

The advantages of such protocol are that it enhances synchronous growth of the follicles, might lead to a better yield in eggs (reported as 1-2 more eggs in most studies) and is considered more convenient to the physician considering the inhibiting ability of the agonist to the pituitary ovarian access.

However, it may take longer days to stimulate the ovaries, which entitles more use of HMG or FSH, and since only HCG trigger can be used, this puts a patient at a risk, though minimal, of ovarian hyperstimulation syndrome.

The Short Antagonist Protocol commences typically on day 2 or 3 of the cycle with the straight administration of ovarian stimulation medications (HMG or FSH) until the follicles reach around 14 mm in size where a GnRH antagonist is then used for the rest of the cycles along with (FSH or HMG) until the follicular size is (18-20) mm in size.

• Age group ( >37 years).
• Poor responders
• Patient attended 2-3 of the period.

• On Day 2- 3 of the period do TVS US . It could be NOT be any later than Day 4 of the period . The scan is to check thin endometrium (ET) < 5mm and no collection cyst > 20mm. If any of the previous two points present cannot use the short protocol.
• Start Decapeptyl 0.1 µg subcutaneous daily for 8 days at the same time of the day (preferably in the evening), and start the stimulation according to the suitable dose form the next day for 7 days. Both medications will finish on the same day.
• At day 8 of stimulation TVS US to check ET and folliclometry. ET is expected 8 mm and the leading follicle 14-16 mm. Adjust the stimulation dose accordingly and repeat the scan as need. Expected growth of recruited follicle 1-1.5 mm per day.
• When reaching 3 follicles ≥ 17 mm consider the patient for egg collection. There is no need for the patient to receive stimulation or Decapeptyl on the day of the HCG injection however if the patient already received the injection one can proceed with treatment as planned.
• Triggering of ovulation 10,000 iu HCG IM or 5000 iu HCG if more that 10 follicle >16mm or more than 15 follicle in total. HCG injection 36 hours before the egg collection procedure. Example HCG injection on 10pm Saturday the egg collection at 10 am Monday.

In regards to cost, and considering the GnRH antagonist to be expensive in most countries, it is regarded to be of slight financial increase compared to the long protocol.