Ovarian Suppression

Downregulation – GnRH Agonist

In order to optimize pregnancy rates, medications are given to increase the number of eggs produced in an IVF cycle. To prevent premature egg release (ovulation) and control the timing of retrieving mature eggs a GnRH agonist is given. These medications cause a temporary state of menopause and are administered as either an intranasal spray, or subcutaneous (needle under the skin) injection. In some circumstance the birth control pill may be used in combination with these medications. Your physician will determine which protocol is used based on your individual medical history. The nursing staff will start your medications on set days of your menstrual cycle. Once a patient is on the IVF waiting list she will phone in her last menstrual period on the first day of full flow. Subject to wait-list and Covid-19 capacity restrictions, you will most likely be offered treatment within one to two months of registering for treatment.

Suppression Check – Pelvic Ultrasound

After a patient has had approximately 2 weeks of GnRH agonist, or just prior to completing a package of birth control pills, a pelvic ultrasound is performed. This ultrasound is necessary to confirm ovarian suppression and to ensure that no new findings (such as an ovarian cyst) have developed that may interfere with treatment. The transvaginal ultrasound is usually done at the clinic; however, for patients who live a long distance away, alternative arrangements may be made.

Medications/Side Effects

GnRH agonists are commonly known as Suprefact® or Lupron®. These medications may occasionally cause nausea, vomiting, hot flashes, night sweats, and headache. You should notify your doctor if you develop rapid heartbeat, chest pain, breathing difficulties, fever, chills, severe headache, or visual changes.

GnRH Antagonist

In some circumstances, an alternative to GnRH Agonist downregulation may be required or preferred. A GnRH antagonist prevents premature release (ovulation) of eggs by producing a rapid, reversible suppression of pituitary LH secretion. This medication is administered by subcutaneous (under the skin) injection. This is started during the controlled ovarian stimulation phase of the cycle. The specific protocol used will be determined according to your medical history and stimulation response.

Suppression Check – Pelvic Ultrasound

The patient is not suppressed during an antagonist cycle. However, a pelvic ultrasound is required within a day or two of starting menses and prior to stimulation medication to ensure that no new findings (such as an ovarian cyst) have developed that may interfere with treatment.

Medications/Side Effects

GnRH antagonists are commonly known as Orgalutran® or Cetrotide®. These medications may cause skin reactions such as redness, with or without swelling at the injection site, or occasionally headache, nausea, dizziness, lack of energy or strength (asthenia) and malaise.

Controlled Ovarian Stimulation (Superovulation)

In a normal menstrual cycle, the ovaries typically produce a single mature egg. In order to maximize pregnancy opportunities, medications are administered to stimulate the ovaries to produce many eggs in an IVF cycle. These medications are called follicle stimulation hormone (FSH) and are administered by subcutaneous (SC) injection. These medications are required for 9-14 days (on average 12) and are self administered by the patient. The follicular development is monitored by serial transvaginal ultrasound examinations and estradiol (E2) levels. Once the monitoring results indicate mature eggs (appropriate follicle size and estrogen levels), another hormone called Human Chorionic Gonadotrophin (hCG) is given to complete the final maturation process and the egg retrieval is scheduled for 35 hours later. These medications rescue eggs that would otherwise be discarded naturally in a normal menstrual cycle.

A typical IVF cycle will require an ultrasound examination and/or estradiol levels prior to starting superovulation (suppression check). Repeat testing by ultrasound and/or estradiol levels will be arranged on Day 4, Day 7 and about every second day after day 7 while on the FSH medication. The monitoring process is individualized and patients that are at high risk for ovarian hyperstimulation syndrome (OHSS) may require daily monitoring.

All monitoring with estradiol blood tests and ultrasounds are done at the Regional Fertility Program during treatment. The IVF team including physicians, nursing staff and the embryology staff meet daily and discuss patients’ results in order to ensure the best decisions are made with regard to medication dosage, timing of hCG and number of embryos to transfer.

Side Effects

The active medication used to stimulate the ovaries is follicle stimulating hormone (FSH). These medications are commonly known as Gonal F®, Puregon® and Menopur®. These medications act directly upon the ovary to stimulate multiple follicular development. Common side effects include bloating, enlarged ovaries, nausea, diarrhea, and tender breasts. Serious side effects can occur as a result of ovarian hyperstimulation syndrome (OHSS). This may cause ovarian enlargement, fluid in the abdomen (ascites), difficulty breathing, kidney failure and blood clots which in rare and extreme circumstances may even result in death.

Over Response

If over response to ovarian stimulation occurs this can be potentially very serious. However, several options exist. These options will be discussed and individualized accordingly. In general, options include:

continuing with the cycle including embryo transfer and monitoring for ovarian hyperstimulation syndrome (OHSS),
continuing with egg retrieval and freezing all embryos for use in a Frozen Embryo Transfer cycle later
canceling the cycle and restarting at a lower dose of stimulation medication or different protocol.

Suboptimal Response to Ovarian Stimulation

The age of the female partner and day 3 FSH level will generally help to predict the ovarian response to ovarian stimulation. The stimulation regimen and dosage used will depend on these factors. If suboptimal response is evidenced by low levels of estradiol or low egg numbers (less than 4 eggs) these issues will be discussed individually with the couple and recommendations made. There are a number of options:

The IVF cycle may be converted to Superovulation/IUI if the semen analysis is normal and tubes are patent,
The cycle may continue to egg retrieval albeit with a lesser chance of success
The cycle may be discontinued and a more aggressive stimulatory protocol used in a subsequent cycle.

If these more aggressive stimulatory protocols fail to produce an appropriate ovulatory response consideration should then be given to egg donation.