Advanced Fertility Services

DIAGNOSIS AND TREATMENT OF SUBCLINICAL HYPOTHYROIDISM

The Thyroid Gland is a small, butterfly-shaped mass of tissue found in the neck, just below the “Adam's Apple.” Despite its small size, it has a critical role in determining how our bodies function, and, ultimately, how well we feel. The thyroid controls the body's metabolism, which  …. read more.

OVARIAN SCLEROTHERAPY FOR OVARIAN ENDOMETRIOMAS

An Endometrioma is a type of benign (non-cancerous) ovarian cyst situated within the ovary. This type of ovarian cyst is lined with the same cells that line the endometrial cavity of the uterus and are filled with a thick chocolate colored material …read more.

THE EUROPEAN PROTOCOL

this protocol is a potent stimulator of egg production, widely used in Eastern Europe.  The simultaneous combination of Clomid and FSH/LH, given on alternate days, yields a maximal response in terms of egg production, using many fewer injections and requiring approximately 50% less injectables, compared with the purely injectable regimens. Not only does this protocol save a great deal of money with respect to drug costs, it also greatly reduces the number of injections that a woman needs during a treatment cycle.

BCP x 21 days (last pill on a Thursday)

THE JAPANESE MINIMAL STIMULATION PROTOCOL 

In Chapter 4 of my book "The Pregnancy Prescription", I discussed the “minimalist approach” to treating infertility and IVF stimulation. Proponents of minimal stimulation IVF believe that only a few high-quality eggs should be stimulated and harvested, with the goal of a single or dual embryo transfer. They cite several reasons for their approach. The most compelling reason is that this method virtually eliminates high-order multiple births by ensuring that there is not an excess number of embryos to transfer. The basis of their theory rests on the supposition that intense ovarian stimulation, which produces a great numbers of eggs, ultimately creates an excess of genetically abnormal embryos which are virtually indistinguishable from chromosomally perfect ones. In support of this theory is the fact that a surprisingly small percentage of normal-appearing embryos are found to be genetically perfect when subjected to genetic analysis. Since minimal stimulation is a very new concept, it remains to be seen whether this approach will prove beneficial for all patients or just certain subclasses of patients. To be sure, this method has certain advantages over traditional IVF stimulation in that it requires many fewer injections and less monitoring and should reduce the cost of an IVF cycle (less medication and fewer embryologic expenses). Moreover, the risks of ovarian hyperstimulation and high order multiple births are virtually nonexistent with the minimal stimulation protocol.

The European and Minimal Stimulation protocols are primarily useful in patients who are low responders. They are also ideal for patients who dread injections or have an aversion to high doses of fertility medications.

 NATURAL IVF

As its name implies, Natural IVF is an unstimulated cycle. The goal of which is to retrieve the single mature egg created in a normal ovulatory cycle. The theoretical basis for advocating its usage is that the biologic process of natural selection will cause the highest-quality oocyte in the pool of eggs available for development in a given month to be contained in the dominant ovarian follicle. The trick is to carefully monitor the patients’ cycle so as to retrieve the egg from the follicle when it is mature, but prior to follicular rupture and its release. In addition to monitoring follicle size via ultrasound (it should be 18-20 mm at maturity), careful attention must be paid to the LH levels. Once an LH surge has been detected in the blood, it is often impossible to predict when the patient will be in the narrow zone between egg maturity and its release. Scheduling the retrieval too early will result in the absence of an egg in the follicular fluid that is aspirated from the follicle, since if there is an insufficient time of exposure to LH, the oocyte will not complete its maturation and will not separate from the follicular wall. Yet if too much time is allowed for egg maturity, the egg will be released from the follicle prior to retrieval. 

Fortunately, several strategies can be used to improve the chances of successful egg retrieval in Natural IVF. The most commonly used method is to give HCG when the follicle reaches a diameter of 17-18 mm, prior to the natural LH surge. The HCG, like LH, causes the egg to mature. Since the time of the initiation of egg maturity is precisely known, egg retrieval can be scheduled 32-38 hours later, when the egg is fully mature, yet prior to its release from the follicle. Antagonists, such as Antagon or Cetrotide, can also be used to block the LH surge when administered on a daily basis from the time that the follicle reaches 14 mm. HCG is then given to complete egg maturation when the follicle reaches 18-20 mm. Egg retrieval can then be scheduled at an optimal time.

This approach is appropriate for patients who do not produce many follicles in response to maximal stimulation protocols. It is certainly logical to use no medications when the same result is achieved both with and without them. This method may also appeal To patients who are opposed to the creation of extra embryos for religious reasons or those who may not be comfortable with the use of fertility-enhancing medication. This approach has the advantage of being able to be repeated on consecutive months, since the ovaries do not need a rest period to recover from the effects of the fertility medications used for controlled ovarian hyperstimulation. In addition, since the patient has only a single follicle to be aspirated, a minimal dose of Demerol can be used to manage any discomfort associated with the procedure. It is important to note that the pregnancy rate using Natural IVF is only about 6% per cycle. This approach is, for the most part, employed in only the most difficult clinical situations.