Minimal Stimulation Protocol Using Aromek(Letrozole) and Follitrope(recFSH) Combined With INVOCell-Low Cost IVF (MSP-IVC)

Infertile couple following MSP with IVC

OVARIAN STIMULATION:

In previous cycles, cycle length and ovulatory status must be assessed and documented.

STEP 1: ANOVULATION by ORAL CONTRACEPTION

• Place patients on monophasic low dose of oral contraceptive pills (OCP) such as Marvelon (Organon, 0.03 mg) continuously for 21 days, 22 days but no more.
• Before stopping the oral contraceptive pills, perform an ultrasound to check for the absence of cysts (no cyst > 10 mm).
• Give estradiol (2mg, 3 times a day) for 3 days from D21 or D22 and wait for bleeding.

STEP 2: STIMULATION and MONITORING Day one of the cycle equals the first day of bleeding (not spotting).

• On Day 3 (D3), start letrozol 2.5mg (AROMEK) for 5 days (D7). LetrozolE can be pushed for 2 more days.
• Start hMG or FSH (75 IU a day) on Day 3 like LetrozolE and continue for 5 to 7 days without increasing the dose. The dose of hMG OR FSH can be increased to 150 IU a day if low responder.

Other Names:

• Aromek (Letrozole 2.5 mg);
• Follitrope (Recombinent FSH - 75 IU)
• IVF-C 5000 IU (HCG)
• Ova-Surge (Urinary LH Surge Kit)
• Indomethacin 50 mg

Baseline Day-2 Ultrasound to estimate antral follicles; Follow-up TVS scans on Day- 5,6,7,8 and 9 of the stimulated cycle. Ideally the lead follicle should be 18 mm on or around day 10 of the cycle.

• When the leading follicle reaches 14 to15 mm (D8 or D9), give Indomethacine (50 mg, 3 times a day) until the evening preceding the egg retrieval. The Indomethacine will prevent a premature ovulation.

The endometrium should be minimum 8 mm on the day of HCG (IVF-C 5000 IU x 2)

No need of LH testing, or E2 testsing during the stimulated cycle.

IVF-C (HCG 10000 IU) shall be injected to trigger the ovulation, when any of the following occur:

• E2 level is over 150 pg/ml/per mature follicle (> 15 mm)
• Domminent follicle is greater than 18 mm in mean diameter
• LH Remains as Baseline, OR
• The day when Urinary LH Surge is positive

Other Name: IVF-C 5000 IU

Ultrasound guided Ovum Pick-Up is performed 34-36 hours after IVF-C (HCG 10000 IU) injection.

Embryo Transfer is performed after 48-72 hours of incubation at 4-8 cell stage.

Maximum of 2 embryos are transferred, using ultrasound guided transfer.

Cancellation Criteria:

• Poor patient compliance
• Premature Ovulation
• Premature LH Surge
• Endometrium < 7 mm
• Poor Follicular Development
• E2 Level > 2,500 pg/ml

Other Names:

• Ovum Pick-Up
• Embryo Transfer
• Ultrasound Guided

Sperm preparation through Swim-Up or Gradient is performed 1 hour prior to the oocyte retrieval; Fill the device without air bubble. Only 30000 motile spermatozoa are added into the device; After follicle aspiration, oocyte(s) are identified in the follicular fluid and immediately placed into the device; The device is closed, placed into a protective outer rigid shell and then positioned into the vaginal cavity for 2 to 3 days; No activity restriction is required for the patient, except baths. After 2 or 3 days of incubation, the retention system and the device are removed from the vagina in sterile environment. The device is opened and the contents are observed in a sterile environment under microscope to find the embryos. The two best quality embryos are loaded into embryo transfer catheter and transferred immediately unto the uterine cavity using aseptic techniques.

Other Names:

• INVOCell
• Diaphragm (Retention Device)