Egg pick up is done after detailed investigation and getting fitness from the anaesthetist. BMI less than 25 yields best results. BMI more than 35 with comorbidity or more than 40 need to undergo bariatric surgery. AMH and AFC on day 2 and day3 is done and patients classified into
- Normal responder-AFC 8-15 and AMH- 2-3.5
- Hyper responder- AFC more than 15 and AMH more than 3.5
- Poor responder- AFC less than 8 and AMH less than 1.5.
Patient with low ovarian reserve is treated with supplements. Ovarian stimulation is done on day 2 of menstrual cycle. Starting dose / type of gonadotropin Is decided based on past history of ovarian response BMI AMH . Normal responders are treated with reFSh or highly pure HMG from day 2 for 9-11 days. Follicular monitoring done on day 2 ,7 ,10.
HCG/ Gnrh trigger is given when USG shows 2 leading follicle of more than 17 mm . following which egg pick up is done under GA within 35-36 hours. Urinary HCG injection 5000/10000 units sc or recombinant HCG injection 250-500units sc. Gnrh trigger 0.2 mg of triptorelin sc. Or combination HCG or Gnrh injection. Oocyte retrival is a 30 min procedure. Patient is discharged in 2-4 hours. Mild ovarian stimulation needs low doses of hormonal injection, generally given in combination with oral tablets such as CC/ letrozole or tamoxifene, thus reducing consumption of gonadotropin and related complications like OHSS. In patients needing multiple cycle it is cost effective. Can also be used in normal responders with low budget.
As the no. of embryos are less as compared to standard stimulation, cumulative pregnancy rates are also low. Our unit uses this protocol in patients with PCOS or AMH more than 5. In these patients we start with letrozole 5mg/CC 100mg for 5 days starting from day 32 and then add 300-450 units of highly pure HMG or recFSH daily from day 6.
Antagonist given when leading follicle more than 14mm double trigger (HCG +Gnrh) when two follicles more than 17 mm. Pick up done after 35 hours.