Oak Medical Group is a Clinical Group focusing on women's issues such as infertility treatment, artificial insemination⁄in vitro fertilization, pregnancy check-ups, gynecology (obstetrics and gynecology), and diet.
Ovulation Induction Method of IVF
Ultra Long Method
|Antagonist Method||HMG Cetro Method|
|Low - Medium Stimulation Method||Completely Natural Cycle
【Ovulation Induction Method】
In in vitro fertilization, it is a thing that we retrieve many satisfactory oocytes, but for success we need a direct connection. The ovulation induction method is that method of allowing the follicles to develop as we aim toward their retrieval. Therefore, choosing an adequate ovulation induction method becomes a very important step. From the many numerous ovulation induction methods, we will reference the many factors below in selecting the method that matches that person.
- Pituitary Hormone(FSH LH)
- Ovarian Hormone(E2 P4)
- Male factor(semen observation)age
- Past Egg Pick-up Cycles
- Possible number of visits
- Whether or not there is a limit on the egg pick-up day
- Either one or both members of the couple live far away or overseas
I will discuss for each case, the advantages, what should be taken into account, those who are primarily subject, and the cost.
The pFSH ⁄ HMG injection is administered from the 3rd day of menstruation. The kind of injection and the dosage will vary from patient to patient.
As a guideline, 150 units for those in their 20’s, 150-300 units for 30’s, 300 units for Mid-30’s-40’s, and 450 units for those with no response(Gonal F®and other recombinant products will be set at a slightly less amount.). It is possible to measure the follicle size appropriately, and adjusting the number of eggs to be picked-up.We will make use of Agonist (mainly a nasal spray, rarely an injection) and Antagonist (abdominal skin injection) as methods to suppress the ovulation before the pick-up of oocytes.
Depending on when you start with Agonist, there is the Short Method, Long Method, and Ultra Long Method.
The Short Method is from the first day of menstruation, the Long Method is from the previous cycle’s mid-term high temperature, and the Ultra-long Method starts many months before.
Antagonist will get 3mg on the 6th day of menstruation, and thereafter for every 4 days until the decision of egg pick-up, it will be added.
|Advantages||· Many number of eggs retrievable, can choose a good egg.
· Easy to ensure the frozen eggs.
· The inner membrane will not become thin like it does with Clomifene.
· Can control the number of developing follicles.
· Few empty follicles after ovulation(especially cases after use of Agonist, there are seldom empty follicles).
|Points to consider||· It is necessary to come everyday to the clinic for an injection(However, self-injection and injection from a closer facility is possible).
· There could be a case of OHSS.
· As for cases when the number of follicles are many(we aim for about 10 at our clinic), in order to avoid OHSS and because it will mean cryopreservation of all the embryos, there are times when we can’t do an embryo transfer in the same cycle.
|Adaptation||· People who want to have many eggs retrieved
· People who want to have cryopreservation of many embryos
|Cost||Increasing the amount of injections, and because we will be cryopreservation of eggs more frequently, the cost in regards to the egg pick-up will become more expensive, but, on the other hand, if you can ensure the many that undergo cryopreservation and because the number of egg pick-ups will decrease, you can slightly suppress in total.|
Below, we will talk about the various advantages and drawbacks and the like, in regards to the stimulation cycle.
· Short Method
|Advantages||· The flare up of the pituitary hormone (instigating rebound by being pressed once) can be used for follicle development within 2-3 days after beginning use of Agonist.|
|Points to consider||· Because we can’t use Agonist for oocyte maturation method and we will be using HCG, there is a possibility of developing OHSS.
· In the case where the ovarian reserve is low, the suppression will work too well and follicle development will worsen.
|Adaptation||The majority of people maintain the ovarian reserve to some extent.|
|Remarks||There is also the Ultra Short Method that uses only the flare up after using Agonist for 2-4 days only, but in that case, it will be necessary to take Antagonist for the ovulation suppression.|
· Long Method
|Advantages||· Due to the start of the ovulation induction medicine after completely suppressing the pituitary hormone, the follicle development will become equal.
· Hardly any chance of ovulation.
· Control of the egg pick-up day is easy.
|Points to consider||
· The amount of injections will increase because of the complete suppression of the pituitary hormone.
· Persons of young age
· Persons whom need control of the egg pick-up day
· Ultra Long Method
We will start the ovulation induction after we have reached a state of completely suppressing the pituitary hormone, which will take a few months. Thus, we will start the injections after reaching a state that menstruation will not start. As for the pituitary suppression, we use Leuplin® injections, and nasal sprays Busercur®, and Suprecur®. It is the same as the Long Method. It is often done in order to fix the implantation environment for those with endometriosis, especially adenomyosis.
|Advantages||· Improvement of the implantation environment of those with endometriosis|
|Points to consider||· If there is a low ovarian reserve, then the follicles will not grow
· Pituitary suppression will continue for a while
· The amount of injection will increase because of the complete suppression of the pituitary hormone
· Uterine myoma
· HMG Cetro Method
The HMG injection will start from the 3rd day of menstruation. The abdominal injection of Cetrotide®(also Ganirest®)3mg will be used from the 6th day of menstruation. Until the decision of egg pick-up after the follicles have been well developed, every four days there will be additions.
|Advantages||· From the beginning stage because it will not suppress the pituitary hormone, when compared to the Agonist Method, it is easy for the follicles to develop.
· Just as with Agonist, it is one-time use, and the Pituitary suppression will not last long.
· If there is a risk of OHSS, we will not use HCG for the oocyte maturation, but rather go through the Agonist Nasal Spray so there is safety.
|Points to consider||· In the case where follicle development is slow and because the price of Antagonist is a bit high, the cost will become expensive.
· Compared to Agonist, there is a slight possibility for the ovulation to happen.
|Adaptation||· For those whom have less than 3 developed follicles by Short Method|
Low˜ Medium Stimulation Method
· Complete Natural Cycle
In principle, regardless of oral and injections, we will not use ovulation induction medicines. However, there are times when we will use Antagonist or HMG 1 or 2 times in order to prevent ovulation before the egg pick-up.
|Advantages||· The number of times you will need to come in to outpatient are few.
· There are few burdens on the body because we do not use ovulation induction medicines.
· It is possible to do back-to-back cycle egg pick-ups.
|Points to consider||· It is impossible to do if your menstruation is irregular.
· The number of egg pick-ups will increase because we do it from that point when it is unsuccessful.
· There are times when the follicles are empty.
· There are times after ovulation when we can’t do an egg pick-up.
· There are times when we will not be able to freeze the embryo nor perform an embryo transfer when fertilization and or division did not go well because we can only do the egg pick-up once.
|Adaptation||· Over 44 years of age, decline of the ovarian reserve of low value of AMH etc., and those who desire
· In the case where there is a high value of FSH
|Cost||The cost is lower than usual in regards to the egg pick-up, and it is often the case that even if only 1 egg is retrieved from the pick up the cost for cryopreservation is unnecessary.|
· Clomifene(Clomid®, Serofene®)
Medication starts from the 3rd day of menstruation. There is also adjusting of the number of follicles through HMG injection used jointly with Cetrotide.
|Advantages||· Number of visits to outpatient is very low because it is an oral medicine
· Possible back-to-back egg pick-ups
· 1st selection of PCO
· For every 1 cycle the cost is low because the number of the egg pick-up and the number of frozen eggs are few
· However, if it is unsuccessful, for every 2-3 cycles, the cost will become a little more expensive because there will be an implementation after egg pick-up.
|Points to consider||It is common that there is a frozen embryo transfer on a different cycle because the inner membrane will become thin.|
|Adaptation||· Those who will desire by a natural method but if possible who would want to take 2-3
Medicine name: Cyclophenyl. This is a non-steroidal ovulation induction medicine that has a weak estrogen effect. It is said to affect the pituitaries and encourages the secretion of gonadotropin, but there are still many unclear points. When compared to Clomifene, the affects of the ovulation induction are weak. We might also use it jointly with injections during the process. Medication is taken from the 3rd day of menstruation for 5 days.
|Advantages||· Number of visits to outpatient are very low because it is an oral medicine
· It is possible to do back-to-back egg pick-ups
· There are many cases that it is possible to the embryo transfer in the same cycle because the inner membrane does not become thin as when compared to Clomifene.
|Points to consider||· The affects on ovulation induction are weak, will usually get around 1 developed follicle. We can’t use cryopreservation.
· When compared to Clomifene, the follicles are in a small state and easy for LH surgery to happen, and there is a high risk of ovulation before egg pick-up.
|Cost||It is about the same as a complete natural cycle.|
Medicine name: Retrozol. It was originally used as a treatment medicine for postmenopausal breast cancer. Within the ovaries, because we will inhibit the aromatase that has the enzyme necessary for when the male hormone is exchanged with oestradiol, it is said that the generation of oestradiol is suppressed and ovulation is induced when the secretion of FSH has risen by negative feedback, but there are still many unclear points. It is used just as Clomifene, from the 3rd day of menstruation.
|Advantages||· Affects of the anti estrogen are few, and the inner membrane will not become thin.
· Even where the ovarian reserve is depleted and the Clomifene doesn’t seem to be working, there is a case of follicles developing.
|Points to consider||· Used outside of application, use as a ovulation inducing drug is still not generally accepted.|
|Adaptation||· Example of non development by Clomifene
· History of Breast Cancer
|Adaptation||· History of Breast cancer|
· Estrogen Rebound
Direction to expect follicle development by taking estrogen and the results of the Rebound Method.
|Adaptation||· Those whom have difficulties with follicle development|
❈The costs are a simulation from a treatment model.
❈The prices are subject to change without notice.
Oak Medical Group has been from the time we opened, supporting the many issues of women's health, building performance and trust, and not only here in Osaka, but centering in Kansai we are receiving patients from across Japan.
Especially with our infertility treatment, we are widely covering the various tests to IVF/ICSI's Advanced Reproductive Technologies. Depending on the cause of the infertility, we are handling the treatment of each patient one by one. If you have some concerns, please don't hesitate to consult with us.