Wednesday, April 05, 2017

The zero OHSS clinic

While IVF is usually safe , one of the dreaded complications of IVF treatment is ovarian hyperstimulation syndrome ( OHSS.)  If not managed properly, it can lead  to hospitalisation in the ICU, and even death. This is why it's so important to prevent it.

Step number 1 is to identify patients who are at increased risk for developing OHSS. These are typically patients with PCOD - those with a high AMH level and a high antral follicle count.
For these patients, we use the 3-step " antagonist downregulation-agonist trigger-freeze all  " protocol to prevent OHSS. This means we have become a Zero OHSS clinic.

How does this work ?

We superovulate you with gonadotropin injections, such as Gonal F; downregulate you with GnRH antagonists ( such as Ovucet or Cetrorelix) from Day 7 onwards; and then, instead of using HCG as a trigger, we use GnRH agonists ( such as Decapeptyl) to trigger ovulation.

Your eggs are collected after 36 hours, and all the embryos are frozen on Day 5 ( blastocysts) . No transfer is done in the fresh IVF cycle; and the frozen blastocysts are then  transferred in the next cycle, one at a time. With this protocol, the chances of developing OHSS are virtual zero. This allows us to collect lots of eggs safely, and then transfer the frozen embryos , one at a time after thawing them in subsequent cycles. This offers a lot of safety; and maximises the chances of your having a healthy singleton live birth , which is the holy grail of IVF treatment.

This is what the protocol looks like.

IVF/ ICSI treatment starts from Day 2 of your cycle. Day 1 = Day of bright red bleeding. If the bleeding starts after 6 pm count the next day as Day 1. Ignore the spotting.
On Day 2, we do an ultrasound scan at our clinic to confirm there is no ovarian cyst, and to count the number of antral follicles. We then start your superovulation .
Inj Gonal-F ( 75 IU FSH ), 2 amp ( 150 IU ) daily from Day 2. The dose of Gonal-F (  FSH) will depend upon your ovarian morphology and your antral follicle count.
From Day 7, we start Inj Cetrorelix/Ovucet/ Orgalutron/ Antagon, 0.25 mg daily . This is a GnRH antagonist. The Gonal-F continues.
We do the next scan on Day 7, after which you would have to be in Bombay for about 10 days. Your husband is needed on Day 12-Day 14 ( the day of the egg pickup). All the treatment is performed at our clinic, which means you never have to go elsewhere.

This is what the daily schedule would look like.

Day 1. No action
Day 2. Vaginal ultrasound scan to confirm there is no ovarian cyst. If there is no cyst, we can commence superovulation.
If there is a cyst, we aspirate ( puncture) it and continue with the treatment.
Day 2 . Inj Gonal-F ( 75 IU), 2 amp ( 150 IU ) sc daily
Day 3 Inj Gonal-F ( 75 IU), 2 amp ( 150 IU ) sc daily
Day 4 Inj Gonal-F ( 75 IU), 2 amp ( 150 IU ) sc daily
Day 5 Inj Gonal-F ( 75 IU), 2 amp ( 150 IU ) sc daily
Day 6 Inj Gonal-F ( 75 IU), 2 amp ( 150 IU ) sc daily
Day 7. Vaginal ultrasound scan to monitor follicular growth. If the response if fine, we continue with the same dose of Gonal - F; and add the GnRH antagonist
 Inj Gonal-F ( 75 IU), 2 amp (150IU ) daily. Inj Cetrolix, 0.25 mg daily
Day 8 . Inj Gonal-F ( 75 IU), 2 amp (150IU ) daily. Inj Cetrolix, 0.25 mg daily

Day 9 . Inj Gonal-F ( 75 IU), 2 amp (150IU ) daily. Inj Cetrolix, 0.25 mg daily
Day 10. Vaginal ultrasound scan to monitor follicular growth
The Gonal-F and Cetrolix injections continue until the follicles are mature ( approx Day 12).
Then a GnRH agonist ( Triptorelin, Decapeptyl, 0.2 mg sc) injection is given as the trigger , and eggs retrieved 36 hours after this.

These are fertilised with your husband's sperm, and all  your embryos are frozen on Day 5 ( blastocyst). We provide you photos of these.

You can travel back 3 days after the egg collection.

You then come back after one month for the transfer of your frozen embryos.

Did you develop OHSS in your earlier IVF cycle ? Want to make sure you don't run that risk again ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !






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