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Department of Obstetrics and Gynecology -
WVU Center for Reproductive Medicine

Treatment Protocols

Treatment Protocols

The treatment protocols listed here are those associated with Assisted Reproductive Technologies.

Superovulation

Clomiphene citrate

  1. You will take 2 tablets of Clomiphene citrate per day for 5 days (usually cycle day 2-6 or 3-7):
  2. You will be scheduled to return for ultrasound (usually 3-5 days after finishing the clomiphene citrate.
  3. If your follicles are not mature, you will be instructed to return for ultrasound.
  4. When your follicles are mature, you will receive an injection of hCG to cause follicle rupture and releaseof the egg(s). This is usually given the evening of the day that the follicles are mature.
  5. The egg will usually be released 36 hours after the injection.

Clomiphene citrate plus gonadotropins

    1. Clomiphene citrate, 100 mg, is begun on cycle day 2 or 3 and continued for 5 days.
    2. Gonadotropins (usually 2 ampules/day) are administered every other day (i.e. 2,4,6 or 3,5,7) or may be prescribed after finishing the clomiphene citrate. The space choice of gonadotropin, protocol, and dosage will be tailored to your specific needs.
    3. You will be instructed to return for ultrasound 1-2 days after your last injection.
    4. If your follicles are not mature, you will be instructed to continue taking gonadotropins every other day and to return for ultrasound.
    5. When your follicles are mature, you will receive an injection of hCG to cause follicle rupture and release of the egg(s). This is usually given the evening of the day that the follicles are mature.
    6. The egg will usually be released 36 hours after the injection.

    Gonadotropins

    1. Gonadotropins are administered on a daily basis beginning day 2-3 of the cycle. The choice of gonadotropin and dosage will be tailored to your specific needs.
    2. You will be instructed to return for ultrasound.
    3. If your follicles are not mature, you will be instructed to continue your medications and return for ultrasound.
    4. When your follicles are mature, you will receive an injection of hCG to cause follicle rupture and release of the egg(s). This is usually given the evening of the day that the follicles are mature.
    5. The egg will usually be released 36 hours after the injection

    Gonadotropins plus Gonadotropin Releasing Hormone analog: During the normal menstrual cycle, the mid-cycle surge of Lutenizing hormone (LH) occurs in response to a specific level of estrogen that has been present for a critical period of time. The use of gonadotropins will result in multiple eggs, so the critical level of estrogen will be reached before the eggs are actually mature. Gonadotropin releasing hormone analog (GnRH-a) causes an initial stimulation of FSH and LH release but is followed approximately a week later by absence of release of FSH and LH. Thus, the use of GnRH-a can be used to prevent a premature LH surge

    • Long protocol (mid-luteal start)
      1. You will begin the use of GnRH analog approximately 7 days after ovulation (usually cycle day 21)
        • If you are using the nasal spray form of the analog, Synarel, you will use one puff in one nostril in the morning and one puff in the other nostril at night (usual dose)
        • If you are using the daily injectable analog, Lupron, you will inject 0.1ml subcutaneously each day (usual dose)
      2. Menses will usually begin 8-10 days after starting the analog
      3. Return to clinic on cycle day 2-3 for baseline ultrasound and hormonal testing to see if ovarian function is suppressed
      4. If ovarian function is not suppressed, you will continue the GnRH analog on a daily basis and will be instructed to return for ultrasound evaluation.
      5. When ovarian function is suppressed, daily gonadotropin injections will be added to the daily use of the GnRH analog. The dosage and timing will be determined specifically for you.
      6. You will be instructed to return for ultrasound.
      7. If your follicles are not mature, you will be instructed to continue your medications and to return for ultrasound.
      8. When your follicles are mature, you will receive an injection of hCG to cause follicle rupture and release of the egg(s). This is usually given the evening of the day that the follicles are mature.
      9. The egg will usually be released 36 hours after the injection.

      Flare Protocol (Day 1 start): This protocol makes use of the fact that GnRH-a causes an initial stimulation of FSH and LH release. Thus your own pituitary hormones as well as those that you are injecting will stimulate your eggs. By the time that estrogen levels would reach the point that a LH surge would occur during a normal cycle, the GnRH-a will have caused your own FSH and LH levels to be low and will thus prevent a premature LH surge.

      1. You will begin the use of GnRH analog on the first day of menses
        • If you are using the nasal spray form of the analog, Synarel, you will use one puff in one nostril in the morning and one puff in the other nostril at night (usual dose)
        • If you are using the daily injectable analog, Lupron, you will inject 0.1ml subcutaneously each day (usual dose)
      2. Return to clinic on cycle day 2-3 for baseline ultrasound
      3. Daily gonadotropin injections will be added to the daily use of the GnRH analog. The doseage and timing will be determined specifically for you.
      4. You will be instructed to return for ultrasound.
      5. If your follicles are not mature, you will be instructed to continue your medications and to return for ultrasound.
      6. When your follicles are mature, you will receive an injection of hCG to cause follicle rupture and release of the egg(s). This is usually given the evening of the day that the follicles are mature.
      7. The egg will usually be released 36 hours after the injection.
    Gonadotropins plus Gonadotropin Releasing Hormone Antagonist: During the normal menstrual cycle, the mid-cycle surge of Lutenizing hormone (LH) occurs in response to a specific level of estrogen that has been present for a critical period of time. The use of gonadotropins will result in multiple eggs, so the critical level of estrogen will be reached before the eggs are actually mature. The GnRH antagonist prevents a spontaneous surge of LH. In contrast to the GnRH analog, there is no initial stimulation of FSH and LH.

    Fixed Protocol

    1. Oral Contraceptives are usually given in the cycle prior to therapy
    2. Gonadotropins are begun on cycle day 2 or 3.
    3. You will be instructed to return for ultrasound and hormonal studies
    4. A single dose of GnRH-antagonist (usually 3 mg) is given between cycle day 6-9.
    5. When your follicles are mature, you will receive an injection of hCG to cause follicle rupture and release of the egg(s). This is usually given the evening of the day that the follicles are mature.
    6. If your follicles are not mature, you will be instructed to continue using gonadotropins and return for additional ultrasounds and hormonal studies.
    7. If the follicles do not become mature within 96 hours of the original dose of GnRH-antagonist, low doses of GnRH-antagonist (0.25 mg) will be given on a daily basis until the hCG is given.
    8. Follicle rupture usually occurs approximately 36 hours after administration of the hCG

    Flexible protocol

    1. Oral Contraceptives are usually given in the cycle prior to therapy
    2. Gonadotropins are begun on cycle day 2 or 3.
    3. You will be instructed to return for ultrasound and hormonal studies
    4. Daily low dose GnRH-antagonist (usually .25 mg/day) is begun when the Estradiol level has reached at least 400 pg/ml and the lead follicle is 12-14 mm in size.
    5. When your follicles are mature, you will receive an injection of hCG to cause follicle rupture and release of the egg(s). This is usually given the evening of the day that the follicles are mature.
    6. If your follicles are not mature, you will be instructed to continue using gonadotropins and the GnRH-antagonist and return for additional ultrasounds and hormonal studies.
    7. Follicle rupture usually occurs approximately 36 hours after administration of the hCG

    Intrauterine Insemination

    • Inseminations areusually performed the day of or the day following an LH surge as detected by ovulation predictor kits or 34-36 hours after administration of hCG.
    • The semen is collected by masturbation at home or in the clinic
    • Do not use lubricants or condoms because they may contain substances that will kill or immobilize sperm
    • Collect the semen in a small, clean, wide-mouthed container (sterile urine containers are preferable). Attempt to collect all of the ejaculate.
    • If you are collecting the specimen at home, bring the specimen to the lab as soon as possible, but no later than one hour after collection. The specimen should be kept at body temperature during transport. This can be achieved by keeping the container next to your body in your clothing.
    • The semen will undergo special preparation in the laboratory and will be placed in a syringe attached to a special catheter
    • When the concentrated sperm is ready, a speculum will be placed in the vagina
    • The catheter will be inserted into the uterine cavity and the prepared sperm will be injected into the uterine cavity.
    • You will need to lie still for the subsequent 10 minutes
    • There are no restrictions on your activities for the remainder of the day