Ovarian Stimulation – a Path to Success

There are different reasons for couples who suffers from Infertility to apply for a Surrogacy program. The wide range of fertility complications and problems lead the patients to choose one of the most effective solutions recognized as ovarian stimulation. This includes the hormonal stimulation of patients’ follicles (known as “self-cycle”) for in vitro fertilization and then transferring embryos to a surrogate mother.

A main precondition for the program are a set of mandatory tests from both male and female patients.

What should be considered for the self-cycle before, during and after the program:

Ovary accessibility – IVF doctors usually don’t recommend to start the stimulation if the ovaries are not well-accessible and for instance, are located high in the pelvis due to the possibility of hyperstimulation. It makes it very difficult to reach follicles vaginally for egg retrieval. That is why the purpose of the first ultrasound also is to detect the ovaries’ locations that help the doctor to make the decision whether or not to start the hormonal treatment.

Cysts – Another sign against launching the stimulation are the cysts in the ovaries. The reason is that the cyst may also respond to the stimulation like the follicles, they may increase in size and burst that can lead to the removal of ovaries or cause other consequences (blood intoxication).

In this case the recommendation is to start taking the birth control pills and after approximately 21 days stop taking them. In about 5 days take another ultrasound to observe whether the cyst is dissolved or not. If it is still there, it definitely must be aspirated and the patient is able to undergo the stimulation only after some time of the surgical intervention.

Contraceptive pills – stimulation can be started on a fresh cycle without taking the birth control pills or on the second day of menses after taking pills. When the patient is on contraceptive pills, the cycle can be controlled and the patient is advised to take the last pill according to the program dates. Most importantly, the date of the last pill is calculated considering the necessity of synchronizing the patient’s stimulation with the surrogate mothers preparation. It is worth to mention here that the surrogate preparation lasts several days longer and consecutively starts earlier than the stimulation.

Options of doing stimulation – Intended Parents should consider that there are two options to do the stimulation: starting the hormonal treatment under the supervision of the local IVF doctor and arrive on Day 9 of stimulation to be examined at the receiving clinic where the egg retrieval will be done, or alternatively be completely stimulated at the country where their surrogacy program is being planned.

Length of stay – If the stimulation is done at the local clinic, it is optimal for intended parents to stay in the country of their surrogacy program for 6 days, and if not they should stay for about 17 days.

Medical plan – as the stimulation is a very delicate process, its careful planning and management plays a significant role in the final result. That is why some important details should be considered for the stimulation and shared with the receiving clinic:

– The patients should request from the local IVF doctor the medical/stimulation protocol, which includes a list of hormonal supplements, by Day 8.

– Ultrasound scans are to be done on Day 1, Day 5 and Day 8 of stimulation with photos, sizes and quantities of follicles in each ovary written in the medical report.

– Estradiol tests are to be done on the same days of ultrasound to measure the hormonal level and ovarian respond to the medications

– Complete blood count and blood coagulation (prothrombin) tests are to be done on the 7th Day of stimulation.

After the IVF doctor of the receiving clinic examines the patient personally they tell them when to take the final trigger shot which is taken 36 hours before the egg retrieval. It is impossible to tell this without personal examination exactly when the egg retrieval can be done, because doctors makes decisions based on the follicles’ size and patient’s readiness for the medical manipulation.

Important note: The IVF doctor of the receiving clinic cannot prescribe the medications from a far as this is against the medical protocol, but the IVF doctor needs to be fully involved in the stimulation process and prepare the surrogate mother based on the stimulation response of the intended parent. That is why it is very important to provide the doctor with the above mentioned information in a timely manner.

Each stimulation protocol is individual and reflects the patient’s medical history, previous stimulation plan, current health conditions, ovary reserve and number of follicles in ovaries.

There are some medications to be taken in second half of the day (7-8 pm) and others in the morning. However, the local doctor needs to give the patients precise instructions about the dosage and when to take the prescribed medications. IVF doctors have different methods of stimulation, for instance, when 1 or several follicles reach 14 mm or at least 13 mm in size, some doctors add Cetrotide or Orgalutran. That is why it is important to know the size of the follicles by Day 5 of stimulation.

Empty Follicles Syndrome – on very rare occasions, patients have Empty Follicles Syndrome (EFS) that means no oocytes/eggs are retrieved after the aspiration, but this should not be considered a reason to give up the hormonal medical treatment. In this case, along with other recommendations, IVF doctors suggest to change the stimulation protocol for the next attempt which, can lead to a pregnancy and a healthy baby.