IVF/ICSI protocols of controlled ovarian stimulation (COS)
Ultra-long protocol: to receive the first injection of long-acting GnRHa
(Triptorelin Acetate®; Ipsen, France; Leuprorelin Acetate®; Lizhu,
China; Goserelin Acetate®; AstraZeneca, UK) with a dose of 3.75 mg or
3.6mg subcutaneously on day 2 or 3 of the menstrual cycle. The
anteroposterior diameter of uterus was measured 28 days after each
injection. If the diameter was more than 70 mm, another injection of
long acting GnRHa was repeated until the third injection. 28 days after
the last dose, standard downregulation was evaluated by transvaginal
ultrasonography(TVS) and serum hormone examination. Eligible
downregulation was defined as endometrium thickness ≤5mm, serum
estradiol ≤50pg/mL, LH ≤5IU/L, diameters of follicles <8mm in
bilateral ovary and no functional cysts.
Long protocol: a daily dose of triptorelin acetate (0.05–0.1mg) for
pituitary downregulation lasted for 14 days. If downregulation criteria
were achieved, ovarian stimulation started.
Short protocol: a daily dose (0.05–0.1 mg) of GnRHa (triptorelin
acetate®; Ipsen, France) was given on day 2-4 of the menstrual cycle
until HCG trigger. After 1-2 days of GnRHa, gonadotropin was used for
ovarian stimulation and lasted for about 8-12 days.
Antagonist protocol: a daily dose (0.25mg) of GnRH-ant injection
(Orgalutran®, MSD, Netherlands) was used following fixed protocol
(started daily on the fifth or sixth day of goandotropin till trigger
day) or flexible protocol (started when primary oocyte diameter≥14 mm or
the primary oocyte diameter≥12mm and the level of estrogen ≥300 pg/ml).
Ovarian stimulation
150–300 IU gonadotropin (Gonal F®, Merck Serono, Switzerland; Puregon®,
MRK, China; Lishenbao®, Lizhu, China) daily was administered for COS
according to age, body mass index (BMI) and ovarian reserve. The
adjustment of gonadotropin and addition of recombinant LH (Luveris®,
Merck Serono, Germany) were decided by follicular development.
Routinely, 8000-10000 IU of urinary human chorionic gonadotropin(HCG)
(hCG®; Livzon, China) was used intramuscularly for triggering when at
least two follicles measured ≥18mm. If high risk of ovarian
hyperstimulation syndrome (OHSS) existed, 2000-4000 IU of HCG combining
with 0.2mg GnRHa was administrated. Oocyte retrieval was performed
34h–36h later. The choice of IVF or ICSI depended on sperm quality.
Cancellation of fresh ET and whole embryo frozen was carried out in the
conditions of high risk of OHSS, hydrosalpinx or unsynchronized
endometrium status. All embryos were cultured for 3 or 5 days with two
high-quality cleavage-stage embryos on day 3 or one blastocyst on day 5
transferring into the uterus under
the guidance of abdominal ultrasound. The high-quality
embryos were defined as 2PN-derived
embryos with 7-10 cells and scores ≥ 3 on day 3 or ≥ 4BC on day 5(12). Oral dydrogesterone tablet (Duphaston®, Abbott,
Netherlands) 10 mg twice daily and vaginal progesterone gel (Crinone
gel®, Merck Serono, Switzerland) 90 mg once daily or oral dydrogesterone
tablet (Duphaston®, Abbott, Netherlands) 20 mg twice daily and vaginal
progesterone soft capsules (Utrogestan®, Besins, Belgium) 200 mg once
daily were administered as luteal phase support.
GnRHa pretreatment before FET: GnRHa ptreatment was performed in
patients with severer adenomyosis before FET for≥1 months with 3.75 mg
or 3.6mg of GnRHa per month. The uterine anteroposterior diameter was
measured 28 days after each injection. If it was more than 70 mm,
injection of the same dose of GnRHa was repeated until the third
injection. Hormone replacement cycles would be administered 4 weeks
after the last dose of GnRHa.
Protocols of endometrial preparation in FET cycles
Oral estradiol valerate
(Progynova®;
Bayer, Germany) was administrated in a dose-escalating method,
4mg/day
for the first 5 days and subsequently 6mg/day for the second 5 days.
According to the assessment of endometrial
thickness and serum hormone levels of
E2, 8mg/day for another 3-4 days was continued or
not. When endometrial thickness ≥7
mm, progesterone addition was started and the detailed protocol was same
as those in fresh ET cycles. 5 days after progesterone addition one
frozen-thawed blastocyst was transferred into the uterus. Other
protocols for endometrial preparation in FET cycles had been described
in previous study(13).