Simulation processes essentially what we’re trying to do is optimize follicular development. We can get the ideal number of eggs from you. We can use that by using some ovarian reserve markers in advance. The common are follicle counts – we would do a scan to look at your ovaries and measure the number of follicles we’ve got or for Anti-Mullerian hormone. We do that in advance of the cycle and then we’ll optimize your drug. The way that you do that is that you do daily injections at home while we do that for about two weeks and we do some scans and blood tests during that time. We have to always make sure that you don’t just ovulate and release those eggs prematurely, so we use another drug either GnRH antagonist or GnRH agonist to disrupt that feedback. That how we can control the cycle and get that after about two weeks and optimization of those follicles to the right size, we’ll give you a final trigger to mature those eggs and then 36 hours later, we would have you in theater to do an oocyte retrieval and take those eggs out of you.
The ovarian stimulation process, as mentioned before, is the most common protocol so with the short protocols, we wait for the menstrual cycle to start. We first do an ultrasound, to check we can start and that there are no residual follicles from the previous cycles or previous condition to make it a bad moment to start. If everything is okay on the second or third day of the period we begin with the medication. The protocol takes nine to ten days with medication in which we do at least two other ultrasounds, one on day six and the other on day nine. If everything goes according to plan, on day twelve or thirteen of the cycle we do the oocyte pickup. To do the oocyte pick up we first have to have big follicles, at least two or three, seventeen millimetres each. If we have those conditions we go with a trigger which is the final medication for the final oocyte moderation, so we can get them during the oocyte pickup which is on day twelve or thirteen. The rest is up to the patient, if we are going to do a fresh transfer. Three to five days after the oocyte pick up we can do the transfer. We start with the progesteron to prepare the patient with the receptivity of the embryo and we will do this in day three or day five, depending on the laboratory or what you are used to. Nowadays we try to wait till day 5, the blastocyst stage so we have better embryos to transfer and a better chance of pregnancy. If you do not wish to transfer or if the conditions to transfer are not good enough, we will move forward with the creation of the embryo and freeze them with a vitrification protocol and then we prepare the transfer on the next site.
Usually we can start a stimulation between the first and fifth day of the menstrual cycle. For this, before we start, we perform an ultrasound to confirm ovarian rest, do the antral follicle count and decide the dose to use. With this the patient will start to inject the medication simultaneously and we will have them count the follicular growth path through an ultrasound every two to three days more or less.
During the stimulation we will perform an ultrasound every two or three days to evaluate the follicular growth and the stimulation usually takes between ten to twelve days until the moment we trigger the evaluation induction to schedule the puncture to pick up oocyte to do the procedure.
