This is a very technical question, and for me, it’s very simple and very clear. Ovarian stimulation is a subject that we could explore for days without even getting anywhere near sorting it out and agreeing on what’s best. It has a few very important principles. First of all, is how do you define success? What’s the optimum number of follicles and oocytes one would expect from each individual and there’s a lot of markers that would define that. For example, age, the AMH, the AFC is one of the essential markers. If we have a 35-year-old within normal AMH and a follicle count of say 10, we know by definition that if we get less than 10 eggs, then perhaps there’s something wrong with it, so this is very important to communicate with our patients.
I mean the AMH, as most of you know is a very important target market for that, and my team and I have been one of the few in the world who studied and published that more than 10 years ago, so it is important for the woman who is about to be stimulated to have ovarian stimulation to be aware of what’s the successful outcome and what’s the definition. Following the protocols, there are quite a few, so the definition of a successful protocol is the one that helps the patient to reach the number of follicles and oocytes that were defined initially. There’s a lot of things that can go wrong with the protocol, over the years I found that ovarian stimulation varies, and of course, there’s a fixed way you can do I, which means that you can more or less standardize the protocol, which means that you stimulate roughly with one way, with one mode, with one principle if you like.
Minimizing the number of visits and scans at the clinic, which is very tempting and very convenient for our patients. Especially, for the patients that are far away or when scanning and blood testing is expensive, so it’s convenient for the patient. If you tell them, you don’t need a baseline scan, and we don’t need to see you before we add on the antagonist, and we’ll see you once or twice at the minimum cost and then go for stimulation. Although in some cases, this may work, if we want to tailor-make our program and if we want to be bespoke, this may fail perhaps from 10 to 10 of our patients, and of course, this is an absolute disaster. In my opinion, if the unit has the facilities to provide tailor-made treatments, tailor-made protocols, I think it’s very important to have a baseline scan. Plus, another two to three scans to define the optimum dose, and of course, the optimum timing and the method for the final trigger.
Another big issue, of course, is how to trigger, when to trigger, do you trigger at 17 millimeters, or do you trigger at 19 millimeters? Can you pick up, for example, on Saturdays and Sundays, or can you only pick up on Monday, Wednesday, Friday like some units do and of course, this is something that the patient should reflect on perhaps after a failure or even before the failure by evaluating those important factors? Is the clinic working seven days a week? Is the clinic able to scan and get the reports of blood testing within a couple of hours or 4 hours, any time of the week? This may influence success a little bit, and this may not be that important for the 35- year-old with 10 eggs. But it may be very important for the 41-year-old with 3 eggs because it would make a huge difference to collect from a 40-year-old 1 egg or 2 eggs, so ovarian stimulation is not an easy thing and is not, in my opinion, something that should be totally standardized and totally rigid. It has to be individualized, and we have to have the opportunity to modify the protocols depending on the response, and of course, how do we measure hormones, and what kind of hormones do we measure? Do we measure progesterone? Do we measure LH? Is it important, if we measure estradiol?
Then we’re going on to the pickup, most of us, when we’re learning, we were told that perhaps the egg collection is suitable for a more junior doctor, whereas the embryo transfer should be in the hands of the more experienced doctor. I would probably disagree, again, the technique of the pickup is very important, and the technique has to do also with the patient, with the anesthesia. Some people still do ovarian pickups without anesthesia or with very mild local anesthesia, which may be fine for most of the patients. For the individual patient with difficult access or with some sort of pelvic adhesions that doesn’t allow the operator to collect all the eggs, it may make a little bit of a difference, and who is doing the egg collection? Is it a research fellow with all due respect, that’s how we all learned, but of course, the yield of eggs and the quality of the eggs that were collected maybe a little bit different if you have an experienced consultant versus a young research fellow?
The conditions in the lab at the time of their collection are important, I could go on forever, so in my opinion, a failed pickup, for example, or a bad stimulation or a bad egg collection doesn’t necessarily mean that this is the potential of the ovarian capacity of any woman, and I’m sure there is always, perhaps a little room for improvement.