Minimal Stimulation Protocol (MSP) in IVF: An alternative hope for females with poor ovarian reserve, a case report.
Dr Sasmita Naik , Dr Lipsa, Dr Akshya ku Mahapatra, Dr Rohani Nayak
Case report
Key Words – MSP, Low ovarian reserve, AMH, AFC, COH
Introduction – Many stimulation protocols are available for controlled ovarian hyperstimulation (COH) in in vitro fertilization (IVF). Over time IVF or assisted reproduction techniques have evolved to fulfil the needs of patients who range from low, intermediate and high responders. The discoveries of gonadotropin-releasing hormone (GnRH) analogues and inhibitors of natural steroid hormone (oestradiol) such as clomiphene citrate (CC) have offered multiple options in terms of assisted reproduction.
Patient Information
Mrs XYZ age 29 years,w/o Mr ABC age 31 yrs. Visited our hospital with h/o primary infertility for 8 years. She had a normal feminine feature, on physical examination, there was no apparent abnormality. In routine evaluation her complete blood count was in the normal range, blood group B+ve, Sr TSH 4.48 IU, LFT, RFT, & blood sugar within normal limit. Prolactin was 24mg/dl. High-pressure liquid chromatography (HPLC) revealed no haemoglobinopathy. Antimullerian hormone (AMH) 0.24 ng /dl. Ultrasonography (USG) finding on day 25 of her cycle revealed an anteverted uterus without any focal lesions with a homogenous endometrium having a thickness of 9 mm, b/l ovaries S/O decreased ovarian reserve without any lesion and there was no detectable pathology in either tube. Husband has no history of medical illness. Semen analysis shows a total count of less than 2 million, motility occasional s/o severe OATS on separate occasions. The treatment plan was IVF (OPU-ICSI) with minimal stimulation Protocol.
1st cycle IVF
Stimulation started from day 2 of menses with CC 100 mg and HMG 150 (INJ MENOPURE) that continued till the day of trigger. After 7 days of stimulation, GnRH-antagonist was added (0.25 mcg Cetrorelix) when follicles reach 16 mm. Three follicles were growing. Tigger with inj. recombinant (r-hCG 250) mcg was given SC on day 14 of stimulation. OPU planned after 36 hrs. Three follicles were retrieved (M2- 2, M1 -1). ICSI was done. On day 5 two blastocysts were formed (one grade I & one-grade I-II). Two embryos were cryopreserved. Frozen embryo transfer was done on the next cycle after sequential administration (12 days of estrogen therapy & the last 6 days of intramuscular progesterone (100 mg). Sr β-hCG was done after 14 days of transfer and the value came to be less than 1 IU.
2nd cycle IVF
The couple was counselled for the 2nd IVF cycle with minimal stimulation protocol. Stimulation started on day 2 with CC 100 mg OD and inj recombinant FSH 150 IU (INJ GONAL F) as per our protocol. The antagonist started on day 6 of stimulation. After 14 days of stimulation, trigger was given with Ovitrelle (r-hCG 250). OPU was done 36 hrs later. Three M2 stage oocytes were retrieved. On day 3 assessment one 7 cell gr 1 embryo was formed. The fresh embryo transfer was done after 3 days of inj Progesterone. S β-hCG was done after 14 days and the report was 984.7 mIU/ml. On 6 wks scan SLIUF corresponding to the calculated GA. Regular obstetrics follow up done till 37 weeks. The antenatal period was uneventful. At 37 wks the patient delivered a healthy male baby weight of 2.5 kg by elective LSCS.
Discussion
The final maturation of oocytes is usually induced by either intramuscular hCG or GnRH agonists. When patients desire fresh embryo transfer, hCG is the preferred agent for final oocyte maturation. MSP appears to be an effective protocol for controlled ovarian stimulation in infertile women. It is easy to administer, requires less intense monitoring, fewer medications, and is cheaper. On drug costs alone, the MSP protocol is 1/3rd cheaper than the hMG protocol. These factors make minimal stimulation protocol a reasonable therapeutic option.