You are currently browsing the Dr Licciardi blog archives for December, 2006.

The Holidays are Tough

To all of you still without a pregnancy, I hope the new year brings you your best year ever. It’s hard to think that when 1/1/07 comes along we will still have to work on our projects from 2006 or before. Try to enjoy the holiday season, rest up, and look forward to an impressive 2007.

Dr. Licciardi

More On Lupron and Why We Don’t use it as Much

So Lupron prevents premature ovulation. What else does it do? We sometimes use it to temper the stimulation in a woman who we feel may make an above average number of eggs. The injectable fertility drugs (Follistim, Gonal–F, Menopur, etc) are mostly comprised of FSH, and this is the hormone that gets the ovary to produce many eggs at one time. At the same time, the body is producing some FSH, and this can add to the ovarian stimulation. If Lupron is used, the body will not make FSH, so the only FSH that gets to the ovaries is from the injections; therefore the stimulation is a little more controlled. Lupron may also have some effects at the ovary itself, slightly suppressing the action of the injected FSH.

So it seems that Lupron is a good idea and yet we don’t use as much as we did in the past, in fact I rarely use it these days. Why? Because if we want to lessen a patients response to the FSH we just give less. This sounds intuitive but it took a long time for us to be comfortable lowering the dose of the FSH. We realize we don’t need as many eggs from each patient as we once thought.

Also, if we want to block a premature LH surge we use Cetrotide or Ganirelix. These drugs are much easier to use than the Lupron. Lupron needs to be started day 21 of the cycle prior, so women need to take it for about 3 weeks total. The other drugs are started just a few days prior to the retrieval; so only 2-4 injections are needed.

In addition, the suppressive effects of Lupron cause the cycle to be a day or 2 longer than a cycle using Cetrotide or Ganirelix. Lupron is still used quite a bit be certain doctors. This is not a bad thing, it’s just up to your doctor. A little more on Lupron next time.
Dr. Licciardi

References:

  • Al-Inany HG, Abou-Setta AM, Aboulghar M. Gonadotropin-releasing hormone antagonists for assisted conception: a Cochrane review. Reprod Biomed Online 2007; 14(5):640-9.
  • Jones GS, Muasher SJ, Liu HC. Gonadotropin stimulation protocols in the Norfolk IVF program–1988. J Steroid Biochem 1989; 33:823-5.
  • Muasher SJ, Abdallah RT, Hubayter ZR. Optimal stimulation protocols for in vitro fertilization. Fertil Steril 2006; 86:267-73.
  • Shanbhag S, Aucott L, Bhattacharya S, Hamilton M, McTavish A. Interventions for ‘poor responders’ to controlled ovarian hyperstimulation (COH) in in-vitro fertilisation (IVF). Cochrane Database Syst Rev; 2010 Jan 20;(1):CD004379.
  • Reh A, Krey L, Noyes N. Are gonadotropin-releasing hormone agonists losing popularity? Current trends at a large fertility center. Fertil Steril. 2010 Jan; 93(1):101-8.

What is Lupron and Why Are Only Some People Using It?

The last blog about hormones set up this question and answer. Lupron has 3 main functions. The most important is to prevent premature ovulation during an IVF cycle. Ovulation is caused by a large release of LH (lutenizing hormone) from the pituitary gland. The GnRH has been sending signals to the pituitary to make and store LH, and a high estrogen level (the level is different for different people) causes the LH to be released in a burst, causing ovulation. Going back to the last blog, GnRH also controls the FSH which gets the follicle to grow, but it’s the LH surge causes the egg to pop out (ovulate).

The hCG we use to trigger ovulation takes the place of the LH surge. The chemical composition of hCG is very close to LH and so we use hCG because it more readily available and considerably less expensive.

Because in an IVF cycle the estrogen level is much higher than in a natural cycle, the LH surge may occur before we want. Back in the day, we used to collect urine samples around the clock from patients to be sure the LH surge did not occur prematurely. If it did we and would try to time the retrieval to about 24 hours after the LH was highest in the urine. This meant the doctor and the team doing retrievals at all hours of the night. The timing was never great, so this practice was abandoned.

So Lupron blocks the GnRH. Therefore LH is not made and stored in the pituitary, therefore the LH surge can not occur, nor does premature ovulation. This is a very valuable function. About 10% of IVF patients can have a premature surge, leading to cycle cancellation. With Lurpon this does not happen. I suspect there are some of you reading this saying, “I surged on Lupron”. I have heard of this, but it has not happened to any patient of mine, it’s a very rare phenomenon.

More on Lupron next time. Dr. Licciardi

References:

  • Al-Inany HG, Abou-Setta AM, Aboulghar M. Gonadotropin-releasing hormone antagonists for assisted conception: a Cochrane review. Reprod Biomed Online 2007; 14(5):640-9.
  • Jones GS, Muasher SJ, Liu HC. Gonadotropin stimulation protocols in the Norfolk IVF program–1988. J Steroid Biochem 1989; 33:823-5.
  • Muasher SJ, Abdallah RT, Hubayter ZR. Optimal stimulation protocols for in vitro fertilization. Fertil Steril 2006; 86:267-73.
  • Shanbhag S, Aucott L, Bhattacharya S, Hamilton M, McTavish A. Interventions for ‘poor responders’ to controlled ovarian hyperstimulation (COH) in in-vitro fertilisation (IVF). Cochrane Database Syst Rev; 2010 Jan 20;(1):CD004379.
  • Reh A, Krey L, Noyes N. Are gonadotropin-releasing hormone agonists losing popularity? Current trends at a large fertility center. Fertil Steril. 2010 Jan; 93(1):101-8.