Alternative Stimulation Protocols

Abstract

A 29-year-old nulligravid woman presented to the emergency department with chest pain and shortness of breath. A computed tomography (CT) scan of the chest was unremarkable, and she was discharged home. She returned 3 months later with worsening symptoms at which time a repeat chest CT scan demonstrated a new 6.6 × 5 cm anterior mediastinal mass, suspicious for malignancy (Fig. 38.1).

Review Questions and Answers

• Q1. A 32-year-old nulligravid woman was recently diagnosed with breast cancer. Her oncologist has recommended she begins cancer treatment in the next 6 weeks. She has regular menstrual cycles every 28 days and, at the time of initial REI evaluation, she is on the 11th day of her cycle with an estradiol level of 218 pg/mL, an LH level of 4.2 mIU/mL, and a progesterone level of 0.78 ng/mL. The patient would like to cryopreserve oocytes prior to starting treatment. What ovarian stimulation protocol would you recommend?

• A1. Since the patient’s oncologist has indicated that treatment can be deferred for 6 weeks, the patient is a candidate for a conventional ovarian stimulation protocol with the start of her next menstrual cycle. Based on her menstrual history and labs, she is in the late follicular phase, and her next menstrual cycle should occur in 2–3 weeks. As most conventional stimulation protocols require 2 weeks from initiation of medications to oocyte retrieval, she will be able to complete the stimulation process within the recommended time frame even if she awaits her next menstrual cycle.

• Q2. A 27-year-old gravida 2, Para 2 woman was recently diagnosed with B-cell lymphoma. Her oncologist has recommended that she begins cancer treatment within the next 2–3 weeks. She has regular menstrual cycles every 27–29 days and, at the time of initial REI evaluation, she is on the 13th day of her cycle with an estradiol level of 256 pg/mL, an LH level of 14.8 mIU/mL, and a progesterone level of 1.12 ng/mL. The patient would like to cryopreserve embryos prior to starting treatment. What ovarian stimulation protocol would you recommend?

• A2. The patient’s menstrual history and laboratory results suggest recent ovulation. Since the onset of menses typically occurs 2 weeks after ovulation, and ovarian stimulation can require up to 2 weeks, the patient is not a candidate for a conventional ovarian stimulation protocol. Therefore, a random luteal start protocol is recommended to avoid delay in cancer treatment. This would involve starting gonadotropins immediately and adding a GnRH antagonist once the lead follicle is ≥12 mm.

• Q3. A 36-year-old nulligravid woman was recently diagnosed with a glioma. Her oncologist has recommended that she begin cancer treatment as soon as possible, ideally within 2 weeks. The patient would like to cryopreserve oocytes prior to starting treatment. At the time of initial REI evaluation, she is on the 12th day of her cycle with an estradiol level of 243 pg/mL, and an 18 mm dominant follicle is noted on transvaginal ultrasound. Is this patient a candidate for oocyte cryopreservation? If so, what ovarian stimulation protocol would you recommend?

• A3. The patient’s menstrual history and laboratory results are consistent with the late follicular phase, with ovulation expected in the next 2–3 days. Like the patient from question two, she is not a candidate for a conventional ovarian stimulation. However, rather than await spontaneous ovulation to pursue a luteal start protocol, ovulation can be triggered with HCG or GnRH agonist and gonadotropins initiated 2–3 days later. With this protocol, she should be able to complete stimulation within the recommended time frame.