Step up protocol

What we ned t know about “Step up high dose protocol” ?

1)           Indications of step-up? :- 1) WHO Group II Anovulatory PCOS who are resistant to CC or failing to conceive with CC despite ovulation.

2)           Contraindications? High LH .

3)           Advantages? Why Low dose step up? The purpose is to achieve monofollicular growth, thereby avoiding  multiple pregnancies and also minimize the incidence of OHSS.

4)            Inclusion criteria:      Who are suitable? 1) She must have been tried at least 3 cycles of OI with 100 mg of CC.  2) WHO Group II women-PCOS women-with Chr anovulation as was diagnosed by amenorrhea/oligomenorrhea/ or women with regular cycle length but anovulation was documented by serum P assay in cycle length of 21-35 days.

3) Infertility of at least 1 year, BMI 19-35 kg/M²

4) At least one tube must be patent.

 5) TVS- exhibits normal pelvic anatomy

6) Day 2 FSH ranging from 1-12 IU/Lit

7) Normal Prolactin & total Testosterone

8) Normal semen/ Donor

   9) Signed informed consent.

5)           Exclusion criteria:-A)More than 12 unsuccessful OI(to proceed for ART) . B) persistent Ov cyst> 15 mm on day 3 of proposed cycle. C) Ovarian endometriomata D) To keep a gap of at least 1-2 months –after previous CC, Metformin , or gonadotrophins E) Cong malformations of genital organs.

6)           Treatment Efficacy:-How effective is low dose step-up protocol ?

In WHO Group II  hose anovulatory PCOS who are resistant to CC or failing to conceive with CC despite ovulation . In fact as many as 50% of women will achieve monofollicular growth by this method .

7)           Dose schedule? Initiation:- by starting with HP-FSH 75 IU daily subcut from any day 2 – to day 5, f spont cycle or even may be initiated after P withdrawal as well . The drug HP-FSH is  available as powder with solvent-prepd solution and to make  1 ml for both . R-FSH subcut is a better choice though costly .

8)            For first 7 days such dose of 75 units was maintained and looking at response after 7 days of 75 i.u. Of Gtrophin à then dose was increased by another 37.5 i.u. Any dose change must be maintained for at least 7 days in that schedule. Maximum dose can be 225 iu per day and maximum duration of Inj were as long as 6 weeks. A tie up with an nearby ART center is a must in case the is sudden severe OHSS occurs though in step up such chance is rare.

9)           When to stop Gonadotrophins & go for trigger? A) at least one follicle was > 17 mm

I most cases there will be  two-three follicles of  > 15 mm are achieved by induction day 8 . However,. if there was no response after as long as 6 weeks of Gtrophin Ry then should cancel the cycle and plan for ART.

10)    Trigger by which agent?- HCG 5000 iu by subcut or   -i.e.- and serum P was assessed 9 days after hcg as no luteal support is obligatory .

11)    When not to push trigger?  If no. of follicles > 4 follicles above 15 mm in dam and or E2 > 2000 pg/ml.

12)     Luteal support-a necessity:- No luteal support usually “ Optional