Suppression Phase

During a normal menstrual cycle, a hormone released by the hypothalamus, GnRH, stimulates the pituitary gland for the synthesis and secretion of pituitary gonadotropins, i.e. FSH (follicle-stimulating hormone) and LH (luteinizing hormone). Under the effect of FSH mostly, a cluster of 8 - 12 ovarian follicles (small egg-containing cysts) start to grow. About the 8th day of the cycle, one of these follicles dominates and releases the egg under the effect of the luteinizing hormone (LH) 4-5 days later. The remaining follicles will regress and become "atretic". With the medication administered during the stimulation phase of the IVF process, all these ovarian follicles are saved from atresia and mature. This medication consists in synthetic gonadotropins identical to those released from the pituitary gland in a woman's brain. We closely monitor ovarian stimulation checking the estradiol (Ε2) levels produced by maturing follicles and measuring the follicle size with ultrasound scans. In order to achieve multiple follicle growth, gonadotropin doses must be fully controlled, which is best attained when the pituitary gland does not produce these hormones at all.

Our strategy is as follows:
In the first stage of the treatment, the production of FSH and LH gonadotropins is inhibited; in the second stage, synthetic gonadotropins are administered to assist ovaries to grow multiple ovarian follicles (stimulation phase).

Suppression Phase
The medication used for stimulation in IVF may confuse your body leading to an early and often irregular LH release. Eggs that are exposed to LH too early may not be fertilised. To prevent this we administer the so called GnRH analogues prior to the stimulation medication. These analogues suppress completely the LH secretion for as long as they are administered. Once the treatment is discontinued, your pituitary gland resumes its normal function and your menstrual cycle returns to normal.

The side-effects of this medication is minor and totally harmless; there might be headaches, hot flushes, perspiration, etc. Moreover, while on medication, you may experience atypical menstrual bleeding after your regular menstruation stops, which however should not alarm you as it is expected. The analogues used have the trade names Suprefact, Daronda or Arvekap and are marketed as subcutaneous injections. Their active substances are identical. They have been administered to thousands of women over the past fifteen years without any cancer or other serious adverse effect reports. The type of analogue, mode of administration and dosage will be determined prior to the start of the treatment.

Once you start you treatment with Suprefact, Daronda or Arvekap injection, you will not stop until the time for “midnight injection” comes (Pregnyl, Profasi or Ovitrelle). The standard duration of the suppression phase is 10 - 15 days. About 15% of women may need to take the analogues for more than two weeks to achieve ovarian suppression. This is usually due to the creation of a functional ovarian cyst secreting oestrogen. These cysts are easily treated with plain transvaginal aspiration before stimulation injections start.

Depending on the length of the GnRH analogue administration, there are two principal treatment protocols: the long and the short.

If you follow the long protocol, you should invariably start your suppression treatment on the twenty first (or second) day of your cycle. It is reminded that "first" day of your menstrual cycle (period) is the day when bleeding starts. In order to have a fixed reference point, if you get your period before midnight (even at 11.30 pm), it is considered as the first day of your cycle. You should then contact BioDimiourgia to report that you have started your suppression treatment and that your menstruation began, and arrange your next visit to our Centre.

According to the long protocol, you should usually start suppression treatment on day 21 of your menstrual cycle and come to the Centre at the end of your period. If you start on the day 2 of your menstrual cycle, you should come to our Centre approximately 10 - 15 days later. Then, your uterus will be examined with transvaginal ultrasound scan and you will also get a blood test to check the estradiol (E2) levels, in order to establish the progress of the suppression. If the ovarian suppression is not adequate, you will continue taking the analogue for another week, when the estradiol test will be repeated. No later than that day, the husband will have provided us with sperm specimen, so as to check sperm count and motility.

If you follow the short protocol, you will start taking the analogue on the second day of your menstrual cycle. You should come to BioDimiourgia on that same day to perform uterine and ovarian ultrasound scan and take blood sample for estradiol measurement. In this case, there is no need for fifteen day to elapse: stimulation starts on the same or the next day (second or third day of the cycle).

Alternatively, the so called GnRH "antagonists" may be administered. The preparation used are also marketed in the form of subcutaneous injections under the trade names Cetrotide and Orgalutran. This protocol is quite similar with the standard short protocol. The key difference is that antagonists are administered daily after the 6th day of the suppression treatment until the time of the "midnight injection". So in this case you start with stimulation followed by suppression.

The main advantage of antagonists is that the required number of injections administered for suppression is considerably smaller.