Many patients get completely confused by the large variety of medications which are used during an IVF cycle. This plan will help you make sense of what you are taking - and why you need it !

Actually, IVF treatment is basically quite simple. All we are trying to do is to help you grow more eggs, so that we can fertilise them in vitro in the lab. This is called superovulation, and uses medications which mimic the action of the gonadotropin hormones. These meds are the workhorses of an IVF cycle, and come in many flavours, including urinary hormones and recombinant hormones.

Before superovulating you, we need to downregulate you, to make sure your eggs do not ovulate on their own, as we need to ensure that the eggs we collect are mature.

Here's a generic treatment plan. This uses the short protocol. Please understand that there are many variants of this. For example, in a long protocol, while the superovulation remains exactly the same, we start your downregulation 7 days before your period starts ( Day 21 of the earlier cycle; or Day -7). Similarly, instead of using GnRH analogs such as Lupride, it's also possible to use GnRH antagonists for downregulation. These are short acting and are usually started on Day 7.

It's also possible to use gentler superovulation by using letrozole instead of gonadotropin injections. These cost much less - but also yield fewer eggs.

Many doctors have also developed different protocols to try to optimise the ovarian response in patients with poor ovarian reserve. However, these patients can be quite difficult to superovulate !

Treatment starts from Day 1 ( the day the bleeding starts) of your cycle. At this time, we downregulate you by starting you on Inj Lupride GnRH analog mfr by Sun Pharma) , 0.2 ml sc daily . On Day 3, you need to do an ultrasound scan to confirm there is no ovarian cyst, after which we start your superovulation with 4 ampoules of FSH ( Gonal-F) daily. If the cyst is larger than 30 mm, we may need to aspirate this. The dose of HMG will depend upon your ovarian morphology and your antral follicle count.

This is what the daily schedule looks like.

Day 1. Inj Lupride, 0.2 ml sc. ( Downregulation starts)
Day 2. Inj Lupride, 0.2 ml sc.
Day 3. Inj Lupride, 0.2 ml sc. Vaginal ultrasound scan to confirm there is no ovarian cyst. If there is no cyst, we can commence superovulation.
If there is a cyst which is larger than 30 mm, we aspirate/ puncture it under ultrasound guidance and continue with the treatment.
Day 4 Inj Lupride, 0.2 ml sc. Inj Gonal-F ( 75 IU), 4 amp IM. Superovulation starts.
Day 5 Inj Lupride, 0.2 ml sc. Inj Gonal-F ( 75 IU), 4 amp IM
Day 6 Inj Lupride, 0.2 ml sc. Inj Menogon ( 75 IU), 4 amp IM
Day 7 Inj Lupride, 0.2 ml sc. Inj Menogon ( 75 IU), 4 amp IM
Day 8 Inj Lupride, 0.2 ml sc. Inj Menogon ( 75 IU), 4 amp IM
Day 9 Inj Lupride, 0.2 ml sc. Inj Menogon ( 75 IU), 4 amp IM
Day 10. Inj Lupride, 0.2 ml sc. Inj Menogon ( 75 IU), 4 amp IM.
Vaginal ultrasound scan to monitor follicular growth
The Lupride and Menogon injections will continue on a daily basis; and scans will be performed every alternate day, until the follicles are mature. This is usually Day 14- Day 16 for most patients. At this time, an HCG injection will be given, and eggs retrieved 36 hours after this.
Embryo transfer is performed 5 days later ( blastocyst transfer) ; and supernumerary embryos, if any, are cryopreserved.
In many patients, our advice is to freeze all the embryos, rather than do a fresh transfer, because transferring frozen embryos has a higher success rate

If we do a fresh transfer , luteal phase support is provided with daily Progynova ( estradiol valerate 2 mg, 3 tab daily; and Susten ( 400 mg), 2 vaginal suppositories daily.
You can travel back 3 days after the embryo transfer.

12 days after the transfer, you need to do a blood test for beta HCG to confirm a pregnancy.

You can print out an IVF calendar ( of a typical IVF cycle ) at
www.drmalpani.com/ivfcalendar.php

Of course, we use alternative treatment plans, depending upon your particular problem.

Thus , for patients with poor ovarian reserve, we use natural cycle IVF or mini IVF. You can read more about this at Click here

For patients with poor ovarian reserve; or those who've had poor quality embryos in the past; or those who have failed multiple IVF cycles, we use the Letrozole -Antagon protocol . This helps you grow more eggs of better quality.

ICSI treatment starts from Day 2 of your cycle.
Day 1 = Day of bright red bleeding. If the bleeding starts after 6 pm count
the next day as Day 1. Ignore the spotting.
On Day 2, you need to do an
ultrasound scan at our clinic to confirm there is no ovarian cyst, after which we start
your superovulation .
Tab Letrozole 5 mg daily from Day 2 - Day 6

Inj Gonal-F ( 75 IU), 8 amp ( 600 IU ) daily from Day 2. The dose of HMG
will depend upon your ovarian morphology and your antral follicle count.

From Day 7, you stop the Letrozole and start Inj Orgalutron/ Antagon, 0.25 mg daily .
This is a GnRH antagonist. The Gonal-F continues.

We do the next scan on Day 7, after which you would have to be in Bombay
for about 10 days. Your husband is needed on Day 12-Day 14 ( the day of the
egg pickup). All the treatment is performed at our clinic, which means you
never have to go elsewhere.

This is what the daily schedule would look like.

Day 1.
Day 2. Vaginal ultrasound scan to confirm there is no ovarian cyst. If
there is no cyst, we can commence superovulation.
If there is a cyst, we aspirate ( puncture) it and continue with the
treatment.
Tab Letrozole 5 mg daily . Inj Gonal-F ( 75 IU), 8 amp ( 600
IU ) daily
Day 3 Tab Letrozole 5 mg daily . Inj Menogon ( 75 IU), 8 amp
( 600 IU ) daily
Day 4 Tab Letrozole 5 mg daily .Inj Menogon ( 75 IU), 8 amp (
600 IU ) daily
Day 5 Tab Letrozole 5 mg daily . Inj Menogon ( 75 IU), 8 amp
( 600 IU ) daily
Day 6 Tab Letrozole 5 mg daily . Inj Menogon ( 75 IU), 8 amp
( 600 IU ) daily
Day 7. Vaginal ultrasound scan to monitor follicular growth
Day 7 . Inj Menogon ( 75 IU), 8 amp ( 600 IU ) daily. Inj Orgalutron, 0.25
mg daily
Day 8. Inj Menogon ( 75 IU), 8 amp ( 600 IU ) daily. Inj Orgalutron, 0.25 mg
daily
Day 9. Inj Menogon ( 75 IU), 8 amp ( 600 IU ) daily. Inj Orgalutron, 0.25 mg
daily
Day 10. Vaginal ultrasound scan to monitor follicular growth
The Menogon and orgalutron injections continue until the follicles are
mature ( approx Day 12). Then the HCG injection is given, and eggs retrieved
36 hours after this.
Embryo transfer is performed 5 days later, if we do a fresh transfer.
After the transfer, luteal phase support is provided with daily Progynova
( estradiol valerate 2 mg, 3 tab daily; and Susten( progesterone, 400 mg), 2 vaginal
suppositories daily.
You can travel back 3 days after the embryo transfer.
12 days after the transfer, you need to do a blood test for beta HCG to
confirm a pregnancy.

You can print out an IVF calendar ( of your cycle ) at
www.drmalpani.com/ivfcalendar2.php

A common question patients ask us is - can we reduce our stay in Mumbai ? The answer is - Yes, provided your local doctor is willing to help. He will need to do only two things to help you.
1. Prescribe your meds for you, which you can buy locally, or from www.ivfmeds.com.
2. Help to organise your Day 3 scan for you.

If he does so, then you can start your treatment locally; and come to Mumbai directly on Day 10. This was you have to spend only 10 days in Mumbai.

If you choose to go down this route, then it is important that you inform us by email and phone when your cycle starts; and also email and phone us with your Day 3 vaginal ultrasound scan results. You need to find a digital ultrasound scanner for your the Day 3 scan . They will burn the images as a jpeg file on a CD or flash drive.
You need to email us the raw images as jpeg files please - not scanned in copies of the paper printout, because there is too much loss of resolution with this !

The vaginal ultrasound scan on should check for the following.

a. ovarian volume
b. antral follicle count
c. uterus morphology
d. endometrial thickness and texture

Please do not start your superovulation without emailing us. The Day 3 scan is important, because it's based on the antral follicle count that I have to decide your dose of superovulation.

I need the results of ALL the following simple medical tests before starting
an IVF cycle.

1. semen analysis for your husband ( to check his sperm count and motility);
2. blood tests for you for the following reproductive hormones - FSH ( follicle-stimulating hormone),LH ( luteinising hormone),PRL ( prolactin) , AMH ( anti-Mullerian hormone) and TSH ( thyroid stimulating hormone) on Day 3 of your cycle, ( to check the quality of your eggs).
3. A vaginal ultrasound scan on Day 2 or 3 and Day 10 or 11 which should check for the following.

a. ovarian volume
b. antral follicle count
c. uterus morphology
d. endometrial thickness and texture

Please send me the ALL the detailed test results and medical reports . You can scan them in as a single Word file and email them to me.

If the tests have been done in the past one year, there is no need to repeat them.
If there is a problem, then we can treat it prior to starting IVF!

It’s best you do your tests locally. In case there is a problem, we can fix it before you come here for your treatment. If we find a problem in your test results after you come here, we will not be able to proceed with the treatment in the next cycle ! This option will save you time and money, so we can start with the treatment directly when you come