Physician-To-Physician Consult

Dear Colleagues,

Kindly I would like to ask you about control ovarian hyperstimulation in patient who suffers from stage IV endometriosis, who underwent several open surgeries because of ovarian endometrial cysts, with low AMH level (0,7 ng/mL).
She is receiving now daily Dienogest 2 mg (Visanne, Bayer HealthCare, Berlin, Germany).

What is the best stimulation protocol for this patient?
Which gonadotropins and how much dosage should be used?
When to start ovarian hyperstimulation? Right away? Or maybe wait for the menstruation? Or maybe induce estrogenic priming?

Thank you and have my best regards.

Przemyslaw Ciepiela MD, PhD,
Specialist Ob/Gyn
Department for Reproductive Medicine and Gynecology,
Pomeranian Medical University, Poland

View Answers

Answer by Michael Alper

Patient at risk for diminished ovarian reserve so I would use higher dose FSH stimulation with some LH activity. I do not know her age, BMI or knowledge of any prior stimulation, but I would in general start with 300 IU of FSH and 75 IU of HMG combined as a single injection. I would add estrogen to the progestin for 2-3 weeks and then withdraw both to induce a period before starting her stimulation. I would start stimulation on day two of the period. I would add the antagonist when the lead follicle reaches 14 mm or an E2 level of >400 pg/ml. In the unlikely event that she over-stiumulates, then I would trigger with agonist.

Answer by Manish Banker

1. Any information on her age, AFC and response to treatment in the past would be of help.

2. Would stimulate her with a combination of FSH and LH [ 300 IU of rec FSH + 150 IU of hMG ] after a proper E+P withdrawl.

3. Antagonist when leading follicle is > 14.

4. Agonist [ Decapeptyl 0.2 mg ] trigger in the rare instance of hyper response.

Answer by Norbert Gleicher

I must be missing something: how can a woman with AMH of 0.7ng/mL be at risk for OHSS?
This woman with overwhelming likelihood canNOT have suffered from OHSS. Her symptomatology was, likely, the consequence of her STAGE IV endometriosis, and that is not surprising because, if she, indeed, has STAGE IV disease, she has a frozen pelvis and any ovarian enlargement, even if relatively minimal, will lead to pain.
This appears to be a woman with very low functional ovarian reserve. Here at CHR, she would be pre-supplemented with DHEA until her testosterone levels are adequate, and then would she entered into IVF. her stimulation, after estrogen priming in the preceding luteal phase, would be a microdose lupron (agonist cycle) with FSH preponderance and 150IU of an hMG product daily.
How much FSH is difficult to say since you did not give us the age of the patients (!!!). If she is under 35, we, likely, would give her 300IU, if she is older 450IU daily.

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