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Launching Ovarian Stimulation with a BCP: How Does it Affect Response?

by Dr. Geoffrey Sher on November 15, 2015

One often hears the expressed opinion that the BCP suppresses response to ovarian stimulation. This is not the case, provided that the BCP is overlapped with administration of an agonist (e.g. Lupron, Buserelin, Superfact) for several days leading up to the start of menstruation and the initiation of ovarian stimulation cycle with gonadotropin drugs. If the latter precaution is not taken, and the cycle of stimulation is initiated coming directly off the BCP the response will often be blunted and subsequent egg quality could be adversely affected.

The explanation for this is that in natural (unstimulated) as well as in cycles stimulated with fertility drugs, the ability of follicles to properly respond to FSH stimulation is dependent on their having developed FSH-responsive receptors . Pre-antral follicles (PAF) do not have such primed FSH receptors and thus cannot respond properly to FSH stimulation with gonadotropins. The acquisition of FSH receptor responsivity requires that the pre-antral follicles be exposed to FSH, for a number of days (5-7) during which time they attain “FSH-responsivity” and are now known as antral follicles (AF). These AF’s are now able to respond properly to stimulation with administered FSH-gonadotropins. In regular menstrual cycles, the rising FSH output from the pituitary gland insures that PAPs convert tor AF’s. The BCP (as well as prolonged administration of estrogen/progesterone) suppresses FSH. This suppression needs to be countered by artificially causing blood FSH levels to rise in order to cause PAF to AF conversion prior to COS commencing, otherwise pre-antral-to –antral follicle conversion will not take place in an orderly fashion and the follicles will not readily respond to gonadotropins (FSH) , thereby delaying follicle development by up to 7 days and compromising egg quality. GnRH agonists (e.g. Lupron, Buserelin, Superfact) , cause an immediate surge in release of FSH by the pituitary gland thus causing conversion from PAF to SAF. This is why, women who take a BCP to launch a cycle of COS need to have an overlap of the BCP with an agonist.

By overlapping the BCP with an agonist for a few days prior to menstruation the early recruited follicles are able to complete their developmental drive to the AF stage and as such, be ready to respond appropriately to optimal ovarian stimulation. Using this approach, the timing of the initiation of the IVF treatment cycle can readily and safely be regulated and controlled by varying the length of time that the woman is on the BCP.

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  • AnnP - December 31, 2015 reply

    Dr. Sher,
    Thank you for all of the great information you provide on your website. I have a questions about the use of BCP. I know that you recommend the use of the BCP for a couple of months prior to an IVF cycle for older woman. (I am 41 with an FSH of 5.5 and a LH of 7.6). Should the use of the BCP be continuous, or would there be harm in doing a cycle of BCP, breakthrough bleed, doing a cycle of BCP, breakthrough bleed, then starting the BCP for the IVF cycle. Or would it matter?

    Thanks,
    Ann

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - January 1, 2016 reply

    Thank you Ann,

    You can use the BCP cyclically. There is no absolute need to use nit for several months, but it wont do harm doing so. But you are correct…older women and women with DOR might benefit from suppressing LH through longer use of the BCP. I do at a minimum recommend launching all cycles of stimulation coming off the BCP.

    I invite you to call 702-699-7437 or 800-780-7437 and set up a one hour Skype consultation with me to discuss your case in detail.

    I also suggest that you accessthe 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

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