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Preventing Severe Ovarian Hyperstimulation Syndrome with “Prolonged Coasting”

by Dr. Geoffrey Sher on November 8, 2015

I do not use antagonists in high responders (e.g., PCOS) because it interferes with the assay of E2 (often causing the value to be understated), a valuable index in assessing risk for the development of severe/critical OHSS. I also do not believe in the agonist trigger to prevent OHSS. The reason is that the magnitude of the induced LH surge varies and if too little LH is released, meiosis can be compromised, thereby increasing the oocyte aneuploidy index.

Down-regulation + “prolonged Coasting: My approach is consistently to use a long pituitary DR protocol with an agonist, coming off 1-2 months on the BCP. The latter is intended to lower LH and thereby reduce stromal activation (hyperthecosis) in the hope of controlling ovarian androgen release. I then stimulate with low dosage FSHr to which I add a smidgeon of LH/hCG (Luveris/Menopur) from the 3rd day and watch for the # of follicles and [E2] starting on the 7th day of COS. If there are > 25 follicles, I keep stimulating (regardless of the [E2] until 50% of all follicles reach 14mm. Then, provided the [E2] is >2500pg/ml, I stop the agonist and the gonadotropin stimulation and follow the E2 (only) daily, without doing further US examinations. The [E2] will almost invariably climb and I watch it go up (regardless of how high the concentration of E2reaches) and track it coming down again. As soon as the [E2] drops below 2500pg/ml (and not before then ever), I administer 10,000U hCGu or hCGf (Ovidrel/Ovitrel-500mcg) as the “trigger” and perform an egg retrieval 36h later. ICSI is a MUST because “coasted” eggs usually have no cumulus oophoris and eggs without a cumulus will not readily fertilize on their own. All fertilized eggs are cultured to blastocyst (up to 6 days). And up to two (2) are transferred transvaginally under US guidance.

The success of this approach depends on precise timing of the initiation and conclusion of “prolonged coasting”. If you start too early, follicle growth will stop and the cycle will be lost. If you start too late, you will encounter too many post-mature/cystic follicles (>22mm) that usually harbor abnormally developed eggs. 

Use of the above approach avoids unnecessary cycle cancellation, severe OHSS, and optimizes egg/embryo quality. The worst you will encounter is mild to moderate OHSS and this too is uncommon.

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  • Sara sam - December 7, 2016 reply

    Hello Dr. Sher,
    I am a patient at Sher clinic in Dallas with Dr. Saleh.
    I have an autosomal dominant mutation and we are going through ivf to prevent passing the gene to our children.
    My first ivf cycle was a short protocol and resulted in 4 embryos- of which all were affected.
    I went thru a second cycle, and retrieved 19 eggs, and 12 are grade 1 and 2.
    We are doing frozen transfer in a month or so, if we get lucky with he negative mutation embryos.
    My AMH level was 6.5. I was given higer doses of gonal F and Lupron 5 to prevent ovulation. I had no symptoms until the hcg trigger 2 days back.
    I am a sick puppy since then. I had an ultrasound today which showed some ascites ( not enough to drain).
    I am getting monitored at an out side clinic in a different state- and following sher clinic orders.
    No labs were ordered. I was given Bromocriptine 2.5 mg ( half tab once nightly)- which is not touching me.
    I am on bed rest for 2 days and trying to drink gatorade as mucu possible. Cannot keep anything solid down even on zofran.
    My question is how long would this take to normalize? Should i admit myself in a near by hospital for paracentesis even for mild ascites? I have mild labored breathing.
    The reason I am hesistant to go a hospital is that I am unsure if any of the ER or internist or ob-gyn would know how to treat my condition.
    Please suggest.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - December 7, 2016 reply

    The 1st 7 days (or so) after the hCG trigger is associated with a worsening condition. From 7-10 days (r so) following the hCG trigger, the condition plateaus and thereafter RAPIDLY (within days) improves and abates.

    Good luck!

    Geoff Sher

  • K Engel - February 14, 2016 reply

    Hi Dr Sher,

    I was wondering if you could give us some advice on our situation. My partner and I are nearing the end of our IVF cycle (will include ICSI) and all of our doctors are off because it’s Sunday.

    My estrogen level was 2,360 pg/nl yesterday– if it doubles every 48 hours then today it could be at 3,500 pg/nl, and on Monday morning it could be 4,720. Which seems to put me at risk of OHSS – we’re pretty concerned about this.

    We have the choice of triggering (10,000 Pregnyl and 2mg Lucrin/Lupron) Sunday (tonight, day 13 of stims) for a day 15 egg retrieval or triggering Monday (day 14 of stims) for a day 16 egg retrieval. We’d prefer to leave them to grow out another day because we’ve had problems with immature eggs and think the extra day will help. We’re interested in trying coasting tonight so we can trigger on Monday, would you advise this? Would you just reduce the dose of Menopur or skip it entirely?

    I’m on 450 Menopur (evening) with orgalutran in the morning. Here is a summary of my latest results:

    The two scans and blood tests we have show:

    11/2/16 (day 10 of stims)
    R (14F): 16,13,13,13,12,11,11,11,10 rest <= 9.
    L (5+5F): 19,14,10 rest <= 9
    Estrogen: 292 pg/nl

    13/2/16 (day 12 of stims)
    R (14F): 21, 17, 16, 15, 15, 14, 13, 13, 13, 12, 12, 11 rest <= 10
    L (7F): 22, 16, 12 rest <= 10.
    Estrogen: 2,360 pg/nl

    If we trigger tonight (Sunday), taken the growth rate across the previous 2 day gap in the above scans, the likely follicle sizes on the day of trigger (day 13) will be as follows:
    R (14F): 23.5, 19, 16, 16, 16.5, 15.5, 14, 14, 14.5, 13.5, 13.5 rest <= 10
    L (7F): 23.5, 17.5, 13.5

    And if triggering Monday the 15th, then the sizes on the day of trigger (day 14) are likely to be as follows:
    R (14F): 26, 21, 17, 17, 18, 17, 15, 15, 15, 16, 15, 15 rest?
    L (7F): 25, 19, 15

    So the Monday trigger looks better in terms of general follicle sizes, but the leads could be huge by the day of egg pickup (31 and 28).

    Thanks so much,
    Kerry

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 14, 2016 reply

    It is so difficult to advise without controlling the situation. First, coasting does not work well in cycles where an antagonist is used. It is designed to be used with lupron treated cycles. Second, based on you follicle sizes, it seams to me that you might not be ready for a trigger shot on Monday…but I could be wrong. Third, while a Lupron trigger does to some extent reduce the risk of OHSS, in my opinion, this comes at a price which is that there is no way to quantify or predict the magnitude of the LH surge it induces which is often too low to optimize egg maturational division (meiosis), potentially increasing the percentage of dysmature eggs. The same would in my opinion apply if a reduced dosage of hCG (i.e. 5000U) or Ovidrel (i.e. 250mg were to be used for the trigger.

    For all of these reasons, it is not possible or appropriate for me to jump in with advice at this stage, especially without having hands on.

    However, here is the way in which I stimulate and manage patients at risk of developing OHSS:

    My approach is consistently to use a long pituitary DR protocol with an agonist, coming off 1-2 months on the BCP. The latter is intended to lower LH and thereby reduce stromal activation (hyperthecosis) in the hope of controlling ovarian androgen release. I then stimulate with low dosage FSHr to which I add a smidgeon of LH/hCG (Luveris/Menopur) from the 3rd day and watch for the # of follicles and [E2] starting on the 7th day of COS. If there are > 25 follicles, I keep stimulating (regardless of the [E2] until 50% of all follicles reach 14mm. Then, provided the [E2] is >2500pg/ml, I stop the agonist and the gonadotropin stimulation and follow the E2 (only) daily, without doing further US examinations. The [E2] will almost invariably climb and I watch it go up (regardless of how high the concentration of E2reaches) and track it coming down again. As soon as the [E2] drops below 2500pg/ml (and not before then ever), I administer 10,000U hCGu or hCGf (Ovidrel/Ovitrel-500mcg) as the “trigger” and perform an egg retrieval 36h later. ICSI is a MUST because “coasted” eggs usually have no cumulus oophoris and eggs without a cumulus will not readily fertilize on their own. All fertilized eggs are cultured to blastocyst (up to 6 days). And up to two (2) are transferred transvaginally under US guidance.

    The success of this approach depends on precise timing of the initiation and conclusion of “prolonged coasting”. If you start too early, follicle growth will stop and the cycle will be lost. If you start too late, you will encounter too many post-mature/cystic follicles (>22mm) that usually harbor abnormally developed eggs.

    Use of the above approach avoids unnecessary cycle cancellation, severe OHSS, and optimizes egg/embryo quality. The worst you will encounter is mild to moderate OHSS and this too is uncommon.

    I do not use antagonists in high responders (e.g., PCOS) because it interferes with the assay of E2 (often causing the value to be understated), a valuable index in assessing risk for the development of severe/critical OHSS. I also do not believe in the agonist trigger to prevent OHSS. The reason is that the magnitude of the induced LH surge varies and if too little LH is released, meiosis can be compromised, thereby increasing the oocyte aneuploidy index.

    Please visit my new Blog on this very site, http://www.DrGeoffreySherIVF.com, find the “search bar” and type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.

    • Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
    • Understanding Polycystic Ovarian Syndrome (PCOS) and the Need to Customize Ovarian Stimulation Protocols.

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

    I also suggest that you access the 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

  • sharon - January 31, 2016 reply

    Thanks dr. Sher we are expecting that 50% of the follicles will be > 14mm tomorrow so we will start coasting then. Do you usually coast for about 3 days to get the e2 levels lower than 2500.

    Sharon - January 31, 2016 reply

    With e2 levels of 11,000 and starting coasting tomorrow will coasting get it lower than 2500… Or has my cycle gone too far out of control and should I cancel it.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 1, 2016 reply

    It wont matter if it drops below 2500pg/ml.

    Geoff Sher

    sharon - February 1, 2016 reply

    Thanks my doctor has agreed to give me 10000 of the trigger in 2 or 3 days but that I cannot go ahead with fresh transfer as she feels we will have missed the windows. .. gutted but now praying for good blasts to freeze… thanks for your help during the cycle

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 1, 2016

    Hi Sharon,

    Thanks for posting here. Sorry but I am not sure I understand…Why does your RE believe you will have missed “the window”? Surely the day of the trigger will determine the ideal time for ET???? Please clarify!

    Geoff Sher

  • sharon - January 30, 2016 reply

    Hi. I am going to start coasting in 2 days but already my e2 levels are 11000, will coasting get me below 2500 and how many days would that usually take. Thanks

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - January 30, 2016 reply

    The timing at which the “coasting is started is not determined by the E2 level. It is initiated based on 1) there being at least 25 follicles 2) at least 50% have reached a mean diameter and he E2 having exceeding 2500pg/ml. If 50% the follicles have not reached that 14mm cut-ff, the stimulatin continues until they have. If the coasting starts too early the follicles will tank and if the coasting only starts when the follicles are much larger, the follicles will become over-ripe (too large) and will harbor dysmature eggs. Timing is critical here.

    My approach is consistently to use a long pituitary DR protocol with an agonist, coming off 1-2 months on the BCP. The latter is intended to lower LH and thereby reduce stromal activation (hyperthecosis) in the hope of controlling ovarian androgen release. I then stimulate with low dosage FSHr to which I add a smidgeon of LH/hCG (Luveris/Menopur) from the 3rd day and watch for the # of follicles and [E2] starting on the 7th day of COS. If there are > 25 follicles, I keep stimulating (regardless of the [E2] until 50% of all follicles reach 14mm. Then, provided the [E2] is >2500pg/ml, I stop the agonist and the gonadotropin stimulation and follow the E2 (only) daily, without doing further US examinations. The [E2] will almost invariably climb and I watch it go up (regardless of how high the concentration of E2reaches) and track it coming down again. As soon as the [E2] drops below 2500pg/ml (and not before then ever), I administer 10,000U hCGu or hCGf (Ovidrel/Ovitrel-500mcg) as the “trigger” and perform an egg retrieval 36h later. ICSI is a MUST because “coasted” eggs usually have no cumulus oophoris and eggs without a cumulus will not readily fertilize on their own. All fertilized eggs are cultured to blastocyst (up to 6 days). And up to two (2) are transferred transvaginally under US guidance.

    The success of this approach depends on precise timing of the initiation and conclusion of “prolonged coasting”. If you start too early, follicle growth will stop and the cycle will be lost. If you start too late, you will encounter too many post-mature/cystic follicles (>22mm) that usually harbor abnormally developed eggs.

    Use of the above approach avoids unnecessary cycle cancellation, severe OHSS, and optimizes egg/embryo quality. The worst you will encounter is mild to moderate OHSS and this too is uncommon.

    I do not use antagonists in high responders (e.g., PCOS) because it interferes with the assay of E2 (often causing the value to be understated), a valuable index in assessing risk for the development of severe/critical OHSS. I also do not believe in the agonist trigger to prevent OHSS. The reason is that the magnitude of the induced LH surge varies and if too little LH is released, meiosis can be compromised, thereby increasing the oocyte aneuploidy index.

    I strongly recommend that you visit my NEW personal website at http://www.DrGeoffreySherIVF.com and when you reach the home page, go to my new Blog find the “search bar” and type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.

    • Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
    • The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
    • Frozen Embryo Transfer (FET): What Does it Involve?
    I invite you to call 702-699-7437 or 800-780-7437 and set up an one hour Skype consultation with me to discuss your case in detail.
    I also suggest that you access the 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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