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ART in Endometriosis

ART in Endometriosis

Indications of ART
1.Stage III and IV endometriosis
2.Altered tubo-ovarian relationship
3.Multiple failed IUI
4.Age factor of the female
5.Associated male infertility

IVF in Endometriosis- What Differs?
1.Lower ovarian response to Gonadotropins
2.Poor response – 29.7% required to discontinue cycle
3.Lower number of oocytes retrieved
4.Poor oocyte and embryo quality
5.Decreased fertilization and cleavage rate
6.Decreased implantation rate
7.Release of embryotoxic substances from endometriotic implants

IVF protocols in Endometriosis
Controlled ovarian stimulation with both GnRH-a and GnRH antagonist protocols has similar IVF outcomes in patients with mild-to-moderate endometriosis.
However, agonist protocols have a significantly higher number of MII oocytes and available embryos that can be cryopreserved compared to patients treated with the antagonist protocol. When the outcome of subsequent freeze–thaw cycles are considered, cumulative fecundity rate will be higher in the agonist protocol.

1.Ultra Long Agonist protocol
GnRH Agonist (Inj. Leuprolide depot 3.75 mg IM once in 21 days x 3-6 cycles) prior to IVF stimulation improves Clinical Pregnancy rates and decreases miscarriage rates in Infertile women with Endometriosis.(ESHRE Guidelines on Endometriosis Sept, 2013)
Once downregulation is achieved, gonadotropins are started, no need to give any agonist during the stimulation. If required, antagonist may be added if we find increasing LH

2. Long Agonist Protocols
a)Long Follicular Protocol
Agonist (Inj. Leuprolide depot or daily dosage) given from Day 2 of previous cycle till day of trigger
GnRH is started from Day2 once down-regulation has been confirmed by blood tests (E2/ LH/ P4)

b)Long Luteal protocol
Agonist given from Day 21 of previous cycle till day of trigger, dose of agonist is halved once GnRH are added

3.Microdose Flare Protocol
Used in poor responders
Utilizes the initial flare effect of agonist
Initial stimulatory effects- enhances folliculogenesis
Followed by pituitary desensitization

GnRH Antagonist protocol
1. Multiple Dose Protocol (Long German –Lubec Protocol)
(Inj. Cetrorelix/ Cetrotide/Ganirelix)
Half – Life -13 Hours
Antagonist injections are given daily – 0.25 mg s.c till the day of trigger
2. Single Dose Protocol (Short French Protocol)
(Inj. Cetrorelix 3 mg s.c) Not yet available in India
Action lasts for 96 hours (3 – 4 days)

Trigger injection is given once ≥ 18 mm follicles of ≥ 3 numbers
Agonist protocol – HCG 5000 IU or 10,000 IU IM or rHCG 0.25mg s.c
Antagonist protocol
1. Inj. Leuprolide 2mg s.c
2. Inj. Triptorelin ( Decapeptyl) 0.3mg s.c

Advantages of an Agonist protocol
Synchronous follicular growth
Allows Flexibility in IVF Programming
Favours “Batch IVF ”
Agonist is less expensive than GnRH Antagonist

Less ‘Patient Friendly’, stressful due to longer treatment cycles
( 3- 4 wks for GnRH Agonist )
Less Safe * Increased Gonadotropin Dose

  • Only Inj. HCG as Trigger
  • Increase risk of OHSS

Costly due to increased Gonadotrophin cost
LH Suppression – Slow follicular growth, LPD

Advantages of an Antagonist protocol
More physiological
More ‘Patient Friendly’, less stressful due to shorter treatment cycle
( 2 wks Vs 4 wks for GnRH Agonist)
More Safe

  • Decrease Gonadotropin Doses
  • Minimal Ovarian Stimulation
  • Inj.GnRH Agonist as trigger
  • Decrease in OHSS incidence

Does not suppress raised LH level in the early phase of stimulation
(unlike Long GnRH Agonist Protocol)
Does not allow flexibility in IVF programming
Does not favour “Batch IVF”
GnRH antagonist is more expensive than GnRH Agonist

About GarbhaGudi:

GarbhaGudi is a chain of New-Generation Infertility Treatment Hospitals equipped with state-of- art-infrastructure & cutting-edge IVF Technology to address infertility issues & their emotional & mental effects on couples. We have a team of qualified & experienced doctors; their in-depth knowledge & expertise leaves no stone unturned to solve all your infertility issues. The Supportive & caring staff is always by your side to motivate & guide you throughout the journey. GarbhaGudi IVF, the best fertility treatment hospital in Bangalore, provides emotional support to couples facing infertility issues and sexual problems

For further details, you can also write to GarbhaGudi at or directly talk to our team at 8880000909

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