Individualized Controlled Ovarian Stimulation

29Mar, 2023

ICOS - Individualized Controlled Ovarian Stimulation

Assisted reproductive techniques are aimed at optimising the treatment so that it is safe, cost-effective, and also gets the best outcomes.

Since infertility is a very heterogenous condition with a wide profile of patients and the couple, varied causes, and differences in response; a one-size-fits all cannot be adopted for treatment. Hence it is imperative that each patient must be evaluated individually, and treatment ought to be tailor-made.

What is iCOS?

iCOS or individualised Controlled Ovarian Stimulation implies individualised, evidence-based approach that follows a hierarchy of treatment based on clinical, biochemical and sonological parameters.

How is treatment individualised in iCOS?

Women are categorized as normal, poor, or hyper-responders based on their initial evaluation. This evaluation mainly involves assessing the ovarian reserve of a woman. Antral follicle count (determined by scan on the second or third day of periods), AMH (Anti-Mullerian Hormone) levels are the main determinants that influence the classification of women. Age of the woman is a separate parameter that can impact the ovarian reserves. Serum FSH and Inhibin B levels also may help in categorising the women.

Younger women (< 35 years), with a normal body mass index, short duration of infertility with satisfactory ovarian reserve & having predominantly tubal or male factor cause for infertility are probably normal responders.

High responders are those at a high risk of OHSS (Ovarian Hyperstimulation Syndrome) and include women with PCOS (Poly cystic Ovarian Syndrome) -especially lean PCOS, those requiring increased doses of gonadotropins, E2 on the day of trigger being over or rapidly rising during stimulation.

Poor responders can be further categorised by the POSEIDON criteria depending on their age, AFC, AMC, and previous response to stimulation.

Individualisation of treatment may also be needed when women resort to fertility preservation before chemotherapy or radiotherapy.

Women who have history of thrombosis or prone for thrombosis or those with estrogen sensitive malignancies like ER-positive breast cancer, may also need individualised treatment plans which aim to maintain lowest possible levels of estrogen.

The actual iCOS includes:

a) Correct dosing of gonadotropins based on the categorization. ESHRE recommends using 150-300 IU, 150-225 IU,100-125 IU of gonadotropins for stimulation respectively for the poor, normal and high responders. GnRH antagonist protocol is the recommended first line protocol. The gonadotropin recommended may be rFSH, purified FSH, HP-FSH or hMG.

b) Appropriate monitoring of follicular growth and estrogen estimation on case-to-case basis, as needed.

c) Triggers in Poor and normal responders include 10,000 IU of hCG or 250 micrograms of rHCG. Gn RH agonist trigger can be used in GnRH antagonist cycles. Freezing all embryos can be resorted to in the hyper-responders with appropriate measures for prevention of OHSS.

d) Luteal phase support in the form of micronized natural progesterone (IM/SC/ Vaginal) or oral dydrogesterone.

Various stimulation protocols are appropriately individualised for special category of women mentioned previously.

To conclude, iCOS ensures that women are treated with the right dosage, type and timing of medications which are patient-friendly, evidence based, and hopes for the best outcomes.

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