Interesting cases
Each case we assist with is unique. On occasion we publish them, but most become simply another layer of experience.
Ovarian stimulation with patient’s own FSH
In our very first Term Stim™ case, a physician reached out with no expectations — just hoping for an idea of what else could be tried for a 37-year-old patient, with elevated baseline FSH, whose embryos always stopped developing on Day 2.
She had already completed two conventional IVF cycles. Each time, eggs were retrieved and fertilized normally, but embryo growth halted on day 2. Suspecting an abnormal sensitivity to FSH, the physician tried natural-cycle IVF. Out of four attempts, three yielded oocytes with normal fertilization — yet again, all embryos arrested on Day 2. The patient firmly refused donor eggs, and the physician had run out of options.
While reviewing her cycles, we noticed a pattern: her follicular phase in treatment cycles was always short, around 10 days. During stimulation cycles, because follicles grew faster than expected reaching critical size that required triggering; in natural cycles, the physician was triggering early to preempt LH surge.
After discussing the case, physician decided to extend the cycle by lowering patient’s FSH with oral estradiol and then stopping the pills and allowing FSH to rise instead of providing external FSH, which is effectively stimulation with patient’s own FSH. After a few days, we did add exteranal FSH to keep total circulating FSH at around 10 IU/L. The follicular phase was extended to 14 days. The table below illustrates the actual protocol. Note that in this patient, unexpectedly, a small addition of estradiol was sufficient to suppress FSH – something that could not have been predicted from her prior history and not what is usually observed. For the first time, she produced three blastocysts from 7 eggs. The first frozen-embryo transfer failed, but the second resulted in the birth of a healthy, full-term child.
When the “same protocol” produces a different outcome
A 40-year-old woman (Patient B) with a baseline FSH of 10 IU/L entered treatment using the same short antagonist protocol her physician had previously used successfully for another 40-year-old patient (Patient A), who had nearly identical ovarian reserve markers (AMH, estradiol, and AFC).
At first, Patient B’s stimulation response followed expectations. But by Day 7, after Cetrotide was introduced and additional FSH was added to compensate for the anticipated suppression of endogenous FSH, something changed — follicular growth accelerated from ~1.1 mm per day to about 3 mm per day, accompanied by a proportional rise in estradiol. The physician was forced to trigger ovulation on Day 9, when the lead follicle measured 19 mm. Mature (MII) oocytes were retrieved and fertilized normally, but none developed to the blastocyst stage. A repeat cycle reproduced the same pattern.
While analyzing the case, we noted that when Cetrotide was started on Day 7, the expected transient drop in estradiol seen in Patient A did not occur in Patient B. We proposed that Cetrotide had failed to suppress her endogenous FSH production. The physician agreed to investigate this possibility, and measurement of serum FSH after antagonist initiation confirmed the suspicion.
It became evident that the exogenous FSH dose—intended to offset the presumed loss of endogenous FSH—had instead compounded total FSH exposure, accelerating follicular growth and shortening the follicular phase. In the next cycle, the compensatory FSH increase after Cetrotide was omitted. Follicular growth normalized to ~1.1 mm per day, the follicular phase extended to 12 days, and the cycle resulted in normal blastocyst development and, ultimately, a term delivery after frozen embryo transfer.
Extending stimulation by 7 days in 42 years old patient
A patient 42 years old, BMI 30, AMH 1.13 ng/ml, G0, P0 with two prior failures of IVF due to the lack of chromosomally normal embryos. The attempts were similar in all aspects, except the monitoring and administering FSH – Term Stimulation method.
Table: Summary of three IVF attempts
The target duration of stimulation was set to 17 days, calculated from the first day of the period. Based on the patient’s baseline FSH, her target serum FSH level was set to the range between 15 and 20 mIU/ml. Ovarian stimulation was initiated on the second day of the menstrual cycle. The amount of FSH for administration was calculated to achieve and maintain the circulating level within this band. If the circulating FSH level deviated from the band, the amount of injected FSH was adjusted accordingly.
Table: Details of the Term Stimulation cycle (follicle sizes are rounded up).png)
Extending stimulation by 4 days and reducing FSH
Term stimulation in a 37-year-old patient, AMH 1.87 ng/ml, BMI 29, G0, P0, with two previous IVF failures due to poor embryo quality. The attempts were similar in all aspects, except the monitoring and administering FSH – Term Stimulation method.
Table: Summary of three IVF cycles
The target duration of stimulation was set to 17 days, calculated from the first day of the period. Based on the patient’s baseline FSH, her target FSH level was set to 5 and 10 mIU/ml. Ovarian stimulation was initiated on the third day of the menstrual cycle. The amount of FSH for administration was calculated to achieve and maintain the circulating level within this band. If the circulating FSH level deviated from the band, the amount of injected FSH was adjusted accordingly, including coasting on days 10 and 14. Table summarizes the Term Stimulation cycle.
Table: Details of the Term Stimulation (follicle sizes are rounded up).png)
Once the 17-day duration of the follicular phase was achieved, hCG was administered to trigger ovulation. Eight mature eggs were retrieved, all fertilized, and five developed into good-quality cryopreserved blastocysts. Subsequently, two blastocysts were transferred in a frozen cycle, resulting in a singleton pregnancy and uneventful term delivery.