DƯỢC LÍ Goodman & Gilman's The Pharmacological Basis of Therapeutics 12th, 2010

1844
A.
Gonadotropin (IU)
75
75
75
75
75
75
150
150
150
150
150
150
150
150
150
hCG
Intercourse
or IUI
SECTION IX
SPECIAL SYSTEMS PHARMACOLOGY
B.
C.
Gonadotropin (IU)
GnRH agonist
luteal phase
Gonadotropin (IU)
Menses
Menses
Menses
4 8
12 16
Ultrasonography
( ≤2 follicles ≥17 mm)
225
225
225
225
225
225
225
225
225
hCG
Oocyte
retrieval
225
225
Embryo
transfer*
4 8 12 16
Ultrasonography
( ≥3 follicles ≥17 mm)
225
225
225
225
225
225
225
225
GnRH antagonist
hCG
Oocyte
retrieval
225
225
225
4 8
12 16
Embryo
transfer*
Ultrasonography
( ≥3 follicles ≥17 mm)
Progesterone
Progesterone
Figure 66–1. Schematic diagram of idealized regimens using exogenous gonadotropins for fertility induction. A. Step-up regimen for
ovulation induction. After menses, daily injections of gonadotropin (75 IU) are started. Follicle maturation is assessed by serial measurement
of plasma estradiol and follicle size, as discussed in the text. If an inadequate response is seen, the dose of gonadotropin is
increased to 112 or 150 IU/day. When one or two follicles have achieved a size of ≥17 mm in diameter, final follicle maturation and
ovulation are induced by injection of human chorionic gonadotropin (hCG). Fertilization then is achieved at 36 hours after hCG injection
by intercourse or intrauterine insemination (IUI). If more than two mature follicles are seen, the cycle is terminated and barrier
contraception is used to avoid triplets or higher degrees of multifetal gestation. B. Long protocol for ovarian hyperstimulation using
gonadotropin-releasing hormone (GnRH) agonist to inhibit premature ovulation, followed by in vitro fertilization (IVF). After the
GnRH agonist has inhibited endogenous secretion of gonadotropins, therapy with exogenous gonadotropins is initiated. Follicle maturation
is assessed by serial measurements of plasma estradiol and follicle size by ultrasonography. When three or more follicles are
≥17 mm in diameter, then ovulation is induced by injection of hCG. At 32-36 hours after the hCG injection, the eggs are retrieved and
used for IVF. Exogenous progesterone is provided to promote a receptive endometrium, followed by embryo transfer at 3-5 days after
fertilization. C. Protocol for ovarian hyperstimulation in an IVF protocol using a GnRH antagonist. The cycle duration is shorter
because the GnRH antagonist does not induce a transient flare of gonadotropin secretion that might disrupt the timing of the cycle,
but many other elements of the cycle are analogous to those in B. IU, intrauterine.
placenta acquires the biosynthetic capacity to take over this function;
regimens include progesterone in oil (50-100 mg/day intramuscularly)
or micronized progesterone (180-300 mg twice daily
vaginally). Vaginal preparations containing 100 mg (ENDOMETRIN)
or 90 mg (PROCHIEVE, CRINONE) of micronized progesterone are
approved for administration two or three times daily as part of IVF
and other fertility technologies.
Aside from the attendant complications of multifetal
gestation, the major side effect of gonadotropin treatment
is OHSS. This potentially life-threatening event is
believed to result from increased ovarian secretion of substances
that increase vascular permeability and is characterized
by rapid accumulation of fluid in the peritoneal