Lupron treatment in IVF
Lupron (leuprolide acetate, a GnRH Agonist)
Lupron has several possible uses in assisted reproduction:
as the trigger injection prior to egg retrieval to reduce the risk of hyperstimulation
as part of the “flare” protocol to help women who respond poorly to fertility medications.
suppression of the pituitary to prevent ovulation
How does Lupron work?
Lupron acts by suppressing the pituitary gland (the gland which is normally responsible for triggering ovulation). However, before suppression occurs, Lupron will briefly stimulate the pituitary causing an increase in the pituitary hormones LH (luteinizing hormone) and FSH (follicle stimulating hormone). This is called the agonist or flare phase (see picture). If the Lupron is continued, it will eventually stop the pituitary from producing LH and FSH. This is known as the suppression phase.
Since it requires an extended period time to reach the suppression phase, Lupron is usually started a few weeks before starting the other medications needed for a particular treatment. This allows the patient to “get past” the stimulation phase and into the suppression or desensitization phase.
During the suppression phase, spontaneous ovulation will not occur. You may hear the staff refer to the patient during this phase as being “down-regulated” or “suppressed”. This suppression effect will even persist for a few weeks after the Lupron is stopped.
Today, Lupron suppression is used primarily for frozen embryo transfer cycles and egg donation cycles. Some programs may still use Lupron for fresh IVF cycles . At IVF1, we use a newer class of medications to prevent premature ovulation in fresh IVF cycles. We like to use Cetrotide or Antagon instead of Lupron.
The flare effect of Lupron can be used at the beginning of a fresh IVF cycle to help stimulate the development and maturation of eggs. Lupron is given for a few days and then injectable fertility medications are started. The flare protocol is rarely used anymore since it does not appear to produce any benefit over other simpler protocols.
The “flare effect” of Lupron can also be used at the end of an IVF stimulation in place of the hCG trigger injection. This use of Lupron is primarily reserved for women who have responded too vigorously to the fertility medications and are at risk for ovarian hyperstimulation syndrome.
Method for using Lupron for ovarian supression
Because the flare phase can sometimes result in annoying problems like the development of ovarian cysts, we try to minimize he occurrence of those problems by starting the Lupron in one of two ways:
Lupron can be started after ovulation has occurred. If a woman has a 28 day menstrual cycle, she would normally ovulate around Day 14. Lupron would be started by checking a blood test to verify ovulation (progesterone level) between the 18th and 25th day. If ovulation were verified, the Lupron would then be started.
Using birth control pills
The problems with Lupron can also be reduced by first starting a woman on birth control pills. The pills can be given for variable lengths of time but at least for 10 days. The Lupron can be started at any point after the fifth day. Once started, the birth control pills would be continued for five additional days and then stopped.
Once a patient achieves pituitary suppression, she will sometimes get a period, but not always. Therefore, in order to verify pituitary suppression, we will have the patient come to the office for a blood test and ultrasound. We will ask the patient to call us to schedule this appointment if she gets a period while on the Lupron but in any case if she has taken two weeks of Lupron.
Method for using Lupron as part of the trigger injection
There are a few instances where Lupron may be used instead of or in conjunction with hCG to trigger final maturation of the eggs.
- Egg donors
- Women at risk for ovarian hyperstimulation syndrome
- Women who are not going to have a fresh embryo transfer
A very high dose of Lupron is used for this purpose. When used for ovarian suppression, the dose of Lupron is 0.5 mg to 0.25 mg. The injections are given daily for a few weeks. When used for a trigger injection, the dose is 4 mg and is given as a single injection.
Click here to learn how to administer Lupron