❓ What exactly does “ovarian stimulation” mean in IVF?
In a normal menstrual cycle, your body grows one egg. In IVF, we want multiple mature eggs to increase your chances of creating good embryos.
To do this, we give gonadotropin injections (FSH or HMG) that “wake up” several follicles at once.
This is called ovarian stimulation.
It sounds high-tech, but the goal is simple — to get enough good eggs safely while avoiding an excessive response that can cause discomfort or OHSS (Ovarian Hyperstimulation Syndrome).
❓ Are there different types of ovarian stimulation protocols?
Yes. IVF clinics use different strategies to control your hormone levels and prevent premature ovulation.
The main options are:
- GnRH antagonist protocol – the modern, flexible, and safest option for most patients.
- GnRH agonist protocol (long protocol) – the older, traditional version.
- Progestin-only (PPOS) protocol – a newer approach often used when all embryos will be frozen (“freeze-all”).
ESHRE 2025 strongly recommends the antagonist protocol for most women because it’s as effective but safer — especially for those at risk of overstimulation.
❓ How does the clinic decide which protocol is right for me?
Your protocol depends on your ovarian reserve — basically, how many eggs your ovaries can make.
This is measured using your AMH (Anti-Müllerian Hormone) level and AFC (Antral Follicle Count) on ultrasound.
Normal responders: usually start with 150–225 IU of FSH daily.
High responders (often women with PCOS or high AMH): start with a lower dose to reduce the risk of OHSS.
Low responders (older women or those with low AMH): increasing the dose above 300 IU does not help — quality, not quantity, matters most.
So if your doctor says, “You’re a high (or low) responder,” it’s just a way of predicting how your ovaries might behave — not a reflection of your fertility value.
❓ Is it true that “more eggs = better chances”?
Not necessarily.
The evidence shows that having more eggs doesn’t always mean a higher chance of a baby.
Beyond a certain point, extra eggs add little benefit but increase the risk of OHSS and discomfort.
What truly matters is egg quality, which depends mostly on age and not on the number of injections or milligrams of hormones used.
❓ What medicines are used during ovarian stimulation?
The main drugs are gonadotropins, which contain FSH (follicle-stimulating hormone) and sometimes LH (luteinizing hormone).
According to ESHRE 2025:
- Recombinant FSH (rFSH), purified FSH (p-FSH), and HMG (a mix of FSH + LH) all work equally well.
- Long-acting FSH injections (like corifollitropin alfa) are as effective as daily shots.
- Adding LH or hCG to FSH doesn’t improve results for most women.
- Cheap urinary FSH preparations are fine — you don’t need expensive recombinant versions unless clinically justified.
Bottom line: the simplest, least expensive stimulation plan is often just as good as the fancy one.
❓ Should I take “add-on” treatments like DHEA, growth hormone, or antioxidants?
Short answer — no.
The new ESHRE guideline clearly says there’s no proven benefit from add-ons such as:
DHEA, testosterone, or growth hormone for “poor responders”
Metformin, myo-inositol, or aspirin unless you have a specific medical reason
These add-ons only add cost and confusion. There’s no magic injection that can fix egg quality.
❓ Can my doctor adjust the hormone dose midway if I’m not responding well?
It’s tempting to “increase the dose” midway, but the evidence says it rarely helps.
What matters more is starting with the right dose based on your AMH and AFC.
Adjustments during the cycle usually don’t improve results — they just make you spend more.
❓ How is ovulation prevented during IVF stimulation?
Because you’re growing many follicles, your body may try to ovulate early.
To prevent that, clinics use one of three types of medicines:
- GnRH antagonists (daily shots for a few days)
- GnRH agonists (long protocol)
- Progestins (oral tablets) — only when planning to freeze all embryos
The antagonist protocol is preferred because it’s shorter, safer, and easier on your body.
❓ How do doctors know when to give the “trigger shot”?
When several follicles reach about 18–20 mm, it’s time to mature the eggs.
Traditionally, this was done with hCG, but ESHRE 2025 recommends using a GnRH agonist trigger for women at risk of OHSS — it’s much safer.
Some clinics use a “dual trigger” (hCG + GnRH agonist), but this doesn’t seem to improve success rates.
For most patients, a single trigger shot is enough.
❓ What happens after the egg collection — why do I need progesterone?
After your eggs are retrieved, your body’s natural hormone production dips.
To support the uterine lining, you’ll take progesterone through vaginal capsules, gel, or injections.
This is called luteal phase support.
ESHRE 2025 confirms that:
- Progesterone is essential after IVF.
- Any form — vaginal, injectable, or oral (dydrogesterone) — can be used safely.
- Adding extra estrogen doesn’t help.
- Progesterone should continue at least until your pregnancy test.
If the trigger was done with a GnRH agonist (not hCG), your doctor might adjust the dose or timing because luteal support becomes even more crucial.
❓ How can OHSS be prevented?
OHSS (Ovarian Hyperstimulation Syndrome) is the main safety risk of IVF.
It happens when too many follicles grow and hormone levels skyrocket.
The 2025 guidelines emphasise these preventive steps:
- Identify high-risk patients early using AMH and AFC.
- Use a lower FSH dose and the antagonist protocol.
- Use a GnRH agonist trigger instead of hCG.
- If hormone levels are very high, freeze all embryos and transfer them later (“freeze-all strategy”).
- Dopamine agonists like cabergoline can further reduce OHSS risk when hCG is used.
With these precautions, severe OHSS is now extremely rare in good IVF clinics.
❓ What’s the takeaway for patients starting IVF?
The new ESHRE guidelines reinforce something I’ve been telling my patients for years:
“IVF success isn’t about doing more — it’s about doing what’s right for you.”
Personalised ovarian stimulation means:
- Using the simplest effective protocol
- Avoiding unnecessary add-ons
- Preventing OHSS with smart choices
- Focusing on egg quality, not egg count
When you understand why your doctor recommends a particular plan, you feel less anxious and more in control — that’s what I call Information Therapy.
💬 Final Word from Dr Malpani
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