Oral Contraceptive Pills Before IVF
OCPs are commonly used before IVF primarily for cycle scheduling and logistical convenience, but they require longer stimulation duration and higher gonadotropin doses without improving pregnancy outcomes in most patients. 1, 2
Primary Rationale for OCP Use
Cycle Scheduling and Programming
- OCPs allow precise timing of IVF cycle initiation, enabling coordination of multiple patients, staff scheduling, and laboratory workflow 1, 2
- Treatment can be planned in advance rather than waiting for spontaneous menstruation 1
- This administrative benefit is the main reason OCPs are used in contemporary IVF practice 2
Specific Clinical Indications
High Responders and PCOS Patients:
- Dual suppression with OCPs followed by GnRH agonist significantly improves outcomes in high responders, reducing cycle cancellations from excessive response to 13.1% and achieving 46.5% clinical pregnancy rates 3
- This protocol lowers LH/FSH ratio and reduces serum androgens, particularly beneficial for PCOS patients who are hypersensitive to gonadotropins 3
- Prevents premature LH surge in minimal stimulation protocols using clomiphene citrate, achieving 32.8% pregnancy rate per retrieval 4
Poor Responders:
- OCP pretreatment combined with flare protocol does NOT improve outcomes in poor responders, with similar abandonment rates (39.5% vs 36.8%) and pregnancy rates regardless of OCP use 5
- This represents a common pitfall—OCPs should be avoided in poor responders as they provide no benefit 5
Impact on IVF Cycle Parameters
Stimulation Requirements
- OCP pretreatment consistently requires 1-2 additional days of stimulation (10.76 vs 9.21 days in young patients; 10.48 vs 8.73 days in older patients) 1
- Total gonadotropin consumption increases by approximately 600-1000 IU (young: 3,210 vs 2,565 IU; older: 4,973 vs 3,983 IU) 1
- Number of oocytes retrieved shows minimal increase (β 0.22,95% CI 0.12-0.31) after adjusting for confounders 2
Pregnancy Outcomes
- Fresh live birth rates are equivalent between OCP and non-OCP groups (ORadj 0.89,95% CI 0.69-1.15) 2
- Cumulative live birth rates remain unchanged (32.4% vs 31.6%, P = 0.712; ORadj 0.94,95% CI 0.73-1.21) 2
- Implantation rates are not affected by OCP pretreatment regardless of age group 1
Optimal OCP Protocol When Used
Duration and Type
- 12-30 days of OCP administration is standard, with most protocols using 21-25 days 3, 2
- 5-day washout period before starting gonadotropins is recommended 2
- No difference exists between third-generation (desogestrel) and fourth-generation (drospirenone) progestins for IVF outcomes 2
- Typical formulations: ethinylestradiol 30 μg with either desogestrel 150 μg or drospirenone 3 mg 2
Timing Considerations
- GnRH agonist should overlap with final 5 days of OCP administration in dual suppression protocols for high responders 3
- Gonadotropin stimulation begins on day 3 of withdrawal bleeding 3
Clinical Decision Algorithm
Use OCPs before IVF when:
- Cycle scheduling is necessary for logistical reasons 1, 2
- Patient is a high responder or has PCOS requiring dual suppression 3
- Using minimal stimulation with clomiphene citrate to prevent LH surge 4
Avoid OCPs before IVF when:
- Patient is a poor responder (age >39, elevated FSH, history of <4 oocytes retrieved) 5
- Minimizing gonadotropin dose and cost is priority 1
- Time-sensitive fertility preservation where random-start protocols are preferable 6
Important Caveats
- The increased cost from higher gonadotropin requirements must be weighed against scheduling convenience, as OCPs add approximately $500-1000 in medication costs per cycle 1
- OCPs provide no fertility benefit—their use is purely for logistical scheduling or specific suppression needs in high responders 2
- In GnRH antagonist protocols, OCP pretreatment is optional and chosen based on clinic workflow rather than medical necessity 1
- Random-start stimulation protocols can be initiated at any menstrual cycle point without OCPs when urgent treatment is needed 6