Dear Dr Sher,

You have written that pre-antral follicles require exposure to FSH for 5 – 7 days to be able to develop into Antral Follicles. However, taking Birth Control Pills (BCPs) prior to COS suppresses FSH, and therefore does not allow PAF-AF conversion. This could lead to both follicle and egg development being compromised. Therefore, women who take BCPs to launch a cycle of COS need to have an overlap of the BCP with an agonist, because the agonist would cause an immediate surge in release of FSH by the pituitary gland thus causing conversion from PAF to SAF.

My question is – can the same not be achieved by overlapping the BCP with small (or large) amounts of Gonal-F for a few days?

Furthermore, you also suggest that women need exposure to small amounts of LH to produce testosterone, which in turn is converted into Estradiol. Therefore, for women taking BCPs prior to COS, would they also not see a suppression of LH? and as a result, there would be a hindrance to follicle and egg growth?

In this case, rather than overlapping BCP with agonists, can the patient overlap BCP with Menopur (to get just the right amount of FSH and LH) in the system?

Thank you.