Ovulation Induction

Ovulation Induction

This slide shows the various treatment options for ovulation induction.A thorough understanding of the presently available treatment options will greatly simplify the management of infertile couples. It than becomes easier to identify couples who will benefit from a particular type of treatment option and others who will not. Now, we will consider each option briefly.

Oral Medication
Clomiphene Citrate

The first and foremost drug is, Clomiphene citrate which is the most popular agent for the induction of ovulation and has been in use for more than 35 yrs. It has a structure that shares key similarities with that of oestrogen.
Treatment with CC is commenced at 50mg -100mg(max 150 mg) daily for 5 days in each menstrual cycle beginning from day 3 or 4. CC should not be used for more than 12 cycles in a patient’s life time or for more than 6 cycles continuously.
Infertility specialist clinics will often add intrauterine insemination to clomiphene cycles in order to increase the chance for pregnancy. Insemination is particularly beneficial for women that already ovulate on their own and are using the Clomid to get extra egg production.

Clomiphene with injectable gonadotropins

Sometimes clomiphene is used in conjunction with injectable gonadotropins, particularly when the female is not responding and ovulating well with Clomid alone. Injectable gonadotropins contain FSH hormone. There are several protocols for adding the injectables in a Clomid cycle. It is important to monitor follicle development with ultrasound scans and blood hormone levels when injectable FSH products are used. This is because using Follistim, Gonal-F, Menopur, or (injectable FSH brand names) with Clomid can greatly increase the follicle number. One example of a monitored Clomid + injectable protocol is shown here:

  • Clomiphene pills taken days 3 to 7
  • Start injectable FSH product (Follistim, Gonal-F, Bravelle, Menopur) on day 10 at a dose of 75 units per day
  • Monitor response with estradiol and LH blood levels and ultrasound follicle scans starting on day 13
  • Repeat monitoring visits as indicated by the egg production response in the ovaries
  • Trigger ovulation with 10,000 units of HCG when one or two follicles are measuring about 17 to 19mm in diameter
  • Letrozole is an a aromatase inhibitor.
  • Until recently there were concerns about safety of this drug on fetus, but in 2016 DCGI, India lifted its ban on the use of this drug for ovulation induction.
  • Infact there are more studies now claiming it’s superiority over clomephine for ovulation induction in obese PCOS
  • It is administered in  a dose of 2.5-5 mg per day for 5 days starting from day 2/3/4/5 of menses. Pyramidal regimes have also found to be effective.
Injectable Gonadotropins

Injectable fertility medications, called gonadotropins, contain follicle stimulating hormone (FSH) which causes development of one or multiple follicles when injected into women that do not ovulate.

These medications are given by intramuscular injections or subcutaneous injections on a daily basis. The injections are started early in the menstrual cycle and are continued for approximately 8-14 days until one or more mature follicles are seen with ultrasound examination of the ovaries. At that point an injection of HCG is given which induces ovulation to occur approximately 36 hours later.

Over 90% of anovulatory women can have ovulation induced with this type of therapy. Pregnancy rates per month are better than those with use of Clomid and for relatively young women with no other contributing causes to the infertility pregnancy rates per month of approximately 15% can be expected when this form of treatment is combined with intrauterine insemination.

This type of therapy is usually tried for 3-6 months and if it does not result in a pregnancy in vitro fertilization should be considered.

This monitoring is usually done 3 times a week during the time the woman is taking the injectable medications.

Complications associated with use of these medications include the possibility of overstimulation, called ovarian hyperstimulation syndrome, or OHSS. OHSS is reported to occur in approximately 1% of cycles. Hyperstimulation involves enlarged ovaries, abdominal pain, and fluid build-up within the abdomen.

Multiple pregnancy is also a possibility when these medications are used. In general approximately 75% are single, 20% are twins, 5% are triplets and 1% are quadruplets or higher.

When many mature follicles develop the couple and the physician can have a discussion about the risks of multiple pregnancy and there is always the option of canceling the cycle by not giving the injection that causes ovulation. This essentially eliminates the risk of any pregnancy (single or multiple) occurring in that cycle.