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Ovulation Induction
Many women have ovulatory disorders that cause them to ovulate irregularly or not at all. Ovulation induction is a term that refers to the administration of medication to stimulate ovulation. These medications range from clomiphene citrate to gonadotropins to combinations of the two. Clomiphene citrate - a medication that was developed in the 1960's - can be used alone or in conjunction with injectable gonadotropins to help stimulate the ovaries. Patients who become pregnant taking clomiphene usually do so within the first three to six ovulatory cycles of therapy.
Gonadotropins are injectable ovulation stimulating hormones that are identical to the hormones secreted by the body. These products include Gonal-F, Follistim, Repronex, Humegon and Pergonal. The most commonly used gonadotropin at the Jones Institute at West Penn Allegheny Health System is a man-made form of follicle stimulating hormone (Follistim or Gonal-F) that is identical to the hormone secreted from the pituitary gland. Since this formulation is man-made, it contains very few impurities and can be injected directly under the skin with very few local reactions. Other injectable medications include human menopausal gonadotropin (hMG) which contains both follicle stimulating hormone (FSH) and luteinizing hormone (LH). The administration of these injectable medications allows clinicians to increase the circulating levels of follicle stimulation hormone, resulting in the stimulation and growth of multiple eggs. In addition to increasing the number of eggs with the use of gonadotropins, timing factors (such as when ovulation occurs) can be controlled, maximizing the chance of becoming pregnant. Any evaluation(s), diagnosis or treatment will be provided by physicians, staff or independent contractors of The Western Pennsylvania Hospital or Allegheny General Hospital.
All cycles involving gonadotropins are closely monitored in one of two ways:
- Estradiol Levels - Estradiol is released into the blood by the growing follicles as they respond to medications. Tracking the rise in estradiol levels can help to follow egg development.
- Vaginal ultrasounds - Vaginal ultrasounds can visualize the number of developing eggs and measure their size and growth.
Early in the stimulation cycle, estradiol levels are measured and vaginal ultrasounds are performed every few days to assess growth. Toward the end of the cycle, these assessments are performed more frequently to control the timing factors that will maximize the chances of becoming pregnant, as well as minimize side effects. Ovulation induction cycles are usually followed by the administration of human chorionic gonadotropin (hCG), an injection to induce ovulation. Approximately 34 hours after ovulation, intrauterine insemination (IUI) is performed. Intrauterine insemination uses specially prepared and concentrated sperm, which help to maximize the number of sperm available for fertilization.
There are several side effects and risks associated with gonadotropin use. The most common side effects include discomfort or "fullness" in the lower abdomen, bloating, headache or fatigue. Patients can also experience discomfort in the area of injection. Massaging the area or applying heat is often helpful. Perhaps the most significant risk of using injectable gonadotropins are multiple gestation and ovarian hyperstimulation. Ovulation induction can have up to a 20% incidence of multiple gestation (more than one fetus). Although the majority of these pregnancies are twins, more than two fetuses can sometimes develop.
Vaginal ultrasounds help determine the number of follicles that are developing, but they are only a guide and do not produce a specific count. Pregnancy with three or more fetuses at a time places both the mother and fetus at high risk for miscarriage, pre-term delivery and bleeding. The Western Pennsylvania Hospital and Allegheny General Hospital take this risk very seriously and monitor patients' progress very closely.
Ovarian hyperstimulation typically occurs 5-7 days after hCG injection. After hCG is given and ovulation occurs, the ovaries will sometimes enlarge. If pregnancy results, the ovarian enlargement may persist for up to six weeks. In general, the symptoms associated with ovarian hyperstimulation are mild and may include lower abdominal pain, heaviness and bloating. Sometimes shortness of breath may also develop. It is extremely uncommon for hyperstimulation to result in any severe medical problems. Patients are closely followed via ultrasound and laboratory tests to avoid problems.
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