Ovulation induction refers to the administration of
medications to stimulate ovulation. These medications range from oral
Clomid to FSH
( gonadotropins ) or combinations of the two. Gonadotropins are injected
ovulation stimulating hormones ( FSH ) that are replicas of the hormones
produced by the body.
Many medications are utilized for ovulation induction.
They include Clomid, Metformin,
Parlodel, and FSH ( Gonal
- F, Follistim, Bravelle and Repronex ). FSH is used in IVF cycles
when many eggs are required for assisted reproductive technology ( ART
) procedures. The most commonly used gonadotropin at the Jones Institute
is produced from recombinant DNA technology and is identical to the hormone
secreted by the pituitary gland.
The purpose of ovarian stimulation with FSH is to yield
multiple healthy fertilizable oocytes for ART.
Transfer of multiple embryos significantly improves the pregnancy rate
over single embryo transfers. Excess embryos also can be cryopreserved
for future transfers.
At our institute, ovarian stimulation is individualized
to meet patient needs based on age, prior IVF attempts, and cycle
day - 3 levels of FSH, LH, and E2. We do not have a "universal"
protocol for all patients, but rather individualize the protocol and the
dosage of hormones based on the individual patient. Some of the most commonly
used hormones include:
This is a gonadotropin - releasing hormone agonist (
GnRHa ) that is administered subcutaneously daily. Most commonly, this
hormone is started in the mid - luteal phase ( days 21 to 24 ) of the
cycle preceding the IVF attempt and continued until
the day of human chorionic gonadotropin ( hCG
) administration. In some patients, this hormone is stopped with the
beginning of the menstrual period. The main advantage of this hormone
is to suppress the endogenous levels of FSH and LH, thus preventing a
premature LH surge and avoiding ovulation prior to egg retrieval, allowing
better control of the stimulation process, and improving the number and
quality of eggs obtained.
In some patients, ( over age 40, and poor ovarian reserve
with high cycle day - 3 FSH levels ), the use of this hormone may not
be desirable, as it may negatively affect the stimulation process in terms
of higher cancellation rates, longer days of stimulation, and higher number
of ampoules ( Gonal - F, etc. ) used. Possible side effects include local
redness at the site of the injection and a brief ( few days ) period of
estrogen deprivation symptoms, which may include sweating, hot flushes,
and headaches.
These are natural hormones extracted from the urine
of post - menopausal women. Repronex is a preparation, which contains
equal amounts of FSH and LH, and Bravelle is a preparation that contains
predominantly FSH. FSH and LH are hormones that will stimulate multiple
eggs in a given cycle when given in supra - physiologic doses. The dosage
of Repronex and / or Menopur may vary from two to eight ampoules intramuscularly
daily, depending upon the individual patient. In general, older patients
and those with poor ovarian reserve require higher amounts. The major
side effects include the risk of ovarian hyperstimulation and multiple
pregnancy, which will be addressed below. Although these preparations
are considered generally safe, the long - term health effects, if any,
from there use is currently unknown.
These are synthetic medications using recombinant DNA
technology that are highly pure for FSH. They do not contain the impurities
present in preparations extracted from urine. They have much less batch
- to - batch variability and present the state of the art medications
of the present. They are also given by subcutaneous ( under the skin )
administration. These are the current drugs of choice.
This hormone is given intramuscularly 34 to 36 hours
prior to egg retrieval. This hormone induces final egg maturity and is
essential to retrieve mature fertilizable eggs. This medication also can
be used in the luteal phase after transfer to increase endogenous estrogen
and progesterone production and enhance implantation. The hormone may
be withheld and the cycle canceled if the risk of ovarian hyperstimulation
is high. ( Ovidrel, a new recombinant hCG, can be used subcutaneously
and is our drug of choice. )
These are beginning to be used on an increasing proportion
of cases as adjutant therapy or in place of Lupron where it causes a more
complete suppression.
Patients may be canceled prior to egg retrieval for
any of the following conditions:
- Serum E2 £ 100 pg /
ml on cycle day - 8 or after 5 days of gonadotropin ( Gonal - F, etc.
) stimulation
- Serum E2 < 500 pg / ml
and < 3 follicles of preovulatory size ( 14 mm ) on day of hCG (
the live birth rate is under 5% for these patients in the last 3 years
)
- Serum E2 > 5,000 pg / mL
on the day of hCG, as the risk of ovarian hyperstimulation may be unacceptably
high
- Medical illness during the
course of treatment
If the patient is canceled prior to egg retrieval, she
will be required to pay only the fees of already administered services,
including office visits, ultrasound exams, blood assays ( E2, FSH, LH,
P4 ) and hormonal injections ( Lupron, Gonal F, etc. ).
This is the major potential complication of treatment
with gonadotropins ( Gonal - F, etc. ) and hCG. The mild - moderate hyperstimulation,
consisting of mild - moderate degrees of ovarian enlargement and abdominal
discomfort, is not uncommon with gonadotropin therapy. This usually occurs
five to seven days after hCG and is usually self - limiting, with gradual
improvement in symptoms.
Severe hyperstimulation syndrome is rare, occurring
in less than 3% of cases.
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Phone
800-515-6637 or 757-446-7100