An Ovulation Induction Cycle
A woman’s body normally produces one egg per ovulation cycle. Ovulation is dependent on a delicate balance of reproductive hormones. If the body does not produce these hormones in the right way, ovulatory dysfunction occurs, which more often than not causes infertility in the woman. In many the ovulatory dysfunction is due to a condition known as “polycystic ovarian syndrome” or PCOS. In others, the reason may be mild endometriosis or mild male factor infertility. Treatment with injectable “fertility drugs” or gonadotropins can increase the chances that a pregnancy will happen by stimulating the inactive ovaries to ovulate or produce more than one egg at a time. This process is known as superovulation. In many cases, superovulation is combined with intrauterine insemination (IUI).
Ovulation is achieved through a series of oral and injectable medications that regulate the menstrual cycle by adjusting the levels of certain chemicals in the body. These include:
- Oral medications: Metformin or Clomiphene Citrate (clomid)
- Injectable medications may include one or a combination of:
GnRH agonists, or gonadotropin-releasing hormone agonists – Stimulate high-quality egg production and help prevent mid-cycle increases in estrogen levels. (Lupron)
GnRH antagonists – Prevent premature ovulation. (Antagon, Cetrotide)
FSH, or follicle stimulating hormones, and LH, or luteinizing hormones – Stimulate egg-producing follicles in the ovaries. (Follistim, Bravelle, Gonal-F; Repronex)
HCG, or human chorionic gonadotropins – Prepare eggs for harvesting. (Pregnyl, Profasi, Novarel)
There are some risks associated with these treatments, including side effects from the injection itself (bruising, swelling, tenderness or infection), allergic reaction, and excessive or insufficient response from the ovaries. Increased estrogen levels may cause fluid retention, weight gain, nausea, diarrhea, breast tenderness, moodiness, headache or fatigue. The drugs can cause mood swings. They may increase the likelihood of a multiple pregnancy, although the physician will be closely monitoring the patient with ultrasounds of the ovaries during her treatment to minimize this possibility.
*Many doctors using Clomid, for instance, blunder by increasing the dosage if the patient does not get pregnant in that month, thinking that a higher dose increases the chances of fertility. That is not true! It only risks increasing the number of eggs that the patient ovulates and therefore there is a higher chance of a multiple pregnancy. Unfortunately, many doctors use this as their “magic pill approach” to infertility and will prescribe it without doing an infertility evaluation or determining whether or not it is indicated.
A rare but possible complication, common in women with PCOS, is ovarian hyperstimulation syndrome (OHSS), in which estrogen levels rise sharply and the ovaries produce too many eggs, potentially causing excessive fluid retention, thrombosis and enlarged ovaries. OHSS is a serious condition that requires hospitalization. Severe reactions to the medications usually results in the cancellation of the treatment cycle. One of Dr. Ramirez’s specialties is the treatment of PCOS and all his patients with this syndrome are very closely monitored in order to avoid even the slightest risk of OHSS. It is never recommended to just take Clomid and trying to time intercourse on one’s own (nonintervention method), which is what a lot of OB/GYN’s like to do.
A Typical Clomid Induction Cycle:
1. Patient calls with onset of period or within the first five days of onset. She is scheduled to be seen within the first five days of the cycle.
2. Patient comes in for a baseline ultrasound to evaluate for the presence of an ovarian cyst. Ovarian cysts are a contraindication to using fertility medications and will interfere with the cycle. The cyst may just get bigger and ovulation will not be accomplished.
3. Treatment calendar is made up showing when everything is going to happen, approximately.
4. Patient stops having intercourse on cycle day #10.
5. Patient returns on cycle day #10, 11 or 12 for vaginal ultrasound to check for: whether she is responding to that dose of Clomid as manifest by multiple growing follicles, how many follicles are growing and if the follicular size is appropriate for ovulation. Serial daily or every other day ultrasounds are done until the ovulatory follicle(s) reach the appropriate size of 18-24 mms.
6. Once the follicles reach the appropriate size, HCG is given to trigger ovulation.
7. In a timed intercourse cycle, the patient begins intercourse the next day for four consecutive days, only one ejaculation per day. (By contrast, if it is an IUI cycle, the patient has an IUI the next day and following day.)
8. Vaginal progesterone is then started either on the 5th day after trigger if a timed intercourse cycle, or the day after the second IUI, and continued until the pregnancy test.
9. Blood pregnancy test is done two weeks after the trigger and the progesterone is NOT stopped until this result is negative. If positive, it is continued until 10 weeks gestational age. We DO NOT wait for onset of menses, because often it will not come if progesterone is taken.