Ovulation Induction (OI)

There are various options to stimulate good quality ovulations. The first principle, however, is to attempt to determine the reason for this ovulation dysfunction. Therefore, various hormone blood tests are carried out. If a problem is found, for example, an underactive thyroid, then this endocrine disorder needs to be taken care of first, and then the ovulation process will be reevaluated. Quite often, treatment of such a specific problem will then lead to spontaneous good quality ovulation. Different medications are available for each of these potential disorders.

The simplest means to directly stimulate ovulation is with the medication clomiphene citrate. The brand names for this medication are Serophene and Clomid. This medication is taken orally, typically from the fifth to the ninth day. The medication is started with one pill a day for these five days. If ovulation does not occur, then the dosage is increased to two pills a day, and if necessary, three pills a day. It is unusual to go beyond that dosage. Once the dose that causes good ovulation is established, then the dosage is not typically increased beyond that point. Ovulation would be determined by a blood progesterone level on approximately day 22 of the menstrual cycle. The majority of patients who will conceive on clomiphene citrate will do so within the first three months. Therefore, the patients are often left alone to get pregnant. If pregnancy does not occur, then studies will be initiated during the third or fourth treatment cycle. This is done in order to evaluate the side effects that can develop on this therapy and to make sure that the ovulation dysfunction is corrected. Clomiphene citrate may cause a marked decrease in cervical mucus production, interfering with sperm getting through the cervix. It may also cause a marked thinning out of the endometrial lining, thus interfering with embryo implantation. There may also be a disruption in the normal process of egg stimulation and triggering of ovulation at the appropriate time. Approximately 60% of patients treated with clomiphene citrate will eventually conceive.

Patients who fail to respond to clomiphene citrate or patients who have an extremely suppressed ovulation process will be treated with injectable fertility medication. The most commonly used medications for this include Follistim, Gonal F and Repronex. Follistim and Gonal F are man-made pituitary gland FSH products. Repronex is a very purified human urinary product containing pituitary gland FSH and LH. These medications stimulate the ovaries directly, rather than relying on the brain's stimulation that should occur with the natural cycle or in response to clomiphene citrate therapy. Since the brain is therefore bypassed, it is imperative to make sure that enough medication is being given and also that too much is not being utilized. This therefore requires very careful monitoring with ultrasound and blood testing to assure safe use of these medications. These medications are usually given as subcutaneous injections, just under the skin on the abdomen. Using very small needles, couples are taught to do these injections, which are performed between 4:00 and 6:00 p.m. each evening. The necessary monitoring studies are then done each morning, in order to determine the daily dose requirements. These medications can be associated with two major problems and therefore require careful management. The first concern is that of multiple pregnancy. There is the potential of developing a significant number of eggs, which would definitely not be desired. By careful monitoring, the number of eggs that are likely to ovulate can usually be determined. Strict guidelines are employed to minimize the risk of a multiple pregnancy. Overall, a 20% twin rate would be anticipated. The other concern with this medication is overstimulating the ovaries. If this happens to a significant degree, the Hyperstimulation Ovarian Syndrome can develop. In this situation, the ovaries become quite large and cystic and the patient may become extremely ill with a potentially life-threatening situation. Extreme caution is exercised to minimize the risk of this situation. It would be anticipated that 70% of females utilizing this therapy would eventually conceive.

There are several other medications that are used occasionally to induce ovulation. Among these would be Metformin. This drug is helpful in certain patients who have a tendency toward Diabetes and have an excess in male hormones, giving them the condition of Polycystic Ovarian Syndrome. Occasionally, these patients will require the lowering of their excessive male hormones by medications such as Prednisone. Often times, this is enough to allow patients with PCOS to ovulate on their own. In other cases, the Prednisone or Metformin will allow for a much better response to drugs such as clomiphene citrate.