Controlled Ovarian Hyperstimulation

Several drugs can induce ovulation -- also known as controlled ovarian hyperstimulation.

They are used in women who do not ovulate or ovulate infrequently and also for couples who have other infertility problems.

Your physician will choose the drug used after careful evaluation of your particular infertility problem.

Ovulation Inducing Drugs

The fertility drugs most often used in our clinic to induce ovulation include those listed below. For more complete definitions, please visit the Medications page of our Resources section.

Clomiphene Citrate (Clomid or Serophene)

Clomiphene citrate is a pill taken orally and can cost approximately $10 per tablet. Clomiphene treatment is usually started on day three of the menstrual period and is continued through day seven (a total of five days).

Human Menopausal Gonadotropin and Human Chorionic Gonadotropin (HCG) (Gonadotropins or HMG's such as Repronex, Follistim or GonalF)

Gonadotropins (approximately $50 per amp/vial) and HCG (presently $26 per 5,000 units) are administered by intramuscular injection (IM) or subcutaneous injection (SQ). Consequently a "typical" gonadotropin cycle can cost in excess of $1,500 in drug alone.

Gonadotropin therapy is usually begun within the first few days of the menstrual cycle and requires daily dosing for approximately eight to 10 days.

It is important to inform your physician or nurse clinician of your intentions to begin a treatment cycle prior to your menstrual period so you can have the appropriate medications on hand. HCG may then be given to trigger the maturation and release of the egg from the ovary.

After ovulation is triggered, HCG may again be given to maintain progesterone secretion in the luteal phase (the two week interval after ovulation).

Although no guarantee can be made that ovulation or pregnancy will ensue, the success rate is good (approximately 17 to 20 percent in most cycles).

Risks

There are four major complications of therapy.

• Hyperstimulation with ovarian enlargement: This can cause abdominal distention, abdominal discomfort, and 5 to 10 pounds in weight gain. Treatment is usually conservative, but if severe, hospitalization may be necessary (1 percent). Most of these side effects will subside in time, when the use of the drug is stopped. Although this is a significant problem, it occurs with low frequency.
• Multiple pregnancy (approximately 24 percent of the pregnancies): The vast majority of multiple pregnancies are twins, but there are occasionally triplets or more (approximately 3 percent of the pregnancies). Unfortunately, even with optimal monitoring, multiple pregnancy cannot be avoided completely.
• Premature release of the eggs prior to the time of insemination
• Poor ovarian response to the medication can result in too few or no developing eggs. A poor response may be due to several factors:
  • Inadequate medication: Your recommended dose may not be high enough to adequately stimulate follicular growth. Starting with higher doses on your first cycle increases your risk for complications. After reviewing your chart appropriate dose adjustments will be made.
  • Age: As women age there is a decline in the responsiveness of the ovaries to medications. This is often difficult to deal with from an emotional perspective. Many patients will choose to try donor eggs as an alternative.
  • Timing: Sometimes despite doing everything right there is not a good response to medication. Each cycle can be quite different.

For these reasons, the cycle may be canceled. These cancellations occur more commonly in the first cycle, but may occur with subsequent cycles as well. They may be related to the dose of the medications and can often be remedied by adjusting medication regimens.

Accordingly, every effort will be made to tailor doses to each patient.

Monitoring

A few days after therapy is begun, frequent monitoring by ultrasound or estrogen measurements will begin.

Ultrasound utilizes a machine that sends out high frequency sound waves which produce an image on a screen of the follicles (each of which contains a single egg) in the ovary.

All ultrasounds in our clinic are done with a vaginal transducer and do not require a full bladder. They are performed by the members of the monitoring team including the physicians and nurses. Estrogen monitoring involves obtaining a blood sample.

When monitoring begins, clinic visits may be every few days or daily depending on your cycle progression. As ovulation draws near, daily visits are often necessary.

For monitoring, patients are requested to be at the Fertility Clinic at their scheduled time (usually between 7:30 a.m. and 9 a.m.) for registration (including weekends) and drawing of a blood sample (usually only gonadotropin treated patients).

Our patient load is variable and unfortunately waiting time can not be avoided. We recommend reading material or other distractions to help pass the time.

The dosages of your medication are individualized based on your situation. Dosage (number of amps/vials of gonadotropins) may vary from day to day and cycle to cycle. You will receive instructions regarding your dosage at each monitoring visit. Occasionally the schedule may have to be changed after additional information (estrogen levels) is obtained.

Estrogen levels are measured daily and the information is available around 3 to 4 p.m. For this reason, we ask that you provide us with a phone number where you can be reached in the afternoon (3 to 5 p.m.) during your treatment cycle.

It is imperative that an individual or location be available to give an intramuscular injection every treatment day at the times indicated by the monitoring team for both gonadotropin and hCG injections.

Release

Once your follicles have reached the sizes that are consistent with mature follicles you will be given "release" instructions. You will discontinue using any injectable medications including gonadotropins and Lupron (Clomid patients will have completed their oral medications already).

A dose and time for HCG injection will also be given to you. The time and dose will vary depending on the treatment you are receiving.

The term release refers to the release of the oocyte from the wall of the follicle and the expulsion of the oocyte from the follicle. The timing of HCG to insemination or intercourse is longer than the interval used with in vitro fertilization and oocyte retrieval since the retrieval must be accomplished before the oocyte leaves the ovary.

In general, controlled ovarian hyperstimulation patients will take HCG 36 to 40 hours before the introduction of sperm. If you are not doing an insemination we will assist you in administering your injection while you are in the clinic.

Patients having an intrauterine insemination will usually be instructed to take their HCG at 6 p.m.

Other Information

Mixing Drugs and Injections

Read additional information about mixing drugs and administering injections.

Cost of Treatment

See our cost estimates for approximate expenses for procedures.

Abstinence During COH Cycles

We recommend no changes in sexual activity, but do advise the following guideline: for patients having an insemination: intercourse the night of HCG with abstinence the following day. This allows the sperm count to return to normal for the day of insemination.

Patients who have histories of low sperm counts or motility should ask the monitoring physicians about how to modify the above instructions for them. For patients not having an insemination, the monitoring physician will advise you on optimal timing of intercourse.

Persistent Ovarian Cysts

Controlled ovarian hyperstimulation cycles usually are not consecutive cycles. It is usually necessary to skip a cycle due to persistent ovarian cysts.

These cysts resolve on their own, but may take an additional cycle. They do not alter the success rate in subsequent cycles.

Post Treatment Menses

Patients are asked to call the nurse clinician with the onset of menses following each treatment cycle if pregnancy does not occur.

Similarly, if no period ensues by 18 days after insemination, you should also call to schedule a pregnancy test. A member of the monitoring team can be reached at 919-572-HOPE for further scheduling.