Artificial Insemination
Ovulation Induction with Clomiphene Citrate
Ovulation Induction with Gonadotropin
Progesterone Suppositories
Your Daily Routine During Ovulation Induction
Ovulation Indudction Using Clomiphene Citrate
Clomiphene has been widely used treatment to induce and regulate ovulation. Clomiphene is typically taken orally on either days 3-7 or days 5-9 of the menstrual cycle.
Clomiphene works on the hypothalamus, a small gland at the base of the brain. Clomiphene stimulates the production of gonadotropin releasing hormone(GnRH) which stimulates the pituitary gland to produce follicle stimulating hormone (FSH). FSH stimulates the development of the ovarian follicles which contain the eggs.
It is up to the physician to determine how Clomid cycles should be monitored. Early in treatment, it is common for patients to take clomiphene for 5 days each month and return for a follow-up examination after 3 months of therapy if they do not become pregnant. Sometimes, the physician may wish to monitor the cycles more closely. A combination of ovulation predictor kits and/or ultrasounds may be used to determine the number of follicles present, their rate of growth, and to help pinpoint the time of ovulation. If clomiphene has not produced pregnancy over 6 months alternate modes of treatment should be pursued.
Clomiphene has been used for many years and is considered a safe and effective medication. It does, however, have risks and occasionally there may be side-effects. Clomiphene side-effects can include stomach and bowel upset, dizziness , hot flashes, depression, or breast discomfort. In a few patients, Clomiphene can cause enlargement of the ovary and if this occurs they are advised to seek an internal examination by their physician. Clomid is associated with a 10% incidence of multiple births, but the vast majority of these multiple births are twins and there is no increased risk of birth defects from clomiphene.
Ovulation Induction with Gonadotropin (FSH + LH) or FSH.
As many as 40% of infertile women have some type of ovulation dysfunction. Gonadotropin can be used to stimulate ovulation. These medications work directly on the ovaries to stimulate growth of follicles. The follicles are"blisters" that form on the outside of the ovaries, filled with fluid. An egg is suspended in the fluid of each follicle. We hope to stimulate more eggs to mature than would normally by using these medications. Your doctor will decide what form of gonadotropin for your stimulation (Gonal-F, Follistim, Repronex). Gonadotropins are given by injection (intramuscular-IM or subcutaneous-SC). Our office staff will be an important contact person during your cycle. Our specialized physicians and staff will work together to give you optimal care.
(Injections - Medical staff are available to give daily injections at a directed time or we can teach the patient or spouse to give injections if needed).
HOW THE RESPONSE TO GONADOTROPIN TREATMENT IS MONITORED
Patients on these medications must be monitored carefully during the cycle. The response to gonadotropin is monitored by two techniques: (1) measurement of the blood concentration of estradiol-E2 and (2) measurement of the numbers and sizes of the ovarian follicles by vaginal ultrasound. Estradiol is excreted into the blood by the growing follicles as they respond to the medication. Follicle size and number allows us to visualize the ovarian response directly. The daily dose of Gonadotropin, as well as the number of days that the drug will be given, is ultimately determined by reviewing the ultrasound findings and estradiol measurements. The dose may vary from an average of 1 to 4 ampules per day. Both the dose and the number of days of administration depend upon individual response of the patient. When follicles are mature, as confirmed by estradiol measurements and ultrasound, Between day 9 - day 12, HCG is given to induce ovulation. Ovulation occurs between 34-42 hours after the HCG injection.
Timed Intercourse or Intra Uterine Insemination (IUI) – Follow your doctor’s instructions.
Insemination - Be at center at the specified appointment time. If using your husbands sperm, he will have an Andrology appointment one hour before yours. It is during this time that the sperm is washed and prepared for intra-uterine insemination. If using donor sperm, you will be given one appointment time. The lab will prepare your sample. You may have an ultrasound this day to determine if a second insemination is needed.
SIDE EFFECTS AND RISKS OF GONADOTROPIN
Common side effects of these medications include discomfort at the site of the injection, a feeling of discomfort or fullness in the lower abdomen, bloating, headache or fatigue. If you develop discomfort in the area of the injection this can be handled by simply massaging the area or applying heat on it. All other side effects are likely to resolve spontaneously in a matter of days. Other less common side effects include hot flashes and mood swings. The most significant side effects include multiple gestation and ovarian hyperstimulation. Multiple gestation (more than 1 fetus) is a risk. The vast majority of these pregnancies are twins but more than two fetuses can sometimes develop. Ovarian hyperstimulation occurs because of the effects of Gonadotropin on the ovary. After the HCG is given and ovulation occurs, the ovaries will frequently enlarge. If pregnancy results the ovarian enlargement may persist for up to 6 weeks. In general, the symptoms associated with ovarian hyperstimulation are quite mild and may include lower abdominal pain or heaviness and bloating. Sometimes shortness of breath may develop beginning approximately 5 to 7 days after the HCG is given. It is extremely uncommon for hyperstimulation to result in any severe medical problem or in hospitalization.
If you have concerning symptoms, please call us at (714-771-7800).
If your physician has prescribed progesterone suppositories for you to use, he will give you a prescription for them. The suppositories supply your body with additional progesterone. Progesterone is a hormone that occurs naturally at this time of your cycle and is secreted by the corpus luteum. The corpus luteum is vital to the maintenance of a pregnancy. Current feeling suggests that progesterone provides support for the endometrium (uterine lining). The corpus luteum secretes progesterone until about the tenth week of pregnancy, at which time the placenta is able to produce sufficient progesterone. The suppositories prevent a progesterone deficiency that could occur after ovulation (luteal phase defect). If your physician feels injections of progesterone are needed, you will be instructed as to amount and timing of dose. You should begin using the suppositories two to three days after your insemination. Your physician will instruct you when to start using them. DO NOT STOP YOUR SUPPOSITORIES unless instructed to do so by our staff. This is regardless of bleeding, spotting, or cramping. If you do start bleeding, cramping, or spotting, call us at (714-771-7800).
Your Daily Routine During Ovulation Induction
What happens on each day is determined by the day of your cycle and the response of your ovaries. To count your cycle day, count the first day of your period as Day 1. If you have spotting or a very light flow before your period, count Day 1 as your first day of real flow.
Cycle day 1:
Call our office for your first visit on Day 3.
Cycle day 3:
8:00 am for blood draw (estrogen level) and follicle scan. 4:00 pm start injections with GONADOTROPIN.
Cycle day 5, 7 & 9:
8:00 am for blood draw (estrogen level) and follicle scan. 4:00 pm start injections with GONADOTROPIN.
Cycle day 10,11:
8:00 am for blood draw (estrogen level) and follicle scan. 4:00 pm start injections with GONADOTROPIN.
Between days 8 & 11:
8:00 am for blood draw (estrogen level) and follicle scan. You will receive an injection of HCG usually in the evening. This induces ovulation (release of the egg from the follicle).
If your period has not started 14 days after insemination call us to arrange for a pregnancy test.
You may be able to skip some days as directed by your doctor.
Always check in with receptionist for your next appointment.
For more information you may send us Email at ivf-lab@sbcglobal.net