Ovulation Induction

What is ovulation induction?

Ovulation induction is a treatment protocol designed to increase the number of eggs that a woman ovulates in a cycle. Whereas ovarian stimulation for IVF and ICSI aims to produce many eggs for collection (in women who are usually ovulating), ovulation induction aims to stimulate just a couple of eggs in women who are not ovulating normally. The treatment is most often used in women with polycystic ovarian syndrome (PCOS), a condition characterised by multiple ovarian cysts, irregular or absent periods, and high levels of male (androgen) hormones.

In an unstimulated cycle (natural cycle), a woman typically ovulates a single egg each month. Very rarely, a woman’s ovaries may spontaneously release 2 eggs in any given cycle, which can lead to non-identical twins. In a stimulated ovulation cycle, the aim is to achieve multifollicular growth and ovulation – the ovulation of multiple eggs in one cycle. When several eggs are ovulated at once, the likelihood of conception often increases dramatically.

The treatment is a course of fertility hormones to stimulate the ovaries to produce a mature follicle, and then timed intercourse or Artificial Insemination (AI) / Intrauterine Insemination (IUI) to coincide with ovulation. But, because women with PCOS often react very sensitively to fertility drugs, there is a real risk of multiple follicle production and multiple pregnancies. Regular monitoring with ultrasound and hormone measurements is therefore necessary to ensure only one or two follicles are developing.

Ovulation induction may be performed using orally ingested medications or injectable medications, and is normally combined with intrauterine insemination (IUI). Patients who may benefit from ovulation induction/IUI are couples with unexplained infertility, PCOS, endometriosis, and ovarian dysfunction. To be a candidate for ovulation induction you must have a normal uterine cavity, at least one normal fallopian tube, and your partner must have a normal sperm count. As one of the leading fertility centres in South Africa, Medfem Fertility Clinic has been successfully treating candidate patients with ovulation induction in a responsible and effective manner. This means we employ safe but highly efficient stimulation protocols to achieve high success rates while minimising risks of higher-order multiple gestations (triplets or more).

Who is ovulation induction therapy for?

Ovulation induction might benefit you if:

• You have ovulation problems that have not responded to simpler medications
  (such as clomiphene tablets).
• You have unexplained infertility and wish to try ovulation induction therapy in order to increase the number of eggs produced in each cycle – thus increasing the chance of conception.

How do injectable fertility drugs work?

During a natural menstrual cycle, you release luteinizing hormone (LH) and follicle stimulating hormone (FSH) from the pituitary gland. These hormones stimulate the growth of a follicle – the fluid space in the ovary where the egg grows. Although several follicles grow each month, in a natural cycle only one becomes mature enough to ovulate its egg.

In ovulation induction, women who do not ovulate at all take gonadotropins (forms of FSH and/or LH) by injection to stimulate the growth of one or more eggs. During your treatment, your doctor will carefully monitor you with blood tests and ultrasounds.

What should I expect during treatment?

Your treatment usually starts on day three or four of your menstrual cycle and lasts approximately eight to ten days. A nurse will teach you and your partner how to give the injections at home. You will likely have two to four clinic appointments for blood tests and/or vaginal ultrasounds to monitor your response and adjust your medication dose.

Your appointments will be scheduled between 7:30 am and 9:00 am, and will become more frequent toward the time of ovulation. Although each woman is different, this is an example of a treatment cycle schedule:

When the blood tests and ultrasounds indicate one to four mature follicles, one of our doctors will prescribe a second medication (hCG) to trigger ovulation. You will usually ovulate 36 to 48 hours after this final injection.

Approximately 24 to 36 hours after the hCG injection, you will have an intrauterine insemination (IUI). This is accomplished by inserting a specially prepared sample of your partner’s sperm through the cervix and placing it near the top of your uterus where it has the best chance of fertilising an egg. The procedure takes only a few minutes and should be relatively painless.

How successful is ovulation induction?

Typically, 20% to 25% of healthy, fertile couples become pregnant each month they try. In contrast, the pregnancy rate among couples with infertility is usually between 2% to 10% per month. Ovulation induction usually produces pregnancy rates of 10% to 20% per cycle, depending on a woman’s age, diagnosis, and duration of infertility.

Among women with certain ovulatory disorders, ovulation induction treatment may even restore normal fertility rates of 20% to 25% per month. If you do not become pregnant within the first three treatment cycles we will discuss other treatment options with you.

How do I know if I’m ovulating?

If you are having regular menstrual cycles, you are almost certainly ovulating (regardless of the length of the cycle). To estimate the day of ovulation, subtract 14 days from your average cycle length. So if your cycles are 28 days, you will ovulate on day 14, but if your cycles are shorter e.g. 25 days, by subtracting 14 days, you will ovulate on day 11.

There are a number of signs to look for when trying to detect your ovulation time.

Mucus: you might notice a chance in your vaginal secretions about the time you are ready to ovulate. Throughout the menstrual cycle, the cervix or opening of the uterus produces mucus. Just before ovulation the mucus becomes clear and slippery and looks a little like raw egg white. This mucus helps the sperm to make its way up the vagina and through the cervix.

Pre-menstrual symptoms: The menstrual cycle is often associated with symptoms such as abdominal bloating, breast tenderness and mood changes. These symptoms can often be more pronounced in women who are having problems ovulating, such as those with PDCO or endometriosis.

Temperature: After ovulation your temperature increases and remains higher for the rest of the cycle. This is because your progesterone levels – which help prepare the uterus for implantation and pregnancy – increase with ovulation. You will need to take your temperature every morning. After two to three months of recording your temperature you will hopefully see a pattern and be able to determine your ovulation day. Usually the day before ovulation there is a dip in the temperature which represents the LH surge. This is a good time to have intercourse. It is recommended that you have intercourse three or four days prior and on the day of your ovulation day in order to maximise your likelihood of becoming pregnant.

Why am I not ovulating?

For the vast majority of women the reason they are not ovulating is because of confused hormonal signals from the body which means that ovulation cannot occur in the usual way.

Pituitary dysfunction is a term used to describe a group of disorders in which ovulation occurs on an infrequent basis. The term pituitary failure is used when ovulation fails to occur at all (anovulation) and there are no periods (amenorrhoea). While there are no specific symptoms of the disorder, there might be some associated features that are common to people have trouble conceiving. These can include:

• Amenorrhoea (lack of menstruation)
• Irregular menstrual cycles
• Infrequent menstruation
• Obesity
• Excessive weight loss
• Excessive weight gain
• Abnormal or excessive hair growth on the face and body
• Acne

The vast majority of people with ovulation issues experience amenorrohoea. Primary amenorrhoea occurs in girls under 16 who have not yet menstruated, and is usually due to a hormone deficiency. Secondary amenorrhoea occurs in women who have previously menstruated but have stopped for more than six months. This can coincide with:

• Being overweight: Being just 10 to 15% over your ideal body weights can contribute ot the risk of ovulation problems. Weight lost in women who do not ovulate will often cause the normal process to resume. Being overweight is also linked to PCOS.
• Polycystic ovarian syndrome: PCOS is a condition where eggs mature in the ovaries but are not released into the fallopian tubes and instead they remain in the ovaries and develop into cysts.
• Endometriosis: Endometriosis occurs when the tissue that normally lines the inside of the uterus grows in other places of your body where it doesn’t belong, such as on the ovaries, fallopian tubes and the outside surface of the uterus. Endometriosis found on the ovary can also grow larger and form cysts which can interfere with ovulation.
• Excessive exercise/being underweight: When a woman exercises heavily and particularly if her body weight is low (less than 20% of your ideal body weight, ovulation may stop. Ovulation can be restored by returning to moderate exercise and nutrition.
• Stress: Emotional and other stress such as bereavement can take a toll on a woman’s health and her fertility.
• Ovarian failure: This results in loss of egg supply from the ovary possibly as a result of early menopause.