GONADOTROPIN INJECTION THERAPY (SUPEROVULATION)

Injectable gonadotropins have been utilized for over 30 years; numerous preparations are available, some in convenient pen-like gadget fitted with a tiny short needle and can be easily self administered. These are potent hormones, and you must be carefully monitored by an experienced fertility specialist while you are taking them.

Am I a candidate for gonadotropin therapy?

You are a candidate for gonadotropin therapy if you have normal or low day 3 Follicle Stimulating Hormone (FSH), normal Estradiol levels and

• You fail to ovulate with Clomiphene Citrate (Clomid; Serophene) – Clomiphene resistance
• Ovulate but fail to conceive with Clomiphene
• You have thin uterine lining while undergoing Clomiphene treatment
• You have unexplained infertility
• Your husband is diagnosed with moderate decrease in sperm count; in such cases gonadotropin therapy is coupled with intrauterine insemination(IUI)

How is gonadotropin treatment monitored?

• The treatment is expensive and labor intensive, requiring frequent monitoring by blood estrogen level and ultrasound to measure the number and size of the follicles (which contain the eggs) and thickness of the lining of the uterus.
• In general, you can expect an ultrasound and estrogen level on day 3 of your cycle before you are cleared for treatment. Sometimes an ovarian cyst can be present which may result in cancellation of the stimulation cycle.
• Your doctor will determine the type and dose of the gonadotropins to be utilized and you will undergo daily injections of the hormone for about 10 days. In the course of treatment you will have several ultrasounds and estrogen level measurements until your doctor determines that you are ready for ovulation.
• Generally speaking, when the medication is given to women who do not ovulate for the purpose of achieving ovulation, a single follicle is preferable to avoid multiple pregnancies.
• In cases of unexplained infertility or when utilized in conjunction with intrauterine insemination for male factor, 2-4 follicles may be optimal.
• When the ultrasound demonstrates the largest follicle to measure between 16-20 mm in size and the thickness of the uterine lining is about 8 mm, HCG is administered to bring about the final maturation and release of the eggs.
• If intrauterine insemination (IUI) is planned, it will be scheduled to take place at the time of expected ovulation, 24-36 hours after the HCG shot.
• After ovulation your doctor may decide to treat you with progesterone suppositories or pills to improve the likelihood of successful implantation. A pregnancy test is performed 14 days after ovulation and if pregnant you may be instructed to continue with progesterone treatment 6-8 more weeks.

What is the appropriate type and amount of medication for me?

• Traditionally, a dose 75 international units (IU) of gonadotropin (FSH, HMG) is given daily and is increased every 5-6 days until the desired response is achieved; this approach is usually associated with a cumulative pregnancy rate of 60 - 80% after 6 cycles of treatment but also a high rate of multiple pregnancy.
• More recently a gentler stimulation has been advocated utilizing lower gonadotropin dosage, and slower rate of increase in the medication dose. This treatment is more likely to result in the development of a single follicle (egg) thus avoiding multiple pregnancy and severe complications such as Ovarian Hyperstimulation Syndrome (OHSS).
• Women diagnosed with hypothalamic cause for their abnormal ovulation, usually have low levels of FSH and LH and will benefit from treatment with gonadotropin preparation containing both FSH and LH (i.e. Pergonal, Humegon, Menopur, Repronex)
• Obese patients may not respond very well to this treatment (poor responders) and sometimes metformin is added to improve the likelihood of successful ovulation.
• In some patients undergoing gonadotropin treatment ovulation may occur spontaneously and prematurely before the eggs are completely ready for ovulation; for this reason treatment with medication to block premature ovulation (GNRH agonists or antagonists) has been advocated by some investigators

What will happen if I develop too many follicles?

• Your doctor may decide to cancel the treatment cycle if you develop too many( more then 3-4) follicles to minimize the risk of multiple pregnancy and risks associated with enlarged ovaries; The HCG injection can be withheld to prevent ovulation from occurring.
• Sometimes the medication is stopped for few days (coasting) to allow the smaller eggs to disappear before HCG is given for ovulation. Some doctors use a medication to slow the development of smaller eggs (GnRH antagonist) or give a smaller dose of the HCG medication to decrease the risk of ovarian hyperstimulation.
• Another approach is to convert the ovulation induction cycle to In Vitro Fertilization (IVF); here the eggs are removed from the woman and fertilized with her husband’s sperm in the laboratory. Two of the resulting embryos can then be transferred significantly reducing the risk of multiple pregnancies.

What is the success rate of gonadotropin therapy?

• 60% cumulative pregnancy rate after 6 cycles of treatment in patients with PCOS
• The treatment is most successful in women who fail to ovulate with Clomiphene therapy (Clomiphene resistant).
• At BocaFertility we have experienced a pregnancy rate of 24% per cycle and a delivery rate of 18 % per cycle for all patients treated with gonadotropins.

What are the complications of gonadotropin therapy?

• Cancellation of the cycle because of poor response to gonadotropins; in this situation, adding metformin can be helpful
• Multiple pregnancy resulting from the development of too many eggs
• Ovarian Hyperstimulation Syndrome (OHSS) is a potentially life threatening complication resulting from overstimulation of the ovaries, requiring hospitalization and aggressive treatment. The condition is associated with ovarian enlargement, torsion (twisting) of the ovaries, weight gain, accumulation of abdominal fluid, decrease of blood volume and low blood pressure. OHSS may occur even with very mild stimulation and fortunately the severe form of Ovarian Hyperstimulation Syndrome is uncommon occurring in only about 1% of patients.