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Ovulation Induction with
Anti-estrogens
Ovulation Induction with
Gonadotropins
INTRODUCTION
In fertility care, our goal is to achieve a pregnancy while causing minimal
emotional, physical, and finatial impact on patients' lives. We always start
with the least intrusive treatment and if need be, progressively implement more
sophisticated methods of fertility treatments.
Treatment options are always described in detail and the decision on the type of
treatment which is to be implemented is reached according to patients' wishes.
Ultrasound tracking of a natural cycle
This is the most conservative fertility treatment, and is usually
reserved
for patients with mild male factor infertility undergoing intrauter insemination
(IUI) or patients undergoing IUI with donor sperm. It may occasionally also be
used by patients who are averse to using fertility medication to enhance their
fertility. In patients with mild male factor infertility undergoing IUI or
patients doing donor inseminations the per cycle chance of pregnancy is
generally around 10-15%. If you are undergoing ultrasound tracking of a natural
cycle, you should call us as soon as your menstruation starts to book an
ultrasound scan between cycle day 2 and 4. This scan is performed to exclude the
presence of ovarian cysts, and to verify that the uterine lining is thin.
Thereafter, ultrasound scans are performed around day 10-11 and than every 1-3
days according to the size of the dominant follicle During each follow-up
scan we will measure the number and the size of follicles and the thickness of
uterine lining. When one or more of your follicles reaches 18mm in diameter you
will be given an injection of hCG to provoke ovulation. We will then schedule
your IUI 36 hours after the injection is given.
Ovulation induction with anti-estrogens
This is the simplest ovarian stimulation
regimen. It is used as the
first
line treatment in patients with unexplained infertility or those with irregular
periods. By either decreasing the level of estrogen in your body or by blocking
your estrogen receptors you will produce more follicle stimulating hormone (FSH).
FSH directly stimulates your ovaries, and by increasing your level of FSH we can
increase the number of eggs you release at the time of ovulation. The advantages
of oral anti-estrogen medications such as clomiphene citrate (Clomid, Serophene)
or letrozole (Femara) include ease of use, low cost, and low risk of multiple
pregnancy (8% or less). When clomiphene citrate or letrozole are combined with
intrauterine insemination for couples with unexplained infertility the per cycle
chance of pregnancy is between 8-12%. Side effects may include hot flushes,
night sweats and mood changes such as irritability, anxiety or depression. Very
rarely clomiphene citrate may also be associated with visual disturbances. If
your treatment plan includes anti-estrogen medications then call us as soon as
your menstruation starts to book an ultrasound scan on cycle day 2 or 3. If your
baseline scan is normal then we will start the medication from day 3-7 of your
cycle, and a follow-up ultrasound scan will be scheduled day 9-11 to measure the
number and size of your follicles and the thickness of the uterine lining.
Thereafter, ultrasound scans may performed every 1-3 days until your lead
follicles reach 18mm in diameter. We will then provoke ovulation with an
injection of HCG, and time your intrauterine insemination precisely with the
time of expected ovulation. If there is no menstrual bleeding 14 days after the
hCG injection you should do a home pregnancy test and call us with the result.
Alternatively, if your menstruation starts, call us to arrange for another
baseline scan/treatment cycle.
Ovulation induction with gonadotropins (Injections of FSH)
This is a second line treatment. It is used primarily for patients who
do
not ovulate in response to anti-estrogens, or couples who have already tried
oral medications but have not conceived. By directly stimulating the ovary with
FSH substantial numbers of follicles may be supported to grow. This can then
result in the release of multiple mature eggs at the time of ovulation. The
advantage of FSH injections is the high chance of pregnancy (generally between
15-20% per cycle for couples with unexplained infertility, and possibly higher
for women with irregular menstrual cycles). The disadvantages of FSH injections
include need to learn and perform daily self-injections, the need for frequent
monitoring, the cost of the medication and the risk of multiple pregnancy (as
high as 30%). Side effects are the result of a multiple follicular development
and may include irritability, bloating or lower abdominal tenderness. If you are
prescribed this treatment you should call us as soon as your menstruation starts
to book an ultrasound scan between day 2 and day 3 of your menstrual cycle. The
purpose of this scan is to exclude the presence of ovarian cysts. If there are
no cysts you will either start taking the FSH injections directly, or we may
first initiate treatment with an anti-estrogen (letrozole) and then overlap that
treatment with your FSH injections. The dose of injections depends on your age,
diagnosis and response to medications in previous treatment cycles. Regular
follow-up ultrasound scans will then be done to check your response to
medication. We will measure the number and the size of follicles and the
thickness of the uterine lining. When one or more of your follicles reaches 18mm
in diameter you will be given an injection of hCG to provoke ovulation. If there
is no menstrual bleeding fourteen days after the hCG injection was given you
should do a home pregnancy test and call us with result. If the test is
positive, we will arrange a blood pregnancy test and an ultrasound scan 2 weeks
later. If your menstruation unfortunately starts, call and arrange for a
baseline ultrasound scan. We usually advise patients, depending on their age and
response, to have 3-4 cycles of this treatment prior to considering test tube (IVF)
treatment.
Intrauterine insemination (IUI)
This is a commonly used procedure for couples with mild male factor
infertility,
for couples with unexplained infertility, or for women undergoing treatment for
ovulatory dysfunction. IUI increases the chances of achieving a pregnancy. IUI
is best performed just prior to ovulation, or approximately 36 hours after hCG
injection. At the time of hCG administration you will be given an appointment
for your IUI. Unless otherwise advised, you should refrain from sexual
intercourse between the time of hCG injection and insemination. Your IUI sample
should be produced into a sterile container labeled with your name. Containers
are available either from our centre or from your local pharmacy (ask for a
sterile urine container). For couples where religious restrictions prohibit
semen samples produced by masturbation, we may be able to provide a special
collection condom. Wash your hands and penis thoroughly prior to producing a
sample. Keep a sample well wrapped in a cloth close to your body while
transporting it. If it takes longer than 1 hour to travel from your home to our
centre then we advise you to produce the semen sample at our centre. When you
bring in your sample, it will be identified and analysed. Thereafter, the semen
sample is washed, and the best spermatozoa are isolated and mixed in a culture
medium. The sample is placed into a catheter and the catheter is then introduced
into your uterus. The procedure for insemination is similar to a standard
speculum examination. A speculum is introduced into the vagina and the neck of
the womb (cervix) is visualized. An IUI catheter is then positioned through the
cervix into the uterus and the semen sample is slowly injected into the womb.
The procedure causes very little discomfort and takes approximately 10 minutes
to perform. Patients are asked to stay in the bed for 15 minutes following this
procedure. Following the insemination you can resume your normal activities
immediately. Some vaginal spotting is not uncommon after this procedure.
Donor insemination is the only treatment option
for couples where
the
male partner has no sperm (azoospermia) in the ejaculate and no sperm could be
found on testicular biopsy. It is also a less complicated and less costly
alternative to higher forms of reproductive technologies such as IVF and ICSI,
TESA or PESA treatment for couples where the male partner has a very low sperm
count (oligoasthenospermia) or has been rendered sterile as a result of
vasectomy, testicular injury/surgery, genetic defects, or cancer therapy. Donor
insemination is also a treatment option for single women or same sex couples who
seek a pregnancy. We work with donor sperm obtained from internationally
respected sperm banks that meet the Health Canada criteria, which are among the
strictest in the world. Screening is performed on each donor before collecting
and freezing the sperm. The screening process includes a complete medical and
social history, a thorough family history, and intensive screening for sexually
transmitted or common genetic disorders. Potential donors are not accepted if
abnormalities are detected on any of the screening tests. Moreover, each frozen
specimen is quarantined and only released for use if the sperm donor remains
free of HIV and other infectious illnesses for at least six months after the
last sample was produced. Once you have decided on Donor insemination treatment,
you will meet with your doctor to discuss the selection of a donor and your
individualized treatment plan. We will also initiate a standard fertility
work-up as well as screening for sexually transmitted diseases. Prospective
donor insemination recipients and their partners will also be asked to meet with
a psychologist to ensure that you are well prepared to initiate treatment. You
will then be provided with donor selection information to assist you in finding
a suitable and personalized match. After the donor is chosen you will be ready
to start your treatment. An average of 50 to 60% of women become pregnant
following 6 months of donor insemination treatment.