Ovarian Stimulation

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 facilitate 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 8-10%. 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 on cycle day 2, 3 or 4.

If your ultrasound is normal then you will start the medication and a follow-up ultrasound will be done around day 9-11 to measure the number and size of your follicles and the thickness of the uterine lining. Once you have a follicle that is likely to contain a mature egg we will provoke ovulation with an injection of HCG, and time your intrauterine insemination.

Ovarian Stimulation with gonadotropins (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 higher chance of pregnancy (generally between 10-15% 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 4 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 17mm in diameter you will be given an injection of hCG to provoke ovulation.

Intrauterine insemination (IUI)

This is a commonly used procedure for couples with mild male factor infertility or for couples with unexplained infertility. IUI increases the chances of achieving a pregnancy. IUI is best performed just prior to ovulation. 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 genital area thoroughly prior to producing a sample. Keep the closed sterile container 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 analyzed. 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 or no discomfort and takes a few minutes to perform. Patients are asked to rest for 5-10 minutes following this procedure. Following the insemination you can resume your normal activities immediately. Some mild cramping or spotting is not uncommon after this procedure.

Donor insemination (DI)

Donor insemination is a treatment option for couples when the male partner has no sperm (azoospermia) in the ejaculate and no sperm on testicular biopsy. It is also an alternative to higher forms of reproductive technologies such as IVF and ICSI, TESA or PESA. 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 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.