Gonadotropins are Injectable Fertility Medication Used for Super Ovulation

Injectable gonadotropins have been utilized for over 30 years. There are numerous preparations available. Some come in pen-like form with a tiny short needle that can be self-administered easily. These are potent hormones, and careful monitoring by an infertility specialist while taking these medications is required.

Candidates for gonadotropin therapy include patients that do not ovulate on clomiphene citrate (Clomid, Serophene). In this case, you would be considered a clomiphene-resistant patient. Other situations where you may be a candidate for gonadotropin therapy would be in conjunction with ovulation induction for inseminations or in vitro fertilization if you ovulate, but fail to conceive with clomiphene citrate; or if you have a thin uterine lining while undergoing clomiphene citrate treatment.

Ovulation Induction with Gonadotropins

The treatment with gonadotropins is expensive and labor intensive, requiring frequent monitoring by blood, estrogen levels, and ultrasound to measure the number and size of follicles (which contain the eggs) and thickness of the lining of the uterus. In general, you can expect an ultrasound on day 2, 3, or 4 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 gonadotropin to be utilized, and you will undergo daily injections for about 10 days. During 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 fertility medication is given to women for the purpose of achieving ovulation in women who do not ovulate, a low number of follicles are preferred to avoid multiple pregnancies. In cases of unexplained infertility, when used in conjunction with intrauterine insemination for male factor, 2-4 follicles may be optimal.

When an ultrasound demonstrates large follicles measuring between 16 mm and 20 mm in size and the thickness of the uterine lining is about 8 mm, hCG (Ovidrel) is administered to bring about the final maturation and release of the eggs. If intrauterine insemination is planned, it will be scheduled to take place at the time of expected ovulation 34-36 hours after the hCG (Ovidrel) shot. After ovulation, your doctor may decide to treat you with progesterone vaginally or pills to improve the likelihood of successful implantation.

A pregnancy test is performed 14 days after ovulation. If you are pregnant, you may be instructed to continue progesterone treatment for 6-8 more weeks. Your doctor may decide to cancel the treatment cycle if you develop too many follicles, in order to minimize the risk of multiple pregnancies and risks associated with enlarged ovaries. The hCG injection can be withheld to prevent ovulation from occurring.

Occasionally, follicular reduction is performed. This is a technique whereby the number of follicles can be reduced by placing a small needle into the follicles and removing some of the potential eggs. Sometimes, medication is stopped for a few days (coasting) to allow the smaller eggs to disappear before hCG is given for ovulation. Another approach is to convert the ovulation induction cycle to in vitro fertilization (IVF). The eggs are removed from the woman and are fertilized with the husband’s sperm in a laboratory. One or two of these embryos can then be transferred, significantly reducing the risk of multiple pregnancies.

Success Rate with Gonadotropin Stimulation

The likelihood of success with gonadotropin therapy depends on the reasons the patient is placed on gonadotropin therapy.

In general, pregnancy rates of approximately 25% per cycle are achieved with gonadotropins.

Complications of Gonadotropin Stimulation

Complications associated with gonadotropin therapy include multiple pregnancies resulting from development of too many eggs and ovarian hyperstimulation syndrome (OHSS).

OHSS is a potentially life-threatening complication resulting from overstimulation of the ovaries, and requires hospitalization and aggressive treatment. The condition is associated with ovarian enlargement, torsion of the ovaries, weight gain, accumulation of abdominal fluid, and decrease of blood volume. OHSS may occur with very mild stimulation.

Fortunately, severe OHSS is uncommon and occurs in only 1% of patients.