FSH Ovulation Induction
Gonadotropins, FSH and LH hormones, are secreted by the pituitary gland and control the process of ovulation. The currently available brand names of FSH preparations are: Follistim, Gonal-F and Bravelle. Menopur is the brand name of an FSH/LH preparation.
Gonadotropins are used primarily in two groups of women:
- those who do not ovulate regularly and/or have failed to ovulate and/or conceive with oral agents such as clomiphene and letrazole;
- women who ovulate on their own but may benefit from simultaneous ovulation of multiple eggs and the accompanying enhanced hormonal environment.
In most cases, gonadotropin ovulation induction is combined with an intrauterine insemination (IUI). IUI places a much larger number of sperm inside the uterine cavity than usually get there. Current California regulations require that male partners be tested for HIV (causative agent of AIDS), Hepatitis B and C, HTLV and syphilis (RPR) before their sperm can be used for insemination.
FSH and LH are natural hormones secreted by the pituitary gland. Their use is generally safe but requires experience and close monitoring. In the natural cycle, without any medications, a woman ovulates just one egg under the influence of her own gonadotropins.
Like all medications, gonadotropins have side effects (ASRM Fact Sheet: Risks of Gonadotropins). Ovarian enlargement, known as OHSS (ovarian hyper-stimulation syndrome) is the most common potentially serious complication of gonadotropin use. Mild forms of OHSS can usually be treated by bedrest at home, but in severe cases, intravenous fluids, drainage of excess fluid from the abdomen and even hospitalization might be necessary. Close monitoring of your response with blood tests and ultrasound helps avoid severe OHSS (How to Avoid OHSS).
The risk of multiple births after gonadotropins is approximately 20%, with the majority being twins (The Dilemma of Twins). A few older reports have linked the use of fertility medications, such as gonadotropins and clomiphene, with possible increased risk of developing ovarian tumors, including cancer of the ovary, later in life although the larger recent reports have not supported this association.
You may experience bleeding, pain or redness at the injection sites. Warm soaks with wet washcloths may help alleviate the discomfort. Some women report fatigue and/or headaches. If you have a headache while on gonadotropins, you can take acetaminophen (Tylenol) but we do not recommend full strength of aspirin.
In some cases gonadotropins are used in conjunction with an oral medication, clomiphene citrate (Clomid, Serophene). In other cases, gonadotropins may be combined with an injectable medications, leuprolide acetate (Lupron) or ganirelix/cetrorelix which are used to prevent premature ovulation.
Several days before the first treatment cycle, you and your partner or (designee) need to learn the injection technique. It is not a difficult procedure and it can be mastered after a few practice injections under supervision by one of our nurses. At the time of the injection class the nurse will answer any additional questions you may have.
Gonadotropins are usually started 2-5 days after the onset of menses. If your period starts before 4:00 p.m., call our office at (510) 649-0440 in order to schedule a baseline ultrasound. If your period starts after 4:00 p.m., call the office the next day. On weekends and holidays, leave a message on the answering machine. The first day of your period is defined by onset of regular flow, not just spotting. Prior to starting the injections, a baseline ultrasound is done to detect any pre-existing ovarian cysts. A vaginal probe is used so a full bladder is not necessary. Small simple cysts are common and they usually resolve on their own. However, if a cyst is found, the treatment cycle may be delayed.
At the baseline ultrasound, the nurse will dispense injection supplies such as syringes, extra needles, and alcohol wipes. You will be instructed when to begin your injections. Response to gonadotropins varies greatly from woman to woman. The particular protocol, start date, dosage and length of treatment will be tailored specifically for you. Please make sure we have your current phone numbers as frequent communication is necessary.
After 2-4 days of injections you return for a blood test (Estradiol) and possibly an ultrasound. Estradiol hormone is secreted by the growing follicles. The blood is drawn in our office at 2999 Regent Street, #101-A between 8:30 and 10:00 AM Monday through Friday. Ultrasounds are generally scheduled between 9:00 and 10:30 AM. On Saturdays, visits are between 9:00 and 10:30 AM. In the afternoon of the days on which you have a blood test, we call you with instructions about the dose of gonadotropins for that evening and the following day as well as the time of your next blood test and/or ultrasound. If you have any questions about your instructions, please call our office at (510) 649-0440.
Eggs are contained within follicles (fluid-filled sacs) which are readily seen with ultrasound. Ultrasound is harmless to you and the developing eggs. Depending on the growth of the follicles and the estradiol levels, variable doses of gonadotropins are given for a total of 7-10 days. When the ultrasounds and blood tests indicate that the follicles are mature, a single injection of hCG (human chorionic gonadotropin) is given to trigger ovulation. Based on when you receive your HCG injection, you will be given instructions about the timing of IUI or intercourse. HCG is a natural hormone similar to LH hormone which triggers ovulation in a spontaneous cycle. The preferred brands of hCG are Ovidrel and Novarel. Novarel needs to be mixed in our office before use.
Following insemination many patients receive vaginal progesterone. On progesterone your menses may be delayed even in the absence of pregnancy. If you are not pregnant, your period is expected about 14 days after the day of insemination. If your period is more than 2-3 days late, please call the office to schedule a quantitative HCG before stopping progesterone supplementation.