Women undergoing IVF usually utilize injectable gonadotropins to enhance ovulation. In IVF, the gonadotropins produce multiple follicles, which, when they are mature, are aspirated via the vagina and fertilized in the laboratory. This allows production of multiple embryos, which later can be transferred to the fallopian tube or uterus, resulting hopefully in implantation and pregnancy. There are multiple strategies for IVF. Most of these utilize birth control pills followed by a medication known as GnRH-agonist available in United States under the trade name Lupron or Synarel. This medication puts a woman in a temporary menopause-like state allowing her physician to control the timing of ovulation. This is then followed by the use of the gonadotropins mentioned above. Because GnRH-agonists cause temporary menopause, they are oftentimes associated with hot flashes, vaginal dryness, memory changes, and headaches.

Similarly, ovulation induction is also utilized in egg donation, a process where a woman may produce multiple eggs to donate to another woman.

Success Rates of Ovulation Induction

Ovulation induction utilizing gonadotropins can result in a conception rate of around 80 to 90 percent in women with hypothalamic-pituitary dysfunction after six treatments cycles. In women with polycystic ovarian syndrome, pregnancy rates are slightly lower. Miscarriage rates are around 15 to 20 percent in patients with hypothalamic-pituitary dysfunction. They are higher in women with polycystic ovarian syndrome.

Success rates of women undergoing COH or IVF depend on a number of factors, including whether or not there is a sperm dysfunction in the male partner, or a disease of the fallopian tubes. However, the most important factor determining the success rate of ovulation induction remains the age of the female patient. This is due to a increased genetic abnormalities in a woman's eggs as she grows older. This fact is also reflected in the higher miscarriage rates that occur in older women. Currently most good IVF programs have an approximately 30 percent delivery rate following IVF, and 20 percent following COH.

Ovulation occurs in 80 percent of women with polycystic ovarian syndrome who are using clomiphene citrate (see above). However, as has been mentioned, only 40 to 50 percent of women will eventually conceive. The success rates are higher in women without any other fertility problem. Therefore, it is possible to reach a cumulative pregnancy rate of 75 percent in six months of the therapy. Most of those pregnancies occur in the first three months of the use of the medication, and very few occur after six months. As a result, the use of clomiphene citrate is usually limited to six months of therapy.

Side Effects of Ovulation Induction

Multiple pregnancy occurs in around five percent of patients taking clomiphene citrate. Very few patients will have more than twins. However, multiple pregnancy rates are higher in women taking gonadotropins, frequently reaching 20 to 30 percent. Triplets and higher order pregnancies occur in 2 to 3 percent or less of pregnancies following the use of gonadotropins.

By closely monitoring women, physicians may be able to detect the number of the developing follicles and therefore control to some degree the multiple pregnancy rate. Most women have to be counseled ahead of time about the risk of multiple pregnancy to not only the mother, but also the fetus. Multiple pregnancy fetuses are at risk of prematurity and possible long-term disability.

Clomiphene citrate and gonadotropins can result in symptoms related to ovarian enlargement. Abdominal distension and discomfort may occur as can breast tenderness. Occasionally, women taking clomiphene citrate experience hot flashes. Other side effects include headaches, visual disturbances, and mood swings.

Ovarian hyperstimulation syndrome is another side effect that a woman might experience. It is a very serious and potentially lethal disorder. The incidence of ovarian hyperstimulation syndrome, also known as OHSS, is less than 3 to 5 percent of patients undergoing ovulation induction. It is much less common following clomiphene citrate than gonadotropin use.

OHSS involves enlargement of the abdomen and and accumulation of fluid in the abdomen and pelvis. It also is associated with nausea, vomiting, and difficulty breathing. Rarely, serious complications involving the liver, the kidney, and the lungs may occur. Because of the seriousness of this disorder, it is far better to prevent the occurrence of this syndrome than managing its consequences. Therefore, careful monitoring with ultrasound examinations and blood tests is crucial in assessing the risk of patients undergoing ovulation induction.

Finally, there is still debate on whether prolonged use of ovulation induction agents results in an increased risk of ovarian and breast cancer, though such a risk is minimal in women who eventually conceive and deliver.

Conclusion

I hope that this discussion has been helpful in answering some of your questions regarding ovulation induction. I strongly recommend that you ask your physician about his or her qualifications and board certification prior to commencing therapy, and discuss with him or her any concerns you might have.

Dr. Fayek Nicholas Shamma, board certified in Obstetrics and Gynecology and in Reproductive Endocrinology and Infertility, is the Associate Director of Ann Arbor Reproductive Medicine Associates, the Toledo Fertility Center, and the Mid-Michigan Fertility Center. He is also an assistant professor at Michigan State University College of Human Medicine. Dr. Shamma trained in Obstetrics and Gynecology at Yale New Haven Hospital in New Haven, CT, where he also went on to do sub-specialty training in Reproductive Endocrinology and Infertility. In his practice, Dr. Shamma takes care of patients with a variety of infertility problems. He routinely performs ovulation induction and in-vitro fertilization. He also performs other types of assisted reproductive procedures, including the use of donor eggs or embryos, the injection of sperm into female eggs, and the use of gestational surrogacy. As an infertility surgeon, he also performs various corrective surgeries related to infertility.

Dr. Shamma has written many articles in professional journals on the topics of infertility and in-vitro fertilization. He has also presented several studies in the area of ovulation induction and in-vitro fertilization at major national and international medical meetings.

Copyright © Fayek Nicholas Shamma. Permission to republish granted to Pregnancy.org, LLC.