With gonadotropin therapy, you usually start the medication on the third day of the menstrual cycle, with day 1 representing the first day of the menstrual bleeding. The medication is continued for an average of 10 days. During this period, ultrasound examinations of the ovaries are regularly performed to monitor the growth of the follicles. The follicle is the structure within which the human egg, or oocyte, develops. When it is determined by ultrasound that the follicles have reached maturity, the final trigger of ovulation, human chorionic gonadotropin or hCG, is given to release the eggs. Because this process involves the release of multiple eggs, more than one egg may be picked up by the fallopian tube, and fertilized. If all of these implant, it would result in a multiple gestation, i.e. twins, triplets, or even more.
There is another ovulation induction regimen that can be utilized by women who are experiencing hypothalamic-pituitary dysfunction. This involves utilizing a hormone known as GnRH. This hormone acts on the pituitary gland causing it to produce LH and FSH. This medication is either given in the vein (intravenously) or under the skin via a pump. The pump, however, is cumbersome and seldom used in the United States.
Polycystic ovarian syndrome
This is a more common syndrome in which the brain can produce FSH and LH, but the ovaries do not respond normally to these hormones, and therefore do not develop a mature egg each month. Doctors call the inability to produce an egg each month "chronic anovulation". Polycystic ovarian syndrome usually occurs in women who are overweight and have excess body hair, oily skin, and sometimes acne. Such women will not produce the ovarian hormones estrogen and progesterone which are necessary for the uterus to produce a menstrual period each month. As a result, they have long and irregular menstrual cycles or no menstrual periods whatsoever. One of the recent advances in polycystic ovarian syndrome is the finding that some of the women with this syndrome have a high insulin level in their blood, a condition known as hyperinsulinemia. This is due to an inability of the body's insulin to work effectively (called "insulin resistance").
In women who have polycystic ovarian syndrome, an oral medication called clomiphene citrate is sometimes given to enhance ovulation. This medication acts on the brain resulting in the release of FSH, which in turn acts on the ovary resulting in the development of one or more follicles (see above). Clomiphene citrate is usually started on day three to five of the menstrual cycle and continued for 5 to 7 days. The usual therapy starts with one 50 mg pill daily for five days starting on the third day of the menstrual cycle. Ovulation occurs 5 to 10 days after taking the last pill. If the woman does not have a menstrual period after taking clomiphene citrate, she is either pregnant or did not ovulate. If she did not ovulate, the dose of the medication is increased to two pills daily for 5 days in a later menstrual cycle. This may be continued to a maximum daily dose of 250 milligrams.
Determining if ovulation has occured can sometimes be tricky. This may either be done by performing an ultrasound around mid-cycle, and observing that one or more follicles are developing, or by measuring blood progesterone level a week after the presumed date of ovulation. Body temperature charts which show an elevation of 0.5 degrees Fahrenheit or more for several days can also suggest that ovulation has occurred. In addition, ovulation prediction kits utilizing urine specimens can accurately determine ovulation. Because only approximately 50 percent of patients with polycystic ovarian syndrome eventually ovulate, these patients sometimes have to resort to more intense therapy utilizing injectable gonadotropins. As mentioned above, such therapy involves utilizing injectable rather than oral medications, and is significantly more expensive. Several other forms of therapy are occasionally utilized in women who fail to ovulate following clomiphene citrate or gonadotropins. Metformin is occasionally used in women with insulin resistance. Occasionally, steroids are used to lower the increased male hormones that are sometimes encountered in women with polycystic ovarian syndrome.
Endocrine (glandular) disorders