Ovulation Problems and Infertility: Treatment of ovulation problems with Clomid and other fertility drugs
Advanced Fertility Center of Chicago
Gurnee & Crystal Lake, Illinois
What is induction of ovulation?
Ovulation induction involves the use of medication to stimulate development of one or more mature follicles (where eggs develop) in the ovaries of women who have anovulation and infertility. These women do not regularly develop mature follicles without help from ovulation enhancing drugs.
Some of the women with anovulation have a condition known as PCOS or polycystic ovarian syndrome. These women often have irregular menstrual cycles, increased body hair, and infertility.
Ovulation induction is somewhat different from controlled ovarian hyperstimulation which involves use of some of the same medications to stimulate development of multiple mature follicles and eggs in order to increase pregnancy rates with various infertility treatments.
Who should be treated with induction of ovulation?
Women, such as those with PCOS, who do not ovulate on their own regularly, and want to get pregnant.
Ultrasound picture of a polycystic ovary from a woman with PCOS - polycystic ovarian disease These women do not develop mature follicles or ovulate without medication treatment
About 16 immature follicles (black circular structures) are seen here
Ultrasound photo of a polycystic ovary after Clomid treatment
A mature size follicle is now present, as well as some small ones
Yellow cursors are on the mature size follicle
How is induction of ovulation performed?
There are four basic types of medication that are used to induce ovulation. Treatment with these drugs has the potential to result in pregnancy if the woman has good quality eggs remaining in her ovaries, and if other causes of infertility are not present.
For women with ovarian failure or extremely very poor quality eggs there is not currently any drug available to allow a reasonable chance of conception with any type of ovarian stimulation. Egg donation is the only realistic option for getting pregnant with premature ovarian failure.
The five major types of ovulation drug therapy are discussed here and elsewhere on this site:
- Clomid (Serophene, clomiphene citrate)
- Femara or letrozole and other aromatase inhibitors
- Injectable gonadotropins, injectable FSH hormone products
- The GnRH pump
Pregnancy success rates for induction of ovulation:
Success rates for induction of ovulation vary considerably and depend on the age of the woman, the type of medication used, whether there are other infertility factors present in the couple, and other factors.
Clomid or Serophene (brand names), clomiphene citrate (generic name) for induction of ovulation
Clomid is an oral tablet that is taken either days 3-7 or 5-9 of the menstrual cycle.
Details about use of Clomid for inducing ovulation and pregnancy
Metformin treatment for women with PCOS, polycystic ovarian syndrome
Metformin (brand name Glucophage) is an oral medication that has been used over the past several years by some infertility physicians to assist in inducing ovulation in some women with anovulation and polycystic ovaries. For more information on metformin therapy, follow the link above.
Fertility drugs after Clomid
Femara or letrozole treatment for inducing ovulation
Injectable gonadotropins for induction of ovulation
Injectable fertility medications, called gonadotropins, contain follicle stimulating hormone (FSH) which causes development of one or multiple follicles when injected into women that do not ovulate.
These medications are given by intramuscular injections or subcutaneous injections on a daily basis. The injections are started early in the menstrual cycle and are continued for approximately 8-14 days until one or more mature follicles are seen with ultrasound examination of the ovaries. At that point an injection of HCG is given which induces ovulation to occur approximately 36 hours later.
Over 90% of anovulatory women can have ovulation induced with this type of therapy. Pregnancy rates per month are better than those with use of Clomid and for relatively young women with no other contributing causes to the infertility pregnancy rates per month of approximately 15% can be expected when this form of treatment is combined with intrauterine insemination. Pregnancy rates with injectable gonadotropins combined with intercourse are somewhat lower.
This type of therapy is usually tried for 3-6 months and if it does not result in a pregnancy in vitro fertilization should be considered.
The cost of using this medication is substantial. In the United States injectable gonadotropins cost approximately $50 to 80 per 75 units. The required dose ranges from about 75 units per day to 375 or more units per day for about 7-14 days.
Ultrasound and blood monitoring of the stimulation cycle is essential when using injectable gonadotropins as there are substantial risks associated with overstimulation if the ovaries should over respond to the medication.
This monitoring is usually done 3 times a week during the time the woman is taking the injectable medications. This adds substantially to the cost of the cycle. Some health insurance plans will pay for the entire cost of ovulation induction including insemination if that is desired. Other health insurance plans will pay for some (or none) of the costs associated with this treatment.
Complications associated with use of these medications include the possibility of overstimulation, called ovarian hyperstimulation syndrome, or OHSS. OHSS is reported to occur in approximately 1% of cycles. Hyperstimulation involves enlarged ovaries, abdominal pain, and fluid build-up within the abdomen. It may require hospitalization in extreme cases to control pain or manage the syndrome. Carefully monitored use of injectable gonadotropins can almost always avoid severe overstimulation.
Multiple pregnancy is also a possibility when these medications are used. In general approximately 75% are single, 20% are twins, 5% are triplets and 1% are quadruplets or higher.
In very rare cases, 9 or more fetuses have implanted and shown heartbeat activity on ultrasound studies. Rarely can a pregnancy of more than 5 fetuses result in viable live birth unless a fetal reduction procedure (selective abortion) is performed at about 11-13 weeks of pregnancy.
The risk of multiple pregnancy increases with the number of mature follicles that are seen on ultrasound examination of the ovaries. However, it is often not possible to stimulate the patient so that only one mature follicle develops and multiple follicle development is usually the rule.
When many mature follicles develop the couple and the physician can have a discussion about the risks of multiple pregnancy and there is always the option of canceling the cycle by not giving the injection that causes ovulation. This essentially eliminates the risk of any pregnancy (single or multiple) occurring in that cycle.
Bromocriptine for induction of ovulation
Anovulation caused by elevated levels of the piuitary hormone hormone prolactin can be treated with a medication called bromocriptine. This is an uncommon anovulation disorder. Women with this condition often have no menstrual periods - amenorrhea.
Cost for induction of ovulation:
The costs associated with induction of ovulation depend on the type and dose of medication required and the number of ultrasound and blood tests (if any) required to adequately monitor the cycle. Sometimes artificial insemination will also be recommended which increases the chances for a pregnancy, as well as the cost of the cycle.
A Clomid cycle usually costs between $100 and about $1200, depending on what is done.
A cycle using injectable gonadotropins usually costs between $1500 and about $6000, depending on what is done and how much injectable fertility medication the woman needs to stimulate follicle development.