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JIVA Fertility

Ovulation Induction

Ovulation Induction or OI is a fertility treatment for ovulation disorders (if you do not release eggs or ovulate regularly) which are usually caused by an imbalance of hormones.

OI medications are used to stimulate the follicles (egg containing sacs) in your ovaries to produce eggs in that cycle and control the time you release the eggs, so sexual intercourse or intrauterine insemination (IUI) can be scheduled at a time best suited to result in a pregnancy.

What are the common Ovulation Disorders?

The most common reason why women do not ovulate regularly is Polycystic Ovary Syndrome (PCOS) - https://www.verity-pcos.org.uk/.

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Stress, fluctuations in weight (weight loss or weight gain), disorders of hypothalamus, pituitary gland, thyroid gland, raised prolactin levels and premature ovarian insufficiency (POI) or severely reduced egg reserve (ROR) are the other reasons for ovulation problems.

What are the pre-requisites for OI?

Before we offer OI treatment, we need to perform certain tests in order to establish the actual cause of your problem:

- A trans-vaginal ultrasound scan of the ovaries and womb

- Blood tests to measure various hormones including anti-mullerian hormone (AMH), thyroid gland hormones, prolactin, follicle-stimulating hormone (FSH), luteinizing hormone (LH), oestradiol, testosterone and other androgens (male hormones), sex hormone binding globulin (SHBG) and 17 alpha hydroxy progesterone.

- Evaluation of fallopian tubes patency by HyCoSy or Laparoscopy and Dye test

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OI treatment is not appropriate if you have POI or severe ROR, and your doctor will discuss alternative options.

What are the interventions commonly used for OI?

We use one of the following medications, depending on the cause of ovulation disorder, or a surgical procedure, especially if surgery is required for other reasons.

Aromatase Inhibitors (such as letrozole)
Clomifene Citrate (Clomifene or Clomid)
Gonadotropins
Laparoscopic Ovarian Diathermy
Metformin

Individual responses to treatment can be unpredictable, but in general, about 60-70% women respond to these medications and about 60% of the women conceive with six treatment cycles.

Aromatase Inhibitors (e.g. Letrozole)

Letrozole is used to help you release eggs regularly if you have infrequent or absent periods due to PCOS. The only licensed use of Letrozole is as an additional (adjuvant) treatment of breast cancer. The drug company has not applied for a specific license to allow its use for fertility treatment. It is, however, being increasingly used by fertility specialists for ovulation induction (OI).

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Generally given as oral Tablets, 2.5 mg or 5 mg per day for five days from day 2 to day 6 of your menstrual cycle.

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If you do not have periods or really long cycles, we will give you progestogen tablets (such Provera) to induce a period-like bleed.

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Although letrozole helps produce only one egg in a cycle, we perform ultrasound scans to monitor the development of the number of follicles and blood tests to ensure ovulation. When follicles have reached an appropriate size, intercourse is advised.

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An injection of hCG may be given to ensure the egg is released from the follicle and facilitate the timing of intercourse.

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Many studies have recently shown that using Letrozole for OI results inbetter rates of successful ovulation and has no adverse effects on the lining of the womb, something seen with Clomifene Citrate

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The risk of congenital abnormalities in babies appearsto be lower than with CC and is comparable with babies conceived naturally.

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The common side effect of taking Letrozole is hotflushes, as well as occasional fatigue and dizziness.

Clomifene Citrate or Clomid

Clomifene Citrate (Clomifene or Clomid) – This medication comes in a tablet form and will help you release eggs regularly if you have infrequent or absent periods due to PCOS. It is an anti-oestrogen which increases the production of follicle stimulating hormone (FSH) by the pituitary gland, thereby stimulating follicle growth.

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This tablet is normally taken by mouth in a starting dose of 50 mg per day (can be increased to 150 mg), for five days from D2 to D6 of the menstrual cycle.

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If you do not have periods or really long cycles, we will give you progestogen tablets (such Provera) to induce a period-like bleed.

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Clomifene can cause production of multiple follicles, hence we perform ultrasound scans to closely monitor the number of follicles developed and undertake blood tests to ensure ovulation.

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Common side effects include headaches, blurred vision and hot flushes.

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The risk of twin pregnancies can be as high as one in eight pregnancies - we may have to cancel the cycle if many follicles develop.

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A rare complication that can occur is ovarian hyper stimulation syndrome (OHSS).

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The risk of ovarian cancer with Clomifene is thought to be very small.

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Clomifene can be used for six cycles and generally we do not recommend more than 12 cycles.

Gonadotropins

Gonadotropins are the hormones produced by pituitary gland.

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These are daily injections (subcutaneous: given just under your skin around belly-button or upper thigh) which will directly stimulate follicles development in your ovaries. They contain either follicle stimulating hormone (FSH) or FSH and leutinising hormone (LH).

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You need very close monitoring by regular ultrasound scans +/- blood tests to assess development of follicles and a hCG injection to help release of egg/s.

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The side effects may include abdominal distention/discomfort, bloating sensation, mood swings, fatigue or restlessness.

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There is a risk of multiple pregnancy if more than one follicle develops. If more than two follicles develop, we advise cycle cancellation and abstinence from intercourse to prevent multiple pregnancy. The risk of twin pregnancies can be as high as one in four pregnancies. Triplets may also occur in around one in a hundred treatment cycles.

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There is a small risk of developing OHSS - The symptoms include severe pain in the pelvis, abdomen and chest, nausea, vomiting, bloating, weight gain, thrombosis and difficulty breathing and you may need to be admitted to the hospital.

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What is Laparoscopic ovarian diathermy?

If you require laparoscopy for any other reason such as to check the fallopian tubes or to surgically treat mild endometriosis, we will be able to perform this procedure at the same time. A monopolar electrical energy is used to puncture the ovaries at multiple sites to help release chemicals required for ovulation.

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Laparoscopic ovarian diathermy carries anaesthetic and surgical risks which include infection, bleeding, thrombosis, pelvic adhesions, reduced egg reserve, unable to complete the operation, damage to bowel, bladder and blood vessels requiring laparotomy (open operation) to manage complications, and death (one in 15,000 to 30,000 operations). Pelvic adhesions (scarring) can develop and egg reserve may decline with this procedure.

Can Metformin be used for OI?

Metformin is given to some patients with PCOS, generally in combination with other medications to help ovulation. It can cause nausea, abdominal cramps and upset stomach. These side effects can be reduced by taking the drug with food and gradually building up to the full dose.

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At JIVA Fertility, we are committed to providing expert medical care, emotional support, and tailored treatment plans to help you achieve successful pregnancy.

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