The Leeds Teaching Hospitals NHS Trust


Ovulation Induction


What are the common causes for failing to ovulate?

  • Nearly 1 in 6 couples will require some form of sub-fertility assistance. The exact prevalence of various conditions can vary demographically. Ovulation disorders account for 10-15% of all sub-fertility patients and there are many causes some of which are listed below:
  • Polycystic ovaries (PCO) or Polycystic ovary syndrome (PCOS)
  • reduction in ovarian reserve
  • hyper-prolactinaemia
  • hypo or hyper thyroidism

What happens in a natural ovulatory menstrual cycle?

Naturally the ovary continuously recruits and develops the eggs over 60-90 days but only the last 14 days are in the menstrual cycle. All of development occurs under the influence of the 'pituitary gland' which is located behind the eyes at the base of the brain. It produces the 'Follicle Stimulating Hormone' (FSH) under the influence of which one follicle is selected for ovulation. This follicle becomes visibly larger by the 4th-5th day of the menstrual cycle. Thereafter under the influence of FSH and other hormones it grows.

ahead of others and becomes the 'dominant follicle'. This 'dominant follicle' exerts its dominance and prevents other follicles from growing that month. It ovulates releasing its egg in the middle of the month under the influence of the second hormone also released from the pituitary gland called the 'Luteinising Hormone' or the LH.

Eggs develop within the ovary in a fluid filled sac called the follicle. During this treatment, fertility drugs are expected to encourage eggs to develop to maturity within an appropriately growing follicle and then rupture to release its fluid which hopefully will also contain the egg (ovulation).

The growing follicle produces oestrogen which develops the lining of the womb for pregnancy and also affects the 'pituitary gland'. It stops it from producing more FSH whilst the 'dominant follicle' is completing its development. After ovulation the follicle becomes 'the corpus luteum' which produces mainly progesterone and also some oestrogen. This combination brings in a second phase of development in the lining of the womb for pregnancy. It also affects the 'pituitary gland' and allows it to produce only small amount of FSH and LH after ovulation so that new follicles do not grow in this period.

Naturally after the sperm are ejaculated in the vagina, they swim upwards, through the womb and into the fallopian tubes where they expect to meet the egg. Once the egg is released, it may be captured by the fallopian tube where it will meet the sperm which will enter into the egg (fertilisation). The sperm dissolve the cells surrounding the egg 'cumulus' to reach and fertilise the egg. Once the sperm reach the shell of the egg called the 'zona pellucida', it undergoes a series of changes before entering and fertilising the egg.

Immediately after this the egg undergoes a complex reaction that will stop any more sperm from entering.

Thereafter the fertilised egg will start to grow and form an embryo which will be gently propelled towards the uterus for implantation some 6-7 days after ovulation. Further growth of this embryo will release hormones from the embryo which will stop menstruation that normally occurs 14 days after ovulation and a pregnancy is then thought to have occurred.

After ovulation the 'corpus luteum' will carry on producing oestrogen and progesterone stimulated by another hormone produced this time by the embryo called the human chorionic gonadotrophin (HCG) and in this way further development of follicles does not happen and a pregnancy occurs. If the embryo does not implant or fails to grow, the 'corpus luteum' disintegrates and menstruation occurs during which the lining of the womb is shed and new cycle begins.

In conditions such as polycystic ovaries there are many eggs but the interaction is deranged and this stops ovulation from occurring. When we induce ovulation we stimulate all glands involved in this process to work better. By giving you stimulating drugs however we can allow more than one egg to develop and this is how the risk of multiple pregnancy rises.

Thus in this very complex interaction between various glands and hormones, ovulation and pregnancy occurs. A derangement at many levels can lead to failure of ovulation and or pregnancy such as the pituitary gland, ovarian reserve of eggs, ovary's ability to select and develop the dominant follicle, ovulate and release its egg, fallopian tube's ability to capture the egg, sperm's ability to fertilise the egg uterus receptiveness for embryo or embryos ability to develop. In older women or when ovaries have been affected by a past illness/treatment, the total number of eggs in the ovary goes down and hence the number it can allocate per month also reduces. There are therefore more cycle where ovulation fails to occur or the process is less than satisfactory for conception.

Essential Pre-requisites for this treatment

  1. The essential pre-requisites for this treatment are:
  2. Patent (open) and healthy fallopian tubes confirmed at least by hysterosalpingogram and in some at risk women by laparoscopy
  3. Absence of any disease in the pelvis such as moderate/severe endometriosis particularly that involving the ovaries and/or tubes and pelvic inflammatory disease
  4. A potentially fertile sperm test as defined by conventional methods and also the qualitative assessment with isolation of healthy normal sperm and the sperm antibody testing.
  5. Adequate ovarian reserve of eggs

Oral Glucose tolerance tests

You have been asked to have an oral glucose tolerance test. Here is some information for you to read.

What is Oral Glucose Tolerance Test?

This test is find out how well your body absorbs and uses sugar (glucose)

What do I need to do before the test?

For at least 3 days before the test, you should have an unrestricted diet (rich in carbohydrates)

Diets with reduced calories can cause incorrect test results

The evening before the test, you can have your normal meal and then fast for 12 hours before your appointment for the blood test

During the fasting period, please do not eat, chew gum or drink anything except water.
What do I need to do on the day of the test?

Please take this information sheet with you and report to the reception on arrival

One of our staff nurses will take you to the blood test room

A 5 ml of blood will be obtained from you

You will be given a sugar drink

A second blood test will be obtained in exactly 2 hours later

You will be advised to have some snack before you leave the unit

What do I need to bring on the day of the test?

  • A snack
  • Something to read
  • Enough coins for parking for a period of 3 hours

Methods and Drugs commonly used for ovulation induction

Methods and drugs commonly used for ovulation induction include the following:

  1. Normalisation of weight and Body Mass Index
  2. Clomifene citrate
  3. Metformin
  4. Ovarian diathermy
  5. Hormone injections (gonadotrophins)

Weight & Exercise

Fertility and body weight are inter-related and both under weight as well as over weight women experience difficulties in conceiving. Furthermore, the risk of miscarriage, premature birth, restriction in baby's growth, diabetes in pregnancy, hypertension and several other pregnancy complications are more likely.

The pattern of fat distribution also is important. When the fat distribution is mainly around the abdominal area (central obesity or apple shape), the risk of heart disease, diabetes, cancer of the womb, high blood pressure, diseases of the blood vessels, gall bladder, arthritis, cancer and respiratory problems increases.

Excessive aerobic exercise and especially long distance running can increase your metabolic requirements to the extent that the body's preservation mechanisms see these as a famine state and will switch off the menstrual cycles.Marathonrunners can feel physically fit but often are in a hypogonadal state and their ovaries become inactive. In extreme circumstances they can stop having periods or develop irregular cyclicity with failing to ovulate. So extremes must be avoided but healthy exercise regime is encouraged.
Please ask if we have not already told you of your Body Mass Index. Ideally for fertility this should be between 20-25. When ever appropriate we will give you further detailed advice regarding this issue.

Clomifene Citrate

This is given in a tablet form from the 2nd to the 6th day of the menstrual cycle. Many women undergoing this treatment do not have a natural cycle and this has to be induced with progesterone tablets.

If you do not have a cycle or bleed extremely infrequently such as every 2 or 3 months, you are advised the following:

  1. Take a pregnancy test. If the test is negative, start Provera tablets for 5 days, as prescribed and await menstruation (likely to arrive in the next 3-14 days).
  2. On the 2nd day of the period take Clomifene tablets for 5 days (from day 2-6 of your menstrual cycle).
  3. Expect a period 4-5 weeks after taking the Clomifene tablets.
  4. If a period arrives as expected, it means that you have responded but have not become pregnant. You are advised to start the Clomifene tablets again on the 2ndday of the period for 5 days.
  5. If a period fails to arrive 4-5 weeks after taking Clomifene, it means that either you have not responded or you have become pregnant. You are advised to take a pregnancy test.
  6. If the pregnancy test is negative, repeat the course of Clomifene tablets for 5 days.
  7. If the pregnancy test is positive, contact your GP or us, so that a pregnancy scan can be arranged, when appropriate.
  8. Repeat this cycle until review or a pregnancy has been achieved.
  9. If you do not establish a cycle within 3 courses, please arrange a review, unless you already have one.
  10. It is important to have regular sexual intercourse during treatment. If you start cycling regularly, you may use an ovulation prediction kit in order to improve timing of sexual intercourse. Your fertile period (when having regular 28-30 day cycles) is day 10-14 of your cycle.
  11. Keep all of your dates for review, unless a conception occurs beforehand.

Risks of Clomifene

a. Multiple pregnancy: Sometimes the ovary will respond more than desired and will produce more than one follicle. This means that there would be an increase in the risk of a multiple pregnancy (5% as opposed to 1% risk in the normal population).

We like to monitor at least one of your cycles to ensure that you have controlled ovarian stimulation. Producing more than 3 follicles would mean that we would advise you to abstain in this treatment cycle, abandon that treatment in the future and suggest alternatives.

The number of implantations can be easily diagnosed with ultrasound scans in the first trimester. Amongst the multiple pregnancies twins are the commonest but triplets, and even higher order births have been reported. Fortunately these are quite rare.

b. Cyst formation: Sometimes the follicles fail to rupture and release the eggs. They can enlarge and form painful and tender fluid filled sacs that very uncommonly would rupture or bleed with in. This happens commonly in nature also but when occurring after treatment would be seen as a risk of treatment. There is some evidence that this is more likely to happen in women with polycystic ovaries because they have thicker and more firm ovarian capsule. This may also occur if the ovary is surrounded by scar tissue. In the vast majority of patients these cysts will spontaneously resolve and not require any further action.

c. Ovarian hyperstimulation: The risk of ovarian hyper-stimulation syndrome is theoretically increased although it is rarely seen with oral medication.

Side effects of Clomifene:

  1. Visual disturbance if it occurs would lead us to discontinue medication. This is very uncommon.
  2. Other side effects of lower importance are headaches and hot flushes. These are rarely severe enough to require discontinuation of therapy.

What is the association with ovarian cancer?

There may be an extremely small association between ovulation inducing agents and ovarian cancer. This association at the present time is completely theoretical and the results of appropriately conducted epidemiological studies have been very reassuring once family history and other important features have been taken into account. As in all clinical situations it is important to have a clear understanding of the benefits of treatment and known as well as potential risks. It is also important to establish clearly that the treatment has a reasonable chance of being effective.

Insulin-sensitising drugs - Metformin

PCOS can be associated with a resistance to insulin, leading to the body producing excessively high levels of insulin in an attempt to compensate. This higher level of insulin is known to cause abnormal cholesterol and lipid levels, obesity, irregular periods, higher levels of androgens, infertility due to disturbance of ovulation and an increased likelihood of diabetes.

Metformin belongs to the family of drugs that are known as 'insulin-sensitising agents'. These lower the blood sugar level, in turn reducing the excessively high insulin.

The studies performed to date suggest that Metformin may be useful in helping weight reduction, improving irregular periods (70%), normalising blood cholesterol and leading to ovulation. One study found that when comparing to no treatment, 34% of women ovulated with Metformin as opposed to 4% who did not receive it. When Metformin was combined with Clomifene the ovulation rate rose to 90% as compared to 8% in those who only received Clomifene. These studies only contained overweight women with PCOS and the role of Metformin in treating women of normal weight has not been investigated.

The use of this drug in our centre is limited to obese women with PCOS who have not responded to weight reduction and Clomifene induction of ovulation. It is also important to realise that the investigation is still at a very early stage and long-term effects of Metformin are not known.

Side effects of metformin

The most common side effects are diarrhoea, nausea, vomiting and abdominal bloating. We usually introduce this medication gradually with a slow build up to the full adult dose. This way your body will adapt slowly and side effects will be limited.

Ovarian Diathermy

This procedure is sometimes performed for induction of ovulation in those women where oral medication such as Clomifene citrate and Metformin has not been successful. It is done during a laparoscopy procedure under a general anaesthetic.

Its mechanism of action is poorly understood. Theoretically drainage of peripherally located old follicles drains the excess precursor hormones from the ovary which may have had a suppressive effect on the development of new follicles.

In the medical literature the likelihood of ovulation after such a procedure is approximately 60-70% especially when combined with the use of oral medication such as Clomifene and / or Metformin. Approximately 60-70% of responsive women may then conceive naturally.
Like other forms of induction of ovulation, it is useful to perform such a procedure only if tubal function is normal, male sub-fertility has been excluded and there is no other disease with in the pelvis.

Risks of ovarian diathermy

In addition to the standard risks of the laparoscopy (1% risk of bowel, bladder and vascular injury needing further surgery and repair) and the general anaesthetic (1 in 10,000 risk of complications), bleeding and adhesion formation can occur after ovarian diathermy. To minimise this risk precautions are taken routinely during surgery. One rare complication of this procedure is a reduction in ovarian reserve of eggs and in extremely rare situations even premature ovarian failure has been reported in the medical literature.

Gonadotrophin Induction of Ovulation

Gonadotrophins are pituitary hormones namely the FSH and the LH as described above in section 8. These hormones are administered by a subcutaneous injection and stimulate the ovary to develop follicles containing the egg in your ovary. It is given during the first half of the cycle and is usually given daily although it can also be given on alternate days. You will be instructed on the dose and timing of this hormone.

There are large variations between patients in the number of eggs recruited and developed in response to the same dose of the stimulating hormones (see below). This response is mainly dependent on the female partner's age, the cause of her sub-fertility, her body weight and past treatments or ovarian surgery. There are other genetic determinants also. Having preformed the pre-treatment assessments, we judge the starting dose bearing in mind your clinical circumstances. When uncertain we may perform additional early scans to use the option of 'stepping-up' or 'stepping down' during the stimulation phase for a better response.

What does it involve?

The hormones (Puregon/ Gonal-F/ Menopur) will be started at the appropriate time of your cycle.

My choices?

The difference in the above mentioned drugs is mainly in the way they are prepared, their purity, in the way they are administered and their costs. They are equal in terms of their success rate. We often choose them in combination or separately to suit.

Prescription

If your treatment is funded by yourself then you would need to purchase all the drugs prescribed. Please ensure that all drugs required for the treatment are in your possession before you start the treatment. These drugs are usually not available at short notice and not having injections on the correct day/time can jeopardise your chances of success.

How to inject?

Gonal-F, Puregon and Menopur are usually given by a subcutaneous injection (very fine needle-injection in the fat layer under the skin).

How are they prepared?

Gonal-F and Puregon are synthetic compounds, very pure and with an identical structure to PURE FSH only. Menopur is extracted and purified from menopausal women's urine and is therefore a combination of naturally produced hormones. This can contain protein impurities at a very low level which can rarely give a skin reaction. There are no other reported complications.

Side effects

As stated above, to date the only additional side effect with urinary preparations has been that of an occasional rash on the injection site and rarely a more generalised allergy has been reported. Other risks with protein impurities are purely theoretical and there have been no cases reported to cause concern.

Undesirable effects

This can happen with any of the preparations available. Sometimes the ovaries will recruit a large number of eggs especially in young women and those with Polycystic ovaries. This can put you at risk of developing an illness called The Ovarian Hyper-stimulation Syndrome (see below for further details). We use 'step-up and/or step-down' method to adjust and protect you from this risk during the stimulation phase.

How effective are they?

We have used the Pure and Urinary preparations quite extensively and are happy with them all.

Who should give the injections?

The injections can be administered yourself or by your partner. We strongly advise you to consider learning self-administration.Independencewill save you time, effort and stress of professionals not being available when needed. However, if you are extremely anxious then you may seek the help of your doctor's nurse.

When to take the injections?

The injection is taken once a day at approximately the same time but an absolute and accurate precision is not essential. We will be able to estimate the day of your ovulation/insemination once the growth rate of follicles is established. It will also help in deciding the time of abstinence in preparation for the semen sample to be given on the day of ovulation/insemination.

The hCG (Pregnyl) Injection

When your follicle/s have reached an appropriate size, as assessed by scan, you are ready to be prepared for ovulation. This hormone mimics a surge of a natural hormone that normally causes ovulation. It is given by subcutaneous or intramuscular injection, usually between the 9th and the 14th day of your menstrual cycle and late in the night after 10.00pm. This injection is usually given late in the night normally between 10.00 p.m. and 2.30 a.m. It is specifically timed to be between 35-37 hours before the time of your intra-uterine insemination. We will give you the exact time when you are ready.

Important notice: We will give you precise instructions as regards the time and day this injection has to be administered. It is essential that the hCG injection is given as close to the prescribed time as is possible. Please read the instructions before you leave the unit so that you can ask any member of The Centre if you do not understand any of the instructions.

It is also given after ovulation has occurred to strengthen and support the second half of the cycle after ovulation and insemination. We believe this gives the embryo (formed after fertilisation of the egg), a better chance to implant in the uterus. This support is at a lesser dose of 2,500 units, given twice, generally two days and five days after insemination. Dates and times of these injections will be given to you and occasionally they may differ between patients. Please ensure that you bring your schedule so that these injections can also be properly prescribed.

At the end of the treatment cycle: If you are not pregnant a period will start within 14 days of ovulation. If you miss your period, you need to have a pregnancy test. We will give you a date for the test at the time of your insemination.

Risks of Gonadotrophin Induction of Ovulation

There are no treatments that are completely free of risk. In a treatment cycle there are the following risks:

Hyperstimulation of the ovary

We judge the appropriate dose of hormonal stimulation for you after consideration of your age, body weight, cause of infertility and information that we may have from your previous treatments. The ovarian response to the same dose of the hormone varies between patients for many reasons. Hence these judgements can only be approximate and after your first cycle we can usually make adjustments for your specific needs. Occasionally you can respond by producing too many follicles to the dose that we give you. This can result in excessive number of eggs and also higher than optimum hormone levels. If this occurs you have two options:

  1. Stop the treatment cycle in order to avoid a high order multiple pregnancy and also to protect you from the risks associated with very high hormone levels. You will be advised not to have intercourse also in that cycle until a period occurs. The risk of this happening is greater in women with polycystic ovary syndrome.
  2. In some cases it is possible to convert the cycle to IVF rather than completely abandon the cycle. This would obviously have medical and financial implications and might require arrangements to be made at short notice. We will discuss this option with you if we consider this an appropriate change for you.

Ovarian hyperstimulation syndrome if converted to IVF:

If your ovaries have shown an excessive response then you are at risk of Ovarian Hyperstimulation Syndrome. Everybody receiving drugs for ovarian stimulation in order to produce multiple eggs is at risk. However the risk is not the same in everybody and we have developed clinical tools with which we assess your individual risk. This can vary between mild, moderate, severe and very severe. Young and overweight women with polycystic ovaries are especially 'at risk'.

General advice: You are advised to drink normally and check that you are regularly passing normal amounts of urine. Although mild symptoms are common, severe ovarian hyperstimulation is rare and occurs in only 1-2 % cases. If in doubt, please do not hesitate to contact The Centre or the on call doctor (as per the instructions in the front) at any time. The switchboard at St James's University hospital will be able to put you in touch with the on call gynaecological registrar at all times.
Management of this risk: We will assess your risk before deciding to give HCG, when we do an egg collection and afterwards until we do an embryo transfer. All women in categories a, b and c below receive monitoring with in the unit for early detection of changes and as per our written protocols and those with symptoms will be treated as appropriate. This may include hospitalisation, administration of intravenous fluids and other treatment such as drainage of fluid from body cavities.

  • When in the category of very severe risk, we would not give HCG, advice abandoning the cycle and starting again with a modified regimen.
  • When the risk is severe, we may try to curtail the cycle prematurely with medication, will not do an embryo transfer and will freeze all developing embryos.
  • When the risk is moderately severe we may adopt an expectant individualised approach where we observe your progress carefully whilst we maintain at least some embryos in culture to day 5. If by then you develop signs or symptoms we may freeze all developing embryos still and take other precautions. If you remain well we may perform an elective single embryo transfer.
  • When in this category, you do not require monitoring or specific treatment but we advise you to contact the unit as and when you have problems and as per the contact address and details on the front of this booklet.

Recognised complications: Fortunately with appropriate risk assessment, prophylactic monitoring, early detection and timely intervention most women will have no problems. Your co-operation is therefore essential in ensuring safety. It is a self limiting disorder and there are no problems after the cycle is complete. In women who become pregnant the risk period extends in to the first trimester of pregnancy and complications up to 12 weeks of gestation have been recorded.

Complications occur either as a result of thrombosis in large veins because of thickening of the blood and its sluggish flow or because of collection of fluid in body cavities such as the abdomen or the chest. Strokes, ascitis, pleural effusions, pericardial effusion, cardiac tamponade and deaths have been reported in the literature. The risk of death is less than 0.01%.

Multiple pregnancy

This is a very important clinical matter for both us and you. We know that development of multiple follicles increases the likelihood of at least one continuing growth and implanting. However your risk of a multiple pregnancy is also increased with the ovulation of multiple follicles. Your chance of conceiving a multiple pregnancy depends most of all upon your own age, cause of sub-fertility and also the programmes overall success rate. Occasionally embryos split to form two identical babies and you can get identical twins from a single follicle.

Overall the multiple pregnancy rates with ovulation induction runs in the region of 10% as opposed to 1% naturally. The complications of multiple pregnancies include miscarriage, prematurity, fetal growth retardation, increased risk of pregnancy complications in the mother and the need for delivery by caesarean section. Additional complications of identical twinning include polyhydramnios and twin to twin transfusion syndrome. These complications have high risks for premature delivery. Extremely premature birth has the risk of death in infancy or survival with long-term mental and physical handicap in the children.

Our mission 'One at a time'

Our intention is to give the best chance of a pregnancy but without a high risk of a multiple pregnancy. Whilst trying to come to a decision we balance the probability of a pregnancy against the risks of a multiple pregnancy. We therefore carefully assess where we allow the cycles to continue, where they should be abandoned and where we can safely convert to IVF.

Miscarriage:

The risk of miscarriage after a positive pregnancy test alone is approximately 10-20%. This is no different to that after a normal conception. Once the pregnancy sac has been seen and the fetal heart action identified then the risk of miscarriage is substantially less. The risk of a congenital or genetic abnormality in babies born after ovulation induction is not any higher than that in spontaneously conceived pregnancies. Your personal risk is more likely to relate to your age, your family history and whether or not you have a multiple pregnancy.

Risk of an ectopic pregnancy:

Sometimes even though the tubes have been checked and confirmed patent, they are not healthy within and embryos are not easily transported to the uterus. Thus they can remain in the tube where they implant when ready to do so. If left undiagnosed, the tube may rupture and internal bleeding may take place. We endeavour to make an early diagnosis by performing an ultrasound scan at 7 weeks of pregnancy (3 weeks after your pregnancy test).

Please Note:

  • It is therefore important that a pregnancy test is performed when advised even if you have bled and for the scan after a positive test. If a pregnancy sac is not seen on scan, a blood test is taken to measure the pregnancy hormone (hCG) level in your blood. You may be asked to attend for more tests after a few days interval. If this level is rising or static then we may perform a laparoscopy.
  • If you are unlucky and have a tubal pregnancy then you will require the removal of the tube. We may also counsel you regarding the future of your remaining tube in case it is already known to be irreparably damaged or is found to be such at surgery. We advise you to consider removal of both tubes in those circumstances in order to avoid a recurrence of this complication in future. This is an important decision as it is sterilising and no steps are taken with out your written consent and complete agreement.
  • For the operation you will be admitted to St James's to prevent an untoward occurrence whilst travelling. The risk of an ectopic pregnancy is approximately 3-4%.
  • Occasionally you can have a combined intrauterine and an ectopic pregnancy (heterotopic pregnancy). These are more difficult to diagnose. If present then often but not always, the tubal pregnancy can be removed with out harming the uterine pregnancy.

Risk of equipment failure:

The trust maintains service contracts for all equipment that is regularly serviced. There are also many standard operating procedures in the laboratory that help us have an early warning for problems. Despite all our efforts and very uncommonly equipment failure may sometimes lead to difficulty in ensuring that we can do an IUI preparation. You can still try naturally in these cycles.

Failure to respond to medication

If your ovaries show little or no response and your chance of conceiving is consequently reduced treatment will be abandoned and recommenced the following month with the dose of medication adjusted.

Success rates of Induction of Ovulation with gonadotrophins

These are generally measured per cycle and also over a batch of 3 or 6 cycles. We normally run a success rate of 20% per cycle and find that nearly 60-65% of our patients conceive within 3 cycles of treatment. Please ask if you have not been shown our latest annual report detailing the latest results. A clinical pregnancy is defined as a pregnancy confirmed by ultrasound scans or by histology.

Please also ensure that you read this booklet carefully and seek clarification for all your queries. It is important for you to understand why and how things are done in order for the treatment to proceed uneventfully.

Monitoring the development of the follicle

It is important to assess the effectiveness of treatment with all forms of induction of ovulation, in particular when clomifene and gonadotrophins are used to induce ovulation
Its purpose is to ensure that you are producing a limited number of follicles and eggs and those they are growing in an appropriate fashion.

  • We can do so by performing ultrasound scans at appropriate times and at regular intervals when required.
  • We can also measure the function of follicles by measuring the oestrogen and progesterone levels at appropriate times in your cycle.
  • We also ask you to monitor the LH surge and keep all dates for our reference.
  • We would abandon cycles or ask you to abstain when the number of mature follicles exceeds three in both ovaries.

How do we do it?

The ultrasound scans are performed vaginally and you need an empty bladder for the procedure. probe is gently inserted into the vagina to visualise the ovaries and the uterus (womb). This procedure is not uncomfortable.

Scans are carried out from day 8 or 9 of the cycle and continue approximately every 2 days until the largest follicle(s) has reached the appropriate size. The timing of this varies from woman to woman.

What happens?

  • Follicular scanning at The Centre during your second cycle of Clomifene treatment. You are asked to count day 1 of your period as the first day of bleeding and contact The Centre during weekday hours to arrange a scan which needs to be performed around day 10 of your period.
  • At your appointment at The Centre a pelvic scan will be performed by a nurse or doctor.
  • After the scan has been performed you will be given further appointments as necessary until ovulation has been ascertained. Blood tests may be taken and you will be informed why and when they are necessary.
  • You may be asked to purchase an ovulation test kit and inform the unit when the test is positive. You will also be given advice regarding the appropriate timing of intercourse.
  • A week after your positive LH surge in the urine a blood sample is taken to confirm ovulation in Clomifene cycles.
  • At this time you will be advised whether further follicle tracking is necessary.
  • If not you will be advised about continuing medication and be seen back at the Reproductive Medicine Clinic.
  • During these appointments you will be instructed on if/when to take blood tests when ever appropriate
  • In patients receiving Gonadotrophin for induction of ovulation with IUI:

          HCG may be administered when the follicle has reached the mature size.

          You will then also receive instructions regarding when to provide the sample for IUI               preparation and to come for the insemination.

          You may then also receive further hormonal support during the second half of the                 cycle after insemination has been performed.

Common Questions regarding Ovulation Induction

Who pays for the drugs?

If your treatment is funded by yourself then you would need to purchase all the drugs prescribed. Please ensure that all drugs required for the treatment are in your possession before you start the treatment. These drugs are usually not available at short notice and not having injections on the correct day/time can jeopardise your chances of success.

What happens at the end of the treatment cycle?

If you are not pregnant a period will start within 14 days of ovulation. If you miss your period, you need to have a pregnancy test. We will give you a date for the test at the time of your insemination.

What happens if I do not respond?

If your ovaries show little or no response and your chance of conceiving is consequently reduced. You will be advised to return to the clinic for further advice and discussion.

What are the Success rates?

A clinical pregnancy is defined as a pregnancy confirmed by ultrasound scans or by histology. As an approximate guide with each step of treatment, you may expect that two thirds of the patients will respond to the above drugs alone or in combination with in 3 months. Approximately two thirds of the responders will conceive with in 6 months. We would usually assess suitability to continue drugs at 3 monthly intervals. Most patients will receive treatment for 6 months but sometimes we may continue until 12 months. During the 12 month period if a pregnancy does not occur, a change in management is needed.