Medication plays an important role in the treatment of infertility. While many fertility problems can be addressed through medication alone, even advanced treatment procedures like IVF rely on fertility drugs to stimulate the ovaries and control the menstrual cycle. Fertility drugs like Clomid® and Gonadotropins (FSH injections) make ovulation induction at our Chicago, Illinois-area practice possible.
Ovulation induction is often a critical part of the infertility process. During this step, women take medication to increase their likelihood of producing healthy eggs. There are three commonly used types of medications: Clomid®, Letrozole and Gonadotropin (FSH) injections. These medications differ in how they are administered, their cost, and other factors. In some cases, these medications can be combined. Dr. Jacobs will determine which medication or combination of medications is best for you.
The most common type of fertility medication used to stimulate ovarian function is clomiphene citrate, which is packaged under the brand name Clomid®. By mimicking the chemical structure of estrogen, clomiphene citrate triggers the body to release follicle stimulating hormone (FSH), which is responsible for the development of ovarian follicles and maturation of the eggs within. Clomiphene citrate is taken orally for five days, beginning on cycle day three, four, or five, during which time the ovaries will be monitored via ultrasound. When ovulation is imminent, sperm should be introduced via intercourse or artificial insemination within 24 to 38 hours to maximize the chances of conception. With IUI, the timing is very important. We will usually perform an ultrasound four or five days after the last Clomid® pill has been taken. If the follicles are mature (19 mm or larger) we give the patient an injection of HCG hormone, a pregnancy hormone which mimics the LH (luteinizing hormone) surge. This HCG injection will ideally cause one to ovulate within 24 to 38 hours later, allowing for excellent timing. We perform IUI seven days a week to ensure appropriate timing. Clomid® with IUI is relatively easy to perform, and is less expensive and less risky than other options.
To learn more, read Dr. Jacobs' article about Clomid® and IUI (PDF).
For decades, Clomid® has been the primary oral infertility medication for women with ovulation disorders and PCOS, but aromatase inhibitors, such as letrozole, in some studies, have been shown to result in higher pregnancy rates. Letrozole is a safe alternative to Clomid in the treatment of infertility. For more information on comparison of Letrozole and Clomid, go to Dr Jacobs’ blog article Is Clomid or Femara More Effective for Ovulation?
Gonadotropin (FSH) injections have some significant advantages as well as disadvantages compared to Clomid® and Letrozole. There are many excellent FSH medications, including Bravelle®, Follistim®, Menopur® and Gonal-F®. FSH injections are more potent than Clomid® and Letrozole, and we therefore expect more egg development; however we ideally want to see no more than two mature follicles. With FSH injection medications, any follicle 16 mm or larger will usually ovulate. Unfortunately, on rare occasions follicles as small as 14-15 mm may ovulate, leading to a higher risk of ovarian hyperstimulation (OHSS) and/or multiple births. Another advantage of the FSH therapy is that the cervical mucus quality is much improved compared to Clomid® since the patient will produce larger amounts of estrogen as more follicles develop. Another advantage of the higher estrogen levels is that the uterine lining will be much better stimulated than with Clomid®. For these reasons (more eggs, improved cervical mucus, and a better uterine lining) the pregnancy rates with FSH therapy are higher than with Clomid®.
However, the disadvantages of FSH therapy compared to Clomid® include:
MORE LABOR INTENSIVE MONITORING OF THE PATIENT'S OVARIES (LAB AND ULTRASOUND) IS NECESSARY
The average woman may require 7-10 days of injections. We teach our patients to perform the injections; however, patients will need more intensive monitoring and may have four or five visits to the office for ultrasound and estrogen blood tests. This helps determine the appropriate dose of FSH so that we can achieve a safe stimulation of the ovaries with a handful of mature eggs being released.
CONSIDERABLY HIGHER COST
When performing FSH injections, the average couple can spend $2000-$3000 or more than with Clomid®, because more blood tests and ultrasounds are needed and the medication costs more. However, most insurance companies that pay for infertility treatment will cover this therapy.
HIGHER RISK OF MULTIPLES
With FSH, we can expect approximately 20 percent twins compared to 6-8 percent with Clomid®; 4 percent triplets for FSH compared to approximately 1 set of triplets in 500 pregnancies with Clomid®. On rare occasions, we see quadruplets or more due to the inability to control exactly how many eggs will release when using FSH injections.
COMBINATION OF MEDICATIONS
Occasionally, we will use a combination of five days of Clomid® or Letrazole, plus a few days of FSH injections. This "combo" therapy may improve pregnancy rates over Clomid® or Letrazole alone, and involves less monitoring, cost, and risk than FSH therapy alone.
Patients undergoing gonadotropin therapy (non IVF) will be closely monitored to ensure that follicular development is progressing properly. Because gonadotropins act directly on the ovaries, there is an increased risk of ovarian hyperstimulation syndrome (OHSS) as compared to Clomid®. If signs of OHSS are observed, administration of fertility drugs will be ceased. Gonadotropins with IUI or intercourse may increase pregnancy rates compared to Clomid®, but unfortunately the risks of multiples are considerably higher, as are the costs.
During an IVF cycle stimulation, higher doses of Gonadotropins are administered.
To learn more, read Dr. Jacobs' article "Couples' Guide to Fertility Treatments" (PDF 291KB)
View training videos from Freedom Fertility Pharmacy to learn how to administer injections of fertility medications.
Human Chorionic Gonadotropin (hCG) is used during ovulation induction to trigger the final maturation and release of the eggs. Because the use of fertility drugs often interrupts the body's natural hormonal processes, a patient taking gonadotropins will not have the increase in luteinizing hormone (LH) that would normally trigger ovulation. HCG, a pregnancy hormone produced by the placenta, mimics the effects of LH and prepares the eggs for release or retrieval.
It should be noted that hCG is the hormone that is detected by both urinary and blood tests for pregnancy. The administration of hCG during infertility treatment can result in a false positive on a home pregnancy test. Patients undergoing ovulation induction or receiving fertility drugs will need to have a laboratory pregnancy test, which measures the quantity of hCG and can differentiate between the small amount of residual hCG from treatment and the increased levels that indicate pregnancy.
Under normal circumstances, a woman's body produces progesterone after ovulation, which causes the uterine lining to thicken and provides support for the early embryo, should conception occur. When a woman undergoes ovarian stimulation and egg retrieval for IVF, however, she does not generally produce enough progesterone to achieve these effects. This is because the cells within the follicles that produce progesterone are removed along with the eggs during the IVF follicle aspiration. Therefore, supplemental natural progesterone is given to ensure that the uterus is ready to receive and support the embryo when the transfer procedure is performed.
Natural progesterone may also be administered during ovulation induction treatments, as well as in cases of recurrent pregnancy loss due to inadequate progesterone production.
To learn more, read Dr. Jacobs' article about progesterone supplements (PDF)
Leuprolide, commonly known as Lupron®, is sometimes administered at the end of a prep cycle preceding an ovarian stimulation cycle for IVF. Ganirelix is used during an IVF stimulation. By suppressing the body's natural hormone functions, Lupron® and Ganirelex prevent spontaneous, early ovulation and improves our ability to control the ovarian stimulation process. In some situations, a single dose of Lupron® can also be used as a "trigger" shot during IVF.
To learn more about Clomid® and other fertility drugs used during ovulation induction,contact our Chicago, Illinois-area practice.