Controlled Ovarian Stimulation
Controlled Ovarian Stimulation Overview
Controlled ovarian hyperstimulation (COH) includes the treatment options of ovulation induction and superovulation. COH protocols can be used in combination with either timed intercourse (TIC) or intrauterine insemination (IUI).
When a woman has irregular periods or no periods at all, it indicates that she is not ovulating in a regular, reliable manner. Lack of ovulation means that an egg is not released for that month as it should, which is one of the leading causes of infertility. Various disorders can cause ovulatory dysfunction, including polycystic ovary syndrome and disorders of the pituitary gland such as hyperprolactinemia, hypothyroidism, and functional hypothalamic amenorrhea.
Ovulation disorders can be treated with ovulation induction, which involves taking medications to stimulate a single egg to grow and release at the right time of the month.
When a woman has regular monthly periods, this is a good indication that she has normal ovulation and is releasing a single egg each month. For couples with unexplained infertility, or for women of advancing age, we may recommend superovulation as the treatment of choice. Superovulation is a method in which our goal is to allow for multiple mature eggs to release per month in order to increase your chance of pregnancy. As more eggs release, the risk for multiples (twins, etc.) increase. Your physician can discuss these risks with you based on your individualized treatment plan.
Your doctor will determine your plan of care based on your infertility diagnosis, and create a treatment plan with one or a combination of the following medications. You can take oral medications, injectable medications, or a combination of oral and injectable medications, which we call a ‘sequential cycle’.
The main oral medications which are used to stimulate growth of one or more mature eggs are letrozole (Femara) and clomiphene citrate (Clomid). Your physician may also recommend additional co-treatments to improve your response to the above medications, including metformin (Glucophages), dexamethasone, or tamoxifen.
Injectable medications include FSH (Follistim, Gonal-F) and hMG (Menopur). These medications are made of similar hormones that occur naturally in humans, which are released by the brain to signal the ovaries to grow and release an egg each month. Carolina Conceptions will arrange for you to meet with a nurse to learn just how easy it is to give these injections to yourself, typically on the abdomen just beneath the surface of the skin (much like a diabetic would give themselves an insulin injection). By administering these medications, we can replicate the pattern of egg growth that should occur in a woman each month, and even get more than one egg to grow for the month.
hCG (Ovidrel, Pregnyl, Novaryl) is another medication which is used as a ‘trigger,’ meaning that we trigger the eggs that have grown to release or ovulate. The hCG injection is used to time intercourse or the insemination appropriately, so that the eggs and sperm come together at just the right time for conception to occur that month.
GnRH agonists (Lupron) and GnRH antagonists (Ganirelix, Cetrotide) are additional injectable medications which can be used to prevent your body from ovulating on its own until your physician determines the time is right and instructs you to take your hCG trigger shot.
Example Treatment Plans
1. Ovulation Induction (Letrozole or Clomid) – goal 1-2 eggs, 10-15% chance of pregnancy, 3% chance of twins
• Call our front desk with the start of your cycle. We will schedule a baseline ultrasound on the day 1, 2, or 3 of on your cycle. Carolina Conceptions does not perform baseline ultrasounds on the weekend. If your period begins on Saturday, plan on coming to our office Monday morning between 7:30 and 11:00 for an appointment. Let us know if you are going to do IUI (insemination) or TIC (timed intercourse).
• Day 3 Start Letrozole, two pills per day for 5 days (day 3 to 7) take the pills together, at night.
• Day 12 Schedule a repeat ultrasound. If we see a mature follicle we will instruct you to take one prefilled syringe of Ovidrel (hCG Trigger Shot) that evening and to have intercourse. If we do not see a mature follicle, we will give you specific instructions at that time.
• Day 13 nothing.
• Day 14 TIC (36-40 hrs after ovidrel) or come to Carolina Conceptions for the IUI.
2. Sequential cycle (A combination of pills like letrozole and injections like Menopur) – goal 2-4 eggs, 20-25% chance of pregnancy, 20-25% chance of twins
• Schedule a nurse injection class to learn injection technique and cycle details for your medication.
• Call our front desk with the start of your cycle. We will schedule a baseline ultrasound on day 1, 2, or 3 of your cycle. Carolina Conceptions does not perform baseline ultrasounds on the weekend. If your period begins on Saturday, plan on coming to our office Monday morning between 7:30 and 11:00 for an appointment. Let us know if you are going to do IUI (insemination) or TIC (timed intercourse).• Days 3 to 7 Letrozole, two pills per day- take the pills together, at night.
• Days 7, 8, 9 Gonal F/Menopur 150 IU injections (or specific dose for you) per day in the evening.
• Day 10 schedule an ultrasound.
• After day 10 you will be instructed when to take Ganirelix or Cetrotide to prevent ovulation, additional Menopur/Gonal F, and Ovidrel (hCG Trigger Shot). This will be based on your response to your medications. You may be instructed to return 2-3 days for another ultrasound.
• Plan on 3-5 days of injections.• Usually you will be told to engage in intercourse the same night you inject Ovidrel. Have no sexual activity the next day and schedule IUI or TIC 36-40 hrs after the Ovidrel injection.
3. Controlled Ovarian Hyperstimulation (COH – Injections only) – goal 2-4 eggs, 25% chance of pregnancy, 25-30% chance of twins
• Schedule an injection class to learn injection technique and cycle details for your medication.
• Call our front desk with the start of your cycle. We will schedule a baseline ultrasound on day 1-3 of your cycle. We do not perform baseline ultrasounds on the weekend. If your period begins on Saturday, come to our office Monday morning between 7:30 and 11:00 for an appointment. Let us know if you are going to do IUI (insemination) or TIC (timed intercourse).
• Day 3 to 6 take Gonal F/Menopur 150 iu daily (or your prescribed dose) but may be increased or decreased based on several factors (age, ultrasound, AMH, previous response in other cycles).
• Day 7 repeat ultrasound and possible blood work (estradiol level).
• After day 7 you will be instructed to take Ganirelix or Cetrotide, additional Gonal F/Menopur and Ovidrel.
• In most cases there are 8-12 days of injections and 3-4 ultrasound appointments before taking Ovidrel.
• Ovidrel will be given at 8 pm the evening of trigger, and the patient should have intercourse anytime that evening. IUI or TIC should be scheduled 36-40 hrs after Ovidrel.
* Low AMH levels and/or advanced maternal age- after baseline exam, some women will take FSH 300 iu daily, days 3-7 COMBINED with Letrozole 5mg per day, day 3-7. The next monitoring visit will be day 8.