Gonadotropin induction of ovulation - Controlled Ovarian Hyperstimulation (COH)
Gonadotropins are hormones naturally released by the pituitary gland to stimulate the ovary. This stimulation causes the ovaries to produce a follicle containing an egg. Injectable gonadotropins will usually stimulate multiple follicles to develop. This increases your chance for a pregnancy. Along with this increase in the number of eggs produced there is also an increased risk of multiple gestations and ectopic pregnancy. Careful follow up and attention to the details in this document will help minimize your risk of undesired effects while hopefully maximizing your chance of a successful pregnancy.
- You should have already attended the shot class or plan to attend the shot class prior to starting any injections.
- Injections will be given twice a day.
- You should have discussed the risks and alternatives with a physician and signed a consent form before proceeding with your treatment cycle.
- You should understand this treatment cycle involves follow up ultrasounds starting between medication day 7 and 10. Repeat ultrasounds may be necessary every other day for approximately one week. These ultrasounds are mandatory.
- You may be asked to give a blood sample at each visit.
- Treatment may be terminated at the discretion of the physicians at any time in the interest of your safety.
We will plan to perform an ultrasound on approximately day 22-25 your menstrual cycle. This baseline ultrasound will be used as a comparison during follow up ultrasounds. If your menses are not regular then the specific day of this ultrasound is less important. All patients will require a pregnancy test. Following confirmation of a negative pregnancy test you will begin injections of 0.1 cc (10 units) Lupron (5mg/ml – 14 day kit) using a 1cc insulin syringe. Lupron does not require mixing. Injections should be given in the AM using the subcutaneous (Sub Q) technique. The vial will last your entire treatment cycle though it may appear you will run out. Additional Lupron can be supplied at your next ultrasound visit if you are going to run out.
Lupron will inhibit your natural hormones and induce a menopausal like state. This prevents your body from forming follicles and also blocks your natural LH surge. You will usually experience a normal menses at the expected time. From this point forward we no longer need to be concerned with the day of your menstrual cycle. Essentially you will be on day 0 as long as you remain on Lupron.
You will be given a start date for gonadotropins as well as a date to follow up for an ultrasound. This follow up ultrasound is referred to as the “monitoring” phase of your treatment. If your menses occurs at a time other than expected you should continue the lupron and call the clinic. (More information about injectable infertility medications can be found here)
All of the Injections are subcutaneous and are given just underneath the skin. The thigh, back of the arm, and stomach can be used for these injections. The syringes are marked in increments of 10, 20, 30, etc or 0.1, 0.2, 0.3 etc.
The first day you take gonadotropins is considered medication day 1. Your first monitoring ultrasound should already be scheduled sometime between day 7 and day 10. Most of the time the first ultrasound will be on day 9. On medication day 1 you will also need to decrease your Lupron dose by half. You will be taking 0.05 cc or 5 units. Continue this dose until you are told to stop taking medications. On average, a cycle will last 12-14 days of gonadotropins with occasional treatments ranging from 9 to 16 days.
During the monitoring phase you may be asked to have your blood drawn to check your estradiol. This is to prevent hyperstimulation. Ovarian hyperstimulation syndrome (OHSS) can be life threatening. It is not unusual to experience mild symptoms of OHSS. Moderate to severe OHSS may result in cycle cancellation. Things to look for include:
- Rapid weight gain
- Abdominal and pelvic discomfort
- Shortness of breath
The monitoring ultrasounds will help avoid OHSS as well as determining when the growing follicles are most likely to be mature. When your follicles are ready you will be instructed to take hCG. This is the hormone made by pregnancy but acts just like LH. This mimics your natural LH surge and triggers ovulation after approximately 40 hours. You will receive instructions for an intrauterine insemination (IUI) or intercourse. When you take your HCG you will no longer need to take gonadotropins or Lupron (you should take your morning dose of lupron on the day you take HCG to prevent premature ovulation).
HCG will also need to be mixed as follows:
- Mix 2 cc diluent with all of the powder (10,000 units HCG)
- Draw up 1 cc of the mix 18g needle into a 3 cc syringe
- Discard the 18g needle and use a 25 g 5/8 inch needle to administer the medication using the subcutaneous technique.
- Save the remaining 1cc (5,000 units) in the refrigerator.
- 3 days after the first HCG injection give ½ cc sub-q any time of the day
- 3 days after the second HCG injection give ½ cc sub-q any time of the day. Do not worry if the total amount is less than ½ cc.
Intercourse is usually planned for the day of HCG to improve the sperm sample on the day of the insemination. Repeat intrauterine inseminations are not usually not performed due to the precise timing of the initial IUI. The insemination is performed in the clinic by appointment. The sperm processing procedure can take up to two hours. Once the sperm processing is completed, the sperm will be loaded into a small catheter which is inserted into the uterus. The sperm are held in place and will not fall out. There is no need to remain lying down or to limit your activities. Click here for more information about intrauterine insemination or artificial insemination.
Donor sperm can be used for insemination procedures. The clinic can help you to understand this process and provide you with information for obtaining donor sperm for use with intrauterine insemination. We have our own liquid nitrogen storage tanks and will ask that the sperm be shipped directly to our facility for proper handling and storage. We are happy to work with gay and lesbian (same sex) couples and single women.
14-16 days after your insemination you should have a serum pregnancy test performed if you have not had menses. Once pregnancy has been confirmed, you will be scheduled for an ultrasound about 5-6 weeks after insemination.
Common symptoms after a cycle include abdominal bloating, “crampy” abdominal pain, mild nausea, and breast tenderness. Activity levels should be adjusted to the severity of symptoms. If not pregnant, the period following a cycle may be heavier than normal. Early pregnancy symptoms may mimic PMS symptoms so beware of interpreting the symptoms you experience. Also, the cycle between stimulated cycles may be longer than usual.
There are many hurdles where things may not go well during a cycle.
- At the baseline ultrasound we may find large cysts on the ovaries or discover a uterine anomaly. This may require treatment or further assessment prior to beginning a cycle.
- The ovaries may not stimulate well and you may have only a few follicles.
- The opposite may happen and you may have too many follicles or an estrogen level that is dangerously high. Should this occur we will discuss the increased risks of ovarian hyperstimulation syndrome with you and, if necessary for your health, will cancel the cycle.
- Two weeks after insemination a pregnancy test will be performed if you have not had a period. Bleeding can occur with miscarriage, ectopic pregnancy, and normal pregnancies. To determine what is occurring, we may need to do serial blood tests for HCG (the pregnancy hormone). This can be a very frustrating and confusing time. We will try to keep you as informed as possible given the information we have.
- Another disappointment can occur on the day of the ultrasound. Even with normally rising HCG levels it is possible to have an abnormal pregnancy. There may be an empty gestational sac or an ectopic pregnancy. Should this occur, a D&C is sometimes necessary. If an ectopic pregnancy is suspected, a D&C may be performed and/or you may receive a medication to help resolve the pregnancy (methotrexate), and/or surgery may be needed. If the results of the ultrasound are inconclusive we will often wait a week and repeat the ultrasound. Again, this can be a very difficult waiting period.
Once a baby with a heartbeat is seen in the uterus, the chances of an ongoing pregnancy are very good. Once we have this information you will need to schedule an obstetrics appointment. Once you have been seen by the obstetrician, they will take over your care. Of course we want you to stop by to show us your beautiful belly!
- Baseline ultrasound and pregnancy test on cycle day 22-25
- Start lupron that same day after confirming a negative pregnancy test
- Call on 1 st day of menses and a medication start date and ultrasound date will be given
- Start gonadotropins when instructed. Lupron dose cut to 5 units
- Continue daily lupron and gonadotropins
- Monitoring ultrasounds between medication days 7-14 (average range)
- HCG when follicles are ready. Injections given for times.
- Stop gonadotropins and lupron when HCG is given
- Intrauterine insemination occurs 2 days after HCG (if doing IUI)
- Supplemental HCG every 3 days x2 following 1 st injection.
- Pregnancy test 20 days after HCG or insemination (when clinic open).
This is a lot of information and may seem confusing. This is to provide an overview only. Step by step directions will be provided at each visit. Questions are best written down so you won’t forget. Fertility medications can be very dangerous and should be taken only under the direct supervision of a doctor with experience managing the potential complications such as ovarian hyperstimulation or OHSS.