Ovulation induction

SUPEROVULATION AND INTRAUTERINE INSEMINATION
Fertility problems are surprisingly common, affecting one in six couples. Whilst this may cause great distress there are now various treatments to help the majority of couples have a child.

To find the cause of infertility both partners are investigated. Tests are carried out to check for ovulation (production of an egg), to ensure the woman’s fallopian tubes are open and to assess sperm production. Following this a cause for a couple’s infertility may be found and specific treatment offered. For example, tubal surgery or In-vitro Fertilisation (IVF) for blocked fallopian tubes. However, in a significant number of cases we may not be able to identify a problem in either partner and we call this “unexplained infertility”.

Unexplained infertility can be a very frustrating diagnosis but it should also be reassuring as such couples often have a good chance over time of conceiving naturally. At some stage though, treatment to improve the couples’ chances may still be indicated. The choice of treatment will depend upon many factors, including the duration of infertility and the partners’ ages. All the methods essentially involve helping nature to prepare eggs and sperm, allow them to meet in a natural or artificial environment, enable fertilisation to occur and then eventually form a pregnancy in the womb; hence the term often used of “assisted conception”.

The success rate of assisted conception procedures depends upon the age of the female partner and the cause and duration of infertility. . This procedure can be a big undertaking for some couples and unfortunately the waiting times may be long. In some circumstances it may not be available under the NHS leading to considerable expense for the couple. Others may prefer an alternative treatment for personal, religious or ethical reasons.

An alternative or additional procedure is available to couples with unexplained fertility or, in whom the fallopian tubes are open and the sperm count is reasonably normal. This is called superovulation.

Follicle Stimulating Hormone (FSH) itself can be given as a subcutaneous (under the skin) injection on a daily basis. Treatment each month usually takes only eight to ten days and again side effects, if they occur, are usually mild (see list below). FSH is usually used together with another drug that stops the body’s own gonadotrophins from being released. These drugs are copies of a hormone called Gonadotrophin Releasing Hormone (GnRH) and can be given as a nasal spray or injection. When used they can produce menopausal symptoms but their effect is completely reversible. Once again it can take one or more cycles to work out the right dose of FSH. If treatment produces a pregnancy it usually does so in the first two months and so FSH is rarely continued after this.

The response to gonadotrophins is monitored by vaginal ultrasound scanning of the ovaries. It is possible to count the number of follicles and, from their size, calculate when they are mature. At this point an injection of another hormone, human Chorionic Gonadotrophin (hCG), is given to trigger the eggs final development and release (ovulation). Crucial to the success of treatment is the arrival of sperm in the fallopian tube at the time of ovulation. This can be achieved by timing intercourse, by intrauterine insemination or by a combination of both. If too many follicles develop the treatment is abandoned and the couple advised to abstain from intercourse, to limit the risk of multiple pregnancy. The treatment can then usually be repeated safely the next month using a lower dose of drugs.

Intrauterine insemination
There is a chance of pregnancy with superovulation and intercourse alone but it can be improved further when combined with intrauterine insemination. In this technique, when the right day has been reached, a sample of sperm from the male partner is first prepared in the laboratory. It is then passed through the cervix, using a fine tube into the upper part of the uterus (womb), with a procedure very similar to a cervical smear test. This enables more accurate coordination of ovulation and sperm delivery and bypasses the cervical mucus, which may present a barrier to sperm in some couples. The process may be used in combination with intercourse to increase the number of sperm available for fertilisation. It is best to use a fresh sperm sample but on occasions frozen samples may be stored and used.

In the year ending 30th June 2012, the continuing pregnancy rate for superovulation and IUI was 12.5%.

Ovulation and superovulation
Ovulation is the natural process that produces an egg each month. Hormones called gonadotrophins stimulate the ovary to produce a follicle (a small cyst like structure within the ovary). This follicle contains an egg which when released into the fallopian tube may be fertilised by a sperm.

Superovulation is the use of drugs to stimulate the ovary to produce up to three eggs within a cycle. An obvious concern is that this might lead to a multiple pregnancy and even when ultrasound is used to monitor the ovaries, the risk cannot be removed. Twins, but more particularly pregnancies with triplets or more, carry significant risks. There is an increased risk of miscarriage and premature labour. Largely because of prematurity the babies are also at increased risk of long term health problems or handicap. We try to keep the number of multiple pregnancies as small as possible but it is important that you understand these risks before starting. There will be a chance to discuss this with the nurse or doctor supervising your treatment.

Problems and side effects
Multiple Pregnancy – the risk of multiple pregnancy can never be completely removed and the possible consequences are described above. Twins occur naturally in about one in every eighty pregnancies. If clomiphene is used the risk is about one in ten but slightly higher if FSH is used. The risk in IVF is about one in four but the number of embryos replaced can usually be limited to two and so the risk of triplets or more should be very small. With superovulation and intrauterine insemination, even with the use of ultrasound, the risk of triplets is about one in twenty.

Ovarian Hyperstimulation Syndrome (OHSS) – this is a rare, and potentially very serious, condition that can happen when too many follicles grow. It is again a little more common with FSH rather than clomiphene. The symptoms include abdominal distension, discomfort, nausea and difficulty in breathing. Careful monitoring will usually identify those at risk and OHSS can be prevented by abandoning the treatment cycle. In extreme cases hospitalisation may be needed but simple measures often suffice and a contact number is provided for all patients.

Specific Side Effects
Clomiphene – side effects are unusual but occasionally patients may experience; hot flushes, abdominal discomfort, stomach and bowel upsets, breast tenderness, headaches, dizziness and mood changes. A more unusual symptom is visual disturbance but if this happens you should stop the tablets and contact us or your GP.
FSH – occasionally there may be a local reaction at the site of injection with redness and swelling but no specific measures are needed. As with all medications if you have any doubts about a problem you should discuss it with the doctor or nurse supervising your treatment.

Frequently asked questions
Is the treatment safe for the baby? – There is no increased risk of birth defects from any fertility drug. The risks of multiple pregnancy and OHSS have already been described above but if these do not occur then no special measures are necessary for your pregnancy. The risk of having a miscarriage or a baby with abnormalities will be the same as for a natural conception and risks will depend largely on the mothers’ age and whether there is any family history of problems. If you have specific concerns these can be discussed before treatment.

Is the treatment safe for the mother? – Some concern has been expressed about the safety of ovulation induction drugs for the mother. There is no evidence that these drugs cause long term health problems for women. However it is important the drugs are used sensibly as in theory excessive use might cause ovarian growths. It is for this reason that the number of treatment cycles is limited. There is also the risk of OHSS described above but in general the risks to women are less than those of pregnancy.

How long is the waiting list? – At the moment the wait is about sixmonths. Once started however you should be able to receive each treatment after another without interval.

What happens if the treatment doesn’t work? – Most couples will still have a chance of falling pregnant naturally, this treatment should be thought of as an adding to that chance. Some couples may already have other treatment planned whereas others may decide they have had enough intervention. If you complete the treatment and do not fall pregnant a review appointment with your consultant will be offered as soon as possible.

Is counselling offered? – Ninewells Assisted Conception Unit (ACU) has an independent counsellor and a separate leaflet is available detailing her services. Please remember that the staff you see have considerable experience in infertility treatment and there should be time to discuss most concerns that you have.

Costs

For patients who are not eligible for NHS-funded treatment, the costs per cycle are as follows:

Intrauterine insemination – £170

Intrauterine insemination using donor sperm – £250

Drugs – £200 (if fewer than 20 x 75 IU of injections are used, a refund will be given)

Payment must be made before each cycle can start

Additional information

At the first visit, a nurse will discuss more general aspects of your health including lifestyle, weight, diet, alcohol intake and smoking habit where appropriate. We also recommend that you obtain a supply of Folic Acid tablets to commence prior to your treatment. There will be an opportunity to ask questions and to sign the necessary consent forms. It normally takes approximately 20 minutes for this visit.

An ultrasound scan may be performed to examine the ovaries, fallopian tubes and the uterus. This scan is performed using a vaginal probe. Subsequent scans will be arranged to monitor the developing follicle(s) then artificial insemination carried out when appropriate.

Our service is designed to introduce the best treatment at the most appropriate time for you. Your choices, and the reasons behind them, will always be discussed with you.

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