OVULATION DRUGS
Ovulation inducing agents are used in two different ways. First they are used for patients
with irregular cycles to normalize ovulation. Secondly, they are used for normally
ovulating women as an adjunct to intrauterine insemination. This is because insemination
in the natural cycle has poor pregnancy rates. There are two categories of ovulation
drugs: oral and injectable. The oral medications are simple to take,
inexpensive and have modest results. The injectable drugs are more complex to
administer but give far superior results.
Clomid and Serophene (oral medications):
 The first line therapy
are oral drugs such as Clomid or Serophene. These are identical drugs made by two
different companies. They are both oral mild medications with modest results. These drugs
work by stimulating the release of FSH and LH, which are the crucial hormones that
stimulate egg production. The total pregnancy rate with these agents is 35 - 40% after 4 -
6 cycles of use. It is important to know that the lowest effective dose is best. Also most
individuals will get pregnant with lower doses within the first few months of use. Therapy
beyond 6 cycles is not useful in most cases. While the drug is administered, response can
most accurately judged with ultrasound or progesterone levels. The reason some individuals
will not get pregnant with this medication is that it thickens the  cervical mucus and thins
the lining of the uterus. Approximately 90% of all births are single with this medication.
One such example is the young lady who appears below:
The multiple pregnancy rate with this medication should be no more than 7-10%. Most
multiples seen here will be twins. Side effects include hot flushes and mood disturbance.
Injectable Drugs such as Pergonal:
Frequently, first line therapy is ineffective. We must then turn to the injectable
ovulation inducing agents. These agents are in almost all cases functionally equal.
They can be divided into two groups:
- Older compounds that contain follicle stimulating hormone (FSH) and luteinizing hormone
(LH). These compounds include: Repronex,
Pergonal, and Humegon.
- Newer drugs that contain pure FSH: Follistim,
Gonal F and Bravelle.
There has been a great deal of debate over whether FSH only is needed or
FSH and LH. It appears that for most cases, FSH is probably enough. Each case is best
managed individually. These agents share some common points. They are all expensive. One
month's treatment can run $500-$1,000 in drug cost. They are also all injectable.
Typically, 7 - 10 days of shots are required per month. The newer agents (Gonal F and
Follistim) are given with the smallest needles (subcutaneously). They are all prone to
multiples. The incidence of multiples is approximately 15-20%. Most multiples contrary to
popular belief are twins as pictured below. The incidence of triplets is 3-5%.
 These agents are highly
effective and will give cumulative pregnancy rates of roughly 50%. Side effects include
various degrees of ovarian enlargement which causes the patient to feel " crampy or
bloated". Close monitoring will improve results and possibly reduce the number of
multiples seen. During treatment, blood work and ultrasounds are used to monitor response.
Typically no more than 3 or 4 visits are required per month. When the follicles are judged
to be mature, hCG is given to trigger ovulation at a precise time. Ovulation usually
occurs 36-40 hours after hCG. In some cases, insemination will be performed around the
time of ovulation. Injectable drugs are often effective when oral medications have failed.
This is because they often produce better quality eggs and the lining of the uterus is
more receptive to the embryo. It is important to know that the goal of injectable drugs is
quality not quantity of egg production.
The Role of Artificial (intrauterine)
Insemination
One common question that arises is whether insemination is desirable or
necessary when ovulation drugs are used. If we are treating a pure ovulation problem
and the sperm count is normal, it may be purely optional. If however we have a
patient who is ovulating already and we are using ovulation drugs as part of a combined
protocol of ovulation and intrauterine insemination, it is a required part of the
treatment.
For more information on each individual agent, please go to the patient education section.
Useful web sites for drug information are: http://www.seronousa.com and http://www.ferringusa.com. For some fascinating information
about ovarian production of eggs, please follow the following link: http://www.seronocycle.com .
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