Ovulation Induction

Question 1

What medication can people with Group 1 anovulatory infertility be offered?

Answer 1

• Pulsatile administration if gonadotrophin releasing hormone
• Gonadotrophins with LH activity to induce ovaultion

Question 2

What should women with Group 2 ovulation disorders (PCOS) be advised in terms of lifestyle factors?

Answer 2

If they have a BMI of 30 or over then should lose weight as this may restore ovulation, improve their response to ovulation induction agents and have a postive impact on pregnancy outcomes.

Question 3

What monitoring does clomifene citrate initially require and why?

Answer 3

Ultrasound monitoring in the first cycle to ensure that the dose they are taking minimises the risk of multiple pregnancy.

Question 4

How long should clomifene citrate treatment be continued for?

Answer 4

No longer than 6 months

Question 5

If clomifene citrate has not been successful then what are the next treatment options?

Answer 5

Laparoscopic ovarian drilling

Gonadotrophins

Question 6

What are the first line treatment for Group 2 anovulatory disorders?

Answer 6

Clomifene
Metformin
(Often used together)

Question 7

How many days after the LH surge is progesterone at its peak?

Answer 7

8 days

Question 8

What further hormonal tests do we do if a day 21 progesterone does not indicate ovulation?

Answer 8

LH
FSH
E2
Testosterone
Free androgen index
Prolactin 
TSH

Question 9

How large are the ovaries in PCOS?

Answer 9

More than 10cm

Question 10

What appearance of ultrasound is suggestive of PCOS?

Answer 10

• Increased ovarian volume (more than 10cm)

- More than 12 follicles between 2 - 8mm which are usually around the edge (pearl necklace appearance)

Question 11

What % of people ovulate and what % conceive on clomifene treatment?

Answer 11

70 - 80% ovulate

40-50% conceive

Question 12

When and how do you take clomifene citrate?

Answer 12

Start on day 2 - Day 6
Take for 5 days
Monitored with tracking scan and serum progesterone

Question 13

What is the maximum daily dose of clomifene citrate?

Answer 13

150mgs/day

Question 14

What % of people ovulate and conceive with gonadotrophin injections?

Answer 14

70% ovulate

20% conceive

Question 15

What % of people ovulate and conceive with laparoscopic ovarian drilling?

Answer 15

80% ovulate

34% conceive

Question 16

What is the multiple pregnancy rate with clomifene citrate?

Answer 16

10%

Question 17

When is the optimal time to have sex when on clomifene treatment?

Answer 17

5 days after the last clomifene tablet.

Question 18

What are the risks of ovulation induction treatment?

Answer 18

Multiple pregnancy
Miscarriage (Miscarriage rates are much higher in women with PCOS with a high LH)
Risk of borderline ovarian tumours seems to increase if ovulation induction techniques are used for more than 12 months.

Question 19

How exactly does clomifene work?

Answer 19

It is a selective oestrogen receptor modulator. It inhibits oestrogen receptors in the hypothalamus which stops the negative feedback effect of oestrogen on gonadotrophin release leading to up regulation of hypothalamic pituitary gonadal axis.
Increased FSH levels cause more growth of ovarian follicles and subsequent rupture of follicles resulting in ovulation. (most commonly 6 -7 days after a course of clomifene)

Question 20

What are some side effects of clomifene citrate?

Answer 20

Ovarian enlargement (reversible)
Blurred vision (stop immediately if this occurs as it is not reversible)