Hyperstimulation

Controlled Ovarian Hyperstimulation involves using injectible FSH to carefully stimulate the ovaries to develop multiple follicles and ovulate.  The process is carefully monitored with sonograms and estrogen levels to avoid overstimulation and the development of too many follicles.  Below is a sample protocol in which FSH is followed with carefully timed intercourse.  This treatment can also be coupled with intrauterine insemination (IUI).  Please see the IUI page for more details on intrauterine insemination.

Follicle Stimulating Hormone (FSH) with Intercourse Cycle
Your doctor may recommend that you undergo ovulation induction with FSH (follicle stimulating hormone) in conjunction with intercourse for the treatment of your infertility. There are several FSH preparations your doctor may prescribe, such as Gonal-F or Follistim. The goal of the therapy is to induce ovulation in individuals who do not ovulate spontaneously on their own (such as in patients with PCOS or polycystic ovarian syndrome) and have failed clomiphene citrate therapy (Clomid or Serophene). Generally, this treatment is done for up to 4 to 6 cycles.

You will probably be asked to sign consent forms including FSH, HCG, and progesterone. Your doctor’s office will ask you to attend an injection class at prior to the onset of your treatment cycle to learn about the various types of injectible medications you will be using and to teach you how to do the injections. Your doctor or nurse should order all of your medications prior to the onset of your cycle. Many pharmacies do not keep these medications routinely in stock, but your doctor can suggest pharmacies in the area.

 
You will need a baseline sonogram and estradiol level on the second or third day (preferably the second day) of your menstrual cycle prior to starting your injections. The first day of normal menstrual flow (not spotting), is considered day I. At your initial sonogram, the doctor or nurse will do a vaginal sonogram to assess the ovaries as well as to measure the endometrial thickness.  You will also have a blood draw for an estradiol level. You will be given an instruction sheet which indicates the dosage of FSH you will inject for the first several days of stimulation. The dosage varies depending on your age and past stimulation cycles. The typical stimulation lasts between 8 days to 4 weeks. You should take your injections at approximately the same time every day. In general it is preferable to take your medication in the evening if possible as this allows more rapid dosing adjustments based on estradiol levels. You will take your FSH every day until you take HCG. Make sure to keep track of how much FSH you have used and calculate how much you have remaining so you know when you need more medication.  The FSH shot is subcutaneous, can be easily administered to yourself, and is virtually painless.

You will be instructed to return a few days later for an estradiol level (blood test) and possibly a sonogram. Based on your estradiol results, your doctor will make any necessary changes in your dosage. Typically patients who are taking injections due to abnormal ovulation are in the office every 2 to 3 days of injections after the initial estradiol level for further blood work and or sonograms. Depending on your response, you may be in more frequently. Do not be frustrated if your response to the medication appears “slow”. Typically women with PCOS have a tendency to “over-respond”; therefore, we start with a “low” dose and increase slowly to help us achieve the desired result. It is not uncommon to see the estradiol levels fluctuate up and down until reaching a level of 100 pg/mI. Despite careful monitoring and adjustments of dosage, some patients do “over-respond” resulting in cycle cancellation although this is an infrequent event.

Typically during an FSH intercourse cycle, ovulation is triggered at the appropriate time with an injection of HCG (yes the pregnancy hormone). Occasionally, a patient may start to initiate ovulation on her own prior to receiving that injection. For that reason your doctor may recommend the use of an ovulation predictor kit during an FSH/intercourse cycle. Your doctor will give you an instruction sheet regarding the definition of an LH surge, when to test and when to have intercourse and notify the office. Be sure to review this sheet carefully.

Once again, the time for the ovulation is based on the response of your ovaries to the medication. Your doctor will decide when to have you take the HCG injection to trigger ovulation based on the size of your follicles, duration of stimulation, estrogen level as well as your age.  Generally they look for your follicles to approach 18 mm. You will be instructed to have intercourse the evening you take the HCG trigger shot and return the following day for a post coital test. This is a painless test, which involves sampling the cervical mucus and evaluating the number of motile sperm. Depending on the results, your doctor may recommend an intrauterine insemination for that cycle or future cycles. Once the post coital test has been done in an FSH cycle, it is not necessary to repeat it in future cycles unless desired by the patient. Abstinence from intercourse is not necessary during your stimulation. It is preferable to have intercourse a few times during the stimulation such that if spontaneous ovulation occurs, sperm are already present in the cervix uterus/fallopian tubes,

Frequently patients taking FSH to induce ovulation will experience discomfort and cramping particularly around the time of ovulation. If this occurs, please take Tylenol (not Advil, Motrin, Nuprin, etc) and/or use a heating pad. This medication can cause you to mature and ovulate more than one egg, increasing the chance of multiples.

You will return two days following the HCG injection for a sonogram to check for ovulation. At that time you will begin taking progesterone (suppositories, shots, tablets, or cream). Continue your progesterone every day until your pregnancy test. Sometimes in an FSH cycle, clear evidence of ovulation may not be observed. It is recommend that you take your progesterone anyway. Sometimes patients experience spotting or even heavier vaginal bleeding, which they think is their menstrual period BEFORE the scheduled pregnancy test. At this point your doctor cannot determine whether or not you are pregnant. Bed rest at this point is not beneficial. A pregnancy test will be scheduled for 12 days following ovulation. A pregnancy test is called a quantitative beta HCG, which is a blood test to measure the level of HCG (pregnancy hormone).  Do not take a home pregnancy test as your body will still have some HCG from your trigger shot and you could get a false positive.  This test measures the actual level of HCG in your blood to determine if you are pregnant.

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Last modified: March 22, 2006