Ovulation induction with fertility medication (clomiphene citrate
or one of the menotropins) is appropriate in many clinical situations.
Two different goals of fertility medication are
* ovulation induction, where a woman who does not ovulate
takes medication to enable her to ovulate (form and release at
least one mature egg), and
* ovulation enhancement, where a woman who ovulates spontaneously
takes medication to optimize the maturation of recruitable follicles
(and eggs) for a particular cycle.
Ovulation induction may be attempted in any woman who does not
ovulate spontaneously as long as there are some eggs within the
ovaries that may respond. The cycle day 3 FSH and estradiol concentrations
as well as the clomiphene challenge test may help in determining
ovarian reserve.
Clomiphene citrate is the usual entry
level drug for inducing ovulation since it is easier to use than
menotropins. It is
- much less expensive,
- requires less ongoing monitoring (ultrasounds and blood work),
and
- the complications are typically much less severe.
Overall, in women selected for clomiphene citrate ovulation is
initiated or made significantly more regular about 85% of the
time. Regularization of ovulation may allow for a greater degree
of predictability in timing intercourse or artificial inseminations.
If clomiphene citrate fails to accomplish ovulation or if the
woman is intolerant to the side effects, then menotropins should
be considered.
If a woman is ovulating regularly on her own, it is not clear
that clomiphene citrate offers any real fertility advantage.
Common indications for the use of clomiphene citrate include:
* Polycystic ovary syndrome, and
* CNS-hypothalamic dysfunctions when there is adequate
estrogen production for at least a withdrawal flow to progesterone
Ovulation enhancement is an attempt to mature all of the recruitable
eggs for a given cycle. Typically, clomiphene citrate is a poor
ovulation enhancement medication but there is some reasonably
convincing literature predominantly from Europe that suggests
higher doses of this medication starting on cycle day 2 rather
than cycle day 5 may result in better enhancement and regular
development of more than one fully mature egg. The ovulation enhancement
medication of choice is the family of menotropins,
which includes Pergonal, Humegon, Metrodin, Fertinex and two different
recombinant forms of FSH. Complications of
menotropins can be significant. Some common indications
for the use of menotropins include:
* subtle male factor problems,
* endometriosis,
* unexplained infertility,
* some forms of ovarian failure and women with deminished ovarian
reserve,
* tubal factor infertility with patent fallopian tubes
* ARTs (including IVF)
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