Infertility Treatments
Superovulation
What is superovulation?
Superovulation, also known as controlled ovarian hyperstimulation (COH), is the process of inducing a woman to release more than 1 egg in a month. This is in contrast to ovulation induction, where the goal is to release one egg a month.
Who is a candidate for superovulation?
Women with open tubes and whose partners have adequate sperm counts are candidates for superovulation.
If the woman already ovulates and she is not conceiving, we can increase the chance of getting pregnant by causing her to release more eggs. Similarly, if a woman has been ovulating with an oral medication, like clomiphene, and is not conceiving, we can improve her chances of conceiving by stimulating her ovaries to release more eggs.
How is superovulation performed?
Women who naturally ovulate may release extra eggs when they take oral medications such as clomiphene. This is a mild form of superovulation and is generally low in cost and risk. We recommend an ultrasound around the time of ovulation to determine how many follicles are growing. If a woman is producing just one follicle, the dose or medication might be changed in the next cycle.
Many women undergoing superovulation will opt for gonadotropins. Gonadotropins are hormones which cause eggs to grow. Many different brands are available, (Bravelle, Follistim, Gonal-F, Menopure and Repronex) but most are equally effective. These medicines are given by injection, with a small needle, just beneath the skin. The dose and brand will be selected by your physician prior to your treatment. Given in high doses, gonadotropins will cause multiple eggs to grow at the same time. A woman using gonadotropins requires close monitoring to ensure she is not producing too many eggs.
Typically a woman will take 3 days of medication and then return for an ultrasound and blood work. Depending on how robustly her ovaries respond, she will be asked to return to clinic some time during the next 1-3 days for additional monitoring. Once the desired number of eggs are mature, the woman is given an hCG injection to cause ovulation. If she is doing IUI, she returns to the clinic 36 hours after hCG for the insemination.
The entire treatment generally lasts 6-9 days, and requires 2-4 office visits. The cost will vary greatly from woman to woman due to varying amounts of medication and monitoring needed in different women. A large part of the cost is due to the gonadotropin medications; there are often pharmacy or drug company promotions which offer medication discounts to self-pay patients without insurance benefits or offer discounts on future cycles of treatment when the first cycle is unsuccessful. Our nurses will present these options to you if they exist at the time of your treatment. A rough estimate of costs for a cycle of superovulation will be between $1,500 and $2,200 without artificial insemination.
What are the risks of superovulation?
Multiple Births
The major concern with superovulation is the chance of multiple births. Twins occur in 20-30% of successful cycles (versus 1-2% of natural cycles). Of all treatments offered, superovulation has the highest risk of triplets, generally 3% - 5% chance; this is due to the fact that despite close monitoring, we can’t always control exactly how many eggs will be released.
Ovarian Hyperstimulation Syndrome (OHSS)
OHSS is a condition in which the ovaries get very large and filled with fluid in response to the gonadotropin medications. Factors are released by the ovaries which cause a woman’s blood vessels to leak fluid into the pelvis. In mild forms of OHSS, a woman may have symptoms of bloating and pelvic discomfort; this occurs in 10-20% of gonadotropin cycles and resolves quickly after treatment ends. In severe cases, a woman may have difficulty urinating, become dehydrated, gain weight rapidly, and have organ complications involving the lungs, kidneys and liver; this is rare, occurring in 1% of cycles. These women may require hospitalization. Women are at increased risk of blood clots when they have OHSS, and any symptoms of leg pain or difficulty breathing should be reported to your physician immediately.
Risk factors for OHSS include:
- Young age
- Low body weight
- Polycystic ovary syndrome (PCOS)
- Higher doses of gonadotropins
- High absolute or rapidly rising estrogen levels
- Previous episodes of OHSS
- High number of developing follicles
There have been cases of death reported as a result of complications from OHSS. Fortunately, severe cases of OHSS are rare. By closely monitoring your response to gonadotropins, your physician can markedly decrease your chances of developing OHSS. However, if you are at risk, your physician may cancel your stimulation for your safety.
Among women who conceive, symptoms of OHSS may worsen at the time pregnancy is detected and may take longer to completely resolve.
Ectopic pregnancy
Ectopic (outside of the uterus) pregnancies usually involve pregnancies that have implanted in the fallopian tubes or less commonly in the cervix, ovary or pelvic cavity. Ectopic pregnancies occur in 1-2% of all pregnancies, but are more common during fertility treatments due to the fact that many women with infertility have tubal dysfunction and because medications often cause the release of multiple eggs, thereby increasing the possibility that not all eggs that are fertilized successfully move through the tubes into the uterus. This requires medical or surgical therapy.
Adnexal Torsion (Ovarian Twisting)
This is a rare complication (1%) of cycles. As the ovaries enlarge, they may twist, cutting off their blood supply and causing severe abdominal pain, nausea and vomiting, and sometimes low grade fevers. Treatment involves surgical untwisting of the ovary.
Ovarian Cancer
Gonadotropins are not thought to increase the risk of ovarian cancer.
Am I wasting my eggs by doing this treatment?
This is another common concern. Women who pursue superovulation do not go through menopause earlier than other women. From what we understand about the physiology of the ovary, it is unlikely that a woman is wasting her eggs by pursuing this treatment.
A woman is born with a certain number of eggs, approximately 2 million. Every day, a woman loses some of these eggs. She loses them no matter whether or not she is ovulating, if she is on birth control or even if she is pregnant.
Each month a batch of eggs comes out of storage with the purpose of ovulating. However, the hormones which drive ovulation (FSH and LH) are in relatively short supply. In a natural cycle, there are only enough hormones to prompt one egg to grow. The other eggs in that batch die off and are gone forever.
Superovulation rescues a few of these other eggs. By supplying more FSH, more of these eggs will ovulate and have the opportunity to result in a pregnancy.
For more details on this topic see Ovarian Reserve testing.