Ovulation problems are a common cause of infertility for women. There are several reasons why a woman may not be ovulating or is ovulating irregularly, all of which make it difficult to become pregnant.
Ovulation is when a mature egg is released from the ovary. The egg travels to the fallopian tube, where it can “mix” with or be fertilized by sperm. If the egg is fertilized, the resulting embryo travels to the uterus, a journey that takes several days. If the embryo implants, you’re pregnant. If it doesn’t, you’ll have your “period.”
Ovulation induction uses fertility medications to stimulate the release of one or more eggs from the ovary. Sometimes, a procedure called intrauterine insemination (IUI) is used in conjunction with ovulation induction to achieve pregnancy. IUI entails placing washed, concentrated sperm directly into a woman’s uterus via a small catheter.
At Yale Fertility Center, we customize treatment to an individual or couple’s specific needs. “Our staff have specific areas of expertise related to the various causes of infertility, and we can individualize the care for each couple,” says Pinar Kodaman, MD, PhD, a reproductive endocrinologist and infertility specialist.
How does ovulation induction work?
For women who are not ovulating or who have irregular menstrual cycles or unexplained infertility, ovulation-inducing medications are often the first method physicians will try to achieve pregnancy. Medications stimulate the release of hormones that drive egg production. (Sometimes another hormonal injection is used to trigger ovulation, although some women wait for that to happen naturally.)
There are two types of ovulation induction medications:
Oral medications. These are usually the first line of treatment for women who do not ovulate or who ovulate infrequently.
A typical treatment cycle begins with an ultrasound and blood work on the third day of the menstrual cycle. Clomiphene (Clomid) and letrozole (Femara) are oral medications taken between days three and seven or between days five and nine of your cycle. A transvaginal ultrasound will be performed on day 10 or 11 to check for egg development. In the ovaries, each egg is contained within a follicle, or fluid-filled sac, that can be visualized by ultrasound. When a woman ovulates, the follicle releases a then-mature egg. (Several follicles develop in the ovaries during each cycle, but usually only one will release an egg.)
Your doctor may use ultrasound and bloodwork to monitor the development of follicles to let you know when you should start attempting to conceive naturally or determine when to use intrauterine insemination.
“Patients can also monitor themselves at home with ovulation predictor kits,” Dr. Kodaman says. “This works well for women who have limited insurance coverage or those who have difficulty finding time to come into the office early in the morning when monitoring is done. They can simply time intercourse based on the ovulation kit or see us only for the insemination procedure.”
Injectable medications: If oral medications are unsuccessful, injectable medications such as a follicle-stimulating hormone (FSH) are typically the next step. The treatment cycle begins with an ultrasound and blood work on day three of the menstrual cycle. Injectable medications are started on day three and are continued for six to 10 days, depending on response.
During that time, you may require three to four ultrasounds and blood work to monitor the development and pace of the follicle growth. After each visit for ultrasound and bloodwork, you will receive a phone call from the nurses with follow-up instructions.
Once the lead follicle/s measure at least 16 to 18 millimeters in diameter, you will be instructed to take an injection of human chorionic gonadotropin (hCG), which triggers ovulation. IUI or intercourse can then be performed to achieve conception.
What are the risks of these medications?
Although most women do not have significant side effects from the oral or injectable medications, some may experience hot flashes, mood swings, bloating, breast tenderness, pelvic pressure, abdominal pain or nausea.
“Women should also realize there is a chance of multiple births with either type of medication,” Dr. Kodaman says. “With oral medications, the chances are between 5 and 10 percent, and with injectables, they are more like 20 percent.”
How successful is ovulation induction?
Success depends on the woman’s diagnosis and other factors, including her age. “In general, we achieve a 20 to 25 percent success rate of pregnancy per cycle,” she says. “And it’s important to note that the chance of any pregnancy in a young, healthy couple with no fertility issues is, at best, about 20 percent each month.”
What is intrauterine insemination?
IUI is when semen is carefully prepared (including removing chemicals that may impair sperm from reaching the egg) in order to isolate and place the best sperm directly into a woman’s uterus, using a small catheter. The IUI procedure, Dr. Kodaman explains, is similar to getting a Pap smear. “The patient will lie flat for about five minutes after the IUI is complete, and then go about her day,” she says.
According to Dr. Kodaman, IUI is recommended for most couples undergoing ovulation induction, since concentrated sperm placed in the right area at the right time increases the chances of conception per cycle, regardless of semen quality. IUI is specifically recommended for couples with male factor infertility or when a woman is using sperm from a donor. It’s also commonly used for women with mild endometriosis or for infertility without a known cause.
What stands out about Yale Medicine’s approach to ovulation induction?
At Yale Fertility Center, we specialize in treating female and male infertility, from diagnosis to pregnancy and beyond. Our array of services includes a Sperm Physiology Lab, with carefully screened sperm donors, who can be anonymous or direct donors.
For patients’ convenience and to maximize the odds of conception, we offer all monitoring and insemination services nearly every day of the year, including on weekends and major holidays. “A lot of people don’t realize this, and that added convenience makes a big difference,” says Dr. Kodaman.
Dr. Kodaman says that what she finds most rewarding about her work is being able to offer continuity of care. “A patient might come to me for an issue I can treat surgically. Then we move forward with plans to conceive. In patients with a condition like endometriosis, they'll return postpartum for the long-term management,” she says. “For patients, it is comforting to come to one place and be treated from beginning to end, even after pregnancy.”