After two tries with Clomid-assisted intrauterine insemination through our local fertility center, we moved out of state; therefore, we had to find a fertility center near our new residence. We had consultations with two facilities and enrolled with one just in time to start a new cycle (though we missed one cycle during the move). Our new doctor offered us the options of continuing Clomid-assisted cycles, taking the next step and trying gonadotropin-assisted cycles, or jumping to in vitro fertilization (IVF). Before moving out of state, we had discussed doing three Clomid cycles before moving on to gonadotropins, because the best chance of becoming pregnant is within the first three cycles of using Clomid. However, we chose to begin the gonadotropin-assisted cycles with our new doctor, because we were ready to move on and gonadotropin-assisted IUI has higher success rates for Unexplained Infertility than Clomid-assisted IUI. Gonadotropin-assisted IUI is also easier to adjust the dose according to response than Clomid-assisted IUI. Using injectable gonadotropins also comes with intense monitoring with ultrasounds and estrogen levels due to the risk of Ovarian Hyperstimulation Syndrome. We also used Ovidrel, similar to the Clomid-assisted cycles, to induce ovulation.
The gonadotropin drug we used is Gonal-F (follitropin alfa), which is an injectable drug that is administered by subcutaneous injection beginning on cycle day 2 or 3 for a period of 7-12 days, depending on the individual response. Gonal-F is recombinant follicle stimulating hormone (FSH). FSH is primarily responsible for the development of follicles in the ovary (each follicle should contain one egg). Because Gonal-F acts like the body’s own FSH, it causes multiple follicles to develop on the ovary. The risk of multiple-order pregnancy using gonadotropins is about 30% – two-thirds of these are twins, one-third are triplets or more.
We used Ovidrel to stimulate ovulation once the follicles were mature to better time the IUI. Ovidrel (choriogonadotropin alfa) is a subcutaneous injection that can be given at home, and ovulation occurs about 36 hours after the injection. Ovidrel is a recombinant human Chorionic Gonadotropin (r-hCG) and it acts as the body’s natural hormone would to cause ovulation. Insemination is typically performed about 36 hours after the subcutaneous injection is given if doing one insemination, or about 24 hours and 48 hours after the injection if doing two inseminations.
Ultrasound Monitoring and Estrogen Level Testing
Ultrasound monitoring and estradiol level testing is very important when using gonadotropins, because there is a risk of Ovarian Hyperstimulation Syndrome, which if severe can result in hospitalization. An example of schedule of ultrasound monitoring and estrogen level testing is below. NOTE: This is only an example and the actual days are determined by the individual’s response to the drugs.
- Day 1 or 2 – Baseline ultrasound to check for any remaining follicles or cysts. Starting gonadotropins when follicles have not completely regressed can increase the risk of OHS. If the ultrasound is clear, the daily subcutaneous injections of the gonadotropin drug begin. If there are remaining follicles seen on the ultrasound, the cycle must be skipped.
- Day 6 or 7 – Ultrasound and estrogen test to assess the body’s response to the gonadotropins. If needed, the dose can be adjusted at this time if too many/not enough follicles are developing.
- Days 9-11 – Daily ultrasounds and estrogen tests to monitor the follicle development.
- Days 11 or 12 – Once the follicles are mature (18-20mm), the Ovidrel injection is given to stimulate ovulation.
- Days 12/13 or 13/14 – Two inseminations are performed approximately 24 hours apart to maximize the chances of viable sperm meeting a viable egg.
- Days 13/14-30 – Vaginal progesterone suppositories are started to help support a (possible) developing pregnancy. If pregnancy occurs, these are continued through the end of the 11th week.
- Day 30 – Blood beta-hCG pregnancy test. It is important to do a blood pregnancy test, because use of the Ovidrel can cause a false positive urine pregnancy test, and the use of vaginal progesterone suppositories may delay the onset of the next period if not pregnant.
The insemination visits for the Gonadotropin-assisted IUI are much the same as the visits for Clomid-assisted IUI and natural IUI visits. The new fertility center requires lying down for 10 minutes after the visit. They also do two inseminations per cycle (24 and 48 hours after Ovidrel injection) instead of one insemination per cycle.
Part of the monitoring with using fertility drugs involves a blood pregnancy test approximately two weeks after insemination. Ovidrel can cause a false positive urine pregnancy test so we just waited with patience the two weeks between the insemination and the test, hoping for the best.