Treatment - Ovulation Induction
There are a number of reasons why women may not be ovulating regularly. Eighty five percent of women with irregular ovulation will have polycystic ovarian syndrome (PCOS). This is a disorder which is yet to be fully understood. There is a flaw in the ovary, which prevents normal ovulation. Women require initial assessment for this condition, in consultation with their gynaecologist. A blood test and a trans-vaginal scan of the pelvis, usually performed by the gynaecologist in his or her rooms, will confirm the diagnosis, or indicate other causes of the irregular cycle. Initial treatment may include a diet and exercise programme for several months, where obesity is a problem. An anti-insulin drug, Metformin, is often used. If insulin levels in the body are too high, ovulation is impaired, and this is the rationale for using Metformin. If Metformin treatment on its own does not result in regular cycles, Clomiphene treatment is the next step. Clomiphene helps the brain to stimulate the ovaries. It is taken daily for five days, usually starting on day 3 of a menstrual cycle, or following a withdrawal bleed induced by progesterone treatment for 12 - 14 days. Around day 10 of the cycle, a repeat trans-vaginal scan is performed to assess the response of the ovaries to Clomiphene.
If an expanding sac or follicle is seen in the ovary, we know that ovulation will occur in a few days. The exact date of ovulation can be determined by using an ovulation urine test kit. Another option is to use an injection when the follicle has reached an appropriate size, usually around 20mm in average diameter, to trigger ovulation. If the initial course of treatment with Clomiphene is unsuccessful in producing ovulation, higher doses can be used. Up to 3 tablets daily for 5 days may be used in the early part of the cycle.
In women who are resistant to Clomiphene, the gynaecologist will discuss the options of laparoscopic surgery to improve ovulation, or daily subcutaneous injections of follicle stimulating hormone (FSH). The hormone is a genetically manufactured replica of the natural brain hormone, which stimulates the ovaries. The dose of injections can be increased gradually, until a response is seen. The aim is to have a single egg released at the time of ovulation. This treatment is again monitored by trans-vaginal scans, and sometimes blood tests, which can be repeated every few days as the cycle progresses.
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