Superovulation

Superovulation, also known as controlled ovarian hyperstimulation, is the process of inducing a woman to release more than one egg in a month. It is different from ovulation induction, where the goal is to release one egg a month.

Who is a candidate for superovulation?

Women with open fallopian 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 her 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 the ultrasound reveals that the 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 that cause eggs to grow. These medicines are given by injection with a small needle, just beneath the skin. Many different brands are available, including Bravelle, Follistim, Gonal-F, Menopure and Repronex, but most are equally effective.

Your physician will select the dose and brand 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 that she is not producing too many eggs.

Typically, a woman will take three days of medication and then return for an ultrasound and blood work. Depending on how her ovaries respond, she will be asked to return to the fertility clinic some time during the next one to three days for additional monitoring.

Once the desired number of eggs is mature, the woman is given an hCG injection to cause ovulation. If she is doing intrauterine insemination (IUI), she will return to the clinic 36 hours after the hCG injection for the insemination.

How much does superovulation cost?

The entire treatment generally lasts six to nine days, and requires two to four office visits. The cost will vary greatly from woman to woman, due to the different amounts of medication and monitoring that each woman needs.

The gonadotropin medications are a large part of the cost. There are often pharmacy or drug company promotions that offer medication discounts to self-pay patients without insurance benefits, or that 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 cycle of superovulation will cost between $1,500 and $2,200 without IUI.

What are the risks of superovulation?

Multiple births

The major concern with superovulation is the chance of multiple births. Twins occur in 20-30 percent of successful cycles (versus 1-2 percent of natural cycles).

Of all treatments offered, superovulation has the highest risk of triplets, generally a 3-5 percent chance. 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 that 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 percent 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 percent 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 pregnancies occur when a fertilized egg implants itself outside the uterus. The egg may implant in the fallopian tube, or less commonly, in the cervix, ovary or pelvic cavity. Ectopic pregnancies occur in 1-2 percent of all pregnancies.

Ectopic pregnancies are more common during fertility treatments, because many women with infertility have tubal dysfunction, and because medications often cause the release of multiple eggs, thereby increasing the possibility that not all fertilized eggs move through the tubes into the uterus.

Ectopic pregnancies require emergency medical treatment.

Adnexal torsion (ovarian twisting)

This is a rare complication that occurs in one percent of cycles. As the ovaries enlarge, they may twist, cutting off their blood supply and causing severe abdominal pain, nausea, vomiting, and sometimes low grade fevers. Treatment involves surgical untwisting of the ovary.

Not a known risk: ovarian cancer 

According to the New York Times, several recent studies have shown that there is “no convincing association” between the use of gonadotropins and ovarian cancer.

Am I wasting my eggs by doing this treatment?

This is another common concern. From what we understand about the physiology of the ovary, it is unlikely that a woman is wasting her eggs by pursuing this treatment. Women who opt for superovulation do not go through menopause earlier than other women.

A woman is born with a certain number of eggs, approximately two million. Every day, a woman loses some of these eggs. She loses them even if she is ovulating, on birth control or pregnant.

Each month, a batch of eggs comes out of storage with the purpose of ovulating. However, the hormones that 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.