Superovulation

What is 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 this treatment?

Women with open fallopian tubes and whose partners have adequate sperm counts are candidates for superovulation.

If a woman already ovulates and is not conceiving, REI doctors can increase her chance of getting pregnant by causing her to release more eggs via superovulation. Similarly, if a woman has been ovulating with an oral medication (such as clomiphene) and is not conceiving, superovuation can improve her chances of conceiving by stimulating her ovaries to release more eggs.

How is it 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.

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

Once the desired number of eggs mature, the woman is given a human chorionic gonadotropin (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 intrauterine insemination (IUI).

What are the risks of superovulation?

Multiple births

The major concern with superovulation is the chance of multiple births. About 20-30 percent of successful in vitro fertilization (IVF) cycles result in twins (versus 1-2 percent of natural births). Of all treatments offered, superovulation has the highest risk of triplets, generally a 3-5 percent chance.

Ovarian hyperstimulation syndrome (OHSS)

This condition occurs when the ovaries get very large and fill 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, women may have symptoms of bloating and pelvic discomfort; this occurs in 10-20 percent of gonadotropin cycles and quickly resolves after treatment ends.

In about 1 percent of cycles, OHSS is more severe. In these rare cases, a woman may experience difficulty urinating, rapidly gain weight, become dehydrated or have organ complications involving the lungs, kidneys and liver.

Severe cases of OHSS may require hospitalization. Women with OHSS have an increased risk of blood clots; therefore should report any symptoms of leg pain or difficulty to a physician immediately.

OHSS risk factors include:

• • Low body weight
  • Age
  • Polycystic ovary syndrome (PCOS)
  • Higher doses of gonadotropins
  • Rapidly rising or high estrogen levels
  • Prior episodes of OHSS
  • High number of developing follicles.

There have been reported deaths due to complications from OHSS. Fortunately, severe cases of OHSS are rare. A physician will closely monitor response to gonadotropins in order to significantly decrease the chances of developing OHSS. However, if a patient is at risk, her physician may cancel stimulation for her safety.

Women who conceive may develop worse symptoms of OHSS at the time pregnancy is detected which may take longer to completely resolve.

Adnexal torsion (ovarian twisting)

This is a rare complication that occurs in 1 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.

Ectopic pregnancy

An ectopic pregnancy occurs when a fertilized egg implants itself outside the uterus. The egg may implant in the fallopian tube or – less commonly – in the ovary, cervix or pelvic cavity. This condition occurs in 1-2 percent of all pregnancies.

There a few reasons why ectopic pregnancies are more common during fertility treatments. In part 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 and the pregnancy must be ended.

Not a known risk: ovarian cancer

Recent research studies (as reported in the New York Times) show 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, follicle stimulating hormone (FSH) and luteinizing hormone (LH), are in relatively short supply. In natural ovulation, 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 eggs will ovulate and have the opportunity to result in a pregnancy.