The primary medications that are used for either OI or superovulation are clomiphene and FSH, each of which may go by various brand names. The FSH that is used in our treatment protocols is a synthetic version of the human body’s natural hormone that stimulates the ovary to mature an egg. It is used as a subcutaneous injection. Clomiphene works by inducing the pituitary to release more of it’s own natural FSH. It comes in the form of a pill taken orally, usually over 5 days early in the treatment cycle.

For women who are not ovulating regularly, the goal of treatment is to mature and ovulate a single egg – ovulation induction (OI) as referred to previously. Clomiphene alone often works well to cause the ovaries to mature an egg. A typical protocol will involve taking clomiphene each day for cycle days 3-7 or cycle days 5-9. Ultrasounds and blood tests are then used to monitor the egg as it matures. Once the egg is ready, a subcutaneous injection is given of a hormone called hCG (the ‘trigger shot’), which triggers ovulation of that egg approximately 38-40 hours after the injection.

In women whose irregular ovulation is due to PCOS, a medication called metformin may be added to the treatment regimen. For those women who do not respond to clomiphene, FSH may be added to the protocol. In women who do not ovulate due to hypothalamic amenorrhea, injectible medications containing both FSH and LH are used to stimulate the ovaries to mature an egg. An Intrauterine Insemination (IUI) is commonly performed in the OI cycle.

For women undergoing superovulation, the goal is to mature more than one egg at a time (usually 2 -4), sometimes referred to as controlled ovarian hysperstimulation (COH). This is accomplished either with a combination of clomiphene and FSH or with FSH alone. Where possible, the combination regimen is usually the first choice as it requires fewer injections and less monitoring and therefore involves lower cost.

A typical combination protocol may involve taking clomiphene each day for cycle days 3-7, followed by an injection of FSH cycle day 9. A typical FSH only protocol involves taking the FSH injections beginning on day 3 of the cycle and continuing daily until the eggs are mature. Again, the cycle is monitored with ultrasounds and blood tests to follow how many eggs are maturing and how quickly they are maturing.

Often with the combination protocol, additional FSH is used on subsequent days in the cycle if the eggs are not yet mature. When the eggs are ready, the trigger shot is given and the IUI is performed about 1 ½ days later. An Intrauterine Insemination (IUI) is routinely performed in the superovulation treatment cycle.

Intrauterine insemination (IUI) is the process whereby a concentrated specimen of sperm is placed in the uterus. For this procedure, a speculum is inserted into the vagina and the cervix is visualized. A soft, thin catheter is then placed through the cervix and into the uterus. The washed sperm is then introduced into the uterus through this catheter. The procedure is done in the office and takes 1-2 minutes. It is not painful and does not require anesthesia. The sperm sample is specially prepared in the andrology laboratory. The procedure is commonly known as “sperm washing”. This involves placing the sperm sample in a test tube and then a centrifuge. This results in the sperm collecting in a “pellet” at the bottom of the test tube. The seminal fluid is removed and fluid (media) is placed above the sperm. The most active sperm will then swim up into the media. The final sample consists of the most active sperm in a small volume of media. A single IUI is usually performed when a fresh sperm sample is used. Two IUIs on consecutive days are usually performed if a frozen sample is used.

The timing of the insemination is not critical to the exact time of ovulation. Both the sperm and the egg remain viable in the female genital tract for many hours, so the insemination may be done within a window of several hours around the time of ovulation. Following the IUI, daily supplemental progesterone is given, usually in the form of a vaginal suppository, to support implantation and early embryo growth.

For patients who experience infertility due to a complete lack of sperm, pregnancy can still be achieved using donor sperm. Patients can arrange for sperm through one of several national certified sperm banks, such as Fairfax Cryobank or California Cryobank, where donors are appropriately screened and the sperm is quarantined. After a patient chooses a suitable donor, a frozen sample of the sperm is shipped to our facility for use during a treatment cycle.

For women with no cause of infertility other than the sperm factor, an IUI can be done around the time of ovulation during a natural cycle, where ovulation is monitored with home ovulation predictor kits. Usually 1 IUI is done on each of the 2 days following a positive home ovulation test to cover the possible time of ovulation. Alternatively, the natural cycle may be monitored with ultrasounds and blood tests. When the egg is mature, ovulation is triggered with an injection of hCG and an IUI is done during each of the 2 days following the trigger shot.

For women in who natural cycle/IUI has been unsuccessful or who have other causes of infertility in addition to the sperm factor, such as irregular ovulation, a single blocked fallopian tube or endometriosis, IUI with donor sperm is coupled with ovulation induction or superovulation as discussed previously.

Shady Grove has one of the premier andrology departments in the country. The laboratory is certified by several accrediting organizations including JCAHO (Joint Commission on Accreditation of Healthcare Organizations) and the FDA (Food and Drug Administration). There are 11 andrologists in addition to supporting staff who analyze and process over 7500 specimens each year. Each specimen is handled with critical attention to both patient identification and quality control. Patients must present a picture ID when the specimen is taken to the andrology department. Formal procedures then govern how the identity of a single specimen is confirmed at each stage of processing in the andrology laboratory.