Controlled ovarian hyperstimulation (COH) using (FSH containing fertility medications that are called) gonadotropins (menotropins) is effective in a number of clinical situations. Induction of ovulation with menotropins in anovulatory women who fail to ovulate to clomiphene citrate is successful in up to 90% of cases. COH with intrauterine insemination (IUI) can also be used for the treatment of mild to moderate male factor infertility (if IUI alone is ineffective), surmountable pelvic factor infertility (to try to “overwhelm” the existing pelvic barrier) and unexplained infertility (mechanism of action is unclear but research suggests that COH/IUI is one of the effective treatments).
In anovulatory women treated with COH/IUI, the pregnancy rate per cycle of treatment is up to 30% (lower if there is a concomitant male factor or pelvic factor). The cumulative pregnancy rate over 6 cycles may be as high as 90%. Anovulatory women (with normal circulating gonadotropin concentrations) treated successfully with COH/IUI may have a slightly increased spontaneous pregnancy loss (miscarriage) rate (about 25-40%). This increase in miscarriage rate is thought to be primarily due to a higher percentage of multiple pregnancies, somewhat older average age of women undergoing treatment (compared to the general pregnant population), and more precise documentation of early pregnancies (more very early losses are recognized as such rather than going unrecognized). There is no known increase in congenital abnormality rate due to use of these medications.
Couples with a male factor may also benefit from COH/IUI. The IUI component brings sperm close to the mature egg(s) in the fallopian tubes. The COH component often results in the simultaneous development of multiple mature eggs, which serve as “more targets” for the sperm. The fertility rates (per cycle) with COH/IUI over IUI alone in treating male factor infertility may increase (depending on the severity of the male factor) from about 5-10% (for IUI) up to about 15-25% per cycle (for COH/IUI).
In the presence of a pelvic factor such as endometriosis or pelvic adhesions, my usual recommendation is to attempt aggressive surgical repair. If the surgical repair does not restore normal fertility, then I consider COH/IUI for a few cycles followed by IVF (if not pregnant). As with the male factor, the goal is to overwhelm an existing fertility barrier by producing a greater number of mature eggs and placement of the sperm in the immediate vicinity of those eggs. The increase in fertility rates is not clear but may be in the ballpark of 5-10% per cycle without treatment and 20-25% with COH/IUI.
The treatment of unexplained infertility using empiric COH/IUI has been shown to effectively increase fertility rates from about 5% without treatment to about 25% per cycle with COH/IUI.
This discussion of controlled ovarian hyperstimulation includes detailed presentations on the medications that can be used, the usual procedures in a typical cycle, the complications that should be considered, and the technique for administering medications that need to be injected.