Overview of Ovulation Induction Techniques
The menstrual cycle naturally occurs in a woman’s body, regulated by a chain of events involving the brain and the ovaries, known as the hypothalamic-pituitary-ovarian (HPO) axis. Hormones are released from the brain to your ovaries in specific patterns, stimulating them to grow and release an egg (oocyte). This egg then moves into the fallopian tube, where it can meet with sperm and become a fertilized egg (zygote). If this fertilized egg successfully settles in the uterus, it leads to pregnancy.
Sometimes, a woman’s body may not release an egg, which is known as anovulation. This can occur due to disruptions in the HPO axis, and the World Health Organization (WHO) has categorized this into four types:
1. WHO class 1: Hypogonadotropic hypogonadism – low levels of hormones from the brain
2. WHO class 2: Normogonadotropic hypogonadism – normal levels of hormones from the brain but ovaries malfunctioning
3. WHO class 3: Hypergonadotropic hypogonadism – high levels of hormones from the brain but ovaries nonresponsive
4. WHO class 4: Hyperprolactinemia – high levels of the hormone prolactin
Medications can be used to stimulate the ovaries to produce and release eggs, which can help with thickening the layer of the uterus (endometrium) needed for a fertilized egg to implant and grow. These medications also have some other benefits, such as lowering male hormone conversion to female hormones and increasing tissues’ response to insulin. Another treatment option is a minimally invasive surgical procedure known as laparoscopic ovarian drilling, which can trigger ovulation.
Aiming to increase the chances of a couple being able to conceive, these treatments are mainly for women who cannot get pregnant due to anovulation. Assessing the ovaries’ ability to provide eggs that can be fertilized (ovarian reserve) and stimulating ovulation, are important steps in treating anovulation caused infertility.
Anatomy and Physiology of Ovulation Induction Techniques
The ovaries are two small organs found in a woman’s body; they are about 2-3 cm in size and are situated close to the uterus, on either side of it. These are the organs that make female hormones (estrogen and progesterone) and the eggs that can possibly become a baby when fertilised (oocytes). They are held in place by a variety of ligaments.
Oogenesis is the process of producing oogonium, which are cells that will eventually become mature egg cells or oocytes. This process starts very early, when a girl is still in her mother’s womb and continues until puberty, when the outer part of the ovaries, called the cortex, starts producing primary oocyte, the first stage of an egg cell.
At birth, girls usually have about 1 to 2 million follicles (small sacs that contain the eggs or oocytes), but by the time a girl reaches puberty, only about 400,000 to 500,000 follicles remain. As time passes, more and more follicles reduce in number naturally.
At puberty, an important change happens in a woman’s body which enables it to get pregnant. The hypothalamic-pituitary-ovarian (HPO) axis, a chain of hormone signals between the brain and the ovaries, becomes active. This is the chain of command that makes the ovaries release an egg each month, a process we call ovulation. This chain of command also controls the levels of estrogen and progesterone in the body.
One of the command hormones, FSH (Follicle Stimulating Hormone), helps promote the growth and maturity of the egg cells during each ovulation cycle. This hormone is released into the body and saves some follicles (that contain the eggs) from dying off, helping them grow and mature. Furthermore, it helps the granulosa cells (cells that line the follicle) release estrogen.
Estrogen has three main jobs: it slows down FSH production, it boosts LH (Luteinizing Hormone) production, and it helps the uterus lining grow and ready itself for possible pregnancy. Due to estrogen’s effect, all follicles except one (the largest and most mature, called the dominant follicle) eventually die off. The dominant follicle continues to grow until it is ready to be released from the ovary. This process is called ovulation.
The hormone LH plays a vital role in ovulation; it spikes suddenly, promoting the release of the mature egg from its follicle during ovulation. The dominant follicle left after ovulation is converted into an organ known as the corpus luteum.
After ovulation, the body enters what is called the luteal or secretory phase of the menstrual cycle; during this phase, the corpus luteum releases hormones, mainly progesterone, that maintain and thicken the lining of the uterus in readiness for a potential pregnancy. If pregnancy does not occur, levels of these hormones decrease, leading to shedding of the uterus lining, a process we commonly call menstruation.
Why do People Need Ovulation Induction Techniques
Ovulation induction is a treatment used to help stimulate the ovaries to release eggs. This is often used for individuals who are trying to conceive but have certain challenges. Some of the reasons your doctor might recommend you for ovulation induction include:
1. If you fall under the World Health Organization’s Group II classification, which means you’re not ovulating regularly.
2. If you have a luteal phase defect, a condition where the second half of your menstrual cycle is shorter than normal, which can hinder the ability to conceive.
3. If you’re dealing with unexplained infertility, which means doctors can’t identify a specific reason for why you’re not getting pregnant.
4. If you have Polycystic Ovarian Syndrome (PCOS), a hormone imbalance that often results in irregular periods and can make getting pregnant difficult.
5. If you’re going through Assisted Reproductive Technology (ART) procedures, like in-vitro fertilization, where having more eggs can improve your chances.
6. If you’re undergoing intrauterine insemination (IUI), where stimulating the ovaries to produce more eggs can increase the chances of pregnancy.
7. If you have Hyperprolactinemia, a condition with high levels of prolactin hormone which can cause irregular ovulation.
8. If you’re categorized as a ‘poor responder’, meaning your body doesn’t respond well to fertility medications, and more aggressive stimulation may be required.
Ovulation induction can be very helpful in these scenarios, but it’s important to discuss the benefits, risks, and other treatment options with your doctor.
When a Person Should Avoid Ovulation Induction Techniques
Ovulation induction is a treatment that stimulates the ovaries to release eggs. However, in some cases, it’s not considered safe or likely to be effective. These cases include the following:
1. Hypergonadotropic hypogonadism: This is a condition where the body produces too much of certain hormones, leading to problems with sexual development.
2. Liver diseases: If a person has a liver disease, they might not be able to handle the medications used in ovulation induction.
3. Functional ovarian cysts that are larger than 5 cm: Ovarian cysts are fluid-filled sacs in or on an ovary. If a woman has a cyst larger than 5 cm, the induction could stimulate the cyst to grow, potentially causing problems.
4. Tubal factors: This refers to problems with the fallopian tubes, such as blockages or damage. Since the tubes are how the eggs get from the ovaries to the uterus, these problems need to be addressed before attempting ovulation induction.
5. Male factor infertility: If the issue is related to the man’s sperm, ovulation induction in the woman would not help.
6. Severe grade 3 and 4 endometriosis: Endometriosis is a painful condition in which the tissue that normally lines the inside of the uterus grows outside it. The grades refer to how severe the condition is. In severe cases, ovulation induction may not be successful and could potentially make the condition worse.
7. Premature ovarian failure: This is when the ovaries stop working normally before age 40. In these cases, ovulation can’t be induced because the ovaries aren’t capable of producing eggs.
8. Genetic abnormalities such as Turner syndrome: Turner syndrome is a condition that affects only females and is caused by a missing or partially missing X chromosome. This condition can lead to various health problems, including infertility, and ovulation induction would not be effective.
Equipment used for Ovulation Induction Techniques
To successfully carry out the process of ovulation induction, or the stimulation of a woman’s ovaries to produce more eggs, certain tools and resources are needed:
1. A thermometer, used to track changes in body temperature which may indicate ovulation.
2. A microscope, this can be used to examine cells or substances in a lab.
3. A urinary luteinizing hormone kit, a home-testing tool that can help detect the rise of a certain hormone (luteinizing hormone or LH) in your body. This rise usually happens 24 to 36 hours before ovulation.
4. An ultrasound Doppler machine, a special ultrasound technology used to see blood flow and help monitor ovarian follicles (from where eggs are released).
5. Access to a clinical laboratory for hormonal assessment, where doctors can test your hormone levels.
6. Drugs for ovulation induction, these medications can help stimulate your ovaries to produce more mature eggs.
7. Laparoscopy instruments, these are slender tools used during a type of minimally invasive surgery called laparoscopy, to view or treat your ovaries.
8. An operation room, a sterile environment where surgical procedures like laparoscopy are done.
Who is needed to perform Ovulation Induction Techniques?
Having the right group of medical professionals is crucial for your care. This team usually includes:
1. A gynecologist, a doctor who specializes in women’s health, often paired with a laparoscopic surgeon, a doctor skilled in performing surgeries using a thin tube with a camera, called a laparoscope. Their job is to look after your health and perform any necessary surgeries.
2. An anesthesia team is responsible for making sure you don’t feel pain during surgery. They put you to sleep safely so you won’t feel any discomfort and closely monitor you throughout the procedure.
3. Operation room nursing staff are skilled nurses who assist doctors during surgery. They prepare the operating room and make sure everything runs smoothly.
4. Lab assistants help analyze your body samples like blood and tissues to help your doctors understand more about your health.
5. A radiologist is a doctor who reads and interprets images like X-rays and ultrasounds to help diagnose diseases or monitor your progress.
6. Outpatient department nursing staff are nurses who provide care if you’re not admitted to the hospital. They administer medicines, monitor your progress, and provide other necessary care.
7. A pharmacist helps prepare and give out prescribed medications ensuring you receive the correct medicines and instructions on how to use them.
8. A counselor provides emotional and psychological support. They can help you understand and cope with your medical condition and the emotions it might bring up.
Preparing for Ovulation Induction Techniques
Before starting treatment to trigger ovulation, it is important to check the woman’s ‘ovulation reserve’. This term is basically a measure of the woman’s ability to produce eggs that can be fertilized. It depends on the quantity and quality of certain structures in the ovaries called ‘antral follicles’. The number of these antral follicles is a useful way to check the ovulation reserve.
There are several ways to check the ovulation reserve, which can be grouped into three categories:
- Clinical signs: These include the woman’s age and her menstrual pattern.
- Hormone levels: Doctors can examine levels of particular hormones in the woman’s blood on the second or third day of her menstrual cycle. These hormones include follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, inhibin B, and anti-Mullerian hormone (AMH).
- Ultrasound signs: Doctors can use an ultrasound scan to measure the size of the ovaries, count the antral follicles, and check the blood flow in the ovaries.
By looking at all this information together, doctors can get a good idea of the woman’s ovulation reserve. This helps them determine the best way to stimulate ovulation as part of fertility treatment.
How is Ovulation Induction Techniques performed
The process of stimulating ovulation can be done in various ways, including making healthy changes to one’s lifestyle, taking certain medications or undergoing certain surgeries.
Lifestyle Changes for Infertility Related to Obesity
Obesity is when a person’s Body Mass Index (BMI) is more than 30 kg/m2, while being overweight is defined as a BMI of 25 kg/m2 or more. Obesity can make it harder to get pregnant, both naturally and through ovulation stimulation treatment. If you’re significantly overweight, you may also need higher doses of ovulation-stimulating drugs and have more risk of miscarriage. Healthy changes to your lifestyle, including eating right and getting regular exercise, can help treat infertility from lack of ovulation. This is especially the case if you are overweight or obese. A weight loss of just 5 to 10% can be enough to get your ovaries working again. So, if you are obese and having difficulty getting pregnant because you’re not ovulating, Health professionals usually recommend this as the first step.
Medical Approaches
Medical techniques include the use of anti-estrogen drugs, specifically Clomiphene Citrate and Tamoxifen, as well as drugs that stop aroma or smells called “aromatase inhibitor” like Letrozole. There are also drugs that act like dopamine (a chemical in your brain) such as Cabergoline, Insulin sensitizers like Metformin, and “gonadotropins” that directly stimulate your ovaries to produce eggs.
The drug you’re given will depend on what your doctors think is causing your infertility. These drugs all work differently, but they share a common goal: to stimulate your ovaries into producing and releasing eggs.
Surgical Techniques
In certain cases, a minor surgery known as laparoscopic ovarian drilling can be done to treat infertility. This was first introduced in 1984. The procedure is not very invasive and is less severe than other forms of surgery. How it works is that small holes are made in the surface of the ovaries using either a heat source (electrocautery) or a laser. The goal of this procedure is to reduce the volume of the ovaries’ outer layer and to decrease their production of male hormones. This allows for the better development of eggs in the ovaries and helps to restore the balance of sex hormones in the body.
Possible Complications of Ovulation Induction Techniques
The process of fertility treatments can sometimes lead to a few potential complications. One of them is Ovarian Hyperstimulation Syndrome, which is a significant swelling of the ovaries due to hormone injections used in fertility treatments. Another complication can be multiple pregnancies, meaning having twins or triplets, which occurs when more than one egg is fertilized.
Another risk is a spontaneous pregnancy loss, also known as a miscarriage, which can potentially happen if your body naturally rejects the pregnancy. Likewise, certain birth defects, known as congenital anomalies, are also a possible complication. These are health conditions that a baby is born with and they can affect different parts of the body.
In very rare cases, fertility treatments can potentially increase the risk of developing breast and ovarian cancer. However, this is still a subject of ongoing research, as these cancers can also occur due to numerous other factors that may not necessarily be connected to fertility treatments.
What Else Should I Know About Ovulation Induction Techniques?
Ovulation induction is a simple and low-risk technique used to help women who are having trouble getting pregnant because they aren’t ovulating (releasing an egg from an ovary) regularly. Your doctor will choose the best method based on what’s causing the problem and how effective, costly, risky, or complicated each method might be.
Women with this type of fertility problem should try ovulation induction before moving onto more advanced forms of treatment like assisted reproduction, because it can be quite successful. Plus, if it’s carefully monitored by a skilled doctor, the chance of complications is low.
It’s important to understand that inducing ovulation is different from stimulating the development of multiple egg-containing structures (a process called controlled ovarian hyperstimulation) that is part of more advanced fertility treatment techniques. The main goal of inducing ovulation is simply to help the woman release one egg (rather than many) and get pregnant. This increases the chances of having one baby at a time (rather than twins or more) and decreases the risk of a condition called ovarian hyperstimulation syndrome, which involves painful and swollen ovaries.