Safety in ovulation induction

Abstract

Ovulation induction drugs are widely used in reproductive medicine, either as treatment for anovulatory subfertility or for superovulation in assisted reproduction. When used for inducing ovulation in women suffering from anovulatory subfertility, the aim is to achieve monofollicular ovulation. For women with polycystic ovary syndrome, oral agents such as clomiphene citrate or letrozole at starting doses of 50 mg and 2.5 mg respectively should be used as the first-line; sonographic monitoring is recommended in the first treatment cycle to ascertain response and exclude multifollicular development. In case of treatment resistance, gonadotrophin can be the second line, where a chronic low dose step-up approach with judicious monitoring is recommended. Cycle cancellation and contraception should be considered in case three or more dominant follicles are developing. For women with hypogonadotrophic hypogonadism, a gonadotrophin preparation containing LH should be the first-line. When used for ovarian stimulation coupled with intrauterine insemination, cycle cancellation and contraception should be advised if three or more dominant follicles are developing to avoid high-order multiple pregnancy. For ovarian stimulation (superovulation) in in-vitro fertilisation cycles, gonadotrophin dosing should be individualised based on ovarian reserve markers. The use of GnRH antagonist protocol coupled with GnRH agonist trigger in high responders (and freezing all embryos) may reduce the risk of ovarian hyperstimulation syndrome (OHSS). Co-treatment with metformin in women with polycystic ovary syndrome or use of dopamine agonist in women with excessive response may also reduce the risk of OHSS. Early recognition of OHSS and management by experienced personnel is essential to reduce morbidity in case it happens.