Washington Center for Reproductive Medicine

Ovulation Induction with FSH

FSH is produced by the pituitary gland and it directly stimulates the development of eggs contained within the ovarian follicles. When FSH levels are increased by external injection, numerous follicles are recruited. The dosage of FSH is adjusted based upon ultrasound measurements of the follicles and the levels of estrogen to insure proper development and avoid side effects. 

FSH is used in assisted reproductive technology cycles (IVF) because numerous eggs must be produced for successful retrievalculture, and transfer. FSH is also used for ovarian stimulation when products, such as Clomid, fail.

Controlled dosages of FSH are also used to stimulate ovulation in intrauterine insemination (IUI) cycles. Dr. Kustin closely monitors these patients to guard against ovarian hyperstimulation syndrome (painful swollen ovaries) and reduce the chance of high order multiple births. Most cases of quadruplets (or more) result from IUI cycles administered by non-specialists.

Serono Laboratories first introduced an FSH/LH menotropin in the United States under the trade name, Pergonal. Pergonal was a "natural product" derived from the urine of postmenopausal women and it contained impurities and luteinizing hormone. Pergonal is no longer available in the United States and other urinary products such as Repronex, Humegon, and Menopur have taken its place.

Metrodin was introduced in the 1990's.  It was a highly purified form of Pergonal containing only trace amounts of LH. Many physicians administered Pergonal and Metrodin together because of the belief that LH was necessary. Bravelle is an FSH preparation currently distributed by Ferring Laboratories and it is similar to Metrodin.

More recently highly purified forms of FSH have been created using genetic recombinant technology. The products include Gonal-F and Follistim, which are "pure" with no trace of LH. Organon and Serono have released a "pen injection mechanism" which is very convenient to use.

A controversy continues to rage among reproductive specialists as to the necessity of LH for good follicular and endometrial development.  Some feel that in some patients, the pure FSH products do not provide for adequate stimulation.  Some patients respond well with FSH alone whereas others stimulate in a more physiological way by the addition of very low doses of hCG (because of its LH effect) or the addition of Repronex. 

FSH is sometimes used in combination with LH (Luveris).  In all cases, patients administer fertility drugs according to their specific protocol.

Serono Laboratories recently released Luveris, which is a genetically derived pure LH product. LH can now be precisely administered in FSH stimulation cycles when the physician believes LH is necessary. Luveris can also be used to induce ovulation.

One serious side effect of FSH, which can occur, is ovarian hyperstimulation syndrome (OHSS). This is a condition where the ovaries become painfully enlarged and there is a collection of fluid within the abdominal cavity. The patient may experience discomfort including difficulty breathing and abnormal lab test values. 

The condition always improves and may be associated with pregnancy conceived with gonadotropin therapy. Careful monitoring and expert use of these medications reduces the incidence of OHSS significantly. The treatment usually includes pain control and appropriate fluid therapy. Rarely, more aggressive treatment is indicated.

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