Anovulation maybe the cause for infertility in 25% of couples presenting to infertility clinics.

1. PROTOCOLS
OVULATION INDUCTION
(sharing personal experience)
…..Caring hearts, healing hands
DR . SHARDA JAIN
DR. JYOTI AGARWAL
DR. JYOTI BHASKAR

2. Anovulation maybe the cause for
infertility in 25% of couples
presenting to infertility clinics.

3. Group 1: Hypothalamic pituitary failure/
Hypogonadotrophic hypogonadism
Group 2:Hypothalamic pituitary dysfunction /
Normogonadotrophic anovulation
Group 3: Hypergonadotropick hypogonadism/
premature ovarian failure
Ovulatory dysfunction is known to be of
three kinds based on the
WHO classification (1976).

4. OVULATION
Ovulation may need to be :
. Induced in Ovulatory disorders
. Most of the times needed for
ART cycles e.g. IUI , IVF

5. AIM
1. Aim of induction should be
Monofolliculogenesis When OI is carried
out for simple procedures like
TIMED IC or IUI.
2. In other ART cycles MULTIFOLLICULOGENESIS
is the need. This is also called Controlled
ovarian hyperstimulation or COH .

6. PROTOCOLS
Choice of Ovulation induction
protocol is INDIVIDUALIZED
and would depend upon the
type of patient and the
procedure to be adopted .

7. AGENT FOR OI ORAL AGENTS
*Clomiphene Citrate
*Tamoxifene
*Aromatase inhibitors
(banned in India)

8. Gonadotrophins
*Urinary
*HP Urinary
*Recombinant
GnRh analogues:
* Agonists
* Antagonists
INJECTABLES

9. CLOMIPHENE CITRATE :
Dose 50-100mg ./day starting from the 2nd ,3rd or
5th day of menstrual cycle for five days.
The dose can be stepped up to 150mg maximum.
It has been noticed that the maximal benefit is
achieved at lower doses & in 1st 3 cycles.

10. TAMOXIFENE :
Can be used in clomiphene failure
Dose: 20 mg twice daily starting
from daily
starting from day 2 - 5

11. USG Monitoring / HCG TRIGGER
• U/S monitoring can be started from day 10-11 of
the cycle .
• HCG 5000 IU trigger is generally required at
higher doses of CC.

12. WHO GROUP 1
HMG 150 IU daily is the drug of
choice .
• Long stimulation is required
• Follicle may appear on U/S only
after 14-15day of stimulation .one
has to be patient for good results

13. Risk of ovarian hyperstimulation is very high in this
group hence stimulation has to be slow and cautious.
FSH or HMG maybe used at minimal doses -75 IU/
Day and stepped if no follicle is seen after 7 days of
stimulation (step up regime).
• Alternately ,higher dose of 150 iu maybe given in the
beginning and stepped down after a follicle is seen on
U/S.(step down regime).
WHO GROUP 2

14. GnRH Agonists and Antagonists
Generally used in ART protocols where
multifolliculogensis is desired
************
Agonist can be used as a trigger when
OHSS is feared and needs to be
avoided.

15. GnRH Antagonists
Antagonists can be used in ART cycles or IUI cycle
with CC also ---- in a dose of 0.25 ugms / Daily
when the follicle size is 14 mm in order to avoid
pre-mature LH surge , to prevent premature
rupture

16. OC Pretreatment – Long Protocol
Day 5 Day 21 Day 3
Day 14
HCG
GnRha
Advantages
• No Cyst Formation
• No premature LH surge
• No cycle cancellation
• Cycle programming possible
• Improved responses to Gonadotrophin

17. Day 1 Day 14
FSH / HMG day 3
hCG
• Advantages of flare effect – idea for poor responders & prevents LH surge.
PROTOCOL – SHORT

18. Day 1 Day 14
GnRha
hCG
Day 3
FSH / HMG
• Advantage of flare effect – ideal for poor responders
• Disadvantage of premature LH surge.
Protocol – Ultrashort

19. Agonist 1st inj. Agonist 2nd inj. Agonist 3rd inj.
Day 1 or 21
4 weeks 4 weeks
rFSH
Ovarian stimulation in severe
endometriosis
(long long protocol)

20. IMPORTANT TIPS
• To get the best results in ART cycles , OI is must
even for subtle ovulatory disorders
• All cycles need to be monitored to prevent
complications and to get the best results
• Ovulation induction protocol needs to be
INDIVIDUALIZED
• Once ovulation is documented , same protocol and
dose should be used in susequent cycles

21. ADDRESS
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