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    Are Gonadotropin injections advisable while on treatment for ovulation?

Posted on Thu, 10 Nov 2016 in Women's Health
Question: Hi..

I have PCOD since I was young and now I am taking fertility treatment..

I am 30 years old, obese and i am taking treatment for ovulation induction..

Two previous cycles one with 100 mg clomiphene for 5 days that went anovulatory with PCOD picture, next cycle with 150 mg clomiphene for 5 days, maximum size of follicle reached to 14 mm..

My hormonal profile and infertility panel investigations are within range and Transvaginal ultrasound is suggestive of peripherally arranges multiple small follicles suggestive of PCOD..

This month I had my periods on 7th of October, started with Clomiphene Citrate 100 mg for 7 days..
Along with it I am also taking Metformin 500 mg tds, Aspirin once a day and folic acid once a day..
My follicular monitoring started as following:

1. Day 9: left ovary : 13*11mm and 10 *9 mm [ 2 follicles], Right ovary 14*12mm [one follicle and multiple small follicles], Endometrial thickness:3mm
2.Day 11: Left ovary : 15* 10mm and 10* 9 mm and right ovary has multiple small follicles with no dominat follicle.. ET: 4.5 MM.
3. Day 12 [today]: Let ovary: 15* 11 mm and 9*10mm follicles and right has same as 11th day..

I am being advised diagnostic laproscopy and ovarian drilling in the next cycle..

My questions are:
1. Can anything be done at present like gonadotropin injection or anything else to increase follicle size or should leave it as it is?
2. I have a cycle of about 32 days , so since how long should I follow up with follicular monitoring?
3.What should be the appropriate size of the follicle that should be there for ovulation?
4. Will you suggest that I should proceed for the laproscopy and ovarian drilling or still continue with getting inductions done for ovulation?
5. What positive and negative effects can happen with Ovarian drilling?

I would expect the point wise answers to my questions please..

Thankyou so much in advance..

Dr. Honey Arora.

Answered by Dr. Aarti Abraham 1 hour later
Brief Answer:
As below

Detailed Answer:
Thanks for trusting us with your health concern .
Here are your detailed answers pointwise.
1. There is no point in going for gonadotropin injections at this stage as they have little to no role on follicular development on day 12.
2. You should continue follicular monitoring till day twenty at least and then go for one more scan randomly a few days even after that, I because late ovulation is often seen with PCOS.
3. Minimum follicle size for rupture is 18mm .
4. I think you should go for at least three more cycles of follicular monitoring with good gonadotropin stimulation in conjunction with clomiphene before going for laparoscopy and ovarian drilling.
5. Negative effects of the procedure are those associated with any invasive procedure - risks that follow a surgery and anesthesia. Positive effects include a beneficial effect on ovulatory response and knowing the status of your tubes.
Where do you reside?
Looking forward to hearing from you.
Take care
Above answer was peer-reviewed by : Dr. Yogesh D
Follow up: Dr. Aarti Abraham 1 hour later
Thanks for the reply..

I would further like to know in detail that what are the beneficial effects of getting ovarian drilling done as my Gynae told me that once they rupture the cysts/ follicles, the normal ovarian tissue will grow and it will help in formation of a mature ova and at times you can even conceive without induction, so is it true after ovarian drilling?

Secondly I would also like to know that I have read about the side effects of ovarian drilling of having adhesions, blocked fallopian tubes, depleting egg reserve, early menopause etc..
So does it happen frequently?

Also what are the chances of conceiving with PCOD?

What is the maximum dose and duration of Clomiphene that can be given to me by the Gynae?

Can you suggest any super foods that can aid in stimulating follicle growth along with medicine?

I am so tensed and anxious related to this issue..

Answered by Dr. Aarti Abraham 14 hours later
Brief Answer:
As below

Detailed Answer:
Hello again.
There are studies that show that once ovarian drilling is done, a bit of ovarian stroma ( dense tissue ) is destroyed.
This somehow decreases the production of testosterone ( male type hormone ) that comes from the thick ovarian tissue, which is drilled.
Thus, overall hormonal milieu of PCOD is improved.
However, recent studies have shown no such benefit of drilling.
Most patients require ovulation induction , even after ovarian drilling.
Laparoscopy is a surgery, and any surgery can leave some adhesions, but that is not a very likely possibility.
Blocked tubes do not occur because of laparoscopy, in fact, laparoscopy will help you to know by XXXXXXX testing if your tubes are open or closed.
If done properly, depleted egg reserve and early menopause are not major concerns too, since there are guidelines on how many punctures to make on each ovary while drilling.
Where do you reside ?
Women with PCOD have good chances of conceiving, as they have good egg reserve, they just need proper stimulation and induction protocols.
Clomiphene can be taken for multiple cycles, dose depends on your body weight.
Many practitioners use clomiphene for more than 12 cycles, but textbooks say 12 cycles is a limit.
Unfortunately, there are no super foods that are scientifically proved to aid in stimulating follicular growth in PCOD.
Weight loss and lifestyle modification may help a lot, though.
All the best.
Please feel free to discuss further.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Aarti Abraham 2 days later

Yesterday I had my another followup follicular scan and the size of the most dominant follicle has reduced from 15 mm to 13 mm..
It was Day:14.

So what would you suggest me further to do?

1.Should I continue follicular monitoring or not?
2.Shall I proceed for ovarian drilling or wait?
3.If I go for next induction cycle what should be the dose of chlomiphene and for how many days [ I will however take after getting prescribed from doctor only and not without it, just want to have an idea of wheter my treatment is gojng right or not]..

I reside in XXXXXXX .
Answered by Dr. Aarti Abraham 6 hours later
Brief Answer:
As below

Detailed Answer:
I think you should have a scan after three to four days and let me know the result.
Also regarding drilling, in my opinion, you should have at least three more cycles with good stimulation before attempting surgery.
For the next cycle, you should take 100 mg clomiphene along with gonado tropin injections from Day five.
Take care
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Answered by
Dr. Aarti Abraham


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