For women who have difficulty in conceiving and bearing fruit, modern gynecology suggests using the help of drugs based on human chorionic gonadotropin( hCG) and clomiphene. These funds are also an integral part of assisted artificial reproduction technologies - methods:
- IVF;
- ICSI;
- ECO IMSI;
- GIFT;
- ZIFT.
Ovulation Stimulation
The medication for the maturation of the egg is a process that requires special training, functional support and monitoring, and compliance with precautionary measures. Medication ovulation stimulation: choice of drugs, their dosage and schedule of application - the procedure is extremely responsible and should only be performed with the direct supervision of the physician .
The protocol of the procedure for drug-induced ovulation stimulation is strictly individual for each pair and includes:
- graph showing the exact time of individual examinations and analyzes;
- selection of specific drugs, their dosage, pattern and time of application;
- the preferred method of fertilization;
- graph of ultrasound monitoring of the development of the follicle and the first weeks of embryonic development.
Indications
Ovulation stimulation has a very powerful effect on the ovaries, the can be applied no more than 6 times during the reproductive life of the female , therefore, it is prescribed only for its long absence.
For women under the age of 35, this "help" is used if, in the absence of obvious diseases that prevent the onset of pregnancy and with regular unprotected sex for more than one year, the couple does not get to conceive the fruit naturally. After 35, such a period of time unsuccessful attempts, decreases to six months.
Stimulation will not give a positive result, if in choosing a recovery technique, the doctor did not accurately establish the reason why the egg is not maturing. During the above time, care should be taken to measure and chart the basal temperature. It is recommended to pass several tests to check the hormonal background. It is possible that with the restoration of the normal ratio of estrogen, androgens and progesterone, the normalization of the thyroid hormone levels( T3 and T4) and the pituitary gland( TSH and prolactin), the ovulatory cycle is fully restored.
Absolutely justified will be the passage of a spermogram partner. Even if before the real attempts, he already had his own children or his previous partners became pregnant, all the same, one should check the "combat readiness" of sperm for today.
Acknowledgment for use
The basis for conducting an auxiliary excitation of the ovaries is the result of ultrasound monitoring, which confirms a violation of the development of follicles and the yellow body. This observation is carried out according to the following schedule: the first study is conducted on the 8-10th day after the end of menstruation, then every 2-3 days until the next critical days.
Contraindications
In any case, stimulation of ovulation is not performed in the following conditions or diseases:
- renal and / or hepatic insufficiency;
- endometriosis, uterine bleeding for unknown reasons;
- obstruction of the fallopian tubes, ovarian cyst, the presence of neoplasms on the genital organs, malignant tumor of the ovaries;
- thrombophlebitis or predisposition to it;
- pathologically early menopause;
- thyroid hypothyroidism;
- during breastfeeding;
- tumors of the pituitary gland;
- individual intolerance.
Preparation of
Before performing the stimulation, it is necessary:
- Check individual tolerability of stimulant hormonal drugs.
- Get the therapist's conclusion about the ability to bear.
- Make a blood test for the simultaneous determination of FSH, LH and prolactin, and then assess the hormonal status of the reproductive system by making studies of the level of DEA-C, TSH, T3 free, T4 total, GSG, estradiol, 17-OH Progesterone, testosterone, androstenedione, estrone, DHEAS, LH - RH.Determine the circadian cycle of cortisol. Make tests: dexamethasone suppression, ACTH stimulation, LH-RH.
- Exclude contraindications and, if necessary, take a course of pre-estrogen therapy.
- Make sure spermatozoa of the partner - make a spermogram.
- To pass the tests - deployed ELISA, HIV, syphilis, hepatitis B and C.
- Perform a general and oncocytological examination of the smear from the vagina, including making crops for ureaplasma, mycoplasma, trichomonads, chlamydia, gardnerella and candida.
- Check the patency of the fallopian tubes by any of the available methods.
- Hysteroscopy of the uterine cavity according to indications( inflammation or trauma of the mucous membrane).
- Proceed ultrasound to check the condition of the endometrium, ovaries and mammary glands.
- Ensure that there are no acute inflammatory processes in the body.
Important importance should be given to the early support of the body with the help of balanced nutrition, normalization of sleep and vitamin therapy, where first of all to pay attention to satiety with folic acid and monitor the proper intake of potassium iodide.
Stages of stimulation
The exact date and duration of ancillary excitation of the ovaries is determined during the compilation of an individual protocol. Observation with the help of ultrasound is carried out from the 2nd day after the first hormonal drug is taken, and is repeated every 2-3 days, up to the positive dynamics of embryo development in the first weeks of pregnancy.
If during the initial monitoring it was found that the dominant follicle develops independently and normally to the desired size, but can not independently break, but regresses or turns into a cyst, the in such cases applies only a hCG prick, which serves as an artificial stimulus for the rupture. If ovulation does not occur for other reasons, then the introduction of the chorionic gonadotropin is indispensable and the following step-by-step actions are performed.
Maturation of the follicle and clomiphene preparations
Klostilbegit tablets are the most common clomiphene-based remedy, which increases the production of FSH and LH and, thereby, stimulates the development of follicles.
The classical scheme is the reception of the Klostilbegit tablets from the 5th to the 9th day of the menstrual cycle , with obligatory ultrasound on the 7th and 9th day and the subsequent hCG-stimulating prick of Pregnil, Horagon or Prophase. The time interval for taking the tablets can vary from 2( 3) to 7( 10) days if the doctor considers necessary to take advantage of the more gentle varieties of chorionic gonadotropin - menopausal or laboratory recombinant.
For the maintenance of hormonal equilibrium, in parallel with clomiphene tablets, medications containing estrogen are prescribed, for example, Proginova tablets. Reception of these drugs begins simultaneously. The abolition of estrogen occurs on the 21st day of the menstrual cycle.
Refusal to use clomiphene-containing drugs and a fundamental review of the tactics of infertility treatment( for example, replacement for Gonal, Puregon, Menogon) occurs only after three unsuccessful attempts at conception.
Oocyte maturation and hCG prick
When ultrasound examination shows that the selected one or more follicles have grown in sizes up to 17-18 mm, a hCG prick that will promote the final maturation of oocytes( immature oocytes), rupture of the follicle walls and the release of the mature oocytefrom the body of the ovary.
After a gonadotropic hormone injection, the ovaries increase in size and cause a feeling of discomfort in the lower abdomen. However, this condition is not a 100% guarantee of rupture of the follicle , the release of the egg and requires confirmation by ultrasound.
Ovulation onset and fertilization of
Regardless of the injection dosage, 5000 or 10,000, the process of egg maturation and release ends 42-48 hours after the injection.
If the protocol provides artificial insemination outside the female body, the puncture of the follicles is prescribed for the interval between 24 and 36 hours after the injection of the chorionic gonadotropin.
In the case of fertilization of the egg in a natural way, sexual intercourse should be performed daily - one day before, the day of hCG injection and for the next 2 days.
Important - the decisive moment is the exact observance of the calculated time of the introduction of chorionic gonadotropin, and not how many units of the hormone will be injected.
Development of the embryo and progesterone
Immediately after ovulation for additional support, insurance and relief of the yellow body, estrogen administration is canceled, progesterone-based tablets are prescribed - Dufaston or Utrozestan .Progesterone helps to prepare the inner layer of the uterus for implantation( attachment) of a fertilized egg and helps to maintain pregnancy in the first weeks of embryo development. Supportive reception of progestin drugs continues until the full development of the placenta.
Dosage of
Klostilbegit tablets are taken one at a time once a day.
A hCG injection can be performed only once for the entire treatment cycle. The choice of the drug and its dosage remains exclusively within the competence of the doctor. Typically, a gonadotropin injection is given once in a dosage of 5000 or 10,000 IU.The drug is a dry powder, which must be diluted immediately before the injection with the solvent applied to it. The intramuscular injection is performed by the woman on their own and passes painlessly. It is important to closely monitor the dosage, since excess will lead to hyperstimulation, egg death and ovarian depletion , and underestimation will not give the desired result.
There is also a practice in which the protocol for the administration of gonadotropin hormone is corrected and injections are performed several times in one cycle. If the follicles have reached the desired size( 20-25 mm), and ovulation has not occurred, then a second hCG puncture can be prescribed to re-stimulate the rupture of the walls and prevent the formation of follicular cysts. Another extra prick is possible to help the yellow body. The dosage of these injections is small( 300 - 1500 IU).How many will be specifically entered units - the decision is made by the doctor.
Overdose during stimulation - excess gonadotropin, may cause ovarian hyperstimulation syndrome or result in their rupture. Use of the drug more than 6 times threatens ovarian malnutrition and an early menopause.
Prick of hCG during pregnancy
During pregnancy, it is necessary to monitor the level of gonadotropin in dynamics: after conception, its level doubles every 2-3 days;by the end of the first trimester reaches the maximum rates "then a little reduced and must remain unchanged until delivery. If such monitoring indicates a decrease in concentration or a complete stop of the production of chorionic gonadotropin, will prescribe HSG injections to maintain pregnancy, prevent fetal fading or miscarriage, which will maintain gonadotropin levels within normal limits, depending on the gestational age. Typically, the dosage ranges from 1000 to 3000 IU.
