Infertility Treatments

At Piedmont Reproductive Endocrinology Group (PREG), infertility treatments will be recommended by Dr. John Nichols or Dr. John Payne based on you and your partner's medical history, physical findings, infertility testing, evaluation and prior fertility treatments.

Click on a topic below to learn more.

Ovulation Induction

Ovulation Induction is the use of medications to cause or improve the ovulation process in conjunction with timed intercourse or intrauterine inseminations (IUI).

Clomiphene Citrate

Clomiphene Citrate (Clomid, Serophene) is usually taken daily for 5 days beginning on cycle day 3 through 7. Can also be started on cycle day 4 or 5 for a total of 5 days. Doses range from 50 mgs (one pill) up to 200 mgs (four pills).

Clomiphene works through the brain to cause release of FSH (follicle stimulating hormone). FSH is necessary to cause growth and development of follicle(s) in the ovaries.

Side effects include hot flashes, mood swings, decreased cervical mucus and possible thinning of lining of uterus (endometrium).

Monthly pregnancy success rates with the use of Clomiphene ovulation induction/ IUI is 5-12% per cycle.

Multiple birth rates with use of Clomiphene is approximately 10% with the majority of multiple pregnancies being twins.

Medication costs: 5 day course at 50 mgs/day; generic $15 to $20, Brand name; $40 to $60 depending on place of purchase.

Letrozole (Femara)

Letrozole (Femara) is usually taken daily for 5 days beginning on cycle day 3 through 7. Can also be started on cycle day 4 or 5 for a total of 5 days. Doses range from 2.5 mgs (one pill) up to 5 mgs (two pills).

Letrozole works through the brain to cause release of FSH.

Side effects include hot flashes, mood swings, decreased cervical mucus and possible thinning of lining of uterus (endometrium).

Monthly pregnancy success rates with the use of Letrozole ovulation induction/ IUI is 5-12% per cycle.

Multiple birth rates is approximately 10% with the majority of multiple pregnancies being twins.

Medication costs: 5 day course at 2.5 mgs/day; $40 to $60 depending on place of purchase.

hCG (human chorionic gonadotropin; Pregnyl, Profasi, Ovidrel)

An injectable medication given intramuscular (IM, in the muscle, usually thigh or buttocks) that can trigger or boost ovulation to better time intercourse or intrauterine insemination (IUI). hCG is usually given when there are mature ovarian follicles (egg sacs) seen on vaginal ultrasound (size >18 to 22 mm) or in conjunction with a positive urine LH surge detection kit. Usually given in a dose of 10,000 units of hCG per vial.

You will be instructed on how and when to give hCG. 

Gonadotropins (Repronex, Pergonal, Humegon, Bravelle, Gonal-F, Follistim)

An injectable fertility medication that can be given either intramuscular (IM) or subcutaneously (SQ, under the skin). These are very potent medications that contain FSH (and some with LH) which act directly on the ovaries to cause growth and development of ovarian follicles. Gonadotropins are usually given as daily injections for 7 to 10 days as part of a Stimulated Ovulation Induction Protocol or for an In Vitro Fertilization (IVF) cycle. Generally, 2 to 4 or more ampules of gonadotropins are used daily in either a single or twice daily injection. Occasionally, gonadotropins are given in combination with Clomiphene or Letrozole (Minimal Stimulation Protocol). Since these are very powerful fertility medications, ultrasound monitoring and blood testing is needed while taking these shots. The different types of gonadotropins are based on their composition and how they are processed:

• Repronex, Pergonal, Humegon: Contain both FSH and LH in equal amounts and are derived from human urinary products. These are generally given as IM injections. Costs; $35-$50 per ampule.
• Bravelle: Contains mostly FSH with a little LH and is also derived from human urinary products. Can be given as a SQ injection. Costs; $40-$50 per ampule.
• Gonal-F, Follistim: Contains pure FSH only and are derived from recombinant DNA technology and are given as a SQ shot.

Our staff will be available to teach you, your partner or designated person to prepare and administer the medications (gonadotropins, hCG, etc.) given by injection. Since many of these medication shots are given at night it is strongly recommended that you learn to self -administer or have your partner give you the injections.

Intrauterine Insemination (IUI)

IUI is a procedure where partner’s sperm is placed into the uterus through the cervix using a small thin catheter. Semen specimen is collected by masturbation into a sterile collection cup. Semen collection kits are available upon request from the office. If specimen is collected off premises then it must be transported to the andrology lab, keeping the specimen warm (body temperature, not any hotter), within 30 minutes of collection for best results (in general, sperm do not do well in plastic cups for long periods of time). It takes about an hour to wash, count and process the sperm sample prior to use for IUI.

IUI is based on timing from either a positive ovulation predictor kit or by timing of injection of hCG.

If based on an urine ovulation predictor kit, the IUI is performed the morning after a positive response is detected. In some cases a hCG shot will be given the same day as a positive ovulation detection to help boost the process of ovulating.

If based on a hCG shot to trigger ovulation (no evidence of a positive urine ovulation detected), IUI is usually performed 36 hours after hCG shot is given. This means most hCG shots will be given at night and IUI done two mornings later. You will be instructed on when to give your hCG shot and arrive for your IUI by our staff.

IUI generally adds 3-5% pregnancy success rate to your treatments. IUI are generally done in combination with ovulation induction medications for best results.

Minimal Stimulation Protocol

Minimal Stimulation Protocol: combination of either Clomiphene Citrate (CC) or Letrozole (LT) and injectable gonadotropins. Usually recommended if failure to ovulate with CC or LT alone, no pregnancy after 3-6 cycles of CC or LT, or persistently thin (<6 mm) uterine lining (endometrium).

CC or LT for 5 days usually beginning on cycle day (CD) 3.

Gonadotropins (usually use Repronex due to lower cost) 2 ampules on IM on CD 7 and CD 9.

Follicle scan (vaginal probe ultrasound) on CD 12. If follicles are not of appropriate size (>18 mm) a repeat follicle scan may be ordered 2-3 days later.

hCG (Pregnyl) to be given when appropriate to trigger or boost ovulation.

Can be done with timed intercourse or intrauterine insemination (IUI).

Monthly pregnancy success rates; 8-15% per cycle.

Multiple birth rates is approximately 10% with the majority of multiple pregnancies being twins.

Stimulated Ovulation Induction/IUI (SOIUI)

Stimulated Ovulation Induction/IUI (SOIUI): gonadotropin only stimulation. Usually recommended if failure to ovulate with Minimal Stimulation Protocol (MSP), no pregnancy after 3-4 cycles of MSP or persistently thin endometrium (<6 mm).

Need baseline ultrasound (U/S) on done CD 2 or 3 to rule out any ovarian cysts or uterine lining problems.

Injectable gonadotropins, usually 2 to 4 ampules, daily for 7 to 10 days beginning on CD 3.

Serial monitoring with U/S and blood testing for Estradiol levels to evaluate adequate ovarian response and follicular development (usually 3 to 4 monitoring visits).

Pregnyl (hCG) injection to trigger or boost ovulation and timing of IUI based on U/S size of ovarian follicles.

SOIUI monthly pregnancy success rates; 10-30% per cycle.

Multiple birth rate; 30% chance of multiple births per cycle with <10% chance of triplets or greater (>3). 

It is generally recommended to do 3-4 (no more than 6) cycles of any one treatment before moving on to further investigation or to more aggressive treatments. If an infertility treatment is going to be successful pregnancy will usually happen within the first 3 to 4 cycles of treatment. Your physician will recommend a starting treatment protocol based on your findings and will review your response as you are undergoing treatments and/or at the end of 3-4 cycles of treatments.

In Vitro Fertilization (IVF)

IVF: involves gonadotropin stimulation of ovaries with retrieval of eggs by vaginal ultrasound guidance and fertilization with partner’s sperm in the embryology lab. Embryos are usually allowed to grow 3 to 5 days in the lab before transferring embryo(s) back to uterus. IVF is generally recommended for couples with severe tubal disease or blockage (or previous tubal ligation), severe male factor (low count, motility or morphology), severe endometriosis (Stage III or IV), high amounts of anti-sperm antibodies, or failure to achieve pregnancy with previous afore-mentioned treatment protocols (Minimal Stimulation, SOIUI protocols, etc.).

IVF Treatment cycle; Need baseline ultrasound (U/S) performed on CD 2 or 3 to rule out any ovarian cysts or uterine lining problems.

All patients will have pituitary suppression with either Lupron or Antagon (see below information on these medications). Different protocols will use different combination of medications and your specific protocol will be determined by the physician and IVF team.

Injectable gonadotropins, usually 2 to as much as 8 ampules, daily for 7 to 10 days beginning on CD 3.

Serial monitoring with U/S and blood testing for Estradiol levels to evaluate adequate ovarian response and follicular development (usually 4 to 6 monitoring visits).

Pregnyl (hCG) injection to trigger ovulation and timing of IUI based on U/S size of ovarian follicles. Egg (oocytes) retrieval performed approximately 36 hours after hCG shot. Egg retrieval done under light anesthesia sedation with ultrasound guidance.

Fertilization is performed in the lab with either insemination (placing sperm and eggs together in a small dish and allowing natural fertilization to occur) or by Intracytoplasmic Sperm Injection (ICSI) in which a normal sperm is injected into each egg to allow fertilization to occur. Fertilization rates are generally 60 to 80% for both methods. ICSI is recommended for men with very poor sperm counts, anti-sperm antibodies, some case of unexplained infertility and history of poor fertilization in the past.

Embryo transfer will be on either 3rd day or 5th day after egg retrieval. Your day of transfer will be determined by the IVF team. In general, 2 to 4 embryos will be recommended for transfer with the exact number dependent on several factors including maternal age, quality of embryos and previous IVF attempts.

If there are available excess embryos of good quality, cryopreservation (freezing) can be performed. Frozen embryo transfers can then be done at a later date.

IVF success rates are based on many factors but are generally in the 40-55% success rate per cycle.

Multiple pregnancy rates are approximately 40% with a <10% rate of triplet or greater (>3) pregnancy rate. This rate is certainly dependent on how many embryos are transferred.

Frozen embryo transfer (FET) pregnancy rates are approximately 30-40% success rate per cycle.

Donor Egg IVF

Donor Egg IVF: use of a known or anonymous (unknown) donor or female to provide eggs for to be used for fertilization by the recipient’s partner and placement of resultant embryo(s) into recipient’s uterus. Generally recommended for women with poor egg quality, advanced maternal age (>age 42), history of multiple failed IVF cycles using own eggs or for genetic reasons (adverse inherited traits).

Donor egg IVF success rates are approximately 50% to 65% success per cycle.

Multiple pregnancy rates are approximately 40% with a 10% rate of triplet or greater pregnancy rate. This rate is certainly dependent on how many embryos are transferred. 

Tubal Reversal

Tubal reversal is an out-patient procedure that can be performed in our private surgical suite. It is a microsurgical procedure to put back together fallopian tubes that have been previously tied or ligated. Success depends on the type of tubal ligation that was performed; use of cautery (tubes “burned”), clips, rings or a portion of the tubes removed. In general, the more tube that is left or undamaged to work with the better the reversal success rate. Success rates are also depended on other factors such as maternal age, presence of a male factor or hormonal imbalances.

There is a higher risk of ectopic pregnancy after having a tubal reversal, approximately 15%.

The tubes may re-scar and block again despite a successful reversal.

Success rates after tubal reversal; 50% to 70% of couples (with no other infertility factors present) usually conceive within one year of having both tubes successfully put back together.

In general, we cannot guarantee that all patients undergoing infertility treatments will become pregnant, not suffer a miscarriage or have a child without a birth defect.

Prenatal Vitamins

We recommend that all females be on a prenatal vitamin or a multi-vitamin with at least 800 micrograms to 1000 micrograms (1 milligram) of Folic Acid daily. Males should be on a daily multi-vitamin as well but do not necessarily need the extra Folic Acid.

Lupron

Lupron is a gonadotropin releasing hormone (GnRH) agonist that is given as a daily SQ injection. Lupron is given to suppress (down-regulate) the pituitary gland from releasing LH and preventing a spontaneous LH surge and ovulation. In programmed cycles such as IVF, suppression of the LH surge is needed to allow growth of multiple ovarian follicles and prevent premature ovulation. With IVF, Lupron is usually started 2 weeks before beginning gonadotropins (luteal or long protocol) or 1–2 days prior to starting gonadotropins (flare protocol). After adequate ovarian stimulation and the follicles are of appropriate size and number, hCG is given to cause the final maturation of the follicles and will take the place of the LH surge to induce ovulation. In IVF cycles, the eggs are retrieved just prior to the ovulation event.

Antagon, Cetrotide

Antagon, Cetrotide: a GnRH antagonist that also suppresses the pituitary gland (like Lupron) to prevent the release of LH and the LH surge. Antagon works more rapidly than Lupron and is usually given after 5 to 7 days of gonadotropin stimulation as a daily injection to prevent premature ovulation and the LH surge.

Prednisone

Prednisone: a very mild corticosteroid hormone usually given to women with elevated adrenal androgens (DHEAS, >200 mg/dl) as a nightly 2.5 mg dose. Prednisone helps to suppress the elevated DHEAS level that can interfere with ovulation. This is a very small dose and is not related to significant adrenal suppression or weight gain.

Metformin

Metformin: a medication given to patients with Polycystic Ovarian Syndrome (PCOS) to reduce their insulin levels and improve their chances for ovulation and pregnancy success. It is usually taken two to three times a day (500mg to 850 mg doses) and started at least 2 months prior to beginning infertility treatments. It is recommended to also be on a daily exercise program (20 to 30 minutes a day) and a low carbohydrate diet (<30% carbohydrates daily) and low calorie diet (<1800 calories daily). Metformin, in combination with a daily exercise program and low carbohydrate diet, can result in significant weight loss as well. In general, we recommend at least a 10% to 20% or greater loss of your present weight as a goal for all obese patients prior to beginning infertility treatments. Metformin is generally continued for at least the first 12 weeks of pregnancy as well.

Side effects include nausea, abdominal bloating, gas, and diarrhea. These side effects will improve the longer on the medication.