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Test of tubal potency

  • HSG
  • Sonosalpingography
  • Laparoscopy & chromotubation
  1. CTest for uterine defects
  • Hysteroscopy
  1. Immunological tests
  • PCT

Management of infertility

Ovulation Induction Agents

  1. Clomiphene citrate (CC)
  2. Letrozole, Anastrozole, Tamoxifen
  3. Gonadotropins

Clomiphene Citrate: It is a racemic mixture of enclomiphene and zuclomiphene. Enclomiphene is a more potent isomer responsible for its ovulation-inducing action.

  • Dose = 50-250 mg. However, the US FDA-approved maximum dose for CC is 100 mg
  • CC blocks "E" receptors -> increase FSH from pituitary -> growth of follicles
  • With CC Success rate for ovulation is 80% and success for pregnancy is 40%

Letrozole = aromatase inhibitor blocks conversion of testosterone to estrogen, leading to increased FSH from pituitary.


Gonadotropins: HMG (Human Menopausal Gonadotropin) (from the urine of the menopausal women) and recombinant FSH.

  1. Menopausal women have high FSH and LH levels in their blood, urine, and HMG is extracted from urine of menopausal females. It mainly contains FSH.
  2. Follicular study is done along with ovulation induction to monitor the growth of follicles and when the dominant follicle is 18-20 mm, ovulation trigger is given to rupture the follicle
  3. For ovulation trigger, MC drug used is hCG (derived from the urine of pregnant women or by recombinant technology)
  4. Recombinant LH is can also be used but is very expensive
  5. Ovulation occur 36 hours after injecting hCG

Side Effects of Ovulation Induction

  1. Multiple pregnancies: 3-8% with CC, 15-30% with Gonadotropins
  2. Ovarian hyperstimulation syndrome (OHSS)
    • Most dangerous complication of ovulation induction
    • Risk factors: PCOS patients and past history of OHSS

Classification of OHSS



Ovary Size (em)




Abdominal distention ± GI upset


> 10

Moderate ascites, normal renal function, hematocrit <0.45


> 12

Marked ascites



Hypovolemia WBC



Hematocrit >0.45



Venous thrombosis



Renal function, ± DIC

  • Various factors responsible for development of OHSS include estrogen, prostaglandins, histamine, cytokines, IL-2, IL-6, IL-8, renin, angiotensin II, and Vascular Endothelial Growth Factor (VEGF)
  • VEGF is considered to be the most important
  • The risk of OHSS is very high when estradiol levels are more than 2500 pg/mL, but OHSS can also happen when it is >1500 pg/mL
  • Treatment: IV fluids, albumin, USC guide taping of ascites and aspiration of follicles
  • Surgery is done only if there is bleeding within ovaries or torsion ovaries
  1. Increased risk of epithelial ovarian cancers: Prolonged use of gonadotropins/CC (>6-12 months) increases the risk of epithelial ovarian cancer.

Insulin Sensitizers

  • MC used drug = metformin; others = rosiglitazone/pioglitazone
  • Metformin will help the patient to lose weight and will either cause spontaneous ovulation or increase the success of ovulation induction drugs
  • MC side effects: nausea/vomiting and bloating (GI upset)
  • Most dangerous side effect: lactic acidosis
  • Metformin was thought to be teratogenic, but recent consensus is that metformin can be continued throughout pregnancy and it decreases the risk of spontaneous abortion and development of gestational DM (GDM)
  • Newer insulin sensitizer myoinositol is now available. It is better tolerated than metformin.

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