Patients in treatment

Medications used to stimulate the ovaries

Synthetic FSH (Bemfola, Gonal-F; Rekovelle, Puregon) and urine-derived hMG (Menopur) contain the same hormone that the body produces in the pituitary gland, which stimulates the development of a mature follicle. Since these hormones are deliberately given in higher doses, the ovaries are stimulated to produce multiple follicles, leading to higher estrogen levels.

Known side effects
Symptoms from the ovaries may occur – bloating, tenderness, sometimes pain. Increased estrogen levels from the follicles can cause increased discharge, breast tenderness, tiredness, and nausea.

A relatively uncommon side effect is ovarian hyperstimulation syndrome (OHSS), which can occur in women with a good ovarian reserve when developing a large number of follicles. Overstimulation only develops after egg maturation has been triggered with hCG (Ovitrelle) and can be avoided by adjusting the treatment plan.

Medications that prevent the release of LH (ovulation hormone)

GnRH agonists (Suprecur, Synarela) are usually given as a nasal spray. After a short stimulation of the pituitary release of FSH/LH, this release is suppressed after 10–14 days (downregulation with the long protocol), after which ovulation is blocked during hormonal stimulation. Downregulation is verified through a blood test (estrogen should then be at a low level) or ultrasound (no growing follicles visible).

Known side effects
Hot flashes, sweating (due to low estrogen), headache, difficulty concentrating. Development of a functional ovarian cyst may occur (usually disappears over time, can also be punctured via vaginal ultrasound).

GnRH antagonists (Fyremadel, Cetrotide, Orgalutran) are given as daily injections starting on stimulation day 5–6. They effectively prevent the release of LH and thereby ovulation (short protocol).

Local side effects at the injection site are common: itching, swelling, due to histamine release. These symptoms usually subside quickly.

Medications that trigger egg maturation

For eggs to mature and become fertilizable, stimulation with LH or an LH-like hormone (hCG) is required.

hCG (Ovitrelle) itself has no significant side effects, but it can cause follicles to grow further, creating a sensation that ovulation is approaching. Because hCG has a long half-life, it also stimulates the corpus luteum formed after egg retrieval. This may lead to a continued feeling of bloating. If many follicles (more than 15–20) develop and estrogen levels are high, there is a certain risk that the hCG injection may lead to overstimulation.

If there is a risk of severe overstimulation, Ovitrelle may be withheld and Suprefact used instead (possible in short protocols).

Suprefact injection is used to trigger the release of ovulation hormone from the pituitary so the eggs can mature and be retrieved. In this case, it is usually necessary to freeze all embryos and wait one month before transfer. Since Suprefact has a very limited effect on hormones, this option completely avoids the risk of overstimulation.

Medications that support the uterine lining after embryo transfer

Progesterone (corpus luteum hormone) is necessary for an embryo to implant in the uterine lining. After egg retrieval, progesterone.

Discontinued Treatment and Risks and Side Effects

Discontinued treatment

Sometimes stimulation must be stopped. If the number of developing follicles is too few, it may be better to discontinue hormonal stimulation. Your doctor will make a medical assessment of whether a dose adjustment might give a better response or not.

Another reason may be that a given hormone dose results in too many growing follicles. If there is a risk of hyperstimulation developing, treatment may be stopped and resumed later with a lower dose.

In some cases, treatment is continued with a reduced hormone dose, followed by egg retrieval and fertilization. If the patient is feeling well, a fresh embryo can be transferred in the same cycle; otherwise, embryos of good quality are frozen for transfer once overstimulation symptoms have subsided.

It is rare that egg retrieval produces no eggs. Sometimes no eggs fertilize or the fertilized eggs do not continue dividing. When the outcome is not as expected, you will have a consultation with your doctor regarding possible reasons and options for future treatment attempts.

If, for any reason, you yourself wish to discontinue the treatment, please contact us to discuss the best way to proceed.

Risks and side effects

For women
Ovarian hyperstimulation syndrome (OHSS) occurs in 1–2% of IVF treatments. A given hormone dose causes too many follicles to develop, leading to abdominal swelling, pain, and sometimes shortness of breath. In some cases, treatment must be stopped before egg retrieval, but most often symptoms appear after the embryo transfer.

The measures taken in cases of overstimulation depend on severity. Usually, rest and outpatient monitoring are sufficient, but occasionally hospitalization is required. The pregnancy itself is not negatively affected.

With the shorter stimulation protocol (antagonist protocol), the risk of OHSS has been further reduced.

Good to know:

• Miscarriage rates are not higher after assisted reproduction compared to natural conception.
• Ectopic pregnancy (extrauterine pregnancy) may occur in rare cases after IVF. In such cases, the embryo placed in the uterus migrates into the fallopian tube and implants there. Symptoms of a pregnancy growing outside the uterus are bleeding and pain.
• Infection in the ovary after egg retrieval is very rare but important to detect and treat with antibiotics.
• So far, studies have shown no long-term increased risk of cancer after hormonal treatment.

For men

Bleeding or infection after sperm retrieval with a needle from the epididymis or testicle is rare.

Surgical sperm retrieval from the epididymis or testicle can be performed repeatedly without deteriorating sperm quality.