Ovarian stimulation

A woman usually produces a single egg cell inside a follicle during a normal menstrual cycle (follicle growth / ovary). In each menstrual cycle there are on average 10 follicles competing with each other for dominance. Only one follicle containing an ovum will continue to maturity while the others will stop growing and die.

Due to ovarian stimulation this cohort of follicles competing for dominance with each other can be rescued. Please do not worry, for ovarian stimulation is not associated with premature menopause in women. Anyway, only those egg cells are rescued, which would otherwise loose the battle for domination - and every month this struggle starts from the beginning.






1. Ovarian stimulation by hormonal therapy
2. Intrauterine Insemination
3. Injection Techniques

In order to induce the production of mature follicles (containing the egg cells) in the ovary, different drugs and hormonal medication should be administered for a certain period of time.







Treatment protocols may vary, according to whether an intra-uterine-insemination (IUI) (prepared semen, equally referred to as sperm, spermatozoa is inserted into the uterine cavity) or an egg-retrieval by follicle puncture (followed by the fusion of egg cells and sperm in a petri dish) is scheduled.







Most commonly the hormonal therapy during ovarian stimulation consists of hormones that occur naturally in the human body (gonadotropins). These hormones are mostly administered by intramuscular or subcutaneous injection.

As a first step, IUI may be recommended to young women (up to 36 years of age) with the option of 3 to 6 cycles. Basic preconditions, however, are non-obstructed fallopian tubes in the woman and a normal semen analysis in the man.

A Polycystic Ovary Syndrome (PCOS) often is the underlying cause for the desire for children remains unfulfilled. In this case, stimulating hormones / gonadotropins or clomiphene (clomifene) are used to induce the ripening of 1 – 2 follicles in the ovary.

Subsequently, ovulation is triggered by injecting human chorionic gonadotropin (HCG) and the semen is placed into the uterine cavity.

Sperm cells migrate through the uterus into the fallopian tube where they meet the egg cell. Fertilization of the egg by only one single sperm typically occurs in the ampulla (upper part of the fallopian tube).

Then the fertilized egg (zygote) subsequently referred to as embryo, starts its 5 days migration towards the uterine cavity. At the blastocyst stage it then reaches the uterus and starts implanting in the uterine lining (endometrium).

To appropriately prepare the inner lining of the uterus for implantation, certain hormones (e.g. progesterone) have to be taken either until the heart can be seen beating via ultrasound four weeks after ovulation or up to the 12. week of pregnancy.

             

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There are two different injection techniques:

1. Intramuscular Injection (i.m.) 
2. Subcutaneous Injection (s.c.) 



1. Intramuscular Injection (i.m.)

Intramuscular injection is the injection of a liquid pharmaceutical into a muscle using a syringe and needle.

The following drugs should be administered by intramuscular injection: 
Gonadotropins (e.g. Merional, Menogon, Menopur)
Human Chorionic Gonadotropin (e.g. Pregnyl (A, CH) = Choragon, Predalon (D), Brevactid, Gonasi)
Progesterone (e.g. Gestone, Prontogest, Progesteron Streuli)

Injection needles:
To dissolve the medication please use the needles 18G / 1,2 x 40mm.
For intramuscular injection please use the green needles 21G / 0,8 x 40mm.

Administration of intramuscular injection:

1. Locating injection site

    
Gluteal muscle                                                           Thigh

2. Preparing injection solution (for dry substances such as Merional, Fostimon, Menogon, Menopur, Pregnyl etc):
The dry substance contains the medication, the liquid serves as diluent. Inject the liquid into the dry substance, which dissolves immediately and can be drawn into the syringe. You should always use an equal number of ampoules containing the powder (dry substance)  and ampoules of liquids (diluent), e. g. mix 3 x dry substances with 3 x liquids.

3. Clean the skin at the injection site thoroughly with an antiseptic pad.

4. Contact time of disinfectant should be about 30 - 60 seconds.

5. Attach a new needle to the syringe (for the injection please use the green needle, attach the needle securely to the syringe).

6. Inject the needle straight down (90° angle) – do not insert the needle completely, inject slowly!

The term subcutaneous refers to the fatty layer of tissue just under the skin. This subcutaneous tissue consists largely of fatty tissue and connective tissue just under the skin.

Medication that should be administered by subcutaneous injection (s.c.):
GNRH-Agonist and -Antagonist (e.g. Decapeptyl, Orgalutran, Cetrotide)
Gonadotropins (e.g. Puregon, Gonal F, Fostimon)

Injection needles:
To dissolve the medication please use the needles 18G / 1,2 x 40mm.
For subcutaneous injection please use the short needles 27G / 0,40 x 20mm. Puregon or Gonal F comes in a PEN (automatic injection pen). Special removable pen needles are attached to the injection pens (e.g. 29G / 0,33 x 12mm or BD Micro-Fine Pen-needle)

Administration of subcutaneous injection:

1. Locating injection site: you can inject the medication either in the abdomen below the navel or in the front of the thigh. To make sure that the injection is given into the subcutaneous tissue and not into the muscle you should grasp the skin between the thumb and index finger before inserting the injection needle. The needle can be inserted at a 45 - 90 degree angle.



Grasp skin as shown                Only the skin, not the muscle   Insert needle at a 45° angle


2. Prepare the injection solution (for dry substances see point 1.2 regarding intramuscular injection). Some medications are available as ready-to-use injectable solutions. Puregon and Gonal F come with a special pen for injection: see instructions for use (package leaflet) or go to www.puregonpen.com or www.fertilitylifelines.com

3. Clean the skin at the injection site thoroughly with an antiseptic pad.

4. Contact time of disinfectant should be about 30 - 60 seconds.

5. Attach a new needle to the syringe (for the injection please use the grey needle, attach the needle securely to the syringe) / for Puregon und Gonal F Pens 29G / 0,33 x 12mm or BD Micro-Fine Pen-needle

6. Quickly thrust the needle into the skin at a 45° angle, pull back gently on the plunger then inject the medication at a slow but steady rate.