Gonadotropins - follicle stimulating hormone (FSH) and luteinzing hormone (LH) - play an essential role in a woman’s natural cycle. Both are produced by the pituitary gland; FSH stimulates the follicles to grow and produce the female hormone oestrogen. The ova (eggs), which develop within the follicles, start to mature at the same time. During the average cycle, on day 14, the pituitary releases a quantity of LH (the LH peak). LH stimulates the final maturation of the eggs and triggers ovulation - the release of one mature egg from the dominant follicle into the fallopian tube.

• Gonadotropins are also used in various fertility treatments:
  Ovulation induction.
• Mild ovarian hyperstimulation in combination with intrauterine insemination.
• Controlled ovarian hyperstimulation in combination with IVF or ICSI.

Treatment with gonadotrophins - which are administered by injection is a more - intensive form of ovulation induction than treatment with tablets (clomiphene). The reasons for switching from from clomiphene to gonadotropin injections are:

• Ovulation does not occur even after the maximum dosage of clomiphene tablets;
• Severe side effects with clomiphene;
• Failure to become pregnant;
• The absence of quality cervical mucus at the time of ovulation;
• If only small amount of hormones are released by the pituitary.

The risks associated with gonadotrophin ovulation induction are also somewhat greater than with clomiphene, and include a greater chance of multiple pregnancy and overstimulation of the ovaries. Consequently, patients are therefore carefully evaluated before embarking on treatment with gonadotropins. Women are tested for ovarian suitability and for abnormalities of the fallopian tubes and uterus (womb) perhaps via laparoscopy or hysteroscopy. A semen analysis is also performed in the male partner and possible hormonal problems are checked.

Gonadotropins stimulate ovulation in a direct manner, because they contain the same hormones - FSH and LH - that, in a natural scenario, are responsible for the stimulation of the growth of the follicles and ovulation induction. They must be administered by injection, because they would be immediately destroyed in the gut if they were given orally (by tablet). Fortunately, methods have been developed which make it easier for women to administer these injections themselves.

Traditionally, these hormones are extracted from the urine of postmenopausal women, which contains high concentrations of FSH and LH. This is called human menopausal gonadotropin or HMG. Aside from FSH, menopausal gonadotropins contain a small amount of LH. These have to be injected into the muscle.

Nowadays, gonadotrophins can also be produced in the laboratory through the use of biotechnological (recombinant DNA) techniques. In this manner, a ‘factory’ of cells is able to produce highly purified human FSH. (As the administration of LH is rarely necessary, most women only need purified FSH.) An example of these recombinant FSH product is Puregon®.

Recombinant FSH is purer than urinary products, but due to the complicated method of production, they are somewhat more expensive. An added advantage of these recombinant FSH products is that these drugs can be administered through a highly efficient and patient-friendly hypodermic system, allowing injection just under the skin - subcutaneously - rather than into the muscle. It is a sort of adapted insulin pen (Puregon Pen®) with which the patient can finely adjust the dosage delivered according to her needs.

Treatment with gonadotrophins is more complicated than with tablets. Gonadotropins are administered using hypodermic injections. Usually, a nurse at the clinic will teach the person who is to administer the injections how to do this. These days, there are increasingly user-friendly administration methods, which make it easier and less painful for the woman to inject herself. An example is the use of a sort of insulin pen, which can be filled with special cartridges and in which the exact quantity of the injection can be set.

A woman must administer the injection at least once a day over a period of between one to two weeks. (This is one difference with treatment using tablets, where the tablets have to be ingested for five consecutive days every cycle.) The duration of the gonadotropin treatment will vary from woman to woman and depends on how quickly the follicles mature. It may be that the woman will have to visit her doctor relatively frequently. The formation of follicles on the ovaries is carefully monitored using ultrasound and sometimes also through blood tests. If it appears that the ovaries are not reacting, then the doctor can increase the dosage.

Couples who are receiving treatment for ovulation induction may be advised to have intercourse on the day of the subsequent hCG injection (used to stimulate actual ovulation), and once a day for the next two days. (For IVF and IUI treatments, separate instructions follow.)

If three to six courses still produce no results, the following next step would be assisted reproductive techniques such as IUI or IVF ICSI.

It is important to distinguish between the side effects of the drug and the risks associated with the treatment for which they are being used.

Potential side effects of gonadotrophins:

• Swollen breasts.
• Rash at the site of injection.
• Mood swings.
• Possible stomach ache and a bloated feeling as a result of overstimulation ( hyperstimulation syndrome).

Potential side effects of the treatment:

• Increased risk of multiple pregnancy (careful dosing and check-ups can significantly lower this risk).
• Higher risk of ectopic pregnancy (where the pregnancy occurs outside of the womb, normally in a fallopian tube).