It’s day 2: Pills, injections or both? Ovarian stimulation options: Which is best?

It’s day 2: Pills, injections or both? Ovarian stimulation options: Which is best?

by Prati A. Sharma, author on The Conception Diaries Prati A. Sharma 16 June 2017

It’s day 2 of your menstrual cycle, and you are ready to start your first, or perhaps another, cycle of fertility treatment. Exciting but daunting. Often, there are mixed feelings. What is the right next step? Should you be more aggressive or take a cycle off and go natural? What are the side effects of the medication? Will you be moody or gain weight? Will the injections hurt, and how will you manage to stick yourself for 10 days straight?

These are all natural and expected questions, whether it’s your first cycle or you are coming back for subsequent cycles.

Once you have had an infertility consult and evaluation, your doctor will review your results and likely come up with a treatment plan that involves fertility medications to help stimulate your ovaries to produce one or more eggs to increase your chances of pregnancy. Typically, this starts at the beginning of your menstrual cycle, on day 2 or 3 of bleeding. This may be coupled with intrauterine insemination (IUI). If initial treatments don’t work, your doctor may suggest stronger medication to stimulate the ovaries and possibly moving on to in vitro fertilization.

What medications are involved with these treatments, and how do they work?

Fertility pills

Fertility pills are typically the first medication that fertility patients will start on.

Clomiphene citrate (Serophene/Clomid) or Letrozole (Femara): These are low-dose fertility medications taking orally for five days at the beginning of your menstrual cycle (typically from day 2 to 5 for five days). They are used to stimulate the growth of one or more follicles or eggs to increase the chances of pregnancy.

The pregnancy rate per month is about 10 to 15%, but after 6 cycles can be up to 80%. Producing more eggs can result in multiples, which includes twins and triplets, but the risk is low, approximately 5 to 7% for twins and less than 1% for triplets.

Side effects are minimal but can include headaches, mood changes (women say they are a little more moody and irritable on oral fertility medication!) and, in rare cases, visual changes. Make sure to check in with your doctor if you have any untoward side effects.

Clomid can occasionally make the lining of the uterus thin or can thicken the cervical mucus. In these cases, your doctor might suggest another medication or IUI. Some patients will respond better to Clomid and some to Femara. Often, doctors will start patients on one pill and, if it doesn’t work, try the other. You will need to monitor your response to the medication with ultrasound and, often, blood work, which will require approximately five to six visits to the clinic over the first two weeks of your menstrual cycle.

Fertility injections

You have tried Clomid and Femara for a few months with no success. Your doctor says to move on to something stronger, involving injections. What does this mean? Fertility injections are gonadotropins, which mimic the natural hormones that our brain makes to help an egg grow and develop each month.

These hormones are named FSH and LH. In a fertility treatment cycle, by giving these hormones, we can stimulate the ovaries to make multiple follicles to increase the chances of conception. Typically, this involves taking injections, usually in the fat tissue underneath the skin either in the thigh or in the stomach. This usually lasts about 7 to 10 days.

Afterwards, ovulation is triggered with another injection, named HCG, and either you will try to conceive naturally or with an IUI. Because this is a stronger treatment, the risk of multiples is higher, approaching 25%. However the pregnancy rate is higher, too, almost 25 to 30%.

Side effects of injectable fertility medications are mild mood changes, bloating due to the development of multiple eggs and, in rare cases, ovarian hyperstimulation syndrome (OHSS).

OHSS is a complication of fertility treatment that results in enlarged ovaries from stimulation, bloating and fluid retention. Typically, OHSS can be managed conservatively with diet changes and frequent monitoring.

As fertility doctors, we are very careful to monitor the dosing of these injectable medications and to monitor patients’ responses closely with frequent blood work and ultrasounds, to avoid increased risks of multiples and OHSS.

Many patients are worried about the needles involved, both for blood work and for the injections. The truth is that most patients do very well, and once they learn how to do the injections, they are relatively well tolerated, with minimal side effects.


If fertility pills and injections don’t work, your doctor may suggest in vitro fertilization (IVF). This treatment involves the use of similar injectable fertility medications (FSH and LH), often at higher doses to stimulate the ovaries to make up to 20 eggs. These eggs are retrieved from the ovaries, then combined with sperm in the IVF laboratory to make embryos.

The important thing to remember is to select the treatment that is best for you. Your fertility doctor will help you do that. The choice of what treatment to start and continue with is based on many factors: age, finances, prior treatments, infertility testing results, and concern about multiples, amongst others. Make sure you are comfortable with the treatment you are undergoing. This will ensure the highest success rate with the least risk. Many times, multiple different treatment options are available, and it is best to individualize treatment plans based on the patient’s unique picture.