Every fertility specialist seeks to design the most effective treatment strategy possible for each couple seeking to become pregnant. Treatment is usually a complex process and fertility drugs are often part of the regimen. Along with the benefits of such drugs, however, come risks such as multiple gestation or pregnancy.

Fertility drugs target specific fertility issues. For example, approximately 25% of women unable to conceive have ovulation problems -- including the inability to mature and release an egg regularly (oligo-ovulation) or to ovulate at all (anovulation). Drugs may be used to temporarily correct ovulation issues and stimulate development of multiple eggs to use for conventional treatment or for in-vitro fertilization (IVF). Use of these drugs is called controlled ovarian stimulation (COS).

The most widespread protocols involve oral medications such as clomiphene citrate (Clomid, Serophene) or letrozole (Femara), and injectable fertility drugs called gonadotropins (Follistim, Gonal F, Menopur).

Clomiphene, which stimulates the pituitary gland to increase the amount of hormones needed for ovulation, is often recommended as a first treatment before gonadotropins. It is less expensive, easier to use, and has a lower multiple gestation rate -- approximately 8% for twins and ½ % for triplets. It is often used with intrauterine insemination (IUI).

Gonadotropins are designed to make eggs grow to a mature size through a follicle-stimulating hormone (FSH) alone or combined with luteinizing hormone (LH). Often used in an IVF cycle or with intrauterine insemination (IUI), patients are closely monitored to minimize any serious problems such as ovarian hyperstimulation syndrome (OHSS).

The most serious risks associated with gonadotropins are multiple gestation and ovarian hyperstimulation syndrome (OHSS).

Multiple pregnancies can occur in up to 30% of gonadotropin-induced cycles -- approximately three-fourths are twins and one-fourth, triplets or more. This compares to approximately 1% in naturally occurring pregnancies. Such multiples carry a higher risk of miscarriage, preterm delivery, and infant abnormalities or even death, usually due to early delivery, and other major maternal complications.

OHSS may occur after COS and results in enlarged ovaries, fluid in the abdomen and other medical problems. Mild cases happen approximately 10% to 20% of the time and usually resolve quickly, without complication. While severe OHSS is rare -- just 1% of the time -- it often requires hospitalization for intensive monitoring. The odds of OHSS are increased for women with polycystic ovary syndrome and those who become pregnant during the cycle in which gonadotropins are given. The condition usually lasts only a week or two but can be longer if
the woman is pregnant.

While all fertility patients should be carefully counseled and closely monitored, this is especially true for those taking gonadotropins because of the higher risks.