Hormone treatment - managing the risks

The NICE guidelines (Fertility assessment and treatment for people with fertility problems, Clinical Guideline, February 2004, section 7.11) state that, ‘Women with clomifene citrate-resistant PCOS treated with conventional regimens of gonadotrophins have a 36% multiple pregnancy rate.’

What is the official guidance?

The NICE Guidelines (Clinical Guideline 11, February 2004, paras 1.6.3.1 and 1.6.4.1–4) on hormone treatment and multiple pregnancy state that: 

  • Women with polycystic ovary syndrome who have not responded to clomifene citrate should be offered laparoscopic ovarian drilling because it is as effective as gonadotrophin treatment and is not associated with an increased risk of multiple pregnancy.
  • Gonadotrophins can be offered to women with World Health Organisation (WHO) Group II ovulation disorders who do not ovulate with clomifene citrate (or tamoxifen).

It further advises (paras 1.6.11) that:

  • Women who are offered ovulation induction with gonadotrophins should be informed about the risk of multiple pregnancy and ovarian hyperstimulation before starting treatment.
  • Ovarian ultrasound monitoring to measure follicular size and number should be an integral part of patient management during gonadotrophin therapy to reduce the risk of multiple pregnancy and ovarian hyperstimulation.

See the NICE website for more information.

Minimising the risks

To balance the risks of multiple pregnancy with the chance of a positive outcome, the following approach is recommended:

  • Gonadotraphins are an appropriate treatment for women with WHO group II ovulation disorders who do not ovulate with clomifene citrate or tamoxifen.
  • It is important to inform women who are offered ovulation induction with gonadotrophins of the risk of multiple pregnancy and the problems with which multiple pregnancies are associated. (see What are the risks?) 
  • Follow up with written information (leaflets, brochures, etc).
  • Women with polycystic ovarian syndrome who have received unsuccessful treatment with clomifene citrate should be offered laparoscopic ovarian drilling. This treatment is as effective as treating with gonadotraphins but does not carry the associated increased risk of multiple births. Recent research suggests that multiple pregnancy rates with ovarian drilling is as low as 1%, as opposed to 16% with gonadotrophins.
  • Offer ovarian ultrasound monitoring to ensure dosage is appropriate (that is, it should increase the chances of pregnancy while minimising the risk of multiple pregnancy).
  • Some recent evidence indicates that using a mild stimulation regime may reduce the risk of multiple birth.