Introduction

Use of gonadotropins for ovulation induction (OI) in intrauterine insemination (IUI) cycles increases pregnancy rates per cycle compared to IUI alone or with clomiphene (CC-IUI); however, whether pregnancy rates per couple are increased is less certain. Gonadotropin use for OI may be complicated by multiple pregnancies, particularly triplets and higher orders, and by ovarian hyperstimulation syndrome (OHSS). Their use as first-line treatment should be limited to those women who have hypopituitary or hypothalamic amenorrhea not correctable by other treatment. Gonadotropins should not be used in the treatment of “unexplained infertility” for patients who ovulate, but fail to conceive, until a minimum of three cycles of CC with IUI have been tried first. Gonadotropins should not be used in place of CC because of its anti-estrogen effect on endometrial thickness and cervical mucus before first trying tamoxifen (TMX) 40–60 mg for five days instead of CC. These proscriptions will, if followed, significantly reduce the risk of multiple pregnancy and the risk of OHSS.

The risk of multiple pregnancy is related to the number of preovulatory follicles (more with gonadotropins, fewer with CC and TMX), patient's age and initial cycle of treatment.