Before IVF, there are simpler options. These are suitable in some situations but a waste of time in others. Knowing which is which makes all the difference.
Many patients come to the clinic after a year of taking tablets prescribed by a GP or gynaecologist, without a full assessment and without anyone having checked whether ovulation was actually the problem. This is not a criticism of the treatments themselves, which are useful: it is a criticism of their indiscriminate use.
Ovulation stimulation treats just one thing: the absence or irregularity of ovulation. It therefore makes sense if your cycles are irregular or absent, typically in polycystic ovary syndrome. It serves no purpose if you ovulate normally, except in the context of insemination where the aim is to produce one or two well-timed follicles.
There are two non-negotiable prerequisites: patent fallopian tubes, confirmed by hysterosalpingography or HyFoSy, and a normal semen analysis. Stimulating a woman whose partner has severe oligospermia or whose fallopian tubes are blocked is a waste of time.
Clomid is the oldest and most commonly prescribed drug. It blocks oestrogen receptors in the pituitary gland, which then increases its production of FSH and triggers follicular growth. It is taken as tablets for five days at the start of the cycle.
It induces ovulation in around 70–80 per cent of women who were not ovulating. Its main drawback is an anti-oestrogenic effect on cervical mucus and the endometrium, which may become thinner. The risk of multiple pregnancy is around 5–8 per cent. After six ovulatory cycles without pregnancy, a change of strategy is required: continuing will no longer be of any benefit.
An aromatase inhibitor, it temporarily lowers oestrogen levels and produces the same pituitary signal, without the adverse effect on the endometrium. In polycystic ovary syndrome, randomised trials have shown a higher live birth rate than with clomiphene. It is now recommended as first-line treatment for this condition by international medical societies, although its use in France remains off-label in certain contexts — a point to discuss with the prescriber.
Recombinant FSH, sometimes combined with LH or hMG, administered as daily subcutaneous injections. These act directly on the ovary, bypassing the pituitary gland. More effective, more expensive, and above all more risky if not monitored by ultrasound: the risk of multiple pregnancy and ovarian hyperstimulation requires close monitoring. They must never be prescribed without monitoring.
The guidelines I follow, which are shared by most doctors:
A simple stimulation cycle alone does not justify travelling abroad: it can be carried out very effectively in France, with local monitoring and reimbursement. What drives people to go abroad is what comes next — the delays in egg donation, the age limit, and access to PGT-A. If you’re at the stage of taking tablets, my advice is to first undergo a full assessment and not to rush through the stages unnecessarily. If you’re on your sixth cycle without a clear response, it’s time to seek a structured second opinion.
In polycystic ovary syndrome, randomised trials show letrozole to have an advantage in terms of live birth rates, without the anti-oestrogenic effect of clomiphene on the endometrium. Its regulatory status in France should be discussed with your prescribing doctor.
After six ovulatory cycles without pregnancy, continuing offers no further benefit. It is therefore advisable to change strategy rather than prolong treatment.
Yes, at least two tests: fallopian tube patency and a semen analysis. Without these, stimulation can result in months being wasted for no reason.
They carry a higher risk of multiple pregnancies and ovarian hyperstimulation. They must never be prescribed without close ultrasound monitoring.
Source: https://fertilitegrece.com/en/blog/ovulation-induction-clomid-letrozole/ — Triada Baloukoudis, IVF patient coordination in Greece. General information, not medical or legal advice. Printed on
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