Medication Descriptions

This page describes the medications frequently used in fertility. Italicized terms are also defined.

There are a number of medications you may use during your IVF cycle. This section lists and describes the medications we currently use at our center. From time to time, new medications are introduced, and we will try to keep you informed about them as we begin to use them in our program. If you have any questions regarding any of the medications you are using, please ask a member of our clinical staff.

Estrogen

Estrogen is, like Progesterone, a steroid hormone that plays an integral role in reproduction. It is produced by growing follicles, the corpus luteum (that portion of an egg follicle that remains on the ovary after ovulation), and the placenta. Estrogen supplementation is begun after your embryo transfer and is delivered in the form of transcutaneous patches. The risks and side effects of estrogen include Ovarian Hyperstimulation Syndrome (OHSS). See also Gonadotropins.

Ganirelix or Cetrotide

These are GnRH antagonists and are administered, like Lupron, subcutaneously. They are also used to prevent ovulation, but are only started after gonadotropin therapy has already begun. Your individualized protocol will inform you when to start these medications. Risks and side effects of Ganirelix/Cetrotide: abdominal pain, headaches, vaginal bleeding or spotting, nausea, and irritation at the injection site. All are uncommon, short term, and generally disappear after you stop taking the drug.

Gonadotropins

Gonadotropins are hormones secreted by the pituitary gland. They include FSH and LH. FSH is responsible for the selection and growth of developing eggs and follicles on your ovaries. LH plays an important role in the final maturation of the eggs and also causes ovulation to occur during a natural menstrual cycle.

All gonadotropins can be injected subcutaneously. Some come as a powder that must be mixed with sterile saline or water prior to use, although others come premixed. The Follistim Pen uses premixed cartridges of Follicle Stimulating Hormone (FSH) and a reusable pen delivery system. The Gonal-F Pen uses premixed cartridges of FSH and a disposable pen delivery system. Bravelle (FSH) and Menopur (FSH + Leutinizing Hormone) powder must be reconstituted prior to being injected with a syringe. Your physician will select the drug and dosages that are most appropriate for you and our clinical staff will provide you with instructions on how to use them.

During the course of your IVF cycle, we will closely monitor the status of your ovarian response to these medications with both ultrasound images and blood hormone levels (e.g., estradiol and progesterone). We may alter the dose for you or cancel a cycle that is not producing a reasonable number of follicles. You will be given specific instructions regarding when to take the various medications, what doses of medication to take, and in some instances, what time to take your medication.

Adverse reactions and side effects to gonadotropins include:

• Local irritation at the injection site
• Dizziness, nausea, headache, mood swings, irritability, or hot flashes
• Ovarian enlargement and twisting of the ovary (torsion, which is rare)
• Ovarian Hyperstimulation Syndrome (OHSS), an excessive enlargement of the ovaries and accumulation of fluid in the abdomen

Some of the health risks associated with OHSS include: deep vein thrombosis (clots), pulmonary embolism, and stroke. OHSS ranges from very mild symptoms (pelvic discomfort) to severe (pain, clotting problems, and electrolyte imbalance), which may require hospitalization. The specific cause of OHSS is unknown, but appears to be related to high estrogen levels. Often (but not always), women who develop OHSS are also pregnant from their IVF cycle. The more severe forms of OHSS are fortunately quite rare in IVF (less than 1% of patients who develop OHSS). Some symptoms to watch for are weight gain, bloating, nausea, diarrhea, and shortness of breath.

Gonadotropin-Releasing Hormone (GnRH) Agonists and Antagonists

GnRH agonists have been used in IVF since the 1980s to increase the number of eggs we retrieve from your ovaries and to prevent premature ovulation. GnRH antagonists have been used in IVF since the late 1990s. Both work to prevent premature ovulation. The agonists are typically started 7–14 days prior to starting the fertility (gonadotropin) injections, while the antagonists typically are started after 5–8 days of being on the fertility injections. Different clinical scenarios will dictate if you are prescribed the agoinst or antagonist. All patients will be on one or the other.

Human Chorionic Gonadotropin

Human Chorionic Gonadotropin (hCG) is the hormone associated with pregnancy, and its actions in the body are identical to LH. There are two main categories of hCG used for ART cycles: urinary and recombinant. Urinary gonadotropins, as the name implies, are isolated from the urine of postmenopausal women using special processes to ensure their safety and potency. hCG medications that are urinary gonadotropins include Profasi, Pregnyl, and Novarel. These medications are injected intramuscularly (IM). Recombinant hCG is a product of DNA technology and contains only pure hCG. Ovidrel is a recombinant hCG product used in some IVF cycles, but more commonly for Intrauterine Insemination (IUI) cycles. Ovidrel is delivered via a subcutaneous injection.

hCG is used in an ART cycle to mimic the normal midcycle LH surge, which is necessary to facilitate the final maturation process of the egg. The timing between administering hCG and retrieving your egg is carefully planned so you do not ovulate before we collect your eggs. Your egg retrieval is done before you ovulate your eggs. Our clinical staff will instruct you on both the date and time you are to take your hCG.

Your treatment protocol may also include diluted or low-dose hCG to add a small steady dose of LH during the growth and maturation of your follicles and eggs. Diluted hCG is administered subcutaneously using an insulin syringe. It should be kept refrigerated until used.

Lupron

Lupron is a GnRH agonist that may be administered by subcutaneous injection once or twice daily. It is usually started prior to gonadotropins, and it’s continued until you are ready for egg retrieval. Risks and side effects of Lupron: hot flashes, vaginal dryness, mood swings, vaginal bleeding/spotting, headaches, or insomnia. All are short term and usually disappear after you start your Gonadotropins. Women who use Lupron for more than 6 months may experience some bone density loss; however, our physicians prescribe Lupron for less than 30 days.

Luteal Estrace

Estrace—a synthetic estrogen tablet—may be prescribed during the luteal phase (the last 7–10 days) of your menstrual cycle. You take this 2-mg tablet orally twice per day. It is an alternative to Oral Contraceptives to enhance the ovarian response to Gonadotropins and create flexibility in your IVF schedule.

Micromanipulation and Embryo Transfer Medications

In addition to your retrieval and embryo transfer, you may require the use of micromanipulation on your eggs, embryos, or sperm as part of your ART cycle. The two most common forms of micromanipulation used in IVF are Intracytoplasmic Sperm injection (ICSI) and Assisted Hatching (AH). Preimplantation Genetic Diagnosis (PGD) of embryos is being used more frequently in ART cycles as the technology becomes appropriate for select groups of IVF patients.

Antibiotics are used to minimize infection and augment implantation. Antibiotic (Z-pack, Doxycycline, or others) are given to patients for several reasons during an ART cycle. During micromanipulation procedures, a small hole is made in the outer covering of the egg (the zona pellucida) and the antibiotics prevent bacterial contamination of the manipulated egg or embryo.

Risks and side effects: gastrointestinal upset, nausea, vomiting, diarrhea, photoxicity (allergic reaction to sunlight), and allergic reactions (e.g., rash, itching, or asthma). Alert our clinical staff if you have a known allergy to a specific type of antibiotic so that we may avoid it during your IVF treatment.

Oral Contraceptives

Oral contraceptives (OCPs or birth control pills) contain both synthetic estrogen and progesterone-like compounds. OCPs are sometimes used to enhance your response to the Gonadotropins and to provide us with some flexibility in scheduling and starting your IVF cycle. There are a variety of oral contraceptives on the market, many of which can be used for our purposes. If you have previously taken an oral contraceptive that you tolerated well, let us know so we can consider prescribing it for you. The length of time you will be on the OCPs depends on your history and when you enter the program to start your ART cycle.

Some common side effects of the hormones in birth control pills include nausea, breast tenderness, increased appetite and weight gain, acne, increased breast size, and headaches. Although low, there are also health risks associated with OCPs, including stroke, deep vein thrombosis, and pulmonary emboli. If you are over 35 years of age and smoke, if you are a heavy smoker at any age, or if you have serious heart disease, you may be at increased risk for these complications. If you smoke or just recently (less than 6 months) discontinued, you should not take oral contraceptive pills.

Progesterone

Progesterone (P4) is a steroid hormone that is normally produced by the corpus luteum (that portion of an egg follicle that remains on the ovary after ovulation). Progesterone is important in transforming the uterine lining from one that is growing into one that is preparing for embryo implantation. Progesterone is administered by vaginal suppository or intramuscular injection each night, starting the night of your oocyte retrieval and continuing until your first pregnancy test, approximately two weeks after your egg retrieval. If pregnant, you must continue progesterone support.

Adverse reactions and side effects include: breast tenderness, bloating, and nausea. Because we only use natural progesterone, there are no increased risks to the fetus for birth defects, miscarriage, etc. We no longer use forms of progesterone that are dissolved in peanut oil. Rather, we use ethyl oleate, which leads to a significantly decreased risk of allergic reaction. Please alert our clinical staff, however, if you feel that you are experiencing an adverse reaction so that we may adjust your treatment protocol accordingly.