The following are some of the fertility medications that are frequently used depending on which treatment protocol best suits your specific needs and goals.Clomiphene Citrate
Clomiphene Citrate (Clomid®, Serophene®) has been available since 1968 and is commonly used for women who have infrequent periods or long menstrual cycles. It is in pill form and is taken for 5 days at the beginning of the menstrual cycle. It works by preventing estrogen from binding to estrogen receptors and gives the body the false impression that estrogen levels are low. This causes your body to produce more FSH (follicle stimulating hormone), which will result in the growth of follicles in the ovary. It is the follicle that contains the egg.
Side effects include nausea, headaches, mood swings, vaginal dryness and hot flashes. In some patients, Clomiphene Citrate can decrease cervical mucus and cause thinning of the endometrial (uterine) lining. Complaints of visual disturbances may necessitate stopping the medication. 90% of women who are going to conceive with clomiphene do so in the first 3-4 cycles of taking this medication and for this reason it is recommended not to use Clomiphene Citrate more than 4 cycles.
Clomiphene Citrate may be very effective in women who do not ovulate and women under the age of 35. Women’s ovaries tend to become more resistant to Clomiphene Citrate as they age and for this reason more effective medications such as HMG (human menopausal gonadotropin) and FSH (follicle stimulating hormone) are considered for use in women over 35 with infertility.
Letrozole (Femara®) belongs to a class of drugs called aromatase inhibitors and is used in a similar fashion to Clomiphene Citrate. It is in pill form and is taken for five days at the beginning of the menstrual cycle. Letrozole works by decreasing estrogen levels. Side effects include headaches and hot flashes. It appears that Letrozole may have less of an adverse effect on the cervical mucus and endometrial (uterine) lining. Some data has suggested that women who do not ovulate with Clomiphene Citrate may do so with Letrozole.
These fertility medications are given as an injection under the skin (subcutaneous injection). They are taken on a daily basis to stimulate follicular growth in the ovaries. The dose used depends on multiple factors including the woman’s age, ovarian reserve test results, weight as well as previous response to fertility medications. All patients must be monitored very closely with laboratory blood tests and ultrasounds in order to determine the lowest dose of medication required as the risk of ovarian hyperstimulation syndrome and multiple pregnancies is much higher than with the use of oral fertility medications. As with all injectable medications, bruising, redness, swelling, or discomfort can occur at the injection site. Rarely, there can be an allergic reaction to these drugs. The intent of giving these medications is to mature multiple follicles, and many women experience some bloating and minor discomfort as the follicles grow and the ovaries become temporarily enlarged. Some of the other risks and side effects of gonadotropins include fatigue, headaches, weight gain, mood swings, nausea, and clots in blood vessels.
The various forms of gonadotropins include:
- Follicle Stimulating Hormone- FSH (Follistim®, Gonal-F®, Bravelle®)
These medications contain only FSH.
- Luteinizing Hormone- LH (Luveris®)
This medication contains only LH.
- Human Menopausal Gonadotropins- HMG (Menopur®, Repronex®)
These medications contain equal amounts of FSH and LH.
HCG (Profasi®, Novarel®, Pregnyl®, Ovidrel®) is a natural hormone, which is given as a subcutaneous injection. HCG is used to induce the final maturation of the egg and triggers ovulation and the release of the mature egg. Ovulation usually occurs 36 hours after HCG is given.
Leuprolide Acetate (Lupron®) is a synthetic hormone injected subcutaneously on a daily basis. Initially, it causes the release of FSH and LH from the pituitary gland and with continued administration it causes a temporary depletion of FSH and LH. It is this suppression in LH that prevents ovulation and for this reason is used in conjunction with the gonadotropins in IVF patients.
Lupron has been approved by the Food and Drug Administration (FDA) for treatment of endometriosis and uterine fibroids in women as well as prostate cancer in men. It is not FDA-approved for infertility treatment. However, most IVF centers in the United States have routinely used GnRH agonists (including Lupron®) for more than 20 years. Potential side effects usually experienced with long-term use include hot flashes, vaginal dryness, bone loss, nausea, vomiting, skin reactions at the injection site, fluid retention, muscle aches, headaches, and depression.
There are several protocols that utilize Lupron in IVF. Two of these are:
Long cycle Lupron® protocol
- : in this protocol the Lupron® injections begin one week before the anticipated menstrual cycle where the egg retrieval will be performed. The Lupron injections are given on a daily basis. Once the menstrual cycle begins, the Lupron® injections continue but the dose of the Lupron® may be altered and gonadotropin injections are started. In some patients the Lupron® can be started while you are on birth control pills. The Lupron® and the birth control pill are typically overlapped for a few days after which Lupron injections only continue until the patient next menstrual cycle.
Short Cycle Lupron® protocol (flare or micro dose flare)
- : in this protocol the Lupron® injections begin soon after the menstrual cycle begins in the same cycle as the egg retrieval will be performed. Either a full dose or a dilute dose of Lupron® will be used on a daily basis.
GnRH Antagonists (Ganirelix®, Cetrotide®) are injectable medications that reversibly bind to GnRH receptors in the pituitary gland and prevent release of FSH and LH. By suppressing the LH surge, the antagonists prevent ovulation. They are typically used close to the time of ovulation to prevent ovulation.
Progesterone and estradiol are hormones normally produced by the ovaries after ovulation. After egg retrieval in some women, the ovaries will not produce adequate amounts of these hormones long enough to fully support a pregnancy. Accordingly, supplemental progesterone, and in some cases estradiol, are given to ensure adequate hormonal support of the uterine lining. Progesterone is usually given by injection or by the vaginal route (Endometrin®, Crinone®, Prochieve®, Prometrium®, or pharmacist-compounded suppositories) after egg retrieval. Progesterone is often continued for some weeks after a pregnancy has been confirmed. Progesterone has not been associated with an increase in fetal abnormalities. Side effects of progesterone include depression, sleepiness, allergic reaction and if given by intra-muscular injection includes the additional risk of infection or pain at the application site. Estradiol, if given, can be by oral, transdermal, intramuscular, or vaginal administration. Side effects of estradiol include nausea, irritation at the injection site if given by the transdermal route and the risk of blood clots or stroke
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