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    Medications Used in Ovulation Induction and Art2019-09-18T12:05:38+00:00

    Medications Used in Ovulation Induction and ART

    ART Medications Overview

    A woman’s body normally produces only one egg that is released for fertilization each month. To increase the chances for successful pregnancy, female patients are given certain medications that induce the ovaries to develop several mature eggs rather than the single egg. In addition to fertility medications, additional medications are used to schedule ART cycles, particularly for synchronizing patient cycles with egg donors or surrogates, induce ovulation at the appropriate time and enhance uterine receptivity and embryo implantation. Injectable medications commonly used in ART treatment include:

    1. Gonadotropins: Hormone medications containing follicle stimulating hormone (FSH) and/or luteinizing hormone (LH) that stimulate the ovary to produce multiple follicles (see Table 1).
    2. Human Chorionic Gonadotropin (hCG): A hormone medication with a similar chemical structure to LH, which is used to trigger ovulation at the appropriate time when the follicles are ready (see Table 1).
    3. Gonadotropin releasing hormone (GnRH) analogs: Medications used to prevent the body’s own release of LH and FSH from the pituitary gland (see Table 2). Note: The GnRH agonists (Lupron) can also be used to induce a flare-up or LH “surge.”
    4. Sex Steroids: The natural hormones estrogen and progesterone that are made in the ovary and by the placenta (see Table 3).
    5. Growth Hormone: Used as an adjunct for ovulation induction for low responders.

    Other medications can be administered by alternative routes (oral, vaginal or nasal sprays).The following is a list (in alphabetical order) of medications and hormonal preparations you may be prescribed:

    (5 mg oral tablets) is a progestin given daily for 5-10 days during the second half of the menstrual cycle for planned menstrual bleeding.
    (81 mg tablets) increases blood flow to the uterus and thus may aid in embryo implantation. It is used in frozen embryo transfer and donor egg cycles. Baby aspirin may be kept at room temperature.
    May be used prior to ovarian stimulation, particularly in synchronizing menstrual cycles in donor and surrogate cycles. These
    may be stored at room temperature.
    contains a highly purified preparation of human FSH (75 IU of FSH per vial) which is administered daily during ovarian stimulation to induce multiple follicles to develop. Bravelle may be administered subcutaneously (SC) or intramuscularly (IM), alone or in conjunction with Menopur.
    Is a dopamine agonist prescribed orally (0.5 mg/d) for 8 days starting shortly before or after egg retrieval for prevention or treatment of OHSS (ovarian hyperstimulation).
    Is a GnRH antagonist that is administered as a daily subcutaneous (Sub-Q) injection beginning several days before ovulation and continuing up to the time that hCG is given. Cetrotide suppresses the LH surge and is an alternative to down regulation with Lupron
    Is used primarily for ovarian stimulation in IUI (intrauterine insemination) and timed intercourse cycles for women who have infrequent or irregular menstrual cycles. It is also frequently used to increase the number of eggs released in treatment cycles for unexplained infertility. It has recently been used in conjunction with FSH for “Mini-IVF”. Clomiphene is a tablet taken by mouth at bedtime in doses ranging from 50 to 200 mg (1 to 4 tablets) per day. Clomiphene is usually taken starting on day 3 to 5 of the menstrual cycle, and continued for 5 days. Clomiphene works by blocking the estrogen receptors in the hypothalamus causing it to “think” there is an estrogen
    deficiency. The hypothalamus therefore orders the pituitary to secrete more FSH and LH.
    Is a synthetic corticosteroid that has immunosuppressive and anti-inflammatory effects. At low doses it can be used to augment the ovarian response. It is also used in conjunction with clomiphene to lower androgen levels in PCOS patients.
    Is a naturally occurring hormone produced by the adrenal glands. As women age, production of this weak androgen decrease. Women with low ovarian reserve may benefit by DHEA supplementation (75mg/d) for 6-8 weeks prior to ovarian stimulation. It works by conversion into testosterone via androgen receptors on small follicles, which enhances follicular response.
    (see Cabergoline)
    Is an oral antibiotic. It is prescribed to all patients and their partners who are undergoing an ART cycle to reduce the chance of infection during ART procedures. Doxycycline may be kept at room temperature.
    Is a progesterone vaginal suppository. It is commonly used for luteal support after a fresh or frozen embryo transfer.
    Is an oral estrogen. This is commonly used, instead of the injectable estradiol valerate, for uterine lining preparation in hormone–replacement cycles. Other uses include cycle priming of low responders to synchronize small antral follicles, and for luteal support after embryo transfer.
    Is a long-acting estrogen. It is administered as an IM injection twice weekly for preparing the uterine endometrium for pregnancy. Estradiol valerate is used to prepare the uterine lining for embryo implantation, and is most often used in frozen embryo transfer cycles and for recipients of donor eggs. All recipients of embryos (patients and surrogates) not undergoing ovarian stimulation will have estrogen treatment for preparation of their uterine lining. Estradiol valerate may be kept at room temperature.
    Is a male fertility supplement that combines natural herbs, vitamins and antioxidants. It is taken daily over a 60 to 90-day period prior to ART treatment to improve sperm quality.
    (Gonal-f or Follistim: recombinant FSH; Bravelle: highly purified human FSH) is administered by a Sub-Q injection that helps to stimulate multiple follicular development in women who have normal or elevated LH production. You may experience some of the following side effects: mild fluid retention, breast tenderness, abdominal bloating, mood swings, and ovarian enlargement. You may keep it refrigerated if desired, but not frozen.
    Is a product containing follicle stimulating hormone (FSH) used in ovarian stimulation to induce multiple follicles (eggs) to develop.
    (formerly Antagon) is a GnRH antagonist administered daily before mid-cycle to prevent premature LH surges during controlled ovarian stimulation.
    Is a product containing follicle stimulating hormone (FSH) used in ovarian stimulation to induce multiple follicles (eggs) to develop.
    Is used as an adjunct during ovarian stimulation for patients with diminished ovarian reserve. It may improve ovarian response and egg quality.
    Is an anticoagulant drug used for treatment of recurrent implantation failure or pregnancy loss. This is generally restricted to patients who are not undergoing an egg retrieval procedure due to the possible adverse effect of abnormal bleeding.
    Is an IM injection (Pregnyl, Novarel) or Sub-Q injection (Ovidrel) that matures the eggs and prepares the mature follicles for ovulation. It is administered as a single dose after about 9-12 days of ovarian stimulation, approximately 36 hours prior to the egg retrieval procedure. This may mean that you may take your HCG injection late in the evening. Timing of HCG is critical. Do not take any HCG until
    you have been given specific instructions to do so. Side effects may include abdominal bloating and fluid retention. HCG does not need to be refrigerated.
    Is a subcutaneous (Sub-Q) injection (Menopur) or an intramuscular (IM) injection (Humegon) that helps to stimulate follicular development. This “fertility drug” contains equal parts of the pituitary hormones FSH and LH. FSH and LH stimulate the ovaries to develop multiple follicles for ART procedures. You may experience some of the following side effects: mild fluid retention, breast tenderness, abdominal bloating, mood swings and ovarian enlargement. You may keep it refrigerated if desired, but not frozen.
    Is an aromatase inhibitor used for ovulation induction, for intrauterine inseminations and low-dose IVF regimens. It is taken orally at the beginning of the cycle for about 5 days (doses of 2.5 mg/d or 5 mg/d), followed by gonadotropins. Commonly used for cancer patients, it prevents conversion of testosterone to estrogen, thereby increasing androgen levels within the follicles whilst keeping estradiol levels low.
    Is administered as a daily subcutaneous (Sub-Q) injection, beginning approximately 1 to 4 weeks before egg retrieval (often overlapping with birth control pills) and continuing up to the time that HCG is given, to trigger ovulation. After an initial acceleration in LH and FSH production (the “flare response”) the pituitary stops producing these two hormones (down-regulation of GnRH receptors). Lupron suppresses hormone production causing estrogen levels to drop. As a result, the patient often has symptoms of menopause that may include hot flashes, headache, nausea, breast tenderness, visual disturbances and mood swings. Lupron allows improved stimulation of ovarian
    follicular development, since all endogenous LH and FSH production is suppressed. Lupron should be kept in the refrigerator. At high doses, and in a non-down-regulated IVF cycle, Lupron can also be used instead of HCG to trigger ovulation (for lowering the chance of ovarian hyperstimulation syndrome).
    Is an immunomodulator, which is equally as effective as heparin, but has the added advantage of being administered just once (rather than twice) daily and causes less local irritation or bruising. The usual dose of Lovenox is 40 mg Sub-Q once a day. The dosing for Fragmin is 5000 IU Sub-Q once a day.
    Is a preparation of gonadotropins. Each vial contains 75 IU FSH + 75 IU LH activity administered daily to promote the growth of multiple follicles during controlled ovarian stimulation.
    Is an insulin sensitizer used for improving ovarian response and pregnancy rates in PCOS patients. Dosing varies according to BMI (1000-1500 mg).

    Ovidrel is a recombinant human chorionic gonadotropin which is available in a ready-to-inject prefilled syringe. It is used in fertility treatment cycles to help follicles mature. Ovidrel is taken only once as a single dose, on a specific day and at a specific time as instructed by your physician or nurse coordinator

    (20 mg tablets) is a corticosteroid, an anti-inflammatory medication, used to reduce the number of immune cells present in the uterus. These immune cells, which are intended to protect the body from foreign substances, may compromise embryonic development. Prednisone is started on the day of egg retrieval, or the day that progesterone is started in frozen embryo transfer or donor egg cycles, and taken for about 5 days. Prednisone may be kept at room temperature.
    Is a natural hormone produced by the corpus luteum in the ovary after ovulation. Supplemental progesterone is used to prepare the uterine lining for implantation of the embryo and to prevent pregnancy loss. It is taken either as an injectable form (progesterone in oil), or as micronized vaginal suppositories (or both). Progesterone is usually begun on the day following egg retrieval, or the equivalent in a frozen embryo transfer, and continued as per your physician’s instructions. If you become pregnant, your physician will advise you to continue taking progesterone until around 12 weeksof pregnancy. When taking progesterone, it is common to experience some breast tenderness or mild uterine cramping. Progesterone may also delay the start of a period. Please note you will only be taking a natural form of progesterone that is not associated with birth defects (do not be alarmed by warnings of birth defects that come with your medications).
    Is a synthetic progesterone (progestin) used to induce menstrual bleeding (10 mg/d). It is usually taken for 5-10 days.

    Are used for 5 days prior to stimulation start (at night for 12–14 hours) to enhance ovarian response.

    (12.5 mg of 1.25%) is used for about 20 days during the preceding luteal phase to prime the ovaries (i.e., enhance follicular recruitment) for low responders.
    (25 mg suppositories four times daily) is used for some patients with thin uterine linings to try to increase endometrial lining thickness.
    Are over-the-counter vitamins or prenatal vitamins containing 1 mg of folic acid.
    (brand name for Alprazolam tablet) is an anti-anxiety medication used immediately prior to embryo transfer to help the patient relax during the procedure.
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    Table 1. Gonadotropins available in the U.S. that you may use:

    Urinary
    HCG (Profasi, Pregnyl, Novarel)
    Highly purified hMG (Menopur)
    Highly purified FSH (Bravelle)

    Recombinant
    FSH: Gonal-F (Follitropin alfa)
    FSH: Follistim (Follitropin beta)
    hCG: Ovidrel

    Table 2. GnRH-analogs available in the U.S. that you may use:

    GnRH-agonists
    • Lupron
    • Synarel
    GnRH-antagonists
    • Ganirelix
    • Cetrotide

    Table 3. Steroids available in the U.S.
    that you may use:

    Estrogens (Estradiol)
    • Delestrogen: Estradiol valerate injection (20 mg/ml)
    • Estrace: Micronized Estradiol (oral 2
    mg pills)
    • Estrogen Patches: Vivelle (0.1 mg)
    • Estinyl: Ethinyl Estradiol (0.02-0.05
    mg)

    Progesterone (P4)
    • Progesterone in Oil intramuscular
    injection (50 mg/ml)
    • Vaginal Suppositories (Gel Capsules
    200 mg or 400 mg)
    • Endometrin vaginal insert (100 mg)
    • Prometrium: Micronized progesterone capsule (oral 100 mg or 200 mg)

    Androgens
    • Testosterone Gel (12.5 mg of 1.25%)
    • Testosterone Patches (Androderm
    2.5 mg)

    Currently undergoing fertility treatment?

    Visit our page on “How to Use Common Fertility Medications

    How to Use Common Fertility Medications

    Disposal of Needles and Syringes

    Please Dispose of used needles and syringes carefully in a closed, puncture-proof container. Examples are: coffee can with lid, 2-liter soda bottle with cap or any other non-breakable closed container. Some pharmacies will provide a container designated for the disposal of needles and syringes. You should return this container to the pharmacy that provided it. If the pharmacy from which you purchased your medications does not provide a needle return and disposal service, you may return the sealed container to RSMC.

    Possible Side Effects and Complications of Ovulation Induction Medications

    Most of the side effects of these drugs are minor, involving discomfort, but not usually requiring continuing or unusual medical intervention. Serious complications of these medications, with the exception of multiple gestations, are rare. Please discuss any concerns you have regarding a specific medication with the IVF nurse. For further information regarding risks and complications of ovarian stimulation, including ovarian hyperstimulation syndrome (OHSS) see Chapter 16: Risks and Side Effects of ART Treatment.

    Possible Skin/subcutaneous Reactions to Intramuscular Injections

    A red area may appear around the injection site and/or the injection site might itch and/or bruising may occur. These are all excepted reactions and will disappear over time. Due to the viscous nature of steroids in oil solutions, moderate induration (hardening or thickening) of the subcutaneous tissue may occur. This is normal and is of no cause for concern. If the indurated area becomes very tender and/or warm to touch or if redness/bruising around the injection site appear to be enlarging or spreading, please notify us immediately.

    Possible Skin Reactions to Subcutaneous Injections

    A red area may appear around the injection site and/or the injection site might itch and/or bruising may occur. These are all excepted reactions and will disappear over time. Please notify us if redness/bruising around the injection site appear to be enlarging or spreading.

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