CHAPTER 11

Medications

There's a good chance you'll be taking some form of medication while undergoing your treatment. The doctor will likely start you on the simplest regimen appropriate to your diagnosis and give it a few cycles. If you still aren't pregnant, she'll make a decision about moving to the next step and try that for a few cycles. Don't be surprised if it takes a couple of cycles to determine which one is best. Remember that everyone responds differently to the medication and it may just take some time to find the best one for you.

Oral Ovulation Induction

These pills are the easiest protocol used to induce ovulation. If you know that you are anovulatory, they are the usual first try. Clomid and Letrazole work by inhibiting your estrogen levels. Your pituitary gland pumps out more FSH and LH when your estrogen level is low, similar to the beginning of your menstrual cycle. The additional follicle stimulating hormone (FSH) and luteinizing hormone (LH) encourages follicular growth in the ovaries.

Clomid

Clomid is a pill that you take by mouth every day for five days. Doses range from 50mg to 150mg or even 200mg (one to four pills, at the same time each day). You will be instructed to take your first dose in the beginning of your cycle, usually on day three or day five. Once you have finished taking your pills, the doctor may recommend having periodic ultrasounds or blood work done. The other option is that the doctor may recommend you use an ovulation predictor kit to check for ovulation, and then begin having intercourse with the positive result.

Letrazole

Letrazole works in a similar fashion to Clomid. However, Clomid can inhibit the development of your uterine lining and your cervical mucus. If your doctor notices a thin endometrium during an ultrasound, she can either supplement you with additional estrogen to help counteract the effect of the Clomid, or recommend the use of Letrazole during your next cycle. Letrazole doesn't typically produce this same inhibitory response on your uterine lining that Clomid does.

Letrazole is taken in a similar manner to Clomid — one or two pills at the same time, every day for five days in the beginning of your cycle. You may be periodically monitored or asked to check at home for your ovulation. Once your follicles are ready, you'll be instructed to either have intercourse or return to the office for insemination.

Injectable Gonadotropins

If the oral medications don't work, or your doctor recommends moving directly to injectable gonadotropins or IVF, you will be taking a synthetic form of hormones your body naturally produces, namely FSH and LH. Boosting the level of these hormones causes your body to increase the number of egg follicles that are developing in the ovary.

It can be helpful to determine the extent of your medication coverage before you begin infertility treatment. Talking to your doctor, nurse, or billing associate about your coverage up front can help you maximize your coverage and minimize the amount of money you need to pay.

Which medication you use will depend on the number of eggs desired, your body's hormonal response to the medications, the procedure you are undergoing, and your physician's preference for medications — just to name a few.

It's not unusual to be taking FSH alone, both FSH and human menopausal gonadotropin (hMG) together, or hMG alone. Your doctor will select the best medication protocol for you.

FSH

There are several brands of FSH on the market right now, including:

• Bravelle

• Follistim

• Gonal-F

These brands are all similar, but your physician may have a preference based on his personal experiences. You may also have insurance coverage on one form, which should be factored in to the medication you are prescribed.

They are all taken as a subcutaneous injection, though each is prepared and mixed in a different manner. Follistim and Gonal F both come as a preloaded pen or as individual vials of medication that require mixing.

Once you start taking your stimulation, double check that you have your final trigger injection. Keep it in a safe place where you won't forget it. You don't want to realize that you've misplaced it once you've been instructed to take it. It can be difficult to find a late night pharmacy that carries what you need.

HMG

Human menopausal gonadotropin, or hMG, is a combination of both FSH and LH. The two most common brands are Menopur and Repronex, though Pergonal is sometimes used as well. Again, your doctor will recommend which one he thinks is the best fit for you.

The Trigger Shot

Your trigger shot is the final injection that you'll take prior to your insemination or egg retrieval. It is usually a form of human chorionic gonadotropin, or hCG. The hCG causes the eggs within the follicles to complete their maturation and prepare for ovulation. Unlike the rest of the stimulation, you will likely be given a specific time to take the injection.

Ovidrel

Ovidrel is a lower dose of hCG and is usually given during ovulation induction cycles for insemination or intercourse. You may not even need to take it if you ovulate on your own, depending on what your doctor recommends. Because you'll know exactly when you're ovulating, taking Ovidrel can also help with timing insemination more precisely.

Ovidrel comes in a prefilled syringe. Simply open the packaging and dispel any extra air in the syringe. Do this by removing the cap on the needle and holding it so the needle is pointing upwards. Gently tap on the syringe to move the air bubbles to the top of the syringe. Then, lightly press on the plunger until the air has been removed from the syringe.

Ovidrel and hCG are both detected by urine pregnancy tests. Make sure to wait at least a full two weeks from when you inject it before you take a pregnancy test. Any earlier, and you will likely have a false positive result.

Once the medicine has been prepared, you can inject the medication subcutaneously into the front part of your thigh or lower abdomen.

hCG (Novarel/Pregnyl)

If you are going through IVF, you will need to take hCG as your final trigger injection. As it will cause ovulation around thirty-six hours later, it is very closely timed according to when your egg retrieval will be. Make sure that you take it on time. If you take it too early, your eggs might not be fully mature once they are retrieved. If you take it too late, there is a strong possibility that you may ovulate prior to your egg retrieval. If this happens, your cycle will likely be canceled, as there is nothing your physician can do to remove your eggs once they've been removed from the ovary.

Ovarian Suppression

If you are undergoing IVF, or the doctor finds that you have a tendency to ovulate prematurely, your RE might recommend that you suppress your ovaries' natural inclination to ovulate. This gives your doctor control over how much FSH and LH your ovaries are exposed to. He can be very precise when it comes to your stimulation, allowing you to have a better ovarian response.

Lupron

Lupron is a gonadotropin releasing hormone (GnRH) agonist, meaning that at first it signals your pituitary gland to release a lot of FSH and LH. After about five days, your pituitary becomes incapable of releasing any FSH or LH. This helps prevent an LH surge during your cycle, which in turn prevents you from ovulating prematurely. Your medical team can control your hormonal output with other medications to time everything very closely to allow the maximum number of high-quality eggs to be retrieved exactly when they are ready. Lupron is usually started in the luteal phase of the preceding cycle.

It is injected subcutaneously, into the fatty tissue under the skin of the front part of your thighs or the lower part of your abdomen. You'll begin taking this a few days after you ovulate, through your period and into the follicular phase of your next cycle. Your doctor will instruct you when to stop taking it, usually right before your egg retrieval.

You will only take Antagon OR Lupron, not both of them. The doctor makes the decision based on your age, diagnosis, and anticipated stimulation. Sometimes, the selected medication may not be the best choice because of your response. Your RE can't predict your response ahead of time and may need to put you on an alternate protocol with your next cycle.

The most common side effects of taking Lupron are headaches, hot flashes, and irritability. These tend to be more pronounced if you are taking Lupron for several weeks without any other medication, like your stimulation or estrogen supplements. Lupron puts your body into a state similar to menopause, keeping your estrogen levels low. The symptoms usually are alleviated once you add on the other medications, because they will raise your estrogen level.

Ganirelix

Ganirelix, or Antagon, is a GnRH antagonist. This means that it shuts down your body's natural production of FSH and LH. This also prevents the LH surge, which triggers ovulation. This medication is a little different than Lupron because you will typically begin taking Antagon once you've started your stimulation, usually once a dominant follicle has been identified. Your doctor will instruct you when to begin taking it.

This medication comes as a prefilled syringe, meaning that the medication has already been mixed and loaded into the syringe with a needle attached. All you need to do is open the packaging and inject the medication subcutaneously. You will inject one syringe every night or as instructed by your RE.

Other Medications

Supplemental medications can be nearly anything that addresses an issue that you need help with during your fertility treatment. These medications can encourage implantation, prevent infection, and reduce swelling and inflammation.

Baby Aspirin

Baby aspirin is given to women who have blood-clotting disorders or may have had problems with placental perfusion in previous pregnancies. It is also given to combat some autoimmune disorders, which cause your body to attack a pregnancy as a foreign substance. This oral medication can be taken temporarily in the early weeks of pregnancy or continuously throughout pregnancy. However, it may be advised that you discontinue its use in the third trimester of pregnancy for fear of bleeding problems during the birth.

The Birth Control Pill

The doctor may instruct you to take the birth control pill for one month before your cycle starts. It may sound completely counterintuitive to be taking the birth control pill when you are trying to get pregnant, but the pill does have a few benefits when taking it during infertility treatment.

First, it gives the doctor control over when you will get your period. You'll take the twenty-one days of active pills and usually get a period a few days after you finish taking them. Sometimes the doctor may have you extend the number of active pills you take in order to delay your period. This is particularly helpful if you need to give your employer notice of when you'll be out of work, or if you have a religious obligation that you need to work around.

The pill also keeps your hormone levels low for the month leading to your cycle. This offers extra suppressive action during the month that you are actually stimulating. It is not appropriate for everyone, especially older women who may not stimulate as well.

Medrol

Medrol, or methylprednisolone, is a mild steroid that you may need to take after having an egg retrieval. It helps reduce any post-operative inflammation and assists in implantation. It's generally taken one to two times a day beginning the night of the egg retrieval. You will take it for approximately four days, or as directed by your doctor.

An Antibiotic

If you are undergoing IVF, you will need a short course of antibiotics to prevent infection after the egg retrieval. Despite all of the standard precautions, infection is still a risk after any surgical procedure.

Ask your doctor or pharmacist about how to take the antibiotic. Some commonly prescribed drugs can cause nausea or other stomach upset. Make sure to clarify the instructions so the medication works properly.

Given that the doctor will be transferring embryos back into the uterine cavity within a few days, it is of the utmost importance that any potential for infection be eliminated.

Viagra

Here's a new one to many people: women's use of the medication Viagra. The way that Viagra works on everyone is that it helps blood flow to capillaries, causing certain parts of the body to have increased blood flow. Some fertility centers are using this medication to help increase blood flow to the uterus. It is used as a suppository to be inserted vaginally.

Medications for Men

You will undoubtedly be taking the majority of the medication when undergoing infertility treatment. But there are medications that your partner should be taking as well. It's standard treatment that your partner should take a course of antibiotics prior to producing his sperm for IVF. The lab will need to make sure that they are receiving a clean specimen and that bacteria found in the sperm won't contaminate the rest of the embryos and sperm samples.

Vitamins

Vitamins are a common treatment in sperm-related issues. For a long time it was standard issue to give vitamin B₁₂ injections to men in fertility treatments. It has been found to increase the number of quality sperm in some men. Studies have found that folic acid can also affect the sperm counts of many men. This means that your partner needs to be taking his vitamins as well to ensure proper sperm counts with healthy sperm.

Antibiotics

Sometimes a problem with sperm production may be caused by an infection in your partner's body that may not even have any outward symptoms. This type of problem is usually treated with antibiotics, which may be given as an oral regimen or by injection. A normal course of antibiotics is about ten days long, though some infections may require longer or stronger treatment. Your or your partner's doctor can help you find what treatment is right for you.

Medication Emergencies

Medication emergencies can and do happen at any point. Perhaps you have broken an ampoule of your medications. Maybe your doctor has increased or changed your medications, and it is late at night and you are stuck without enough.

Never hesitate to call the doctor on call to ask what to do. Your fertility clinic may have an emergency kit of medications on hand that they can get to you immediately.

When choosing your fertility clinic, be sure to ask what their policy is on medication emergencies. There may be a specific coordinator to call, or you may just call the line for regular emergencies. Do not despair if you find yourself in this situation.