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Gonadotropin Therapy

The common names for these drugs are Repronex, Bravelle, Follistim, and Gonal-F.

How Gonadotropins work

There are two naturally occurring gonadotropins: LH (luteinizing hormone) and FSH (follicle stimulating hormone). LH and FSH are secreted from the pituitary gland in the brain, and stimulate the ovaries to produce eggs. LH works on the theca cells in the ovary to produce androgens that pass into the follicle where FSH stimulates the granulosa cells to make estrogen. In a way, LH ‘primes the pump’. Some patients will do better with some LH supplementation. Repronex contain both LH and FSH in a 50:50 mixture of 75 IU LH and 75 IU FSH. Bravelle contains about 97% FSH and about 3% LH. Follistim, and Gonal-F contain only FSH. The first generation gonadotropins (all except Follistim and Gonal-F) are obtained from the urine of post-menopausal women. The hormones are extracted, purified, and put into injectable form. The second generation drugs (Follistim, Gonal-F) are made by recombinant DNA technology much like Insulin.

How Gonadotropins are taken

Gonadotropins must be taken by injection, as they are inactivated in the intestinal tract. Injections are begun on the third day of the menstrual cycle (once a baseline ultrasound has been performed demonstrating normal ovaries), and are continued daily (or twice per day for some patients) until egg maturation is achieved. If a cyst is detected at the baseline ultrasound exam that is greater than 15 millimeters, the cycle will be cancelled due to the potential for a poor outcome. The patient may have to go on birth control pills for one month to suppress the cysts. The average number of days required for injections is usually between six and ten. We recommend that injections be done in the afternoon or evenings, as there will be days that you will need to await instructions based upon your test results from that morning. A nurse is available in the office Monday through Friday until 4:30 p.m. to give injections, but for other days or later hours, it will be necessary that a family member or friend be able to give the injections, or that you learn to administer the injections to yourself. Injection instructions will be done as a part of your preparation to begin gonadotropin therapy. Video tapes are available to review at home.

Monitoring the cycle: While taking gonadotropins, it is necessary to monitor the patient’s response, to assure the appropriate dosage is being administered. Beginning on or about cycle day seven, patients are monitored by ultrasound and blood test. The ultrasounds will indicate how many follicles (the fluid-filled sacs that contain the eggs) are developing, and the size they have grown to. The blood test will measure the hormone “Estradiol”. Estradiol is an easily measured form of estrogen that gives an indication of egg maturity.

Ultrasounds are done in the office, and are scheduled by appointment. These are vaginal ultrasounds, therefore, a full bladder is NOT required. Blood tests may be done throughout the day. We may run these tests in the office. If your insurance dictates, you may need to have your blood work done at a specific laboratory for the insurance company to reimburse. It is important that you realize that the blood test results must be obtained on the same day as the ultrasound exam. If we can not get the blood tests done at an outside lab on a daily basis your care could be compromised. Be sure that these issues are discussed with our office manager before we start the cycle, as we may need to do the tests in our office and you would need to sign an insurance waiver. Relative to the cost of a cycle, the blood tests are a small part (see costs below). Ultrasounds and blood tests will continue every two to three days until egg maturity is established. Once the follicles reach a size of 18-22 mm, and the Estradiol level matches (approximately 200 units of Estradiol per mature follicle), the final injection will be taken. We may measure progesterone or LH levels along with estradiol (see below). The final medication is hCG (human chorionic gonadotropin), also called Pregnyl, or Novarel. hCG will assist in the release of the eggs from the follicles. In general, mix 2 cc of diluent (fluid) with the ‘powder’ and inject the reconstituted drug in the hip at the designated time. We have a video to show you on this technique which you could borrow or check out the web site mentioned above. We often time the injection with an intra-uterine insemination (IUI) which is 36 hours later. For instance, if we plan to do an IUI at 9:00 AM the hCG will be given at 9:00 PM two days before.

Conception

You should plan to have intercourse the day you receive the hCG injection, and continue every other day for about one week. It is also very important that you not abstain from intercourse on the days you are getting your gonadotropin injections, in the hopes of “storing up” sperm. Sperm count and motility will be optimal at the time of ovulation if ejaculation has occurred a day or two beforehand.

If Dr. Donahue has recommended that you have an Intrauterine Insemination (IUI) to help with conception, this will be scheduled once the hCG decision has been made. IUI’s involve a specifically timed injection of hCG followed by the insemination at a specific time. Generally the hCG shot is given 36 hours before the insemination. Some studies have shown that a double insemination, at 18 and 42 hours after the hCG shot may improve the pregnancy rates. We do these as well.

Progesterone Support

Beginning 3 days after the hCG injection is taken, we may recommend that you begin progesterone vaginal suppositories. These are a low-dose form of progesterone support to help maintain the anticipated pregnancy. One suppository should be inserted into the vagina at bedtime. These are taken for approximately two weeks. Some patients will take an intra-muscular injection of progesterone. We check a progesterone level on day 21-23 of the cycle to see if the dose needs to be changed. This is at the time of implantation. A pregnancy test is taken 14 days later.

Gonadotropin Side-Effects

As noted above, ovarian hyper-stimulation syndrome is a potential risk. This occurs in 1 %-3 % of patients and can lead to hospitalization for fluid management. It is characterized by enlarged ovaries, abdominal swelling, and intra-vascular volume depletion (dehydration). In its most severe form renal, hepatic, and pulmonary function may be altered. The multiple pregnancy risk is about 30 % twins, 5 % triplets, and 1 % quadruplets or above. Please note that it is impossible to predict singletons, twins, or triplets. Ovarian torsion is a rare risk. Such a patient would have severe pain and need immediate assistance. The risk of ovarian cancer is ultimately unknown. As with any injectable medication, local swelling, pain, or bleeding may occur. Allergic reactions could occur.

 

 

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