Follistim, Gonal-F - These two products produce the same response, and have the same side effects, as the urinary products (Pergonal) discussed below. The difference is that they are recombinant pure products. They are not extracted from urine but instead are made using genetic recombinant technology. Both can be administered subcutaneously. There appears to be little difference in the pregnancy rates for patients receiving Follistim or Gonal-F compared to those receiving Pergonal, Repronex, or Humegon. Follistim and Gonal-F are more expensive than Repronex or Humegon.

Ultrasound and estradiol measurements will always be taken in patients receiving the injectable drugs discussed above, and sometimes in those who receive Clomid (clomiphene citrate). These measurements allow the Reproductive Endocrinologist to follow the development of the follicle and make appropriate dosage adjustments.

Ultrasound allows the physician to physically observe the developing follicle. As a healthy follicle develops it produces estradiol which can be measured. A very low estradiol level may signal poor quality egg.

Estradiol and ultrasound measurements are taken at 7:30 AM. It is very important that these tests be done early in the morning so that the results are available the same afternoon. The results are used to adjust daily dosage. Patients should be readily accessible each afternoon so that the dosage adjustments can be received. Many patients find it convenient to call the office between 1:00 and 3:00 PM on the test day.

Pergonal, Humegon, Repronex and Fertinex - These compounds are human hormones produced by the pituitary gland (LH and FSH) and are used to stimulate ovarian follicular development. (Fertinex is a urinary product with only trace levels of LH). They are urinary, meaning they are extracted from the urine of post menopausal women. These women have no ovarian function and produce high levels of the hormone FSH. This FSH is extracted, purified and made into a powder form.

These drugs can't be ingested orally, and are therefore administered by injection. Pergonal and Humegon are given intramuscularly while Follistim, Fertinex, Gonal-F and Repronex are given subcutaneously.

Injections usually begin on day 2 or 3 of the menstrual cycle and continue for several days until the developing follicles are mature. Daily dosage, and the length of time needed for adequate stimulation, varies from patient to patient, and from cycle to cycle. Most patients will receive injections for 8-10 days.

These compounds are used in women who do not ovulate, who don't ovulate on clomiphene citrate, or to produce multiple follicles (eggs) needed for an ART procedure.

An injection of hCG is given to induce (or time) ovulation when ultrasound and estrogen measurements indicate appropriate follicular development. All of these compounds are excreted from the body and will leave no long lasting effects on the menstrual cycle. Subsequent cycles should return to their usual pattern. Alcohol and over-the counter medications may be taken in small amounts while on these drugs, however, the nurse should be made aware of any prescription medications. Normal activities and sexual relations may be continued during ovarian stimulation.

These drugs can produce serious side effects and should only be given by a specialist trained in their use. When administered by a Reproductive Endocrinologist, who closely monitors the treatment cycle, the incidence of side effects is low. Dosages are adjusted based upon a myriad of factors, including the bodies response to treatment.

Failure to adequately monitor and adjust dosage can lead to a very serious condition, ovarian hyperstimulation syndrome. This syndrome is characterized by ovarian enlargement, abdominal pain, abdominal distention, weight gain, circulatory problems, and often requires hospitalization.

Other side effects can include: ovarian cysts, nausea, vomiting, diarrhea, abdominal cramps. bloating, irritation at the injection site, and multiple births.

Multiple births occur about 25% of the time. The incidence may be lower when the drug dosage is monitored by an experienced Reproductive Endocrinologist.

Lupron (leuprolide acetate) - Lupron is a synthetic preparation chemically similar to gonadotropin releasing hormone (GnRH) a hormone produced by the hypothalamus of the brain. GnRH travels to the pituitary gland through the vascular system and causes it to secrete luteinizing hormone (LH) and follicle stimulation hormone (FSH). FSH causes ovarian follicles to grow and LH causes ovulation to occur. FSH and LH together act on the ovaries to cause estrogen levels to rise.

Lupron is administered by subcutaneous injection and is supplied in a 2.8 ml multidose vial. Lupron is most commonly used when a patient is undergoing a stimulation cycle with injectable fertility drugs (Pergonal, Repronex, Humegon, Metrodin, Gonal-F, Follistim) are used. Lupron "down regulates" or "shuts down" the females hormone system. It suppresses the production of follicle stimulating and leutinizing hormone. Endometriosis responds to Lupron because endometrial tissue depends on the by products of these hormones.

For ART protocols Lupron is usually given in either of two ways:

1. In down regulation (Meldrum) protocols Lupron is started twice daily about 7 days after ovulation has occurred, prior to the anticipated ART cycle. When continuous doses of Lupron are given the pituitary gland becomes "desensitized" and stops producing LH and FSH. Estrogen levels then drop. This inhibition reverses upon cessation of Lupron. When the estrogen levels are low, the daily injections of FSH are begun. This FSH stimulates the development of eggs within the ovarian follicle.

2. The second method is often referred to at the "Flare" or "Garcia" protocol. In this protocol, Lupron is begun once daily beginning on cycle day 2. FSH is initiated twice daily on cycle day 5 to take advantage of the initial Lupron/estrogen response (Flair).

There are many variations of protocols and dosages. Your physician will tailor your protocol to your specific needs.

When scheduling an ART procedure ovulation must be timed precisely. Ovulation is triggered by leutinizing hormone, and Lupron suppresses leutinizing hormone. Ovulation cannot occur in patients receiving Lupron, unless outside LH is administered. The body recognizes hCG as leutinizing hormone and therefore an injection of hCG triggers ovulation.

The side effects of Lupron can include flushing, sweats, and mood alteration, breast tenderness or pain, constipation, dizziness, headache, fatigue, irritation at the injection site, and vaginal dryness. These potential side effects are temporary and abate after cessation of the drug.

Letrozole and Anastrozole - Letrozole and anastrozole are two oral medications that are in the category of drugs referred to collectively as aromatase inhibitors. They have been shown in several preliminary studies to be useful in inducing ovulation in infertile anovulatory women. They especially hold promise for the select group of women that have deficient mucus or underdeveloped endometrial lining while on clomiphene citrate.

The rationale for using aromatase inhibitors in these select anovulatory patients is to avoid the specific side effects from clomiphene citrate. Several investigations are underway to learn more about the safety and potential risks of these agents. So far, preliminary ovulation induction studies have shown that these drugs both have short half-lives and are out of the body before conception and have not been shown to cause birth defects.

At present, anastrozole is under investigation in a large national multi-center clinical trial comparing anastrozole to clomiphene citrate. The use of either letrozole or anastrozole for ovulation induction should only be considered only after patients have been fully counseled regarding the relative risks and alternatives of treatment available for ovulation induction.

Progesterone - Progesterone is a hormone which helps to prepare the uterine lining for implantation of the embryo. Progesterone may be administered daily as 200 milligram of micronized progesterone in vaginal suppositories, orally, as a gel, or by intramuscular injection.

Progesterone is made naturally by the corpus luteum after ovulation has occurred. It is also made by the placenta after pregnancy has occurred. In an ART cycle, progesterone is used to help prepare and maintain the endometrium of the uterus to allow implantation of the embryo.

If injections are prescribed they are usually given in the late afternoon. Side effects mimic premenstrual symptoms and may include feelings of bloating, full breasts, difficulty sleeping, mood swings, and fatigue. The suppositories occasionally cause vaginal irritation. Any persistent side effects should be reported to the office.

The package insert warns women about the possible risk of birth defects in children whose mothers take progestational drug products during the first 4 months of pregnancy.

This warning refers to artificial or synthetic progesterone like the hormone found in birth control pills. The progesterone used in ART is a natural progesterone and does not carry the same risks as artificial or synthetic progestational agents.

Parlodel - Elevated prolactin levels can contribute to infertility. Parlodel is a small tablet taken daily by mouth that reduces elevated prolactin levels. Occasionally women experience nasal stuffiness, light headedness, or nausea during the first few days of tablet administration. These symptoms usually pass quickly. If side effects continue the tablets may be administered intravaginally. Prolactin levels must be monitored periodically.

Human Chorionic Gonadotropin (hCG), Profasi, Pregnyl - hCG is required to ripen the follicles and make ovulation occur. The action of hCG is almost identical to that of luteinizing hormone (LH). LH is normally secreted by the pituitary gland and works with follicle stimulating hormone during the menstrual cycle to develop and mature the ovarian follicle. In an ART cycle hCG serves this function.

hCG is used to induce egg maturation in women who have been treated with on ovulation inducing drug such as Clomid or Follistim.

Side effects can include: headache, irritability, fatigue, and pain at the injection site. hCG is reconstituted in a vial containing 10,000 international units of hCG in dry powder form with 2 cc of diluent. The use of a smaller diluent volume reduces the discomfort of the injection and does not effect the bioavailability of the drug. Please see the instructions for injection.

Our Mission Statement: “...Exceeding patient expectations...”