Medications Used for Infertility Treatment

During a natural menstrual cycle, only one egg is usually produced. Powerful hormones are used in both ovulation induction (OI) and in vitro fertilization (IVF) cycles to stimulate the ovaries to produce multiple follicles, tiny fluid-filled sacs in which multiple mature eggs can develop. Other medications also may be prescribed to the female or her partner to improve the chances for conception.

To limit possible side effects associated with stimulation medications, cycles are monitored carefully by our medical team. Blood tests and ultrasound to track follicular development and allow us to adjust medication dosages, if necessary.

 

What Infertility Medications May Be Prescribed

Antibiotics (Doxycycline, Tetracycline) – prescribed to each partner during an IVF cycle, to control bacteria that may affect implantation in the female and sperm quality in the male.

Method of Administration: Oral.

Timing: Tetracycline is taken by the female four times a day for four days, beginning the day of retrieval. Doxycycline is taken by the male twice a day for a minimum of five days prior to partner’s retrieval or prior to producing a semen specimen for freezing.

Possible Side Effects: Sensitivity to sunlight, gastrointestinal distress.

Birth Control Pills – may be used in an IVF cycle to suppress a woman’s natural cycle, preventing ovulation in preparation for ovarian stimulation and cycle synchronization.

Method of Administration: Oral.

Timing: For 2 or more weeks prior to the start of a stimulation cycle for IVF.

Possible Side Effects: Although oral contraceptives can have serious long-term effects for some women, the short-term affect of using oral contraceptives should be minimal. They may include nausea, headache, dizziness, visual disturbances.

Bromocriptine (Parlodel) - reduces the amount of prolactin released by the pituitary gland. This medication is prescribed in cases where infertility is linked to irregular ovulation resulting from over-production of prolactin.

Method of Administration: Oral or vaginal.

Timing: Introduced gradually over several weeks and continued until the prolactin level becomes normal. It is usually discontinued following a positive pregnancy test.

Possible Side Effects: Nasal stuffiness, nausea, vomiting, fainting, dizziness and high blood pressure.

Clomiphene Citrate (Clomid or Serophene) - used to stimulate the development of follicles and eggs in women with infrequent periods and long menstrual cycles. Clomiphene citrate causes the hypothalamus gland to detect an estrogen deficiency in the blood and react by secreting more follicle stimulating hormone (FSH) and luteinizing hormone (LH) into the bloodstream. The high hormone levels stimulate production of a follicle and egg.

Method of Administration: Oral.

Timing: Starting on the third, fourth or fifth day of a cycle and continuing for five consecutive days. If ovulation does not occur, the dose may be increased or the drug may be combined with injectible medications, in subsequent cycles.

Possible Side Effects: Hot flashes, mood swings and depression while taking clomiphene; nausea and breast tenderness later in the cycle. Women taking this medication have approximately a 5 to 10% chance of having twins, and less than a 1% chance of higher order multiples.

Dexamethasone – taken with ovulation stimulation drugs, it helps the ovaries be more receptive to treatment by decreasing male hormones (androgens) produced by the adrenal gland.

Method of Administration: Oral.

Timing: One pill a day beginning day two of the menstrual cycle and ending with ovulation.

Possible Side Effects: None, based on the low doses prescribed.

Estrogens – (Estrogen – pills/patches/injections for cryo synthetic cyles, recipient cycles)

Human Chorionic Gonadotropin (hCG: Profasi, Pregnyl, Novarel) – like the surge of luteinizing hormone (LH) in a natural cycle, hCG prepares the eggs for ovulation/ retrieval by prompting their release from the follicle wall. Floating free in the follicular fluid, the eggs are aspirated during oocyte retrieval for IVF or are ovulated for insemination/intercourse cycles. Hcg, produced by the placenta during pregnancy, is extracted from the urine of pregnant women. This drug may not be required, or the dosage reduced, depending on how the ovaries respond to stimulation medications.

Method of Administration: Intramuscular injection.

Timing: When follicles are mature. HCG may be given at any time 1-2 days prior to insemination or intercourse. For IVF patients, hCG is given at a prescribed time 34-36 hours prior to the retrieval.

Possible Side Effects: Headache, bloating, irritability, pain at the injection site, ovarian hyperstimulation syndrome (in less than 1% of cases).

Human Menopausal Gonadotropins (hMG: Pergonal, Humegon) – made from equal parts of FSH and LH that are derived from the urine of post-menopausal women, HMG works directly on the ovaries to stimulate follicle development. These medications come in powder form and must be mixed with a diluent prior to administration.

Method of Administration: Intramuscular injection.

Timing: Given daily starting the second, third, fourth or fifth day of the cycle, and continuing for 7 to 12 days or longer if the ovary responds slowly.

Possible Side Effects: Breast tenderness, swelling or rash at the injection site, abdominal bloating, mood swings and slight abdominal pain. Use of gonadotropins is linked to a slight increase in the risk of ectopic pregnancies and a risk of ovarian hyperstimulation syndrome (OHSS) in 1 to 5% of cycles, a risk that is increased in women with polycystic ovarian syndrome. When severe, OHSS can result in blood clots, kidney damage, chest and abdominal fluid, or ovarian twisting (adnexal torsion) that cuts off the blood supply to the ovary and requires surgery. Severe OHSS is rare. Hospitalization may be required for monitoring of OHSS; however, the condition usually lasts only about a week. Gonadotropins have been suggested as a possible link to an increased risk of breast and ovarian cancer, but no statistical significance has been established. Multiple pregnancies (two-thirds twins and one-third triplets) occur in approximately 15-25% of hMG cycles.

Follicle Stimulating Hormones (hFSH: Gonal F, Follistim, Fertinex) – consisting primarily of FSH, with little or no LH, they bypass the hypothalamus and pituitary glands to stimulate growth of multiple follicles. These medications come in powder form and must be mixed with a diluent prior to administration.

Method of Administration: Subcutaneous injection. These medications may be mixed with the HMG medications, but must then be given intramuscularly.

Timing: Generally started on the second, third, fourth or fifth day of the cycle, and continued for 7 to 12 days or longer if the ovary responds slowly.

Possible Side Effects: Breast tenderness, swelling or rash at the injection site, abdominal bloating, mood swings and slight abdominal pain. Use of gonadotropins is linked to a slight increase in the risk of ectopic pregnancies and a risk of ovarian hyperstimulation syndrome (OHSS) in 1 to 5% of cycles, a risk that is increased in women with polycystic ovarian syndrome. When severe, OHSS can result in blood clots, kidney damage, chest and abdominal fluid, or ovarian twisting (adnexal torsion) that cuts off the blood supply and requires surgery. Severe OHSS is rare. Hospitalization may be required for monitoring of OHSS; however, the condition usually lasts only about a week. Gonadotropins have been suggested as a possible link to an increased risk of breast and ovarian cancer, but no statistical significance has been established. Multiple pregnancies (two-thirds twins and one-third triplets) occur in approximately 15-25% of hMG cycles.

Leuprolide Acetate (Lupron) – initially accelerates the pituitary gland and then stops it from producing LH and FSH, allowing for a controlled stimulation cycle prior to IVF. A synthetic hormone, Lupron prevents ovulation and produces a drop in estrogen level which may cause the patient to experience symptoms of menopause.

Method of Administration: Subcutaneous injection.

Timing: Five, ten or twenty units given daily as prescribed during the cycle. It may be overlapped with birth control pills for 3-7 days.

Possible Side Effects: Bloating, bruising at the injection site, hot flashes, insomnia and night sweats, headache, mood swings, vaginal dryness. Many symptoms are relieved by two Tylenol every four hours and usually disappear with the start of stimulation drugs. Symptoms may not occur when Lupron and birth control pills overlap.

Pre-Natal Vitamins – contain folic acid (folate), which may reduce the risk of certain birth defects such as spina bifida and other neural tube defects.

Method of Administration: Oral.

Timing: Taken daily, starting before attempting pregnancy, if possible.

Possible Side Effects: Constipation, nausea, bloating.

Methotrexate – used as a first step for treating ectopic pregnancies, this drug destroys pregnancy tissue and allows it to be reabsorbed by the body. If methotrexate therapy fails, as evidenced by continued elevated beta hCG levels, the medication may be repeated or surgery may be required.

Method of Administration: Intramuscular injection.

Timing: Prescribed after diagnosis of ectopic pregnancy and review of baseline bloodwork by a physician.

Possible Side Effects: Short-term/temporary symptoms include ulcers in the mouth and gastrointestinal system, liver function problems, sensitivity to sunlight and adverse effects from alcohol consumption.

Methylprednisolone (Medrol) – a steroid used for its anti-inflammatory effect after IVF oocyte retrieval.

Method of Administration: Oral.

Timing: One pill daily beginning the day of retrieval and ending the day of embryo transfer.
Possible Side Effects: None, based on the low dose prescribed.

Progesterone – administered to support the uterine lining during early pregnancy.

Method of Administration: Oral capsules, vaginal suppositories/capsules/gel, or intramuscular injection.

Timing: Used daily starting day of IVF retrieval and continuing until the pregnancy test, and an additional four to six weeks if the pregnancy test is positive.

Possible Side Effects: Cramping, headaches, nausea, diarrhea, breast tenderness, swelling or soreness at the intramuscular injection site, mood swings or (if using a gel) vaginal irritation. Allergic reaction (rash, itching, redness) to the oil base used in the intramuscular injection preparation.

 

Taking Your Medications

It is important that you fill your prescriptions several weeks prior to needing them in order to be sure you have the required medications on hand. The dosage and instructions for administration will be given to you during your initial consultation and medication instruction; however, this information may change during your cycle depending on your response to stimulation drugs. You will be instructed when to take medications and when to alter dosages (if necessary), by a nurse or physician.

Never take a medication unless a nurse or physician has specifically told you to do so. All instructions must be followed carefully and timing is extremely important to the success of your cycle. In some cases, failure to follow instructions may result in cancellation of treatment.

Over the counter medications, health food remedies, herbal and nutritional supplements should not be taken during the cycle unless cleared by your nurse or physician. Some of these substances may have adverse effects on the cycle or during pregnancy.

Your Medication Kit
The type and dosage of the medications prescribed for you will vary depending on your treatment and individual medication protocol. However, typical medication kits include:

  1. Clomid Cycle
    Prenatal Vitamins
    Clomiphene Citrate (Clomid)
    HCG 10,000 IU and 5,000 IU
  2. Stimulation Cycle
    Prenatal Vitamins
    Gonal-F, Fertinex or Follistim
    HCG 10,000 IU
    3cc, 22 gauge, 1    1/2 " syringes
    27 gauge,     1/2" needles
  3. IVF Cycle
    Prenatal vitamins
    Oral contraceptives (optional as prescribed)
    Doxycycline 100mg for male partner
    Two-week Lupron kit, or diluted micro-dose Lupron
    Gonal-F, Fertinex or Follistim
    HCG 10,000 IU
    Tetracycline 250 mg for female partner
    Medrol 16 mg
    Progesterone (IM, oral or vaginal gel/suppositories)
    3cc, 22 gauge 1    1/2" syringes
    27 gauge,     1/2" needles
    18 gauge, 1    1/2" needles (to draw up IM progesterone)
  4. Recipient Cycle
    Prep Cycle:
    Prenatal vitamins
    Two-week Lupron kit
    Estrace 1 mg tabs
    Crinone gel

    Actual Cycle:
    Prenatal vitamins
    Oral contraceptives (optional as prescribed)
    Doxycycline 100mg for male partner
    Two-week Lupron kit
    Tetracycline 250 mg for female partner
    Medrol 16 mg
    Progesterone (IM, oral or vaginal gel/suppositories)
    3cc, 22 gauge, 1    1/2" syringes
    27 gauge,     1/2" needles
    18 gauge, 1    1/2" needles (to draw up IM progesterone)
  5. Donor IVF Cycle
    Actual Cycle:
    Oral contraceptives (optional as prescribed)
    Two-week Lupron kit
    Gonal-F, Fertinex or Follistim
    HCG 10,000 IU
    Tetracycline 250 mg
    3cc, 22 gauge, 1    1/2" syringes
    27 gauge,     1/2" needles

The Subcutaneous Injection
Many fertility medications come in powder form and must be mixed prior to injection. Please follow these simple steps to ensure that you receive the proper amount of each. Both dosage and timing are important to the success of your cycle.

Preparing Fertinex, Follistim, Gonal F or Repronex

  1. Always wash your hands with soap and water.
  2. Make sure you have the medication, appropriate syringe and an alcohol swab or alcohol and a cotton ball.
  3. Take out one ampule (vial) of diluent. The diluent is sterile water, used to dilute the medications which come in powder form.
  4. Take out the number of medication vials you were instructed to use. Be sure to check the name and expiration date on each.
  5. Unwrap an insulin syringe or a 3cc, 22-gauge syringe with a 11/2" needle to do the mixing, and a 27gauge, 1/2" needle to switch to for the actual injection.
  6. Break open the vials, using gauze or a napkin to avoid cutting yourself.
  7. Draw up 1/2 cc to 3/4 cc of diluent.
  8. Place the needle into the first medication vial and push the plunger slowly to release the fluid, mixing the medication. Withdraw the liquid medication into the syringe by pulling back on the plunger.
  9. Repeat Step 8 with each ampule/vial of powder until all are mixed and drawn into the syringe. (You can mix up to six vials/ampules with this amount of diluent).
  10. Tap the syringe with a flick of your finger to remove air bubbles.
  11. Replace the cap on the needle, twist it off and replace it with the 27-gauge 1/2 inch needle.
  12. Push the plunger gently to expel air, being careful not to lose any medication.

Preparing Lupron (full-strength dose)

  1. Always wash your hands with soap and water.
  2. Make sure you have the medication, appropriate syringe and an alcohol swab or alcohol and a cotton ball.
  3. Take out the vial of Lupron; check the name and expiration date.
  4. Unwrap a Lupron syringe; remove the protective cap from the vial and wipe the rubber stopper with alcohol.
  5. Pull back on the plunger of the Lupron syringe, filling it half way (25 units) with air.
  6. Place the needle through the rubber stopper on the vial; push the plunger to inject air into the vial.
  7. Turn the vial upside down, keeping the needle inside and making sure the tip is below the level of the medication.
  8. Pull the plunger back all the way, to fill the syringe with the fluid.
  9. Push on the plunger, expelling air and fluid into the vial until it reaches the dosage level prescribed for you.
  10. Tap the syringe with a flick of your finger to remove air bubbles.

Preparing Lupron (diluted/micro-dose)
Micro-dose Lupron can be mixed ahead of time by the pharmacist and stored in the refrigerator. If your pharmacy does not provide this service, you can bring the medication to us and we will mix it for you. If you prefer, steps 1-10 below contain instructions for mixing the medication yourself. Steps 11-17 contain further instructions to prepare for administration.

  1. Always wash your hands with soap and water.
  2. Make sure you have the medication, appropriate syringe, and an alcohol swab or alcohol and a cotton ball.
  3. Take out the vial of Lupron and a vial of 10ml sterile saline, used to dilute the medication. Check the name and expiration date on each.
  4. Unwrap a Lupron syringe; remove the protective caps from the vials and wipe the rubber stoppers with alcohol.
  5. Pull all the way back on the plunger, filling the Lupron syringe with 50 units of air.
  6. Place the needle through the rubber stopper on the vial and push the plunger to inject air into the vial.
  7. Turn the vial upside down, keeping the needle inside and making sure the tip is below the level of the medication.
  8. Pull the plunger back slowly to 50 units, allowing the fluid to fill the syringe.
  9. Insert the needle through the rubber stopper of sterile saline; push on the plunger, injecting the entire 50 units into the vial.
  10. Label the vial as "diluted Lupron" and write the date it was mixed; store both diluted and full-strength medication in the refrigerator for future use. (Discard unused, diluted Lupron once your cycle is completed.)
  11. When it is time for your injection, have the diluted Lupron and a Lupron syringe ready; wipe the rubber stopper with the alcohol.
  12. Pull back on the plunger to fill the Lupron syringe halfway (25 units) with air.
  13. Place the needle through the rubber stopper on the diluted Lupron vial and push the plunger to inject air into the vial.
  14. Turn the vial upside down, keeping the needle inside and making sure the tip is below the level of the medication.
  15. Pull the plunger back, allowing the fluid to fill the syringe.
  16. Push on the plunger, expelling air and fluid into the vial until it reaches the dosage level prescribed for you.
  17. Tap the syringe with a flick of your finger to remove air bubbles.

Locating the Injection Site

It is important that you use the recommended areas of the body for injection, as they will help ensure proper delivery of the medication to your system. Subcutaneous injections should be administered to the lower abdomen (recommended site), the upper and outer side quadrant of the thigh or the upper outer arm. Because repeated injections are required, and the skin may become red and tender, you should move the exact location about two inches from the previous injection site but still within the desired area.

Administering the Medication

  1. Cleanse the site with alcohol.
  2. Grasp the skin gently between the thumb and forefinger.
  3. Insert the needle at a 90 degree angle and slowly inject all of the medication.
  4. Place gauze or a cotton ball on the site and remove the needle quickly, while applying pressure.

The Intramuscular Injection

Preparing hCG, Humegon and Pergonal

  1. Always wash your hands with soap and water.
  2. Take out the vials of diluent and medication, checking the names and expiration dates before removing the protective cap. Do not remove the rubber stopper.
  3. Wipe the rubber stoppers on both vials with alcohol.
  4. Unwrap a 3cc, 22-gauge syringe with a 11/2" needle.
  5. Pull back on syringe to draw in 1/2 a syringe of air.
  6. Push the needle through the rubber stopper of the diluent, being careful not to touch the needle and inject air into bottle.
  7. Keeping the needle in the bottle, turn it upside down and make sure that the needle tip is below the level of the diluent.
  8. Draw up 1 cc of the sterile water by pulling on the plunger, and inject it into the bottle of hCG powder. Roll the vial gently to mix it, then pull the plunger back to draw up all of the liquid mixture.
  9. Remove the syringe from the bottle and flick it with your finger to remove air bubbles. Push the plunger up to expel air, being careful not to lose any medication.

Preparing Progesterone
Because progesterone in suspended in an oil base, the mixture is thick, making the injection more difficult. However, you may warm the medication once it is drawn into the syringe, to make the injection easier (see Step 9 below).

  1. Always wash your hands.
  2. Take out the vial of medication; check the name and expiration date before removing the protective cap. Do not remove the rubber stopper.
  3. Unwrap a 3cc, 22 gauge syringe with the 11/2" needle; keeping the cap on the needle, unscrew it from syringe and place it aside as you will need to re-attach it for the injection. Replace the 22-gauge needle with the 18-gauge (pink) one.
  4. Wipe the rubber stopper with alcohol.
  5. Pull back halfway on the plunger to fill the syringe with air. Push the needle through the rubber stopper and push on the plunger to inject air into the vial.
  6. Keeping the needle in the vial, turn it upside down and make sure that the needle tip is below the level of the medication.
  7. Draw back on the plunger to fill the syringe halfway with progesterone; push the plunger up to the instructed dosage level of 1/2 cc or 1cc, expelling excess medication, air and bubbles back into the vial.
  8. Remove the syringe from the bottle and draw the progesterone back into the syringe.
  9. At this point, you may put the filled syringe in warm tap water to thin the medication and make administration easier.
  10. Place the cap back on the 18-gauge needle, twist it off and replace it with the 22-gauge needle for the injection.
  11. Push the plunger forward to expel air, being careful not to lose any medication.

Locating the Injection Site

The upper-outer quadrant of the buttock (right or left) is the recommended site for intramuscular injections. As an alternative only, injections may be given to the upper front quadrant muscle of the thigh.

Administering the Medication

  1. Administer this and all medications only when a nurse or physician has specifically instructed you to do so.
  2. Cleanse the injection site thoroughly with alcohol.
  3. Hold the muscle by spreading the skin with the index finger and thumb.
  4. Holding the syringe with a firm grip, use a quick thrust to insert it through the skin and as far as it will go into the buttock/muscle.
  5. Hold the syringe with the free hand and pull back on the plunger, approximately 1/4 inch, with the other. If blood appears in the syringe, withdraw the needle, replace it with a fresh one and choose another injection site. Be sure to check again for blood aspiration before proceeding with the injection at the new site.
  6. If no blood appears, position your thumb on the plunger and, using firm pressure, push it in as far as it will go.
  7. Place gauze or a cotton ball on the site and remove the needle quickly, while applying pressure.

 

Helpful Hints for Medication Administration

  • Make sure you do not take any medication unless specifically instructed to do so. Follow dosage and time of administration instructions carefully.
  • Use each needle and syringe only once. For proper disposal, cap them before placement in a solid container, such as a coffee can or detergent bottle. The container should be taped closed and disposed of with your household trash. (IRMS cannot accept used needles from outside sources).
  • Do not touch needles. If an uncovered needle touches anything other than the inside of the medication vial before an injection, it is contaminated. Twist it off and attach a clean needle to the same syringe.
  • Alternate sides of the buttocks, thighs, upper arms or abdomen when giving injections, to reduce redness, pain and swelling at the injection site.
  • Apply a warm, moist cloth (microwave for 20-25 seconds) or heating pad to sore buttocks following IM injections.
  • If you have difficulty locating the right spot for injections, please ask and we will help by marking the skin for you to use as a guide.
  • If you are unsure where the previous day’s injection was, and you want to avoid the same site, you can mark the injection site each day with a small, round Band aid that can be easily removed.

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