There are a number of different medications given by injection to stimulate development of follicles (eggs). These are used when follicles are not developing or when the production of multiple eggs or better timing of ovulation would be helpful. All together these various drugs are known as Human Menopausal Gonadotropins (HMG). These drugs contain hormones that stimulate the ovaries. They are similar to the natural hormones released by the pituitary, a small gland located at the base of the brain. The specific names of the drugs and the hormones they contain are listed below.

Drugs that contain follicle stimulating hormone (FSH) and luteinizing hormone (LH):

• Repronex®
• Pergonal®
• Bravelle®

Drugs that contain mainly FSH:

• Follistim®
• Gonal-F®

Rate of Response
Different women respond to HMN at different rates. Even the same woman will not respond to HMG in the same fashion on each cycle. Some women may need to have the dosage increased or decreased during the cycle. Some women who have responded either slower or faster than usual on previous cycles may be started on different doses. Therefore, it is essential that your treatment be monitored closely. It is important to use the correct amount of medication as prescribed by your doctor and at the correct time to trigger ovulation when the developing eggs become mature. Monitoring involves blood testing and ultrasounds to measure the growth of the follicles in the ovary. Some women may need additional medications such as Lupron or oral contraceptive pills.

Mode of Treatment
HMG needs to be given in an injection on a daily basis, usually over 7 to 14 days. You will need to receive the injections at the same time each day (within 2 hours) usually between 4:00 and 9:00 p.m. Your husband or a friend can give you the injections. You should be able to give your own injections if you are using the subcutaneous medication. We provide a class on how to prepare the medication and give the injections. ALL patients starting HMG therapy MUST attend this class with the person who will be giving their injections, even those who know how to give injections. Besides learning the injection technique, your treatment plan will be reviewed. There is a nursing visit fee for this class.

Risks and Side Effects
There is an increased risk of multiple births using HMG. The multiple gestation rate is approximately 20%, the majority of which have been twins. About 5% of the total pregnancies result in triplets or more. Except for the increased risk of premature labor associated with multiple pregnancy, HMG does not increase the rate of premature labor or birth defects. Since this medication is given as injection, there is a risk of infection at the injection site called cellulitis. Controversial data also exists that may link the use of fertility drugs with an increased risk of ovarian cancer.

Side effects of HMG that may be observed during the cycle are breast tenderness, mood swings, bloating, tiredness, and pelvic discomfort. Many women have cysts form in the ovaries after ovulation. Usually these cysts do not cause any problem other than some pelvic fullness. Sometimes these cysts do grow to a larger size and may cause significant abdominal bloating or pain (referred to as hyperstimulation). If this occurs, it usually begins about 3 to 7 days after you receive the injection of hCG. You will need to call us if you have any problems during this time and particularly if you experience dizziness, decreased urination, or a weight gain of more than 10 pounds. These cysts usually start to go away after 4 to 7 days. On rare occasions they can cause serious problems with accumulation of fluid in the abdomen that would require hospitalization. Under very rare circumstances these cysts may rupture or the ovary may twist. This would possibly require surgery and possible loss of the involved ovary.

SPECIFIC INSTRUCTIONS
1. First Appointment

• HMG is usually started on the second or third day of your cycle, with the first day of menstrual bleeding being counted as cycle day #1.
• You MUST call about one week PRIOR to the onset of your period to receive your medication plan (when to start medication, how much medication is needed, and to see if Lupron is needed).
• You will also need to call on cycle day 1 or 2 to set up a baseline ultrasound appointment. Vaginal ultrasounds (U/S) are scheduled every 15 minutes starting at 7:30 a.m. Depending on the number of women being monitored, your appointment may be anytime between 7:30 and 9:30 a.m. It is important to be on time in order for us to keep on schedule allowing everyone to return to work as quickly as possible. Patients will be seen in the order of their appointment (if they are on time), not the order of arrival at the office. If you are scheduled to start fertility drug therapy, please call the office at 720-848-1690 to set up an ultrasound based on the schedule below. Remember to always schedule with our receptionist for each ultrasound and blood test. If you forget to schedule an appointment, you will have to wait until all scheduled patients are first seen.

Baseline Ultrasound Schedule

In general, each ultrasound visit includes a blood test for hormone levels. This is usually done prior to your ultrasound.

In the afternoon, the physicians will review your lab results. You will be called between 3:00 and 4:30 p.m. with the next step. If you expect a call and you have not heard from us by 4:00 p.m., you will need to call us. Please make sure we have your current work and home phone numbers so that we may contact you easily. If you have an answering machine at home, we will leave a message if you prefer not to be contacted at work.

2. Second Appointment
The second appointment will be on cycle day 6 or 7 for a blood test and ultrasound. At the time of this appointment, schedule a follow-up visit for 2 or 3 days later (cycle day 8 or 9). Follow up visits generally will not occur on Sundays.

3. Follow-up Appointments
All follow-up appointments will be arranged based on the size of the largest measured follicle. Each patients' care is individualized at this point.

hCG (Profasi®, Pregnyl®, Novarel®)
The medications and follicular monitoring are continued until the size of the follicles and the blood results show that the eggs are mature. Once the follicles are mature you will be given an injection of hCG, a hormone that triggers ovulation. Ovulation usually occurs 24-40 hours after receiving the hCG. To increase the amount of sperm reaching the egg, intrauterine insemination (IUI) is performed at this time. In some instances additional hCG booster shots may be given 3 and 6 days after the first dose. If too many follicles are developing, the physician may discuss the option of not giving the hCG injection so that the eggs are not released. This helps prevent you from getting ovarian hyperstimulation syndrome.

IUI (Intrauterine Insemination)
This procedure requires your partner to provide a semen sample. It is best if he collects the specimen in the private collection room in our office. Make an appointment for semen collection and for the insemination which will occur 1 ½ to 2 hours after the collection. Your partner should abstain from intercourse or ejaculation for at least 2 days, but no more than 5 days before collection. No lubricants, saliva, or condoms can be used for the specimen collections.

If you live close to the office, it may be possible to collect at home and bring the specimen to the office within 30 minutes. It is important to keep the semen specimen at body temperature during transportation. You will need to pick up a special specimen cup and instructions from our office ahead of time. Please do not use a container other than the one our lab provides as it may cause damage to the sperm. You will also need to make an appointment to drop off the specimen for insemination.

The insemination procedure is usually quick and you may have minimal cramping. Afterwards, you may resume normal activity and return to work.

Post Insemination Instructions
In some patients, a progesterone level will be drawn 7 to 9 days after the IUI. The physician uses this information when he/she reviews your cycle. This test can take up to one week to return. After your first cycle, we may test to see if you may have started the process of ovulation on your own prior to the administration of the hCG injection. We do this using blood stored and frozen during the stimulation part of the cycle. This process is called “premature luteinization” or a “surge”. If you did “surge”, a medication called Lupron may need to be added to your next cycle if you do not become pregnant. This prevents the process of ovulation from occurring before we want it to. In addition, on occasion an endometrial biopsy may be needed. If you need a biopsy a physician will discuss this with you.

You MUST call the office and speak with a nurse if you get your period after completing a HMG cycle. Please call Monday through Friday, 9:00 am to 4:00 p.m. to report your menses. Call on cycle day 1 if you wish to start another cycle again. Follow the ultrasound schedule to plan the day you will need your baseline ultrasound.

If you are late for a period (16-17 days after your hCG injection), call the office to arrange for a blood pregnancy test.

Medical Costs
Check with your insurance company to make sure of coverage for medicines and procedures. Remember, prices vary from pharmacy to pharmacy so shop for the best price. Because of the high costs, many couples will need to obtain written verification of coverage from their insurance company.

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