Humegon, Pergonal, Fertinex, Follistim, Gonal-F, Repronex and Metrodin are medications that are given by injection to stimulate development of follicles (eggs) either when development of follicles is not occurring or when the production of multiple eggs and/or better timing of ovulation would be beneficial. Humegon, Repronex, and Pergonal consist of two hormones, luteinizing hormone (LH) and follicle stimulating hormone (FSH). Fertinex, Follistim, Gonal-F, and Metrodin consist primarily of FSH. These hormones stimulate the ovaries and are similar to the natural hormones released by the pituitary, a small gland located at the base of the brain. These drugs are collectively known as Human Menopausal Gonadotropins (HMG).
RATE OF RESPONSE AND MODE OF TREATMENT:
Different women respond to HMG at different rates, and 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, and 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 so that the correct amount of medication is given and that ovulation is triggered when developing eggs become mature. This monitoring involves blood testing and ultrasounds to measure the growth of the follicles in the ovary. In some individuals additional medications may be employed such as Lupron or oral contraceptive pills.
HMG needs to be given by 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 pm. You will need to arrange for your husband or a friend to give you the injections unless you are using the subcutaneous medication. We provide an HMG Teaching Course designed to instruct persons on how to prepare the medication and give the injections. ALL patients initiating HMG therapy are REQUIRED to attend this teaching 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:
HMG is associated with an increased risk of multiple births. 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 injectable, there is a risk of infection at the injection site referred to as cellulitis. Controversial data 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 and usually these cysts do not cause any problem other than some pelvic fullness. But sometimes these cysts do grow to considerable 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 but, on rare occasions, 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 possibly requiring surgery and possible loss of the involved ovary.
HMG is usually started on the 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). Patients additionally will 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 8:00 am. Depending on the number of women being monitored, your appointment may be anytime between 8:00 and 10:30 am. It is important to be on time in order for us to keep on schedule allowing everyone to spend a minimum amount of time here and 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 included schedule. Remember to always schedule with our receptionist for each ultrasound and blood test that is recommended. If you forget to schedule an appointment, you will have to wait until all scheduled patients are examined before being seen.
BASELINE ULTRASOUND SCHEDULE:
|If your menses begins on:
|Your ultrasound will need to be on:
Tuesday or Wednesday
Wednesday or Thursday
Monday or Tuesday
In general, for each ultrasound visit a blood test for hormone levels will be obtained. This is usually done prior to your ultrasound.
If possible, we will let you know the next step at the time of ultrasound. In the afternoon, the physicians will review your lab results. You will be called between 3:30 and 5:00 pm. with the next step only if there is a change in plan. If you expect a call and you haven not heard from us by 4:30 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, we will leave a message if you prefer not to be contacted at work.
The second appointment will be on cycle day 6 for a blood test (estradiol level) only. 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 in general will not occur on Sundays.
- Follow up Appointments
All follow up appointments will be arranged based on the size of the largest measured follicle. Each patient's care is individualized at this point.
HCG (Profasi, Pregnyl):
The medications and follicular monitoring are continued until the size of the follicles and the blood results indicate that the eggs are mature. Once the follicles are mature you will then be given an injection of hCG, a hormone that triggers ovulation. Ovulation usually occurs 24-40 hours after hCG administration. 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 initial dose of hCG. 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 to help prevent you from getting ovarian hyperstimulation syndrome.
IUI (Intrauterine Insemination):
Intrauterine insemination is a procedure that allows us to deposit sperm directly into the uterus via a small, flexible catheter. It requires that your partner bring in a semen sample. If you live within one hour of the office, it is probably easier to bring the sample in from home. Make sure to obtain a specimen cup if you plan to produce the sample at home. Please do not use a container other than the one we provide as it may cause damage to the sperm. Please label the container (not the lid) with both your name and your husband's name, your husband's social security number, and date and time of sample collection. The sample is then brought to the andrology lab where the sample is then washed and concentrated. Make an appointment to drop off this sample and an appointment to return to the office between 10:00 and 11:30 a.m. (as scheduled) for the insemination. The procedure is usually quick and you may have minimal cramping. Afterwards, you may resume normal activity and return to work. Some patients may need to have two inseminations performed. If your physician has ordered two inseminations as part of your treatment, please do not forget to schedule both insemination procedures.
POST INSEMINATION INSTRUCTIONS:
In some patients, a progesterone level will be drawn 7 to 9 days after the IUI. This will be of value to the physician 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 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 to prevent the process of ovulation from occurring before we want it to. In addition, on occasion an endometrial biopsy is indicated. 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 a.m. to 4:00 p.m., to report your menses. Call on cycle day one 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.
Check with your insurance company for verification of coverage of 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.