Human Menopausal Gonadotropins (hMG’s) are the hormones that your pituitary gland normally secretes to stimulate the ovulation of one egg from your ovary. These hormones are Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH). When given by injection, hMG’s serve to stimulate or enhance the maturation of several eggs within the ovaries. The following are types of hMG’s that your physician may prescibe: Follistim, Gonal F, Repronex and Menopur. In addition, an hCG product such as Ovidrel or Novarel will be used to complete the maturation of the eggs and allow them to be released from the ovaries for fertilization.
How are these medications given?
Patients often have concerns about the use of needles and syringes to administer fertility medications. Now there are prefilled cartridges with ready-to-use medication, so there’s no mixing or preparation. These are two of the pens that are used to give injectable medications.
How do I know if I need gonadotropins instead of clomid?
Each patient is treated based on age, prior history and individual fertility problems. Patients under the age of 35 often start with clomid for 3-4 months. If no pregnancy occurs, consideration is given to moving on to gonadotropins. If a patient is over 35 she may begin treatment with gonadotropins. Both options are discussed in a consultation with your doctor.
You will need to have had a basic fertility workup, including lab, HSG and a semen analysis for your partner. You will be asked to call the office on day 1-2 of your menstrual cycle to arrange a baseline estradiol blood test and an ultrasound. These tests must be done on day 2 or 3, so if you start your period on a Saturday, please call the office early Monday morning to schedule a same-day appointment. The injections typically begin on day 3 of your cycle and should be given at approximately the same time every day, usually between 6 pm and 10 pm. Injections are given for about 10-12 days or until you are close to ovulation. You or your partner will be administering the injections at home; one of our nurses will carefully review the injection process with you before you leave the office. Current design of gonadotropin injections is extremely user-friendly and causes minimal discomfort.
Your cycle will be monitored carefully with ultrasound and blood estradiol (estrogen) levels. Ultrasounds are performed with a vaginal probe, which enables us to evaluate the size and number of follicles present. Follicles are the fluid-filled sacs within the ovary that contain the eggs. Eggs are too small to see on ultrasound, but measuring the follicle gives information about the maturity of the egg inside. Ultrasounds are usually scheduled after you have been on medication for 5 days and may be required every 1-2 days until your follicles are mature. Estradiol levels are monitored along with ultrasounds to help evaluate the developing follicles. Estradiol is a form of estrogen, which should increase as the follicles mature. Estradiol levels are drawn in our offices between 8 am and 10 am at the Frisco, Dallas and Grapevine locations. Throughout your cycle one of our physicians will review the results of your ultrasound and estradiol levels and adjust your medication dosage accordingly. When the follicles reach a state of maturity as evidenced by your ultrasounds and estradiol results, your physician will have you take your hCG injection to trigger the release of the eggs from your ovaries. Most patients will ovulate 36-40 hours after the injection. On days you have had an ultrasound, and/or estradiol test, you will receive a call from a nurse with medication instructions and your next appointment. We ask that you be available by phone to speak with our staff on the days you have had ultrasound or bloodwork monitoring so we can verbally confirm your medication dose and set up you follow-up appointment.
We recommend that you have intercourse every 2-5 days during the first half of your cycle. Intrauterine insemination (IUI) will be scheduled as close to ovulation as possible, which is approximately 36 hours after your hCG injection. We ask that you abstain from intercourse for 24 hours prior to insemination to maximize the sperm count. You may have intercourse as desired after the IUI. If you are not having IUI, we recommend intercourse the day of hCG, as well as the following 2 days. It is possible to ovulate spontaneously without hCG and this is the reason regular intercourse is suggested.
Gonadotropins stimulate the ovaries and cause mild ovarian enlargement. Well-established exercise programs may be continued prior to ovulation but may need to be limited afterward. Because of the increased ovarian size, activities which may be jarring to the pelvis should be avoided. Limit yourself to routine activities that are not strenuous. Jogging, aerobics, horseback riding and heavy lifting (>25 lbs) may increase ovarian discomfort.
If you have not started your period 14 days after the IUI or timed intercourse, you may do a home pregnancy test. Testing earlier than 14 days may yield a false positive due to residual hCG (which is a pregnancy hormone) in your urine. If you have a positive home test, please call the office to schedule a blood pregnancy test. If your test is negative and you still have not started your period, please let us know.
Because your ovaries have produced a higher number of eggs than they usually do, they may become enlarged causing you to have symptoms of mild hyperstimulation such as abdominal bloating and weight gain of 2-3 pounds. Mild symptoms may be treated with decreased activity and observation at home. Moderate to severe hyperstimulation occurs rarely (<2%) and causes fluid to accumulate in the abdomen making you feel very distended and bloated. If you experience symptoms of pelvic pain, bloating, weight gain of more than 8 pounds, vomiting, difficulty breathing or decreased urine output, please report this to our physicians or staff immediately. In very rare cases, this can lead to a salt/water imbalance, temporary kidney or heart failure and blood clots. These major symptoms require hospitalization until resolution occurs. Even more uncommon (<1%) is ovarian rupture or twisting (torsion). These complications also may require hospitalization. The other major risk of gonadotropin therapy is multiple gestation, which is approximately 30% in contrast to a rate of 1% in the general population. Even with careful monitoring, the risk of multiples cannot be eliminated. While most of these pregnancies are twins, triplet or higher numbers do occur. Multiple gestation is associated with increased risk of pregnancy loss, premature delivery, pregnancy-induced hypertension and post-partum hemorrhage. If multiple gestation does occur, you will be counseled regarding the risks/benefits of continuing the pregnancy with multiples versus undergoing pregnancy reduction (reducing the fetal number). The decision, of course, is ultimately yours.
Yes. If the estradiol levels are not rising appropriately or if there is inadequate follicular development, the cycle may need to be canceled. Conversely, if the estradiol level rises too high or if there are too many follicles present, the doctor may counsel you to discontinue the cycle and not take hCG. It is always difficult for patients to be told the cycle needs to be canceled, but your safety comes first. When hyperstimulation is present and the risk of multiples is high, it is usually the best approach. Even if the cycle is canceled and no hCG is given, there is a 15% chance that spontaneous ovulation may occur. Therefore you will be advised not to have intercourse until your menstrual period begins.