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    nlakshmi's Avatar
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    Fertility Drugs

    CLOMID
    • Clomid (clomiphene citrate) is one of the most common fertility medications used to regulate or induce ovulation. Clomid (50 mg tablets) is taken orally on days 3-7 or 5-9 of the menstrual cycle. If no follicular development occurs (with or without ovulation), dosages can be increased by 50 mg increments (up to 200-250 mg), Once follicular development and ovulation has occurred, there is no advantage to further dosage increases.
    • To understand how Clomid works, it is necessary to have a basic understanding of the hormonal feedback mechanism operating in the ovulatory cycle. The hypothalamus is a small gland at the base of the brain which indirectly regulates the levels of follicle stimulating hormone (FSH), luteinizing hormone (LH) and others via the pituitary gland. It can be thought of as a thermostat that varies hormonal levels based primarily upon the levels of FSH and estrogen.
    • Gonadotropin releasing hormone (GnRH) is produced by the hypothalamus and travels to the pituitary where it stimulates the production of FSH. FSH directly stimulates the recruitment and growth of the ovarian follicles, each of which contains an egg. If FSH levels remain high, as is the case with injectable FSH medications, numerous follicles will develop and mature.
    • As healthy follicles develop, they produce estrogen which travels through the bloodstream to the hypothalamus. The hypothalamus monitors the level of estrogen and varies the production on GnRH accordingly. High estrogen levels signal that the follicles are mature, which causes the production GnRH to decrease thus lowering the levels of FSH.
    • Clomid works by "competing" with the estrogen receptors at the hypothalamus. It occupies receptors that would normally "sense" estrogen making it seem that estrogen levels are low. This "competing" action causes the hypothalamus to produce more GnRH with stimulates the pituitary to increase production of FSH.
    • Eighty percent of patients (who do not already ovulate) that are prescribed Clomid will ovulate and 40 % of those patients will conceive. Once ovulation occurs on Clomid, there is no value in increasing the dosage.
    • In general, Clomid should only be used for a maximum of six cycles, and possibly their is no significant advantage of treating for more than 4 cycles. Numerous studies demonstrate that if pregnancy will occur on Clomid, seventy-five percent will occur within three to four cycles.
    • There is no medical indication for taking Clomid for longer than 6 cycles. Clomid can have side effects and extended use is never recommended. Clomid, or any other fertility drug, should never be administered until the male has had a semen analysis.
    • When Clomid is being prescribed without artificial insemination (IUI), and pregnancy has not resulted after three cycles, intrauterine insemination (IUI) may be added for the remaining three cycles to increase the chance of pregnancy.
    • However, when seeing an Infertility Specialist, it is usually recommended that FSH (injectable fertility drugs)be used to directly stimulate the ovaries. If the patient fails to conceive on Clomid, with IUI after a maximum of three to four cycles, gonadotropin (FSH) cycles with IUI will often be attempted. If a patient fails to conceive on FSH and IUI, in vitro fertilization (IVF) is usually the next step. Each couples treatment protocol is different and based upon the specific cause(s) of their infertility.

    source:fertilitytoday



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    Re: Fertility Drugs

    Fertility Drugs- FSH

    Gonadotropins (pure FSH and mixed FSH/LH products):
    (Gonal-F, Follistim, Menopur, Repronex, Bravelle)

    • Gonadotropins (pure FSH and mixtures of FSH and LH hormones) are the primary injectable fertility medications. For simplicity we will refer to all gonadotropins (pure and mixtures) as FSH.
    • Follicle stimulating hormone (FSH) is a fertility medication used to directly simulate the ovaries. It occurs naturally and is released by the pituitary gland when it is stimulated by gonadotropin releasing hormone (GnRH). GnRH is produced by the hypothalamus which regulates many hormones in a system called the hypothalamic-pituitary-adrenal axis. This is discussed in detail in our section on ovulation.
    • FSH was first marketed as Pergonal, which was derived from the urine of post menopausal women (naturally derived). Since it was a natural product, it contained some "impurities" notably luteinizing hormone (LH). However, many specialists believe that the LH is needed in some patients.
    • Urinary FSH/LH was purified further and marketed as Metrodin,and subsequently highly purified and promoted as Fertinex by Serono Laboratories. The next step was the release of Gonal-F and Follistim which are pure FSH products. These products are a result of genetic recombinant technology and exactly mimic the bodies own FSH. Other LH containing FSH preparations are available as Repronex and Menopur.
    • FSH's effect on the ovaries is much more pronounced than products such as Clomid and Letrozole. It is used primarily in assisted reproductive technologies (IVF) cycles and controlled ovarian hyperstimulated intrauterine (IUI) cycles.
    • When FSH is used in IUI cycles the patient must be carefully monitored to prevent ovarian hyperstimulation syndrome (OHSS) and high order multiple births. FSH stimulates the ovaries to develop numerous eggs that can be released simultaneously at ovulation. Many instances of quadruplets (and more) are the result of IUI cycles administered by non fertility specialists.
    • FSH is used in IVF cycles to cause the development and maturation of multiple eggs which will be withdrawn from the follicles at retrieval. High order multiple births are not common in IVF cycles because the physician controls how many embryos are placed in the uterus.
    • FSH is administered according to patient specific treatment protocols. IVF patients receive Lupron or Antagon which dramatically reduces the internal production of FSH and LH, termed d down regulation.
    • FSH is administered by injection to cause follicular development and patients are closely monitored via transvaginal ultrasound and measurements of estradiol. The dosage of FSH is varied based upon each patient's response. Once the physician judges that the follicles are mature, an injection of human chorionic gonadotropin (hCG) is given and retrieval is scheduled 36 hours later.
    • FSH can produce serious side effects including ovarian hyperstimulation syndrome. It should always be administered by a reproductive endocrinologist with extensive clinical training in its use.



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    Re: Fertility Drugs

    Drugs- hCG, Lupron, Antagon, Cetrotide, Progesterone

    HUMAN CHORIONIC GONADOTROPIN (HCG) PROFASI, PREGNYL, OVIDREL
    • Normally, in a non-stimulated cycle, once the egg(s) is/are mature, the hypothalamus signals the pituitary to release large amounts of luteinizing hormone which triggers ovulation.
    • IVF patients usually receive medications (Lupron, Antagon, and Cetrotide) that prevent the LH surge. This is because ovulation must not occur before the eggs are mature and the IVF team is ready for the retrieval.
    • hCG (the pregnancy hormone) is produced by the placenta once pregnancy occurs and it is the hormone measured by most pregnancy tests. The body reacts to hCG in the same manner as LH. A surge in hCG levels will also trigger ovulation.
    • Once the eggs are mature, hCG is administered by injection thirty five to thirty-six hours prior to the egg retrieval, or intrauterine insemination. This signals the final maturation of the egg and signals the body that ovulation will soon occur. Production of other hormones, such as progesterone, increases.
    • Profasi and Pregnyl are "natural products". being extracted from placental tissue. Ovidrel is a pure hCG identical to that produced by the body. It is produced using genetic recombinant production technology and has no impurities. All of these products have the same effect of inducing ovulation.
    LUPRON, ANTAGON, CETROTIDE
    • The primary use for these medications it to prevent premature ovulation (before the eggs are mature) in IVF cycles. They are administered according to patient specific treatment protocols.
    • Antagon and Cetrotide are gonadotropin releasing hormone (GnRH) antagonists while Lupron is a GnRH agonist. GnRH is the hormone that signals the pituitary to produce follicle stimulating hormone, which initiates and supports follicular development, and leutinizing hormone.
    • Lupron blocks GnRH's action by suppressing pituitary and ovarian function while Antagon and Cetrotide block the production at the pituitary gland. Therefore, the antagonists cause a greater suppression of FSH and LH.
    • Lupron is commonly used to treat endometriosis because it indirectly lowers the levels of estrogen upon which endometrial cells depend. All of these products produce an "artificial menopause" with the accompanying symptoms.
    • Lupron is administered to "down regulated" IVF patients in order to better control and stimulate follicular development. The physician determines the treatment protocol for each patient based upon numerous evaluations, including day three FSH and LH measurements, patient's age, body mass index, and number of follicles on day 2 or 3 on transvaginal ultrasound. Dosing is modified during the cycle based upon estradiol and ultrasound measurements.
    • Some physicians prefer Antagon and Cetrotide because fewer injections are required and the suppression of LH is greater.
    PROGESTERONE
    • Progesterone stimulates the endometrium (lining of the uterus) causing it to thicken and become more vascular. This thickening is necessary to support the developing embryo.
    • After the egg is ovulated from the follicle, the corpus luteum forms from the remnants of the follicle (after ovulation has occurred) and begins to produce progesterone. Once the embryo is implanted in the endometrium, the placenta begins to produce progesterone.
    • Progesterone is administered in IVF cycles to insure adequate levels and offset the effects of high estrogen levels produced by the stimulation. Furthermore, in IVF cycles, since ovulation did not occur, there is no corpus luteum to produce the progesterone. Progesterone can be given by intramuscular injection, vaginally, or by mouth.
    METFORMIN (GLUCOPHAGE)
    • Polycystic ovarian syndrome (PCOS) is a very common cause of infertility. The symptoms of PCOS include increased levels of male hormones (androgens), a pear shaped body appearance, excess body hair, irregular ovulation. And enlarged ovaries with many cysts.
    • PCOS patients are usually insulin resistant, meaning that the body is insensitive to the insulin that is being made so to over compensate by producing excess amounts of insulin. This is due to increased production of androgens (and other factors) by the ovaries. Increased androgens lead to the common symptoms of PCOS including lack of ovulation, and excess facial, chest, or abdominal hair growth.



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