#2 Development of Oocytes

It is necessary to stimulate the ovary to produce multiple follicles (the sac that contains the egg), in order to improve your chances of a successful outcome from an IVF cycle. After the consult with the physician, you will receive an instruction sheet for a specific type of medication stimulation protocol. There are many different medication protocols that the physician may prescribe for you. This decision is based on factors such as your: age, infertility history, a past response to these medications, and a baseline FSH level.

The fertility medications that are necessary to stimulate the ovary are unfortunately all injectable medications (except for Clomiphene Citrate, which is rarely used). You should refer to the package insert that accompanies these medications, for complete information concerning side effects, risks, methods of administration etc.

A. FERTILITY MEDICATIONS:
Follitropins:
This type of medication has been created using DNA recombinant technology. The hormone Follicle Stimulating Hormone (FSH) is now being reproduced in the laboratory. This is a relatively new class of drugs. In addition to consistency of dose, this medication may be given by the subcutaneous route (short needle) or the intramuscular route (long needle).

Menotropins:
This type of medication is a purified preparation of the hormones Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH). The hormones FSH and LH are naturally occurring in the urine of postmenopausal women. This medication must be administered by the intramuscular route (long needle).

Side Effects of Fertility Medications (Follitropins and Menotropins):

1. Overstimulation of the Ovary: The risk of Ovarian Hyperstimulation Syndrome (OHSS) increases as the Estradiol levels in the blood increase and the number of follicles rises. OHSS can occur to varying degrees: mild, moderate or severe.

Signs & Symptoms:

Mild/Moderate - Abdominal bloating, ovarian enlargement, abdominal discomfort, weight gain (up to 10-15 pounds of fluid weight), nausea.

Severe - Large distended abdomen, severe abdominal pain, excessive weight gain (more than 20 pounds), shortness of breath, decreased urination, nausea and vomiting. Hospitalization is sometimes necessary for monitoring, fluid administration and administration of analgesics.

Cases of severe OHSS are more common and the condition lasts longer if pregnancy occurs. It is for this reason that based on your clinical picture (Estradiol level, number of eggs retrieved, your state of well being etc.), the physician may require that after all the eggs are retrieved and fertilized into embryos, all the embryos be frozen for future transfer. We understand that delaying the embryo transfer may be upsetting to the couple. The physician must consider all facts when making the decision that is best for your health. One comforting fact to remember is that the Cooper Center for IVF's Frozen Embryo Pregnancy Rate is very similar to the Fresh Embryo Pregnancy Rate.

Careful and frequent monitoring of blood Estradiol levels and Ultrasound measurements of the number of recruited follicles will assist the physician to prevent the occurrence of severe OHSS. Unfortunately, due to an individuals ovarian response, the risk of severe OHSS will still exist with the administration of fertility medication, despite the most vigorous monitoring efforts.

2. Multiple Births: The risk of conceiving a multiple pregnancy during an IVF cycle is dependent upon many factors. You should discuss with the physician their opinion about your risk for conceiving a multiple pregnancy. Factors such as your age, response to the medications, the quality of the embryos, the number of embryos replaced into the uterus and other unforseen factors are considered when judging your specific risk of multiple births. In the year of 1997 the occurrence of viable twin gestations after a statistical mean number of 3.2 fresh embryos were transferred to women <=39 years of age was 24.8%. The triplet rate for the same group was 8.0%. The live delivery rates may be less than the viable rates.

3. Common complaints: Pain at the injection site, headaches, and fatigue.

A special note: You may have read reports that fertility drugs increase the risk of ovarian cancer. To date there are no conclusive studies that identify an association between taking fertility drugs and ovarian cancer. Ovarian cancer is the fifth most common type of internal organ cancer diagnosed in women. The average age of diagnosis is between 50 and 59 years of age.

Certain factors may be associated with an increased risk of ovarian cancer:

• Family history: For women with a family history of ovarian cancer, the increased risk may be as high as 50%.
• Pregnancy: Women that have successfully conceived a child-even if they have not had a successful birth- appear to have a lower incidence of ovarian cancer.
• Breast feeding and the use of oral contraceptives have been reported to be associated with a reduced risk of ovarian cancer.
• Environmental factors: The incidence of ovarian cancer is much higher in industrialized countries, leading to speculation that ovarian cancer may be associated with exposure to industrial byproducts in the environment.

B. Gn-RH ANALOG (LUPRON)
This medication is administered by subcutaneous injection. It is given to prevent premature release of the oocytes(eggs). Side effects may include: localized skin reaction, allergic reaction, headaches, hot flashes and mood swings. If your scheduled menstruation is late while on Lupron, you should have a pregnancy test.

C. HCG (HUMAN CHORIONIC GONADOTROPIN)
You will be given instruction on the exact time this injection of medication should be taken. It is generally taken 34-36 hours prior to the egg retrieval. This medication should be injected into the muscle using a 1-1/2" needle. This medication completes the maturation of the egg. For mixing instructions, see the patient instruction sheet.

D. PROGESTERONE
You will begin taking this naturally occurring hormone on the day of the egg retrieval. This medication, assists the embryo to attach to the uterus. The side effects that have been reported include: breast tenderness, headache, nausea, fluid retention, fatigue, mood swings, depression, pain at the site of injection (in the case of injectable progesterone), vaginal itching and irritation (in the case of the vaginal form). If you have a history of blood clots or thrombophlebitis you should alert the medical staff.

In 1977 the Food and Drug Administration (FDA) issued a warning that the use of progesterone may increase the risk of birth defects. As evaluated in our own research data, experience in our practice and the work of other researchers, there does not appear to be any increased risk of birth defects following use of progesterone. In fact, we have data to suggest that progesterone may prevent birth problems by lowering the incidence of premature births.

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