Women who are trying to get pregnant want to do everything possible to improve their chances. Even so, many of them say that the thought of giving themselves injections of fertility medications kept them away from the treatment they needed.
Dr. Eric Levens of Shady Grove Fertility’s Annandale office admits that fertility medications are complex, and the process can seem intimidating, but, he says, patients complete thousands of treatment cycles every year, handling their medications expertly.
“Patients are much more apprehensive about the medications than they need to be,” Dr. Levens says. “With the support system we have in place, patients can feel comfortable with their care and confident in their ability to follow the medication plan successfully. In fact, once patients get started, we find many are surprised at how well they tolerate the medication aspect of their treatment.”
Whether you are just starting your research into fertility treatment or you are about to start a treatment cycle, it helps to know which medications are used in which types of treatment and why. It’s also comforting to know how much support you can expect for ordering, administering and affording medications. Protocols can vary greatly from patient to patient, your best resource for specific questions regarding your medication protocol will always be your medical team.
Preparing the Ovaries for Stimulation
Before a cycle of In Vitro Fertilization (IVF) in particular, many women will take birth control pills to suppress their ovaries, which are responsible for producing eggs. Dr. Levens explains, “This reduces the chance that cysts will form in the ovaries, and it allows us to control the timing of the cycle.” Birth control medication allows you and your doctor to choose the date the cycle will start and synchronizes the egg follicles so that they all start at the same stage.
In some cases, such as when a woman has low ovarian reserve, the doctor may not use birth control.
Whether or not a woman is ovulating on her own, her fertility treatment typically will include medications that stimulate the ovaries. Women who are not ovulating regularly may start treatment with the goal of getting their ovaries to release one egg each month. This is referred to as ovulation induction.
The drug most commonly used for ovulation induction is Clomiphene Citrate, branded as Clomid or Serophene. It’s a tablet taken orally for about five days. “Patients doing Clomid therapy with their ob/gyn are not usually monitored during a cycle,” says Dr. Levens, “but at Shady Grove Fertility, patients are monitored regularly with bloodwork and ultrasound to gauge how their bodies are responding to the medication and to reduce the risk of multiples.” For ovulation induction patients that do not respond to Clomid, frequently Follicle Stimulating Hormone (FSH) injections will be added to the medication protocol to encourage or boost ovulation.
Stimulating The Ovaries- IUI with Gonadotropins
Women who ovulate regularly but are still unable to conceive, take medications with the intent to stimulate 2-3 mature eggs at a time during the cycle.
Clomid is sometimes included along with Follicle Stimulating Hormone (FSH). Patients undergoing IUI with gonadotropins are monitored closely with bloodwork and ultrasound throughout the cycle.
Stimulating The Ovaries- In Vitro Fertilization (IVF)
Women who are using more advanced fertility treatments, like IVF, take medications that stimulate and mature as many eggs as possible during the cycle. FSH and Luteinizing Hormone (LH) are the hormones are involved in the natural ovulation process and used to stimulate the ovaries. “Some protocols use FSH only, but most will use a combination of FSH and LH,” says Dr. Levens. “We believe that since LH is present in a natural cycle, it’s important to include it during a treatment cycle as well.” FSH and LH are administered by patients as subcutaneous injections taken daily for 8-14 days. Subcutaneous, also referred to as Sub-Q, means the injections go into the fatty tissue under the skin, usually on the right or left side of the abdomen. The same medications, are used as in a IUI with gonadotropins cycle, except with IVF, higher quantities of the medication are used to increase the number of eggs to be developed and matured.
Preventing Premature Ovulation
If the eggs are released too soon in an IVF cycle, the patient will miss the window for their egg retrieval. So, in women who are high responders to ovarian stimulation, a medication called Ganirelix is added to keep the body from ovulating too soon. This injectable medication is added to your medication protocol as needed by your medical team.
Triggering Egg Maturation and Timed Release
At the end of ovarian stimulation, a final injection is given that causes the eggs to fully mature so that they are ready for fertilization. This injection is strictly timed to the schedule of an insemination attempt in an IUI cycle or the egg retrieval in an IVF cycle. Depending on the protocol, patients may have a trigger shot that is a Human Chorionic Gonadotropin (hCG) or Leuprolide-Acetate. Some are given as intramuscular injections administered into the muscle upper outer quadrant of the buttock in by someone other than the patient.
No matter the treatment type being used IUI, IVF, FET, or Donor Egg, medication to support implantation is usually part of your medication protocol. Patients using IUI or IVF treatment start their implantation support after insemination in the case with IUI, and after the egg retrieval with IVF. Progesterone is the primary medication prescribed while for some patients, estrogen is utilized to keep the uterine lining thick. This gives the embryo the best chance of implanting.
Women who are undergoing a Frozen Embryo Transfer (FET) cycle or a Donor Egg cycle frequently use Estradiol but begin them sooner; this allows the body to prepare the uterine lining before the embryo transfer. IUI patients using clomid occasionally find their uterine lining thin as a side effect of the Clomid. For these patients Estradiol can also be used to help thicken their lining prior to insemination.
In both cases, the medications will likely be continued through the first few weeks of pregnancy to support the developing embryo.
Once your treatment plan has been created, your nurse will sit down with you and go over everything you’ll need to know during the cycle. Ordering medications is a top priority since you’ll need all your medications before the cycle begins.
Sonia Parker, RN, a nurse working with Dr. Levens in the Shady Grove Fertility Annandale office, says patients don’t need to worry about the logistics of getting their medications because the nurses handle most of the process. “We’ll explain all the medications to you,” she says, “and we’ll put the order in to whichever pharmacy you choose. If you’re doing a price comparison, we can submit it to several pharmacies and they will call you with price quotes.”
In some cases, you’ll find that you have a choice between brand names for a medication you’ve been prescribed. For example, patients doing an IVF cycle are often given a choice between Follistim and Gonal-f, two medications that do the same thing. Sonia explains, “Your choice might hinge on price – sometimes a pharmacy will give a discount on a particular drug – or you might choose one delivery method over another one. For example, some medications comes in pre-filled syringes or dial-up style pens while others come in vials. We can explain the pros and cons of these choices to help you decide.”
Fertility medications are expensive, so most of the choices you’ll make have to do with their cost. Sonia says your best ally in affording your medications is your nurse. “Make sure you talk to your nurse if affording the medications is an issue, because we have a lot of resources we can share with you. We usually know which pharmacies have specials and which drugs are cheaper. Sometimes the drug companies themselves will have a special or provide coupons for certain medications.”
To start, Sonia suggests that all patients double-check their insurance coverage. “A lot of patients that don’t have coverage for fertility treatment do have coverage for some or all of their medications, so it’s important to ask specifically about medication.” Often, insurance companies have a different provider for drug coverage than they do for medical coverage, so you may have to call a different company to get the necessary details.
Your insurance plan may dictate where you fill the prescription. In that case, you’ll want to make sure you use the right pharmacy to avoid having to pay out-of-pocket. Sonia adds one caveat, “We have found, in a few cases, that patients who have co-pays that are high sometimes pay more in co-pays with the pharmacy the insurance company uses than they would if they paid for the whole order at a different pharmacy. So, even if you have coverage, we can still submit your order to more than one pharmacy if you want to compare prices.”
In addition to pharmaceutical company coupons and incentives, some specialty pharmacies such as,MDR offer patients price matching and free overnight shipping that can help ease the cost of fertility medication. Click here for a full list of specialty pharmacies for fertility patients.
Most times, you’ll order from a pharmacy that specializes in fertility medications. These specialty pharmacies have nurses available 24 hours a day to answer questions. They also have dedicated insurance specialists who can check your coverage on a drug-by-drug basis to make sure that you’re maximizing your coverage and minimizing your out-of-pocket costs. They usually provide free injection supplies and free nationwide overnight delivery.
Sonia cautions that it’s important to use pharmacies that are vetted by your medical team. “We’ve had some patients recently who have found pharmacies online that advertise really low-priced drugs. When we looked into it, we found that they were overseas, so the medications weren’t inspected or regulated by the FDA.” These drugs could be contaminated or counterfeit. Plus, pharmacies in the U.S. keep strict track of lot numbers in case of recalls and make sure storage conditions are correct for each medication.
In addition to unknown pharmacies, patients should also be wary of offers to buy other patients’ leftover medications. Sonia says, “Not only is it illegal, but they could be expired or stored improperly, so it’s definitely not a good idea.”
Once your medications are ordered, the next step will be to learn how to administer them. For some patients, the prospect of giving themselves injections is the most intimidating aspect of fertility treatment. That’s why Shady Grove Fertility provides injection classes to all its patients.
Injection classes help patients master:
- Understanding which syringes and needles to use with which medications
- How to draw up and mix medications
- The difference between subcutaneous and intramuscular injections and how to administer each
- What to do if you miss a dose
- How to keep track of your inventory of medications so you don’t run out in the middle of your cycle.
Patients can also find videos at ShadyGroveFertility.com that demonstrate injections for each type of medication used.
“Patients who take the class feel more confident in their ability to follow their treatment plan, and I believe it really reduces their stress level.”
Sonia Parker, RN agrees. “I teach one of the injection classes, and I find that a lot of patients’ fears are based on misunderstandings or false information they’ve read online. Those kinds of issues are easy to clear up. Also, patients in the class get to meet other couples that are going through treatment at the same time. They realize that they have similar questions and fears, so there’s a supportive aspect to the class as well.”
Sonia always reminds patients that, besides the class, there are many resources available that they can call on anytime. “There’s always a nurse available during monitoring appointments. Patients can also call their own nurse or doctor – and there is an on-call nurse at the specialty pharmacies that is available 24 hours. So, patients should never hesitate to get their questions answered.”
Monitoring and Dosing
Morning monitoring is an important part of most treatment cycles. Patients have appointments, almost daily, during the ovarian stimulation phase of their treatment to gauge how they are responding to their medications. At these appointments, blood is drawn to check your estrogen level and a vaginal ultrasound is performed to count and measure your egg follicles. The results of these tests are used to determine the dosing of your medications going forward.
Every time you come in for monitoring, you’ll receive a phone call from your nurse that afternoon. The nurse will tell you the dosing of each medication you should take that night and when to come in for the next appointment.
Sonia adds, “The call from your nurse is a great opportunity to ask any questions you have about your medications. You can also review your medication inventory with your nurse. She will be able to estimate the amount of medication you’ll need for the next few days. You’ll want to pay particular attention to this before a holiday or weekend.”
Because they affect your hormones, these medications can produce side effects, such as headaches, irritability, fatigue, and bloating that are similar to symptoms of PMS or menstruation. After an insemination or embryo transfer, you’ll be cautioned that the side effects can be mistaken for pregnancy symptoms but do not mean that you are or aren’t pregnant.
Some women, however, have no side effects. “Everyone is so different in how they respond to the medications that it’s really hard to say how it will affect a particular woman,” says Dr. Levens. “The vast majority of patients tolerate the medications well.”
Although rare, one possible side effect from ovarian stimulation is ovarian hyperstimulation, which occurs in about 1-2% cycles. Ovarian hyperstimulation happens when a woman’s body over-responds to stimulation medications. This can cause fluid to build up in the abdomen and pelvis and possibly lead to blood clots. The good news is that this condition can usually be prevented through close monitoring of a woman’s response to medications. If there are signs that you might be moving toward hyperstimulation, your doctor will reduce the amount of medications you’re taking to avoid it.
Just One Part of the Big Picture
The prospect of a box full of medications arriving at your house can be daunting, but it also signals the beginning of the hopeful and exciting process of fertility treatment. “My advice to patients who feel nervous about the medications is to take it one step at a time,” says Sonia. “In my experience, patients who take the injections class have very few problems or worries about their meds.”
Dr. Levens recommends staying focused on the big picture. “Medications are just one instrument in the complex symphony of treatment. You can be assured that we are working hard to find the best medication regimen for you, that will help us achieve your ultimate goal of having a baby.”
Most importantly, don’t let the fear of doing injections for two weeks keep you from treatment that could change your life forever.