Gonadotropins
What are gonadotropins?
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 Dr. Goldstein may prescibe: Follistim, Gonal F, Bravelle, 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 fertilizaton.
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 injectible 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 Dr. Goldstein.
How do I start a gonadotropin cycle?
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 6:00 p.m. and 10:00 p.m.
Injections are given for about 10-12 days or until you are close to ovulation.
You or your husband will be administering the injections at home, and our
nurse Linda 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.
How is my
gonadotropin cycle monitored?
 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 form of estrogen, which should increase as the
follicles mature. Estradiol levels are drawn in our office between 8:00 a.m.
and 10:00 a.m.
Throughout your cycle Dr. Goldstein 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, he 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, LINDA WILL CALL YOU IN THE AFTERNOON WITH YOUR
MEDICATION INSTRUCTIONS AND NEXT APPOINTMENT. IT IS VERY IMPORTANT THAT YOU BE
AVAILABLE TO SPEAK WITH HER!
When should I have intercourse
and/or intrauterine insemination?
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 and well as the following
two days. It is possible to ovulate spontaneously without hCG and this is the
reason regular intercourse is suggested.
Are there any activity
restrictions?
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 afterwards. 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.
When will I know if I am pregnant?
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.
What are the potential risks of gonadotropins?
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 Linda or
Dr. Goldstein 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%) are 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.
Are gonadotropin cycles sometimes cancelled?
Yes. If the
estradiol levels are not rising appropriately or if there is inadequate
follicular development, the cycle may need to be cancelled. Conversely, if the
estradiol level rises too high or if there are too many follicles present, Dr.
Goldstein 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 cancelled, 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
cancelled 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.
|  | Fertility Specialists of
Dallas
Phone: 214.750.5500
Presbyterian Hospital of
Dallas
8230 Walnut Hill Lane Suite 300
Dallas, TX 75231
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6300 W.
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Plano, TX 75093
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Texarkana Satellite
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Texarkana, TX 75503
903.793.5500
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