Do you know enough about the drugs used to stimulate your ovaries when you go through a cycle of assisted reproduction? Do you know which drugs are currently available, and what are the differences are between them?
Infertility Network UK believes all patients should have access to up to date information about every aspect of their treatment, and that includes any drugs which may be prescribed. Some centres will give one drug or another without any discussion on the subject, whilst others may discuss treatment options with you and offer a choice in the drugs prescribed. But do you feel you know enough to make a decision?
The drugs used to stimulate the ovaries during IVF are mainly female hormones. Human eggs are contained within follicles which grow from microscopic size to large cystic structures as they mature. The principle stimulant is Follicle Stimulating Hormone (FSH) which makes follicles grow, and it is administered to create raised concentrations (high / normal) in the blood, with the aim of producing a number of eggs in just one cycle. There are occasions where the other main drug of this type (luteinising hormone, LH) is also required – and this can be supplied in two formats: directly in a pure form or in a combined form.
Drugs used in fertility treatment
MENOPUR - is a highly purified urinary product comprising FSH and LH activity. It is injected subcutaneously (just under the skin) using a small needle. Patient injection kits are made available by the manufactures that help with administration.
MERIONAL HP - A similar product to Menopur
GONAL F – A recombinant FSH which is injected subcutaneously, and comes ready prepared, in a multidose administrator by use of an injection pen. It is administered by mass (weight) rather than as ‘international units’.
PUREGON - A recombinant FSH, injected subcutaneously. Puregon comes in a ready-for-use solution. A multidose cartridge is also available and both are administered via an injection pen. The product is marketed in multiples of 50 IU.
All these hormone drugs are administered once per day, as they are quite efficiently cleared in the urine.
It is important to note that the concentrations of these hormones in your blood are generally similar to normal levels found in women with normal menstrual rhythm, even when higher doses are given, and much lower than in a menopausal woman. Administration of the drugs over a number of days does however, lead to high estrogen concentrations for a few days, and so the responses do need to be monitored. However, as the drug concentrations are normal, the process has generally a low risk potential, when monitored sensibly.
Other drugs commonly used
Unfortunately, FSH is not the only drug needed, as most programmes use other hormones called GnRH analogues, which can be used in two different ways to do the same job. They are used to stop the process of ovulation (release of the eggs) happening before the eggs can be collected. The traditional, well established method is using GnRH agonists in multi-dose or in depo formulations. It was found that when given in a high frequency (say 4 or 5 times per day, or in a depo under the skin) these drugs block the release of LH, which is the hormone that causes release of the egg from mature follicles (ovulation). The ‘ovulation’ process must be timed precisely so that eggs can be collected at the right time directly from the ovary. The ovulation blocking effect of GnRH-agonists needs about 2 weeks continued treatment to work effectively, so these drugs are started either a week before a menstrual bleed (in the cycle prior to treatment), or soon after a menstrual bleed, and the FSH injections are delayed for 10 to 15 days later. The GnRH agonists can be administered by daily injection (eg Suprecur s.c.), multiple nasal spray applications each day (Suprecur n/s, Nafarelin), or by a single depo under the skin that lasts for approximately one month (Prostap SR, Gonapeptyl s.c.).
The newer versions of these drugs are the GnRH antagonists, which require no pre-treatment as their blocking action is immediate, and they can suppress LH very rapidly. They are needed only when there is a threat of increased LH in the blood, which generally starts around 5 days after starting FSH injections. They generally require daily administration until it is time to stop the FSH treatment and prepare for the egg pickup. The two main products of this type are Cetrotide (0.25mg daily, but also available in a 3.0mg preparation, which lasts for 3 days) or Ganirelix (0.25mg).
When discussing these drug packages with your consultant, what would you want to take into consideration?
Most analyses of effectiveness of the different products in routine IVF programmes, show that, in general, no individual drug or method is significantly more effective than another.
It is important to remember that how much you pay depends on where you buy them. If you are going to have to foot the bill yourself, compare prices and ask your clinic where they recommend you purchase your drugs. You may be able to save yourself considerable sums on whichever drug you have chosen. Many centres now use ‘home delivery services’ to provide the drugs, and also the equipment required, so that the patient deals directly with the pharmacy provider.
If you want to know more about the drugs you've been prescribed, you shouldn't feel nervous about asking the medical team who are treating you. Talk to them about which drugs they recommend, and why. The majority of patients may be perfectly happy to follow their consultant's suggestions, but just knowing more about what you are taking and why may help you to feel more in control of your treatment.
Anyone who needs to purchase infertility drugs should look carefully at the options open to them. Savings can be made by “shopping around” to get the best price. Generally the options available to purchase the drugs are:
· From the hospital/clinic pharmacy
· From the a High Street/Supermarket Pharmacy
· From the a ‘home delivery service’
Each of the above will give you a price for the drug you have been prescribed and enable you to choose your preferred option. Don't forget, you do have a choice and you should be given the information by your clinic which will enable you to make an informed choice. Discuss the options open to you with your clinic or contact Infertility Network UK for more information.
For advice on fertility drugs being used in a treatment cycle or the administration of these drugs, patients should always contact the clinic where they are being treated.
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