Anyone who has ever so much as dipped a toe into the sea of information regarding fertility medications has likely felt at least some sense of overwhelm. There is undeniably a lot to learn and understand about the medications commonly used in fertility treatments like in vitro fertilization (IVF) and intrauterine insemination (IUI), but the right expert guidance can make all the difference. In honor of National Infertility Awareness Week, we spoke with Jane Wu, lead fertility pharmacist at Alto Pharmacy. Here, Jane shares the basics on the different types of fertility medications, how they work, and what every prospective patient should ask their doctor before starting treatment.
What are some of the most common types of infertility medications and why might they be prescribed?
Jane: I usually group fertility medications into three categories: stimulation meds, antagonists, and triggers.
Stimulation medications supplement some of the hormones your body naturally produces. This includes follicle stimulating hormone (FSH) and luteinizing hormone (LH). The goal during this phase of treatment is to stimulate as many follicles — the fluid-filled sacs that typically contain an egg — as possible during the week or so that you're on the treatment. This, in turn, causes egg production and maturation to take place. During the stimulation process, not only is the actual follicle stimulated, but these medications also cause all the eggs to grow and mature. Stimulation medications can be injectables or they can be oral medications — it depends what kind of protocol you're on.
The next big category of medications are antagonists, which are used in IVF and only come in the form of injectables. They prevent the body from prematurely releasing the eggs when they're not yet mature and they do this by blocking gonadotropin-releasing hormone (GnRH). When GnRH is blocked, less LH and FSH is produced. This prevents ovulation from taking place prematurely and allows your eggs to better synchronize its growth. When eggs are released too early, they are too small and not mature enough to be used.
The third category of medication is triggers. These meds are always injectables and they actually have two purposes: they give your follicles one last growth spurt and they tell your body to release the stimulated eggs approximately 36 hours post-injection. Triggers are critical medications in your protocol; because of the time-sensitive nature of how triggers work, you will be instructed on an exact day and exact time to inject it and your injection time is tied to your scheduled retrieval procedure.
There are also what we consider “add-on” or adjunctive drugs; these are medications that are not stim meds, antagonists, or triggers, but are really used as supportive meds. A very good example of this is a growth hormone called Omnitrope. This is a drug that not every fertility patient will be on, but it is common and is used to improve the quality of eggs. It’s often prescribed for women who may have a lower ovarian reserve or a lower level of anti-mullerian hormone (AMH).
How variable can infertility medication protocols be and why might two people with the same infertility diagnosis be prescribed two very different medication protocols?
Jane: There are many factors that contribute to female infertility, including the person's age, their ovarian reserve (the amount of eggs they have left at the time of treatment), the quality of the remaining eggs, hormone imbalances, physical obstruction and blockage of the reproductive organs, and/or additional health conditions. Any number of these factors could play into someone’s infertility diagnosis, so even when two people have seemingly similar conditions, their underlying causes may be very different.
Providers curate a specific protocol based on these underlying causes. This could mean one person has the ability to first try noninvasive therapies like IUI as a first-line treatment while others do not have the ability to try IUIs. This could be because their underlying cause — fallopian tube blockage, for example — would not make them a candidate for IUIs since an IUI treatment would not be able to circumvent a physical blockage.
Lastly, for people who are undergoing IVF treatment, their prescribed dosages and medications can vary because it’s dictated by underlying conditions, reproductive health, the patient's weight, how many follicles the provider sees at the time of treatment, and what the patient's IVF goal is. There are also adjunctive medications which serve a very specific purpose and are not appropriate for every patient.
Why do so many infertility medications need to be injected vs. administered orally?
Jane: Medications used in fertility protocols come in various dosage forms. Some only come as tablets or injectables, others only come in topical forms, and there are a few that are available in more than one formulation. The manufacturers that make these medications determine which dosage form they will be available in. Your fertility protocol will determine whether you will be on oral medications, injectable medications, or a combination of a few formulations. Some families or individuals have the ability to go through a “step therapy” treatment plan which starts off with very minimally invasive treatment options where oral meds are used and transitions, if necessary, to more invasive therapies where injectable meds are used. For example, Clomid and letrozole are two oral medications that are often used as first-line treatments for people with irregular or absent ovulation due to conditions such as polycystic ovary syndrome (PCOS) or unexplained infertility.
Oral medications have to pass through your GI system which causes it to lose some of its effectiveness. Injectable medications go directly into the bloodstream, bypassing the GI system. This makes the hormones more readily available to your body and it has a quicker and stronger onset of action. It is important to remember, however, that injectables are not always the best option just because they are “stronger” or “faster.” Your provider will determine which protocol and what medications are best suited for your individual diagnosis.
What are the most common side effects of infertility medications, along with the most serious risks?
Jane: The common side effects are abdominal discomfort, bloating, cramping, nausea, and potentially vomiting. Headaches are also very common, and so is feeling lethargic throughout the whole treatment process.
When it comes to more serious side effects, it’s important to watch out for symptoms of an allergic reaction or intolerance to the medications. Another big risk is ovarian hyperstimulation syndrome (OHSS), which means the medications have actually hyperstimulated your body, which we actually don't want. If OHSS is not treated or recognized in time, it can be a medical emergency. The symptoms of OHSS include extremely rapid weight gain, as well as much more severe nausea, vomiting, abdominal pain, shortness of breath, and a very enlarged abdomen that goes along with severe cramping. If you experience any of these, you should let your medical team know right away.
What are the three questions you should ask a doctor during your initial consultation?
Jane: 1) Understand the specific treatment options that have been recommended for you and ask the doctor why these are the best options for you. If you are not a candidate for specific protocols, it is equally important to know why not. This is also a good time to understand treatment costs and payment plans so you can weigh your options. The more knowledgeable you are about your treatment, the more confident you will feel embarking on this journey.
2) Don’t hesitate to ask your doctor what the clinic’s overall success rates are. The doctor can help you understand what the statistics represent, how they are calculated, and what they mean for your treatment. It is also important to know how many patients have your doctor treated with a similar diagnosis as you.
3) Ask what the process is like and get an idea of what’s ahead. Are you going to have the same doctor or nurse on your care team the entire time or is there a possibility you may see different people at your appointments? How often do you need to come in for labs and check-ins? Will you be going to the same facility for each appointment? Will labs be performed in-house or somewhere else? Where will your retrieved eggs be stored, on-site or off-site? Are there appointments on holidays, weekends, or in the evenings? It’s important to understand some of the logistics at your clinic so there are fewer surprises.
Carrot: What are the three questions you should ask your provider before starting treatment?
Jane: 1) Once you’re about to start treatment, make sure you know who your point of contact is at the clinic and how best to communicate with your care team. Does the clinic prefer you to call them, text them, or use an online portal for communication? What is the expected turnaround time for a response? What if you have a question on the weekend or in the evenings – how should you get a hold of them. Understanding who and how you're going to be getting help is very important.
2) Ask what happens if you unexpectedly need more medications or refills. Will you contact the clinic for refills or should you contact the pharmacy? It’s not uncommon to run out of medications during your cycle especially if your dose increases or your treatment duration is extended. Having an understanding of who to contact will really help to reduce the stress surrounding refills.
3) Understand what types of restrictions your clinic has for your daily routines because every clinic has its own recommendations. This includes what types of vitamins/supplements or over-the-counter medications you can or cannot take, exercise, travel, intercourse — all of those things. You should understand what your doctor's restrictions are ahead of time.
Carrot: Is there anything else you wish more people knew about infertility treatments before starting a medication protocol?
Jane: When I started at Alto Pharmacy six years ago, we said “one in eight couples experience infertility.” But now, we are seeing it is closer to one in six couples. So know that this is common, you are not alone, and you have more people you can talk to about it. However, it is also important to understand that your body is unique and this means your protocol, your results, and your experience are going to be different from other people’s — and that's okay.
To learn more about the different types of inclusive fertility healthcare and family-building benefits available, including the full range of fertility medications, get in touch with Carrot today.
