Q & A for Injectable Infertility Medications

The term "injectables" describes a group of medications frequently used in the treatment of infertility. Oral drugs such as Clomid stimulate the ovaries indirectly by tricking the brain into thinking there is less estrogen in the body than there actually is. As a result, the body produces more "follicle stimulating hormone" (FSH) which in turn stimulates follicle production on the ovaries. In contrast, injectables actually contain FSH, so they stimulate the ovaries directly.

The term injectables generally does not include injected medications that are used for purposes other than ovulatory stimulation. Examples of these medications include GnRH agonists (e.g., Lupron) and hCG (e.g., Profasi, Pregnyl).

Why does my doctor want me to take injectables?

Most commonly, doctors recommend injectables after unsuccessful use of Clomid. In some cases, Clomid induces ovulation, but simply never results in pregnancy. Some women experience uterine lining thinning and/or cervical mucus hostility as a result of Clomid. Both of these side effects can actually prevent a successful pregnancy, and injectables do not have these side effects. Other patients, for various physiological reasons, simply do not respond to Clomid.

Injectables are also most doctors' ovulatory stimulant of choice for in vitro fertilization cycles, because their use will generally lead to a larger number of follicles than Clomid.

What are the different kinds of injectables?

Upon first encounter, the different types of injectables can seem quite overwhelming. However, many of these drugs are actually just different brand names of what is essentially the same drug. If the different brand names are all grouped together, we end up with only four general categories of injectables.

• Humegon, Pergonal, and Repronex - These injectables consist of equal amounts of FSH and another substance, known as luteinizing hormone (LH). These medications are normally injected intramuscularly in the hip or thigh, using a 1.5 inch needle. The shot is similar to many routine vaccinations.
• Metrodin - This drug contains FSH and no LH. It is also normally injected intramuscularly.
• Fertinex - Fertinex is also FSH with no LH; however in addition, it is highly purified. As a result, it can often be given subcutaneously rather than intramuscularly. Subcutaneous shots are given directly beneath the skin, using 1/2 or 5/8 inch needles. These shots are similar to those used by diabetics to inject insulin.

The drugs in these first three of categories are refined from the urine of post-menopausal women. The drugs in the remaining category drugs are manufactured in the laboratory.

• Follistim and Gonal-F - These drugs are highly pure FSH and are normally given subcutaneously. Outside of the United States, Follistim is called "Puregon."

Injectable dosages are most commonly described in terms of ampules ("amps") or vials. Ampules are all glass, and the top is snapped off in order to access the medication. Vials are glass containers with a rubber membrane in the top. The medication is accessed by pushing a needle through the membrane.

Why would I take one drug versus another?

In recent years, the drugs that are subcutaneously injected have come into favor. Many women find it difficult to give injections to themselves in the hip. Subcutaneous injections are easier to administer; as a result, individuals are able to give the shots to themselves, which increases the flexibility of the medication schedule. The more purified nature of the subcutaneous injectables is also viewed favorably.

Polycystic ovarian syndrome can play a role the type of injectable selected. Because women with this disorder frequently already have elevated LH levels, one of the newer FSH-only drugs is often the injectable of choice.

There is still a place, however, for the original LH-containing intramuscular drugs. Some individuals simply respond to these drugs more strongly than the pure-FSH drugs. Evidence has also emerged that a small amount of LH may be desirable for individuals who do not already have high LH levels. This issue can be especially relevant in IVF patients, whose own LH is normally suppressed by Lupron or another GnRH agonist.

How much will I take and for how long?

The answer is contingent upon age, ovarian responsiveness, and a number of other variables. Patients with highly responsive ovaries who are doing IUI may take as little as one amp or vial per day; on the other hand, poor responders going through IVF make take as many as 6-8 amps or vials per day. Younger patients who are not on Lupron may take injectables for as few as 4-8 days; women on IVF and those being stimulated at a conservative rate may use injectables for 8-12 days or sometimes even more.

Aren't injectables expensive?

There is no way around it - yes, they are. Depending on the medication and the place of purchase, prices can easily approach $60-$70 per vial/amp. Over the course of an entire cycle, these amounts do add up. Adding to the difficulty is the fact that many people's insurance policies do not cover injectables.

The best way to cut expenses for injectables is to order by mail. Many of the pharmacies specializing in infertility drugs have prices that are substantially lower than local drug stores. Additionally, doctors who are at larger research institutions will sometimes offer free or reduced medications as incentive to participate in a research study.

Are there risks in taking injectables?

The primary risks of injectables are multiple births and ovarian hyperstimulation syndrome (OHSS). However, the risks for both are sharply reduced with appropriate monitoring and sound decision-making on the part of the physician and the patient.

In fact, despite all the emphasis placed on choosing one drug over the other, the most important determinant of efficacy and safety for many patients taking injectables is the monitoring. Correct monitoring of follicle size, via ultrasound, and serum estradiol levels will reduce the risk of adverse side effects and will increase the chances of success.