Cycle Medications, Oocyte Retrieval with Ultrasound Guidance

Overview

IVF is an abbreviation for in vitro fertilization. It is one of the more well-known kinds of reproductive technology (ART). IVF works by combining medications and surgical techniques to assist sperm in fertilizing an egg and the fertilized egg in implanting in your uterus.

First, you take medicine to prepare some of your eggs for fertilization. The eggs are then retrieved from your body and mixed with sperm in a lab to assist the sperm fertilize the eggs. Then doctors implant one or more fertilized eggs (embryos) into your uterus. Pregnancy occurs if any of the embryos implant in the uterine lining.

If you're having difficulty conceiving or maintaining a pregnancy, your doctor may prescribe various drugs to address the problem(s) and/or assist your IUI or IVF treatment cycle. Medication can be used to help strengthen, control, or induce ovulation, increase follicle formation, and prevent/delay ovulation. There are treatments that can help prepare or strengthen the endometrial lining, as well as antibiotics to prevent infection and other anti-inflammatory therapies.

Whether you are just beginning your treatment journey with a round of timed intercourse with clomiphene citrate, are in the middle of a medicated IUI cycle, or are well into an IVF cycle, the drugs listed below may be encountered along the route.

 

What are the fertility drugs?

Fertility medicines can help you become more fertile. If you've been trying to conceive for a year without success, your fertility specialist may recommend various drugs to help your cycle. Ovulation issues frequently prevent women from becoming pregnant. As part of your fertility therapy, we may prescribe that you take hormone-stimulating medicines.

You should only use fertility medicines if they are prescribed by a fertility clinic professional. Which fertility medicines are administered depends on the type of treatment and the grounds for it. You may be using fertility medicines, such as follicle stimulating hormone (FSH), as part of an IVF treatment cycle.

 

What are the common IVF medications?

There are several types of fertility medicines used in IVF, some taken orally and others injected. The specific type and amount of medicine used during IVF will be determined by the woman's age, test findings, and the stimulation plan suggested by her doctor. A typical IVF treatment will include a combination of the drugs listed below.

 

Ovulation-Inducing Medications:

Clomiphene Citrate (Clomid)- This nonsteroidal medicine, which is taken orally for five days, acts as a selective estrogen receptor modulator, raising the quantity of hormones that support the formation and development of a mature egg(s), resulting in ovulation.

Letrozole- This medication is taken orally for five days and prevents androgens in your body from turning into estrogen (an aromatase inhibitor), lowering the quantity of estrogen in your body. When estrogen is suppressed, the pituitary gland gets a signal to create follicle-stimulating hormone (FSH), which encourages the ovary to develop an egg.

 

Gonadotropins:

Gonadotropins are hormones that are injected that stimulate the ovaries to create follicles/eggs. The term gonadotropin is derived from the words "gonad," which is the physiological name for an ovary in females and testicle in males, and "tropin," which means to release or stimulate.

Subcutaneous injection of gonadotropins into the subcutis, the layer of skin beneath the dermis and epidermis, is the most common method of administration. When ovulation does not occur spontaneously, a larger number of eggs are required for artificial insemination (IUI), in vitro fertilization (IVF), or when ovulation is timed, they assist in the production of follicles. Gonadotropins such as Follistim, Gonal-f, and/or Menopur may be recommended. 

hCG Trigger- Human chorionic gonadotropin, or hCG, is included in a trigger shot. The hormone hCG causes an ovary to develop and produce an egg. Pregnyl and Novarel are two brands of hCG that we may prescribe.

Leuprolide Acetate or Lupron trigger- Instead of hCG, this drug blocks the LH surge that causes ovulation. It is often utilized when there is a risk of ovarian hyperstimulation syndrome (OHSS).

 

Ovulation Suppression Medications:

Ovulation suppressants (antagon) prevent the body from releasing mature eggs before they are ready. They are frequently used in conjunction with other hormones like as gonadotropins and hCG. We may prescribe Ganirelix or Cetrotide.

 

Uterine Lining Support Medications:

Progesterone- Progesterone is a hormone generated by the ovary's corpus luteum. When an egg is discharged in the midst of the menstrual cycle, it is initially detected (ovulation). Progesterone prepares the uterine lining (endometrium) for the implantation of a fertilized egg (embryo). Medications are often used to prevent premature ovulation during a medicated fertility cycle. These medications may have an effect on progesterone levels. As a result, a progesterone supplement may be administered to compensate for the ovary's decreased capacity to produce progesterone. Progesterone brands that may be prescribed include Crinone, Endometrin, and Progesterone in oil.

Estrogen Replacement- During a treatment cycle, estrogen replacement is used to increase the thickness of the uterine lining in order for an embryo to implant and to maintain the uterine environment in order for a pregnancy to flourish. Estrace pills are a brand of estrogen replacement therapy.

Steroid- Methylprednisolone is a kind of steroid that is used to reduce uterine lining irritation and to help in implantation. Medrol is a well-known brand.

 

Other Medications/Supplements:

During an IUI or IVF cycle, other medications may be needed to support the cycle.

Birth Control Pills: The pill aids in the regulation of menstrual cycles and the preparation of the reproductive system for a fertility cycle.

Prenatal Vitamins: When starting to attempt to conceive, it is strongly advised to take a prenatal vitamin containing at least 400 mg of folic acid.

Doxycycline/Antibiotics: Antibiotics are used to lower the risk of infection after follicle aspiration during egg retrieval.

Valium: Prior to embryo transfer, a muscle relaxant and anti-anxiety medicine is provided.

 

Timeline for IVF medications

Days 1 to 4:

Your health care practitioner will contact you on the first day of your patient's menstrual cycle to schedule a baseline visit for Day 3 of their cycle. This session will include an ultrasound as well as bloodwork. If you are authorized, you will begin hormone injections known as stimulation medicines (stims) for ovulation induction after this session.

These injections promote egg production, causing a woman's body to create many follicles in a cycle rather than just one (follicles house eggs that contain all the hormones and fluids needed to make an egg mature). Patients who have one or more mature follicles may need to wait until their next period cycle or utilize an alternative regimen. Stims are commonly administered between 6 and 9 p.m. on a regular basis.

It is usual for patients to have discomfort or moderate bruising at the injection site as a result of the injection. Common side effects include bloating, cramps, headaches, breast tenderness, and, in rare cases, transient allergic responses.

 

Days 5-10:

During this time, patients will continue to get stims and may begin taking "antagonists" to avoid premature ovulation (i.e., once eggs are released into the pelvic cavity they cannot be retrieved). These drugs inhibit the hormone (gonadotropin-releasing hormone-GnRH) responsible for egg release from the ovaries.

Regular monitoring appointments, which will most likely involve further ultrasounds and bloodwork, will take place between days four and six, and every other day after that. The findings of the visit will then indicate if the nightly doses need to be altered or if an antagonist is required. Patients in these situations frequently have leftover drugs or require refills.

The side effects are identical to those felt on days one through four. Some individuals also suffer from ovarian hyperstimulation syndrome (OHS). In this case, there is an excess of follicles, which can produce severe swelling or discomfort in the ovaries. Treatment may be postponed until a later cycle, depending on the severity. 

 

Days 10+

Patients will have a last ultrasound and bloodwork to see if the follicle pack has matured. If this is the case, a trigger shot is given 35-36 hours before retrieval to encourage the last growth spurt and ovulation.

Trigger shots are hormones that encourage the regular development of an egg in a woman's ovary, effectively activating the egg to go through a last growth spurt and stimulating the release of the egg from the follicles within 36 hours during ovulation. In most situations, patients are taken off all other drugs and sedated for the 15-45-minute retrieval procedure. It is usual to suffer moderate cramps or vaginal spotting after the surgery.

Keep in mind that follicles may be empty or contain an immature egg at the moment of retrieval. This indicates that the number of eggs recovered following egg retrieval may be less than the number of follicles observed on ultrasound or determined by bloodwork.

 

What are the possible side effects of cycle medications?

The IVF process itself necessitates extensive IVF drug use on a strict timetable. As a result, it's critical to understand what you could be administered as well as any potential IVF medication side effects.

 

Clomid side effects and risks:

Clomid works by tricking the body into believing there isn't enough estrogen circulating. It accomplishes this by blocking the receptors in the body that respond to the estrogen hormone. The majority of Clomid adverse effects are caused by these perceived low estrogen levels.

Possible side effects of Clomid include:

• Hot flashes
• Bloating and abdominal discomfort
• Weight gain
• Headaches
• Mood swings
• Nausea
• Dizziness
• Breast tenderness
• Abnormal menstrual bleeding/spotting
• Vaginal dryness

Blurred vision is an uncommon yet dangerous side effect of Clomid. This adverse effect, which occurred in fewer than 1.5% of women throughout clinical trials, might include impaired vision, flashing lights, or floaters. If this happens to you, notify your doctor immediately.

Clomid, like most fertility medicines, can result in a twin pregnancy. Approximately 7 out of every 100 Clomid-conceived pregnancies will result in twins.

 

Letrozole side effects and risks:

Letrozole is a reproductive medication that is taken off-label. (It is actually supposed to be used to treat breast cancer.) Letrozole functions similarly to Clomid (blocking estrogen receptors). Letrozole may be more effective for women with PCOS and those who are Clomid resistant (do not ovulate on Clomid).

Possible side effects of letrozole include:

• Fatigue
• Dizziness
• Headache
• Bloating/abdominal discomfort
• Hot flashes
• Blurred vision (much less common than with Clomid)
• Trouble sleeping
• Abnormal menstrual bleeding/spotting
• Breast pain

There is an increased risk of conceiving twins on letrozole, just as with Clomid.

 

Gonadotropins side effects and risks:

Gonadotropins are injectable hormones used in fertility treatments. They include medications such as Gonal-F (FSH), Follistim, and Ovidrel (hCG). During an IVF cycle, injectables can be administered alone or in conjunction with other medicines.

Possible side effects of gonadotropins include:

• Bloating/abdominal tenderness
• Absentmindedness/feeling "foggy"
• Headaches
• Nausea/upset stomach
• Upper respiratory tract infection
• Mood swings
• Acne
• Weight gain
• Abnormal menstrual bleeding/spotting
• Injection site soreness and redness
• Dizziness

When compared to Clomid and letrozole, the chance of twins with gonadotropins is much greater. Many clinics do not prescribe gonadotropins for timed intercourse or intrauterine insemination since up to 30% may result in multiples.

A single embryo transfer is the recommended standard of care for most IVF patients to limit the possibility of multiples. Transferring more than one embryo is restricted for a few exceptional instances.

 

GnRH agonist side effects and risks:

GnRH agonists, such as Lupron, are frequently used during IVF therapy. They inhibit the body's natural reproductive system, allowing your doctor to regulate ovarian stimulation and maturation. Many of the negative effects of GnRH agonists are caused by low estrogen levels.

Possible side effects of GnRH agonists (like Lupron) include:

• Hot flashes
• Headache
• Mood swings/depression/anxiety
• Vaginal dryness
• Acne
• General body aches/joint pain
• Nausea
• Fluid retention
• Upset stomach
• Weight gain
• Decreased sex drive
• Dizziness
• Injection site soreness

 

GnRH Antagonist Side Effects and Risks:

GnRH antagonists, like GnRH agonists, are used to inhibit the body's reproductive system during IVF therapy. They cause fewer negative effects than GnRH agonists.

Possible side effects of GnRH antagonists include:

• Abdominal tenderness
• Headache
• Nausea/upset stomach
• Abnormal menstrual bleeding/spotting
• Injection site soreness

 

Serious risks of IVF drugs

Fertility medicines can have serious negative effects in rare circumstances. These should be discussed with your doctor. Always notify your doctor if you are having troubling symptoms, especially if you are unsure if they are due to the drug. If you're worried, call your doctor and let him reassure you that everything is alright, rather than ignoring a major side effect that might cause medical injury or risk.

 

Vision Changes:

When using Clomid or letrozole, a very tiny percentage of women will develop visual abnormalities. If this happens to you, you may notice flashes of light, an increase in floaters, or hazy vision.

A significant headache may accompany the hazy eyesight. If this happens to you, contact your doctor straight away. When you stop using the drug, the eyesight difficulties should go away. Long-term harm may occur in extremely rare circumstances.

 

Ectopic Pregnancy:

Women who use gonadotropins4 are at a slightly higher risk of ectopic pregnancy. If left untreated, an ectopic pregnancy can be fatal. Contact your doctor right away if you are experiencing severe pelvic discomfort.

 

Ovarian Hyperstimulation Syndrome (OHSS):

Fertility medicines intentionally stimulate the ovaries to generate more eggs than they would normally. The ovaries become critically overstimulated in OHSS. This is more prevalent during IVF therapy, although it can also happen with Clomid and gonadotropins.

The majority of OHSS instances are minor, however severe OHSS can occur. OHSS can cause blood clots and renal failure in rare circumstances. Severe OHSS might endanger your fertility as well as your life. Early detection and treatment of symptoms is critical.

 

Ovarian Torsion:

A potential complication of OHSS is ovarian torsion. Ovarian torsion affects 2% of women using gonadotropins, but with sufficient precautions (including activity limitations), this problem is extremely rare. Fertility medicines cause ovaries to swell.

The ovary might twist on itself and shut off the blood flow. Surgery to untwist or even remove the ovary may be necessary. Ovarian torsion might endanger your life and fertility. If you have significant pelvic pain, go to the local emergency facility right away.

 

Allergic Reactions:

Allergic reactions to fertility medications are uncommon. However, a reaction is possible, as with any drug (or food).

 

What is ultrasound-guided oocyte retrieval?

Oocyte retrieval is a treatment that removes eggs from your ovaries. It is a stage in the in-vitro fertilization (IVF) procedure. The treatment is frequently performed vaginally. For the procedure, you will be anesthetized. Once the eggs have been extracted from the ovaries, they can be fertilized in a laboratory. The embryos will then be implanted in your womb.

 

How to prepare?

Follow these steps to prepare for oocyte retrieval.

1. Tell your fertility specialist about any medications you've been taking in the past so she can advise you on whether they should be continued.
2. Take the medication (if any) prescribed by your team.
3. Avoid eating anything post-midnight the night before your procedure.
4. Empty your bladder before the procedure

 

How it is done?

The egg (oocyte) retrieval will take place under anesthesia around 35 hours following the hCG injection. To alleviate discomfort during the treatment, intravenous medicines will be administered. The vagina will be washed with sterile water after you get the intravenous medication. Under ultrasound supervision, a needle will be inserted into your vagina and into your ovary. Because of the effects of the intravenous medicines, most women will not feel anything during this treatment.

The follicular fluid (which includes the eggs) from your ovaries is collected in test tubes and delivered to the embryologists at the In Vitro Fertilization (IVF) Lab. The egg retrieval process takes about 20-30 minutes.

 

Following the procedure:

After the treatment, you will be taken to the recovery room for around an hour of relaxation. Pain, infection in the pelvis and ovaries, and harm to the colon, bladder, uterus, ovaries, or major blood arteries are all risks associated with egg retrieval. Because the treatment is performed under ultrasound supervision and the needle can be seen on the ultrasound, the risk of major complications is quite low.

You must have someone ready to drive you home on the day of egg retrieval (you cannot drive on the day of egg retrieval due to the intravenous medications that you will be receiving). You should not plan on working on the day of the egg retrieval. Many women return to work the next day, while others rest the day after retrieval.

You may have some pelvic heaviness, discomfort, or cramps. It is OK to take paracetamol, but avoid ibuprofen. There is frequently some spotting. Your bleeding should be less than that of a typical menstruation. It is suggested that you refrain from immersing yourself in water (avoid swimming, use showers rather than baths, and avoid vaginal intercourse) for several days following the retrieval to enable the vagina to recover.

 

What are the next steps after egg retrieval?

Insemination occurs when your eggs are combined with sperm cells from your spouse or a donor in a laboratory. Fertilization occurs when the eggs and sperm are placed together in a specific container. To enhance fertilization, sperm with decreased motility (that do not swim as well) may be injected directly into the eggs. People working in the lab keep track of how the cells in the fertilized eggs split and develop into embryos.

1 or more embryos are implanted into your uterus about 3-5 days following the egg retrieval (this is called embryo transfer). The doctor inserts a small tube through your cervix into your uterus and puts the embryo straight into the tube.

Pregnancy occurs when any of the embryos adhere to the uterine lining. Embryo transfer is typically painless and performed at your doctor's office or a fertility facility.

Plan on resting for the remainder of the day following your embryo transfer. The next day, you can resume your routine activities. For the first 8-10 weeks following the embryo transfer, you may also be given progesterone tablets or injections on a regular basis. The hormones make the embryo's survival in your uterus simpler.

 

Conclusion

The primary therapy for women with ovulation issues is ovulation stimulation medication. In addition to ovulation stimulants, several different forms of drugs are used in in vitro fertilization (IVF). Fertility medicines function by inducing hormones to be released, which either induce or control ovulation.

To avoid ovulation too early in the treatment cycle, a patient would typically begin an IVF cycle by taking birth control tablets for a few days. Following that, the patient will get injectable medicines to stimulate the ovaries and cause them to produce eggs, followed by a trigger injection. The doctor will execute an egg retrieval when the eggs are ready.

Because it requires less anesthesia and recovery time, transvaginal ultrasonography is currently the standard method of oocyte retrieval. Another advantage of ultrasound-guided retrieval is that inadequate ovarian access is quite rare, even in those with extensive surgery histories.