1. Is it better to administer my Follistim or Gonal-F via IM (intramuscularly) or subcutaneous (s.c.) route?

Gonal-F should be administered subcutaneously only; Follistim can be administrated either IM or subcutaneously.

2. How is an injection given intramuscularly (IM); subcutaneously (s.c.)?

The most convenient site for subcutaneous injections are either in the abdomen or on the navel area where there is a lot of loose skin and layers of fatty tissue, or in the upper thigh. The way to do this is to pick up a large area of skin between the fingers and the thumb. The needle should be inserted at the base of the pinched up skin at a 45° angle to the skin surface. The injection site should be varied with each injection (e.g., if an injection is made on the right side of the abdomen one time, the next injection should be on the left side of the abdomen). The best site for IM injection is the upper outer quadrant of the buttocks muscle. Stretching the skin helps the needle to go in more easily and pushes the tissue beneath the skin out of the way. The needle must be inserted deep enough to reach the muscular layer and at a 90° angle to the skin surface. Pushing in with a quick thrust causes the least discomfort.

3. Are there instructional videos or literature available explaining how to prepare and inject fertility medications?

Yes, tese materials are prepared by Organon, the maker of Follistim and Antagon; Serono, the maker of Gonal-F, Pergonal and Cetrotide; and Ferring, the maker of Repronex.

4. Where do I inject my fertility medications?

The new generation of recombinant gonadotropins, including Gonal-F, Follistim, and Ovidrel, may be given subcutaneously as the preferred route of administration. The older generation of gonadotropin preparations, such as Pergonal, was approved for intramuscular administration. Repronex has been approved for both intramuscular and subcutaneous injection. hCG has been approved for intramuscular injection in the past. A new recombinant form of hCG, called Ovidrel, is designed for subcutaneous administration.

5. Can I mix my injectible medications together in one syringe prior to injection?

Yes, gonadotropin preparations can be mixed together and administered in the same syringe, but consult with your physician if you are combining different preparations. Although commonly done by doctors and some doctors recommend it, there is no study on the stability of this, and none of the manufacturers have any studies showing that they are stable, although it is a common practice.

6. How long before my injection can I mix/draw my medications?

Medications should be used immediately after reconstitution. Any unused material should be discarded.

7. What is the proper way of inserting vaginal suppositories?

Suppositories should be inserted high into the vagina and the patient should lie down for 15-20 minutes afterwards. Sanitary napkins or mini-pads should be used to prevent leakage or staining of clothing.

8. What are the different types of progesterone that a doctor may prescribe for support of the uterine lining after IVF?

There are progesterone preparations for injection, oral progesterone (Prometrium), and progesterone suppositories. Crinone, a vaginal gel, is available now.

9. What is the difference between Gonal-F, Follistim, Pergonal, and Repronex?

Gonal-F and Follistim are follitropins, preparations of highly purified follicle stimulating hormone, or FSH. Both Gonal-F and Follistim are human FSH preparations of recombinant DNA origin. They stimulate ovarian follicular growth. FSH is required for normal follicular growth, meiosis, and gonadal steroid production. Pergonal and Repronex are purified preparations of gonadotropins extracted from the urine of post-menopausal women.

10. Does my medicine need to be refrigerated?

Gonal-F, Follistim, Fertinex, Repronex and Antagon should be stored at room temperature or refrigerated (keep at 37°-77° F protected from light). Cetrotide must be refrigerated.

11. If my fertility drugs expired last month, can I still use them?

Generally, no. However, note that an expiration date of, for example, October 2002, means that the expiration date is the last day of the month, or October 31, 2002.

12. What is the difference between an agonist and an antagonist?

Agonist and antagonist are polypeptide hormones, which selectively act at the level of the hypothalamus and pituitary to affect the secretion of gonadotropins from specific cells in the pituitary. Agonists have an initial effect in stimulating gonadotropin secretion, and increasing the levels of LH and FSH. This is short lived, however. Through a process referred to as "down regulation", the continued administration of an agonist results in suppression of gonadotropin secretion, decreases in the levels of LH and FSH, and a drop in circulating estradiol to the menopausal level. Several agonist preparations are available, which may be administered intramuscularly, subcutaneously, or via the intra-nasal route, respectively. Agonists available in the U.S. include Lupron, Synarel, and Zolodex. Antagonists have direct blocking effects on the receptor for the hormone GnRH. As a result, it causes an immediate and profound suppression of LH and FSH secretions. Unlike agonist, there is no initial period of stimulation, which is referred to as the "flare up" phase. The antagonists available in the U.S. are Antagon and Cetrotide. These medications are remarkably safe and do not effect any other parts of the hypothalamus and pituitary.

13. What is hCG?

hCG is a polypeptide hormone produced by the human trophoblast in the developing embryo. It is composed of alpha and beta subunits. The alpha subunit is essentially identical to the alpha subunits of human pituitary gonadotropins: luteinizing hormone (LH), follicle stimulating hormone (FSH), and thyroid stimulating hormone (TSH). The beta subunits of these hormones differ in their amino acid sequences. As far as its action is concerned, hCG is virtually identical to the pituitary hormone LH. During the normal menstrual cycle, LH participates with FSH in the development and maturation of the normal ovarian follicle. The mid-cycle LH surge triggers ovulation. hCG is used as a substitute for LH in this function. During a normal pregnancy, hCG secreted by the placenta maintains the corpus luteum after LH secretion decreases. This supports the continued secretion of estrogen and progesterone, thereby preventing menstruation.

14. Can hCG be given IM or subcutaneous?

Intramuscular injection is generally recommended for hCG. However, a new recombinant form of hCG is available, Ovidrel, which is designed for subcutaneous administration.

15. Do insurance companies cover the cost of fertility drugs?

Some insurance companies do cover fertility medications, it will depend upon your specific company and plan. We suggest that you send us your insurance information and allow us to do some research on your behalf; sometimes we can obtain prior authorization for payment.

16. My doctor prescribed heparin and aspirin for my IVF cycle. Are there any significant adverse side effects?

The most common adverse side effect of heparin is hemorrhage. Bleeding can occur at virtually any site in the patient receiving heparin. However, with low-dose subcutaneous heparin, bleeding is exceedingly rare. An unexplained fall in hematocrit, falling blood pressure, or any other unexplained symptom may suggest a hemorrhagic event. Heparin can be monitored via rapid laboratory tests to adjust dosage. Other side effects include irritation, rare cases of arrhythmia , and mouth pain. With deep subcutaneous injection of heparin, the formation of a hematoma or skin ulceration is possible. Deep injections should be avoided. An enteric-coated tablet should be the preparation of choice for aspirin. Due to its irritative effect on the stomach lining, aspirin should be taken with or immediately after meals. Aspirin should not be taken in conjunction with coumadin.