IV Medications

Question 1

Precycle Oral medications - Antibiotics:

Answer 1

Doxycycline Hyclate-> Patient scheduling a tubal evaluation (HSG/HyCoSy/SIS w/tubal flush) that meet one of the following:​

History of PID​

100mg BID x 5days starting morning of procedure​

Spring patient completing HSG outside of a Spring facility:​

100mg BID, on day of procedure—take AM of procedure or at least one hour prior with food, second dose ~8 hours later (evening)​

If history of PID or diagnosed with hydrosalpinx- to follow above directions of 5-day regimen
Z-pack (Azithromycin)- Patient and partner usually advised at start of treatment (within 6mths of attempting conception) depending on MD order. ​

500mg first day, 250mg daily the following 4 days (5 days total) = 6 tabs total

Question 2

Precycle Oral medications - Thyroid regulation: TSH levels

Answer 2

Hypothyroidism​:
TSH 2.5 - 4.0, TPO (antibodies) + > Subclinical Hypothyroidism​
TSH > 4.0mIU/L, regardless of TPO –> Hypothyroidism ​

If abnormal results, inquire if patient on biotin supplement. If so, d/c x 2days and repeat test as biotin supplementation can cause false results. See CO2. Management of thyroid function abnormalities. ​

​

Question 3

Priming medication - Estrace (E2)/Estradiol - luteal phase

Answer 3

Indication:​

Used in the luteal phase as a priming medication prior to IVF stimulation to suppress follicular growth that can occur prior to period start.​

Used for development and/or stabilization of endometrial lining for embryo transfer.​

Question 4

Priming medication - when is it used? and what does it do?

Answer 4

Indication: ​
this is to decrease possible follicle growth, makes luteal phase longer
Contraceptive; Progestin​

Used in the luteal phase as a priming medication prior to IVF stimulation to suppress follicular growth. More suppressive than estrace.​

May also be used to help manage Endometriosis​

Dosage/Frequency:​

For IVF priming:​

Per standard protocol: 5 mg (1 tablet) daily for total of 10 days, starting 5 days after +OPK (LH surge)​

Can be manipulated to taking 8-10 days​

Can be manipulated to start 3-6 days post +OPK

Question 5

Priming medication cont. - Birth control pill (Monophasic - the same amount of meds in every pill): this is the most suppressive one

Answer 5

Ethinyl estradiol 0.03 mg and desogestrel 0.15 mg ​

Contraceptive: Monophasic pill containing Estrogen & Progesterone ​

Used as a priming medication prior to IVF stimulation or FET cycle ​

Most commonly started in the follicular ( CD (day)1-3) or luteal phase (LH+5)​

NOTE: if patient taking over 21days, ensure purchases and uses 2nd pack of pills, advise patient to discard the placebo pills- don’t take the last day of rows, this is a placebo pill

Question 6

Priming medication cont. -Testosterone*

Answer 6

Label indications include delayed puberty and male hypogonadism​

it suppresses follicles, and once you take it away you may get a stronger response

Off label indications include transgender hormone therapy (female-to-male)​

At Spring, utilized in priming along with Aygestin or Estrace, to help in increasing FSH receptors on follicles to help improve stimulation outcomes​

ATP IVF protocol : Aygestin/Testosterone Priming​

Options/Dosing: (goal if for patient to receive 2-3mg per 12 hour exposure)​
usually used for 10 days

Androderm Patch: 2mg/24 hour patch (Not currently available)​

1 patch to outer thigh at 9PM and remove at 9AM each day ​

T-Gel: 1% transdermal gel pump – OR-​

T- Cream: Transdermal solution metered pump. 30 mg/actuation (1.5 mL) (CHEAPEST OPTION)​

1 pump once daily applied at 9pm and washed off at 9 am​

*can be difficult to obtain, Alto has:​

C-Testosterone cream 12.5mg/gm (1.25%)–1 click applied at 9pm—washed off at 9am –OR-​

C-Testosterone cream 5mg/gm (0.5%) –2 clicks applied at 9pm, washed off at 9am

Question 7

IVF Stimulation Medications—PO (oral - Clomiphene Citrate (Clomid)- CC - what is the dose?

Answer 7

Dosage (50mg tablets)​

Common dose—100mg/day​

Min/Max dosage: 25mg/day/ Max is 250mg/day (rare)​

Duration—5 days​

Start cycle day 2-5, depending on baseline US or when patient calls with period start..​

Indications:​

Non PCOS pts, first line in Superovulation for IUI​

DOR ​

Concerning side effects: ​

Blurred/Double vision​

Thin Endometrium

Question 8

IVF Stimulation Medications—PO (oral) - Letrozole/Femara- LTZ - what is the common dose?

Answer 8

Dosage (2.5mg tablets)​

Common dose—5mg/day​

Min/Max dosage: 2.5mg/day-7.5mg/day​

Duration—5 days​

Start cycle day 2-5, depending on baseline US or when patient calls with period start..​

Indications:​

Ovulation induction- First line for PCOS patients​

Decrease estrogen levels​

Utilized long term in breast cancer patients​

Can be given during IVF stim to keep E2 low if patient at risk (extended course- ~10-15 days)​

i.e.. Cancer pt., hormonally induced migraines

Question 9

Gonadotropins – Injectable Fertility Meds - rFSH​ - what is the name? where does this come from?

(gonal gonad)

Answer 9

rFSH​

Gonal-F®/Follistim®​

Recombinant FSH​

SQ injection ​

Well tolerated​

Gonal-F Rediject Pens​

offered in 300, 450, & 900 IU pens​

Follistim AQ Cartridge,​

offered in 300, 600, & 900 IU pens. Require a pen to administer.​

Question 10

Gonadotropins – Injectable Fertility Meds - LH - when are these used?

Answer 10

LH​

single use vial (75 IU FSH & 75 IU of LH activity) ​

Referred to as 75iu of LH: lyophilized powder/pellet dispensed with diluent vials (2ml) and Q-Cap® vial adapters.​

Consists of FSH + LH activity. It directly stimulates follicular growth at the ovaries. Often used in combination with rFSH (Gonal-F or Follistim).​

SQ injection​

Redness/pain at injection site common

Question 11

Adjunct—Growth Hormone - (HGH/GH) ​how to store it?

Answer 11

Human Growth Hormone (HGH/GH) ​

Omnitrope 5.8 mg or Zomacton 5mg or 10mg vial depending on availability​

Dose is 1.45 mg daily started with IVF stim​

Omnitrope 5.8mg vial (25 units/0.25 mL) ​

Zomacton 5mg vial (30 units/0.30mL)​

Zomacton 10mg vial (15units/.15 mL)​

May allow for follicles to respond better to gonadotropins​

Can lead to better egg/embryo quality​

Keep Refrigerated at ALL times

Question 12

GnRH Agonist

Answer 12

Lupron ®/Leuprolide Acetate 1mg/0.2ml: Two week kit​

SQ injection ​

IVF or FET/Down regulation: (10 units/0.5mg daily for ~12days)​

This prevents LH and FSH causing the follicle to grow bigger.

Question 13

GnRH Antagonist (Cetrotide/Ganirelix/Fyremadel)

Answer 13

Ganirelix/Fyremadyl (prefilled syringe) /Cetrotide (requires mixing)​

SQ injection ​

Binds to GnRH-receptors, blocking the release of LH-preventing ovulation - this makes the follicle grow bigger.

Can also be used in combination with estrogen in EAP priming to help suppress endogenous FSH secretion and lead to more synchronized starting follicle cohort than estrogen alone.​

When used to suppress ovulation (most common use) begin when follicles ~12-14 mm.​

Continue daily until day of trigger

Question 14

Oral medication to suppress premature ovulation - what is it called?

(provent ovulation)

Answer 14

Provera 10mg Tablets​

Could be used in place of injectable antagonist, for those NOT planning to transfer an embryo in the same cycle.​

Helps to keep medication costs down.

Question 15

TriggerMedications - HCG - what is it similar to?

Answer 15

HCG (Human Chorionic Gonadotropin) : ​HCG is similar to LH

chemically similar to LH – mimics the effects of LH causing final maturation and ovulation.​

Dosage 1600iu to 5000iu, MD will advise based on risk of OHSS​

Question 16

Cabergoline

(OHSS is in the cab with dopamine)

Answer 16

Cabergoline 0.5 mg tablets​

To help to decrease symptoms of OHSS following the retrieval the MD may order Cabergoline (Dopamine Agonist) for those at higher risk.​

This medication inhibits VEGFR-2 phosphorylation and signaling.​

​

one pill orally or vaginally starting on day of trigger for 8 days

Question 17

Additional medication given at embryo transfer - what is the steroid?

(Mildred on steroids)

Answer 17

Valium/Diazepam​

10mg tablet given ~1 hour prior to embryo transfer​

Goal: relax the uterus/individual ​

Patient must have a ride​

​

Medrol​

16mg given for 5 days prior to embryo transfer​

Low dose steroid used to suppress the immune system response and inflammation that may impact implantation

Question 18

Luteal support- ​
Fresh or Frozen Embryo transfer

Answer 18

Estrogen (Estrace tablet/Vivelle patch)​

Used for development and/or stabilization of endometrial lining for embryo transfer.​

Progesterone (Tablet/IM injection or vaginal gel)​

Luteal phase progesterone support

Question 19

Medication costs

Answer 19

Costs for the oral medications are generally low​

-can be sent to any local pharmacy (Rite Aid, Walgreens, etc..)​

Clomid 50mg #10—as low as 8.00 (up to ~20.00)​

​

Letrozole 2.5mg #10—as low as 5.00 (up to 50.00)​

​

Costs for injectable medications are much higher​

~3-7K for full set of fertility medications needed for EF/IVF cycle ​

Need to utilize specialty pharmacy (Alto, MDR, Freedom fertility, or Cloud Rx if insurance)

Question 20

Review Questions

Answer 20

1. What is the name of the oral priming medication, often given in the luteal phase, and is a form of progesterone? What is the dose/typical duration for this medication?​ - Agestin - dose is 5 mg for 10 days
2. Name the two rFSH injectable gonadotropins.​
3. What is the name of the GnRH agonist that can be used as a suppression medication or to trigger ovulation? What is the dosage for suppression vs. Trigger?
   Lupron, supress 0.5 mg, trigger 4 mg ​
4. What type of medication is Ganirelix/Cetrotide/Fyremadel and why are they used?​
   antagonists- used to stop LH surge to prevent ovulation
5. What PO medication might be prescribed to help decrease OHSS symptoms? What is the dosage/duration?
   Cabergoline - 0.5 mg for 8 days, start day of trigger

Question 21

Trigger medications - Ovidrel

Answer 21

Ovidrel (prefilled syringe)- not the preferred medication for IVF triggers since you cannot control the dosage as well. ​

Question 22

Trigger meds -LH - what is it called?

(lupe in the lh)

Answer 22

LH (Lupron):​

Lupron (Leuprolide Acetate) when given as a single high dose (4 mg) will work as a pulse to the pituitary gland to surge production of LH for final maturation and ovulation

Question 23

how much synthroid to take? and what time of day to take it? when to retest TSH?

Answer 23

Synthroid (Levothyroxine) Dosage varied based on need 25mcg-100mcg+​ (usually order like 45 days worth)

Taken daily, first thing in AM 30min-1 hour prior to a meal​

Recheck levels ~ 4-6 weeks after starting medication, once TSH within target range. Recheck lab in ~ 6mths or if pregnancy (at 2nd bhcg). ​

Increase of ~25-30% is generally needed in pregnancy.

Question 24

estrace (estradiol) - why use post hysteroscopy?

Answer 24

Used post hysteroscopy to allow for proliferation of endometrium and allow for healing.​

Question 25

estradiol dosing

Answer 25

hysteroscopyDose/Frequency:​

For IVF priming: 2 mg (1 tablet) BID until menses starts, starting 5 days after +OPK (LH surge) ​

For luteal support (fresh transfer): 2 mg (1 tablet) BID, starting 4 days post retrieval and continue until pregnancy test and if pregnant until approx. 9 wks. gestation​ - this is to get all of the follicles to grow equal sizes so we have more follicles to choose from. this is a low dose.

For controlled FET (embryo transfer) (sub for Vivelle): 1 patch q 72hrs = 1 pill (2mg)/day therefore 1 pill x 6 days, 2 pills x 3 days, 4 pills x 3 days, until P4 started, on P4 start decrease to 3 pills x 3 days, then 2 pills/daily until pregnancy test and if pregnant until approx. 9 wks. gestation​ - this is to help endomentral lining

For post HSC (hysteroscopy): 2 mg (1 tablet) BID typically for 4 weeks (pending MD order). Will often add Provera (progesterone) for 7-10 days overlap to induce period following procedure. This will help endometrium , less scar tissue

Question 26

HCG med names

(HGC is PN)

Answer 26

Pregnyl​

Novarel​

Generic​

Question 27

what is the P4 med called?
(I’m gestin progest)

Answer 27

Aygestin (P4)

Question 28

what time of day to take clomid?

Answer 28

Take recommended number of tablets together, in the evening, ~ same time each day.​

Question 29

what time of day to take letrozole?

Answer 29

Take recommended number of tablets together, in the evening, ~ same time each day.​

Question 30

what is E2 med called?

Answer 30

Estracew

Question 31

what is gonadotropin med called?

Answer 31

Menopur ®​

Question 32

where does monopur come from?

Answer 32

Derived from urine of menopausal women, which has been purified.

Question 33

what days to use provera?

(provent on day 6 until trigger)

Answer 33

Patient advised to begin ~ 6th day of IVF stimulation and continue until day of trigger.​

Question 34

antagonists

Answer 34

bind to receptors blocking them

Question 35

agonists

Answer 35

bind and activate

Question 36

name of GnRH agonist?

(lupe in the agonist)

Answer 36

(Lupron)

Question 37

lupron - how does it work?

Answer 37

GnRH agonist binds to GnRH receptors, initially activating but with prolonged use will desensitize and therefore suppress gonadotropin secretion.​

Question 38

lupron as a trigger

Answer 38

Trigger (4mg)​
Used instead of or in combination with HCG to trigger ovulation prior to egg retrieval. ​

NOTE: If given to down regulate, Lupron cannot be used to trigger ovulation.
can cause menopausal symptoms

Question 39

how does lupron help with OHSS?

Answer 39

Decreases severity or occurrence of OHSS by not using HCG as the primary trigger medication.​

Question 40

OHSS

Answer 40

ovarian hyperstimulation syndrome