Most fertility treatment hinges on the strategic use of drugs to help the body be as fertile as possible. My goal is to give each of my patients a personalized fertility plan with custom calendars of what to do, what drug to take, and when.
I thought it would be useful to walk through a few of these patient calendars (keeping things confidential, of course) and talk about the drugs I commonly use to give my patients the best chance at fertility success.
Are you ready? Let’s talk about drugs!
Birth Control Pills:
Otherwise known as IVF readiness pills. In some cases, we put patients on birth control pills. Wait, why would we do that? We’re trying to help you get pregnant, right? Ah, but yes — birth control pills are in many ways a tool for IVF. They work great as they pause your ovulation and shift things for the entire time.
I don’t like patients to be on birth control pills for an extended period of time as they can suppress the ovaries thereby making it harder for the ovaries to “wake up”.
If I have a patient that needs her ovulation window or egg retrieval to be on a very specific date, then I may even start them for ten days for example then restart and stop them again them so treatment falls according to the schedule that works best for their life schedule.
Here’s one thing you need to know. After you take your last birth control pill it’s normal to have a period. It’s expected and it shouldn’t worry you one bit when it happens. Nothing is wrong. And then there’s the daily spotting, and brownish discharge that is often seen. Why? It can take your body 2–3 months to adjust to a birth control pill. Annoying? Yes. Normal? Definitely.
As long as you know what to prepare for. You will not be worried, surprised or upset.
If you are on birth control pills and you experience severe headaches let your doctor know. If you’re prone to migraines or have high blood pressure, this may not be the best IVF readiness plan for you.
These are the types of things to talk to your doctor about to make sure this is the right protocol for you.
There are several different companies that make drugs called gonadotropins that help the follicles in the ovaries grow. Every patient’s protocol is different, but in a typical IVF cycle, a woman will take a gonadotropin injection every night for approximately 10 nights.
Here are some things that you should know about this drug:
These shots cannot create more eggs than you already have. If you start out with five follicles, you will typically end up with five eggs. It’s definitely possible to see more later but you may start with five and grow two. Knowing what to expect during your cycle helps you manage your emotions during treatment.
Questions to consider asking your doctor:
How many follicles am I growing? How many mature eggs do you expect? What do you think about the cycle? These are questions to ask at every single visit.
This is the type of information I share with my patients and I want you to feel informed about the IVF process as it is YOUR body.
It’s important to remember that despite the elements that we can control (medication and timing) there are still parts that are uncontrollable. I say it all the time to patients: I am a medical doctor, not a medical deity.
Estrace or Estradiol:
When preparing for a transfer, I tell patients to take two of these pills at 8AM and two at 8PM. Estrace (estrogen hormone) helps thicken the lining of the uterus, and then taken with progesterone helps prepare the uterus for implantation.
Estrace side effects include a dull headache, breast tenderness, and egg white cervical mucous because that’s how your body reacts to higher estrogen levels.
Some patients just can’t deal with the side effects and they feel more emotional than normal. So I give them the option of taking the pill by placing it in their vagina. In some patients, this may lessen some of the side effects. I usually get some odd looks from patients when I suggest this, but it’s true — you can do it. And then I give little warning about a condition I call, Smurf-gina. This is something that happens when you place estrace vaginally. They are blue pills and when placed vaginally, cause a blue tinged vaginal discharge. Hence smurf-gina.
There are several brands I often suggest to patients. Ask your doctor and ultimately you want to find one for you that you can tolerate and doesn’t make you feel ill.
We use aspirin to help with implantation and prevent blood clots. I like to prescribe the 81mg dose because the tablets are typically smaller than what you can get over the counter.
I prefer progesterone in ethyl oleate as I find it’s easier for patients to inject (less viscous and easier to tolerate). Progesterone is critical in helping to make sure that an embryo stick and grows.
When it comes to self-administration of the shot (or help from a partner/friend) here are my tips for intramuscular progesterone shots:
Tip 1: Ice the upper outer buttock area first. Make sure you’re going high enough. If you go too low you’ll get a skin reaction. If you go too much towards the middle you may hit your sciatic nerve. You don’t want to do that as you may have trouble walking the next day!
Tip 2: Warm it up. Then do the injection. You can draw up the injection and warm it by wrapping it in a heating pad for a couple minutes or by putting it under your arm pit for example.
Tip 3: After the injection massage the area with a hand-held massager or heating pad or both. If you have one, get your partner to help out.
If you have a partner that thinks it’s funny to slap your butt you may want to share this next part with them.
DO NOT slap the butt of a woman who has just taken a progesterone shot. I repeat, DO NOT slap the butt…okay, you get the idea. This is not a joke. Seriously, save the butt slaps for another day!
Okay, I’ve said my peace.
So how long do you do progesterone shots? 10 weeks.
Usually, by 9 weeks the placenta takes over, but we like to go one extra week to ensure the placenta does what it’s able to do to support the pregnancy.
The word progesterone, when broken down literally, means to promote pregnancy. Pro = for, gesterone = pregnancy (gestation). There is no such thing as too much.
If you have a bad reaction like a rash going down your leg or intense itchiness then tell your doctor so you can get it checked out. Don’t wait to check in with your doctor about these sorts of reactions.
A Benadryl cream or an anti-itch type of lotion is something you can rub over the area. Of course, there are patients where this type of progesterone is not a good option for them and so we take a different route.
Again — no two patients are the same! You deserve personalized fertility care. Make sure you’re getting it from your doctor, or come see me!
Doxycycline: it’s an antibiotic that we put patients on to reduce any risk of infection.
Note that this is not required (as the risk of infection from IVF is 1%) but it’s an extra precaution I like to take. Skip it if it makes you nauseous, are prone to yeast infections, or if you have bad reflux.
Medrol: a steroid to decrease inflammation in the body. Frequent urination and facial flushing are two reactions you may experience. I ask patients to update me with their side effects and if they have facial swelling I tell them to stop. The other thing you should know is that this drug tastes terrible. Put it in ice cream or yogurt. Plug your nose. Do what you can to stomach it. Hot tip: depending on the dose you’ve been prescribed, you can also use a Medrol dose pack if the pharmacy doesn’t have the dosage you need in stock.
In preparing a patient’s uterus for a transfer…
I really like the Vivelle-Dot estrogen patch in that many patients have fewer side effects. The only potential problem is a skin reaction from the patch. There are adhesive removal swabs that you can use that help reduce that and make using it super easy.
Endometrin: I think of it as alka-seltzer for your vagina. That’s how the tablet absorbs, upon contact with moisture. But don’t worry! You won’t feel any fizz. You take the tablet, load it in the applicator and you have to place it three times a day: 8AM 2PM and 8PM are the times I recommend.
If you find that you are having a hard time with the frequency and skip one, then it’s time for the once daily progesterone shot. In my experience, the vaginal inserts are just as good as the injections but if you forget to take one, you’re done!
I like to do rehearsal transfer cycle with my patients. It’s a test run for the real thing, and why wouldn’t we want to test and check that everything can go as smoothly as possible before the real deal? Mock transfer cycles help us understand how your body will react to the different medications and will allow us to make adjustments.
Preparing for the actual transfer:
You can start with birth control pills to prevent ovulation and Lupron will also make sure you don’t ovulate. I like to think of birth control as “pants” and Lupon as “the suspenders”. You don’t want your pants to fall off (or ovulate), and to make extra certain that they don’t you can wear suspenders (take Lupron)!
If you Google “Lupron” you may freak out. I tell patients not to do this as the Lupron that only goes in the skin will not match the horror stories you read about online. The reactions I’ve seen are that some patients report feeling more emotional, having elevated blood pressure, and headaches. For the most part, most patients tolerate it pretty well.
The other medication I use in my frozen embryo protocols is femara. I use this at the first 5 days of the cycle when estrace is taken.
After a transfer, I want to always know that we’ve done everything possible.
Fertility Pills overlapping with Injections for IVF or IUI:
Femera and Menopur (a combination of FSH and LH) help follicles grow and maximize the number of mature eggs you can get.
Cetrotide: injection-site reactions may be common as in my experience, 1 in 4 people will get a reaction. It goes away after 15–20 mins or the next morning.
HGH: a drug that may improve egg quality, also used as a primer to get eggs ready 2–8 weeks before their IVF cycle. This helps us with having the best chance of retrieving the highest quality eggs.
Standard IVF cycle using only injectables from the beginning of the cycle:
The decision I make as far as the protocol to use is based on a patient’s age, their Antral Follicle count and what her goals are.
Some people report feeling swollen from these medications — like a potato. I say they are a very fertile potato. You may also notice some breast tenderness, headaches, and nausea. Patients can take Motrin or Tylenol with a headache and I also treat nausea with anti nausea medications.
Around treatment day 5–7 they may see some egg white cervical mucus, but this is not ovulation because patients take an additional medication to prevent ovulation from happening.
Lovenox is another drug that in certain cases can improve implantation in the right situation. Before giving themselves the shot, stretch the skin, place the needle and go very slow. As you come out with the needle you don’t want to rub the skin as you’ll get a bruise.
At the risk of sounding repetitive:
Talk to your doctor about your protocol and understand why it’s been built for you. Have a plan in place for who you can call if you have an emergency. I make myself available for skype calls and Facetime with my patients between 7–9 PM every night’s when they’re doing their shots.
In closing, I want to talk about the TUSHY method: Tubes, Uterus, Sperm, Hormones, Your Genetic Profile.
Since launching this as a helpful mnemonic in May of 2018 patients come in to see me and they come in prepared! They have all of the results of tests and are ready to talk based on a certain baseline understanding of what and why they may need treatment. They know that diagnosis is critical before treatment.
My style is that if I have a patient that comes in 32 years or older and they haven’t started their family yet, I like to talk to them about fertility preservation.
Until the day that we can put Botox in our ovaries, we need to preserve our fertility and talk to patients about all their options.
If you have a fertility question or there’s a topic you’d like for us to cover in a future show please get in touch.
Send me a note: firstname.lastname@example.org
You can also catch more of me and topics like this through the Egg Whisperer Show. The episodes are live-streamed on YouTube, Facebook, and Twitter and on Wednesdays at 7 PM PST. Subscribe to the podcast too!