Focusing on Fertility Meds & IUI
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Now, last week we began to navigate the treatment piece of the infertility journey and we talked about the three-armed approach that I always tell my patients. So lifestyle, supplements, and then the actual medical treatment that you would be doing in a fertility office.
Today we're going to shift gears and move away from the lifestyle and the supplements and start to focus on the medical treatment. Today's episode will focus on the medications that we use in fertility treatments, as well as the IUI procedure. Next week, we'll be talking all things IVF, which I know is the big dreaded three-letter word in our field. But for today, let's regroup and let's focus on talking about those medications. So there are several medications that you may be recommended to use by your fertility specialist. And each case needs to be individualized. So as we move into treatment, I want to be very clear that this is for education purposes only and really should not be considered medical advice. When we talk about medications, I will typically group them into two large buckets:
One is the oral medications, and then the other one is the injectable medications.
When you talk about oral medications, the two big ones that we talk about are Clomid, also known as clomiphene citrate, and Femara, also known as letrozole. Now, both of these medications are pills. Both of them are taken once a day for five days, and both of them have a dosing of either one tablet, two tablets, or three tablets. It's very rare that your doctor would go above maximum of three tablets a day for five days, which would be a total of 15 (though this may be considered for special circumstances). Now, what is the role of Clomid and Femara? And I'm actually going to use the generics moving forward. So Clomiphene Citrate or Letrozole. Both of them are anti-estrogens. Clomiphene Citrate works on the estrogen receptor in the body. It's considered both an agonist, which is a stimulant, and an antagonist, which is a blocker, depending on the part of the body where it has different mechanisms. Now in the brain, it is a blocker. So essentially what it does is it blocks the estrogen receptor (in the brain) from being able to see circulating estrogen. So in turn, it's telling the brain, ‘hey brain, it's time to get to work. We don't have enough estrogen around. We need to make more estrogen.’ So the brain, as a result of that, releases two hormones, FSH and LH, and it releases them in higher amounts than it would normally because it's sensing this low estrogen. The ovary is now receiving a higher than normal stimulation. The goal in women who have irregular cycles, the most classic one is PCOS, the goal there is to try and recruit an egg for ovulation. For women who do have regular cycles, the goal is to increase the number of eggs that she is producing per month. So most women will produce one egg per month by taking this fertility pill and releasing higher amounts of brain hormone, the goal is to produce more than one, two, three, etcetera. Letrozole works in a very similar fashion. It is also an anti-estrogen, but it doesn't impact the estrogen receptor. Letrozole impacts an enzyme called aromatase. The aromatase enzyme exists in several organs of the body and it makes estrogen. If it blocks the aromatase enzyme, it blocks estrogen production. So the estrogen circulating decreases, the brain recognizes that there is low estrogen around, and the end result is the same. Higher amounts of brain hormones going down to the ovary and stimulating estrogen production i.e egg production. Why do I say that? Because we know that the egg is housed inside a sac and that sac is made up of cells that make estrogen so as that follicle or sac grows more and more granulosa cells are growing and in turn more estrogen is being produced. So clomiphene citrate and letrozole are the two oral medications that we use. One affects the estrogen receptor, one affects the aromatase enzyme. The end result is the same. The end result is to trick the brain into thinking that there is low estrogen around. As a result of that, the brain releases higher amounts than normal of FSH and LH hormone, which in turn stimulate the ovaries to produce and go into action. Now, typically when we prescribe clomiphene citrate or letrozole, we may also be talking to you about a medication called Ovidrel. Now there are other types, that's the commercial name, so that's just one company, but really the medication we're talking about is HCG. HCG stands for Human Chorionic Gonadotropin, and it is made in a lab. It is a synthetic version of the hormone that we make naturally, and the reason that we give it is to mimic the LH surge of ovulation. So for patients who are tracking ovulation in a natural cycle, what you're looking for is that LH hormone, that luteinizing hormone or hormone of ovulation. Turns out that HCG and LH have very, very similar chemical structures and that allows us to provoke the same reaction that we would with LH, using HCG. But because the HCG has a much longer half-life, we're able to time things easier. We're able to achieve a better response. And so most fertility specialists would be using an HCG shot. You may have also heard this used as the trigger shot. That's what we call it commonly. Trigger because we're triggering ovulation. So based on the timing of your trigger injection would be either timed intercourse, the IUI procedure, or if you're doing IVF, the egg retrieval. So going back we have clomiphene citrate and we have letrozole oral medications given for five days, typically given once a day dosing, and typically given either as one pill a day for five days, two pills a day for five days, or three pills a day for five days. Most fertility specialists, if they're using either one of these fertility medications, they're typically giving it with ultrasound monitoring. So your clinic would have you come in typically before and after to check your response to the medication. And then once you're ‘ready’, we would then plan for the trigger shot. That trigger shot would then allow for timed intercourse, IUI, or if you're doing IVF, the egg retrieval. Now, not everybody uses the trigger shot. It's important to understand each fertility clinic is going to be a little bit different. It's not a one size fits all. So you want to make sure that you're talking to your fertility specialist about your tailored plan and why we're using each of the medications.
Looking ahead to injectables, we mentioned the trigger shot already, that is to mimic ovulation, but we also have injectable medication that acts as stimulants of the ovary. So those are known as FSH or HMG. FSH is Follicle Stimulating Hormone, that is a synthetic version of what we make normally. HMG is known as Human Menopausal Gonadotropins, also now made synthetically, but an interesting fact there is that the HMG originally back when all of this first started was purified urine from menopausal nuns from the nunneries of Italy, which is super interesting. So what we found is that women who have gone through menopause actually have very, very high doses of FSH and LH in their urine. We were able to purify that out, so sort of sift that out, clean them out, purify them, and then use those hormones to stimulate the ovaries in young patients. Today's world, it's all lab done, it's all synthetic, so I don't want you to worry about it, but it's an interesting origin to where those medications come from.
Now, there's three to four commercial names that you may hear used. One is Follistim, and that's going to be FSH only. One is Gonal-F. That is also going to be FSH only. There's an older medication called Bravelle. And then you also have Menopur. Now, the three more common ones are going to be Follistim, Gonal-F, and Menopur. Menopur contains both FSH and LH. It's not actually LH. It's that HCG. Remember, we were talking about that. But the idea is to give that second component as a stimulant. And so typically what we will see is that the injectables are used either in very low doses, think 50 units a day, 75 units a day, to stimulate the ovaries for intercourse or IUI, or in much higher doses, typically ranging anywhere from 150 all the way up to 450 units daily for IVF. So we consider that much more aggressive dosing because the goal is different. With IVF, we're trying to recruit as many eggs as possible versus with the lower dosing, we're trying to achieve the same goal as we would with the clomiphene citrate or the letrozole, one, two, or three follicles at a time.
So hopefully this has been helpful. Now again, this is for education purposes only. This is not medical advice. You definitely want to be talking to your physician about each of these medications because there's a lot more to it, right? How are we using it? What potential side effects are there? What can I expect it to do in me, in your individual case? And what is the goal for treatment? So definitely want to make sure you're covering all those questions with your physician, but at least the purpose of this episode is for you to understand what medications are out there and what they do in the body, typically where we use them and the doses that we would generally use.
Now, very, very briefly, I want to talk about the IUI procedure or intrauterine insemination. That is what we call a low-complexity procedure. It is very minimally invasive. It's done in an office exam room. And it is sort of an initial step for patients who are not ready for IVF yet. Now, again, IUI, just as well as these other medications, they all have a role in the fertility journey. So whether or not you are a candidate for IUI depends on your individual case. And that is only a question that your fertility specialist can answer. But for purposes of education, I do want to make sure you understand what an IUI is. So IUI stands for intrauterine insemination, also known as artificial insemination if you Google it.
And basically what we do is we take sperm that has been washed and processed, we place it into a syringe, and we use a very, very small catheter to deposit it inside the uterus. In terms of what you, the patient, would feel, it's very much like a pap smear appointment. We bring you into an office exam room, we have you undress from the waist down, we insert a speculum just like when you have your pap, and then that catheter is so small that most women don't feel anything. Sometimes there can be just a touch of cramping if the catheter touches the top of the uterus, but really there should be minimal discomfort. There's no limitations or restrictions after the procedure. You can go right back to work or go back home.
You can go about your day, resume your normal activities, and there's no restrictions in intercourse either. So if you'd like to have sex, you can, but you don't have to because that's the whole purpose of the procedure. Typically after the IUI is done, two weeks later, you would take a pregnancy test. If the test is positive, Yay! And if it's negative, you would start the next attempt, okay? Success rates do vary with the IUI procedure. You could be quoted anywhere from five to eight percent all the way to ten to twelve percent maybe maxing out at around fifteen percent. It is not a highly successful procedure because of the low degree of complexity. And if you're doing IUI, your fertility specialist is probably encouraging you to do more than one attempt, so two to three cycles or two to three months, because we want to get an added benefit or cumulative pregnancy rate with each attempt. Typically after three to four months, if you haven't gotten pregnant, you're probably regrouping with your physician to talk about next steps.
Again, just like with the medications, the IUI does have side effects, it does have its risks, so you want to make sure you're talking to your physician about those as well.
I hope this has been helpful. Next week we'll be talking all about IVF. See you next week. Bye-bye now.
*This content is intended solely for educational purposes and is not to be construed as medical advice. For personalized recommendations concerning your specific healthcare needs, kindly consult with your healthcare provider.
