Fertility Drugs: The drugs that help boost ovulation and how they work


Modern medical science has made it possible for almost anyone to fall pregnant, through the development of specialized fertility drugs. At CNY Fertility Center, we want you to understand what you put into your body and how these drugs work to help you conceive. Most fertility drugs work by stimulating gonadotropins, hormones that help boost egg production by stimulating the pituitary gland to secrete FSH (follicle stimulating hormone) and LH (luteinizing hormone). Fertility drugs can be used during IVF (in-vitro fertilization) or IUI (intrauterine insemination), or with timed sexual intercourse at home. Below is a list of some of the most commonly prescribed fertility drugs:
Clomid or Serophene (clomiphene citrate)
Clomid has been used for over 25 years to help treat abnormal ovulation. These antiestrogen drugs help stimulate your FSH and LH hormone production by helping your body to first release gonadotropins from your hypothalamus.
Clomid is an oral medication that is taking at a specific dosage for five days, starting a few days after your period. If it works, you should start ovulating within seven days of taking the last pill. Sometimes, the dosage needs to be increased if it fails to cause ovulation, otherwise your doctor will try a new treatment.
Follistim and Gonal-F:
These IV (intravenous) or injectable drugs, are created in a laboratory using recombinant DNA technology. They help your body to produce more FSH, the hormone that causes your immature egg cells to grow into fertilizable ones.
Bravelle or Fertinex:
These IV drugs also work by stimulating FSH production but they are extracted and purified from the urine of post-menopausal women. These drugs are typically less potent and less expensive than the ones manufactured through recombinant DNA technology, which means possibly less side effects.


When should I change my fertility treatment approach?


You may be doing IUIs, or you have done a number of IUIs, or tried intercourse with Clomid or whatever cycle it may be, and now you’ve reached a point where after doing a few of the cycles, one of the practitioners has suggested that you move onto IVF or an IUI injectable cycle, or something a little more invasive than you are used to.  While that decision can be a little challenging and kind of scary, there are good benefits to it as well.  The challenge comes when you are trying to discern whether it’s time to switch, a lot of emotions can arise.
A lot of our patients say that they feel anxiety, grief; a lot of those same original emotions that come from the diagnosis of infertility come up again.  What you’re doing is you’re delving a little further into the topic; you’re further acknowledging that you need some help to conceive.  You’re also further acknowledging that what you’re doing hasn’t necessarily been enough or been right in those cycles.  It’s OK to revisit those feelings of grief and those very basic emotions of anxiety, depression, and stress, just lack of confidence and unknowing, is very common to revisit those.
What you can do is when you’re approached with the idea or when you’re coming to the idea yourself of going onto the next step and you’re feeling those concerns and you’re wondering, “Maybe I should do another couple cycles of IUI, what I have been doing, to start to feel more confident, more ready to switch?”; you can place yourself in that situation.  If you’re discerning between IUI and IVF, place yourself in the situation of doing an IVF cycle.  How would you feel?  Would you be anxious?  Would you be excited?  Would you feel hope?  Would you feel like you didn’t do enough IUIs… maybe there’s still some opportunity there?  Try to really meditate on that for a few moments.  Write down your emotions, maybe see what your partner is feeling, if you’re in a relationship with a partner that’s going through this with you.   Just really try to place yourself in that position.  Try to recreate what that would be like.  Really just get in touch with those emotions.  Also, do the same thing with the IUIs.  If you were to continue doing another IUI cycle or two or three or however many, reassess those emotions as well.  Do you feel like you’re stuck in the same kind of cycle, repeating it over and over again?  Do you feel comfortable that you’re working towards a positive goal and that you’re confident that the treatment is right for you?
Assess your emotions in both areas and really look at them and see which one makes me feel most comfortable?  Which one makes me feel less anxious and less stressed?  Which one makes me feel like I’m moving most towards my goal?  That can be a good gauge for you to decide which way to go, and while this method isn’t foolproof, it isn’t 100 percent; it can give you a little bit of an idea as to when you’re going to make that decision or as you move towards it.  Also, know that you don’t have to make the decision immediately.  It’s always OK to take a break as long as you check with the physicians.  You don’t ever have to feel bad about that or that you’re missing time because it can help.  It can be beneficial sometimes the body, the mind, and the spirit need take a break.  Just take your time discerning what the next step is.
If you ever want to talk to us, you can.  You can always make a follow-up appointment if you want to just get into the office, have a practitioner open your chart up and reassess where you are, take a look at your previous cycles, and where you are physically and mentally right now, maybe come up with a new plan.  You could always call or e-mail me, I’m always able and willing to go through your options with you on more of an emotional level and just kind of help you talk through it and relay back what you’re saying.  It always helps to have a third person just to give you their perspective and just to hear what you’re saying and listen to you and give you some good advice.  So, please, feel free to contact us.  If you are feeling those emotions that you’re stuck between two decisions or protocols; don’t worry, you’re not alone.  There’s always someone here to give you support.


IUI with Clomiphene, a First Line Treatment for Infertility


This information is provided for couples who may just be starting out in fertility treatments and are trying to conceive using IUI with clomiphene. CNY Fertility Centers provide infertility services including low cost IVF (In Vitro Fertilization) for couples who are starting or continuing their families in Albany, New York, Rochester New York and Syracuse, NY. In addition to our local services we work with patients from across the country and world offering affordable IVF and fertility treatments.

Unexplained infertility is when a couple can’t conceive although the woman is ovulating, and her fallopian tubes, uterus and partner’s semen results come back normal after testing. Some of the women have had endometriosis diagnosed and treated, thus are not truly unexplained, but do fit into this category in terms of an approach for treatment.

Clomiphene is inexpensive, and acts in women who already ovulate to stimulate production of several eggs during a treatment cycle. Clomiphene causes the brain to misinterpret blood estrogen levels. This induces the pituitary gland to produce a surge of the follicle stimulating hormone or FSH. The result is the production of more than usual numbers of follicles, each with one egg.  Intrauterine insemination (IUI) places more sperm into the uterus and then the fallopian tubes than could ever reach through intercourse. Thus more bullets are shooting at more targets.

The combined use of clomiphene and IUI has been shown to nearly double the results compared to using clomiphene alone to improve pregnancy likelihood (Guzick, 1998). The master student of IUI, Dr Richard Dickey and colleagues in 2002 compiled a large series in New Orleans and reported almost 10% success per cycle.

The distinguished Boston IVF group in a study led by Dr. Alan Penzias recently confirmed a cycle success rate of 11.5% (Dovey, 2008) from over 4000 cycles of treatment. The patients were ovulatory and some of the men had low sperm counts.  The success of treatments cumulatively over up to four cycles, was successful in 24% of patients under age 35. Age specific pregnancy rates per cycle ranges from 12% under age 35 to 4% over age 40. Corresponding decreases in overall success were seen according to age. Only one patient was successful (1.8%) of the 55 women treated over 43 years of age.

The study verified findings by others who found that 90% of success is found in three or four cycles. Those who are not pregnant by then should move to gonadotropin and IUI or IVF therapy.

At RBA in Atlanta, Dr Massey and colleagues found that the addition of a chemical called PAF to the sperm wash dramatically improved success rates (Roudebush 2004) to nearly double those without it. This is a reasonably simple method which more clinicians might use.

Those who are concerned with cost effective treatment for infertility continue to believe that clomiphene and IUI are a good treatment for younger patients who are trying to conceive, and fit the criteria outlined.

Selected References
Dovey S et al Fertil Steril 2008:90:2281-86
Guzick, DS et al Fertil Steril 1998;70:207-13
Dickey RP et al Fertil Steril 2002;78:1088-95
Roudebush WE et al Fertil Steril 2004;82:52-56


Clomiphene Citrate


Clomiphene Citrate (Clomid)

Clomid citrate is commonly the first medication that is pre­scribed for patients who are unable to ovulate on their own with unspecified infertility in combination with insemina­tion. Women who have normal fallopian tubes, regular 28 day cycles, and partners with a normal sperm count, but are still experiencing infertility, are termed as having ‘unspecified’ infertility. The pituitary gland regulates the amount of FSH (follicle stimulating hormone) and LH (leutenizing hormone) in the system. These two hormones play a key role in ovulation. The levels of these hormones determine when and how many eggs are developed and re­leased. LH is responsible for the further maturation and re­lease of the egg(s).

Clomid citrate is an anti-estrogen medication. This means that it tricks the pituitary gland into thinking that the levels of estrogen in the body are low, causing the pituitary gland to secrete additional FSH and LH. This increase of FSH and LH stimulates the development of the follicles which contain the egg(s). Clomid citrate is taken as a pill, and is generally pre­scribed as one (50mg) pill each day for 5 days in the beginning of the menstrual cycle (days 3-7). A mature follicle is usually found around day 12 of the cycle. If ovulation does not occur, the medication can be changed to reflect the patient’s needs. Ultrasound is the best way to determine the number and maturity of the follicles. Ovulation predictor kits can be used to measure if there has been a surge of LH mid-cycle, indicating ovulation has occurred. Ovula­tion occurs about 24-28 hours after the detection of the LH surge in the urine. Once ovulation has occurred, natural or artificial insemination is performed in an attempt to fertilize the egg(s) that have been produced.


Reproductive Dysfunction


Hi this is Dr. Rob talking about reproductive dysfunction, infertility, the inability to conceive and recurrent pregnancy loss. All these things affect our ability to conceive and deliver a healthy baby.

A 20% delivery rate per month is normal. After one year it may drop down to the 5-10% per month range and after two years it may drop to 1-5% per month range, but it doesn’t drop to zero! Keeping at it, I’m finding, is the key to all of this and I believe that stress, anxiety and fear are some of the major causes of reproductive dysfunction.

I believe in treating the patient as a whole entity, not just treating their reproductive organs. The mind, body and spirit play a huge role in each person’s day to day wellness and quality of life. Incorporating things like yoga, meditation, acupuncture, and maya abdominal massage are some steps from eastern treatments which work toward healing and normal reproductive function. Certainly it’s also important to look at western medical treatments for things such ovulation failure, pelvic adhesions, endometriosis, tubal factors, uterine factors such as uterine fibroids or intrauterine adhesions and diminished ovarian reserve from age factor infertility. All these can all affect egg function and implantation.

Let us not forget the male and sperm factors. There are two important halves to healthy reproductive function, and sexual dysfunction for many of us, can begin with the very basic inability to come together at the right time. There may be an inability to deposit sperm in the right place. There is also the question that if the sperm is properly placed, is the semen of normal count, motility and function?

In reality it all comes down to function, even though everything looks normal, regular cycles every 28 days, a normal hysterosalpingogram that documents that the fallopian tubes are open and the uterus is normal. A semen analysis that documents that there are at least 20 million sperm with 50% motility and the morphology is fantastic and normal. It’s all about the function of our organs (including the brain!), and the gametes. With unexplained factor (idiopathic) infertility there are unknown components preventing conception. It could be a genetic or chromosomal issue, a immunologic factor or a hormonal issue. We can treat these all with eastern and western treatments. We should start with the mind in all of these. With visualizing exactly what we want, we want – a baby, a family. There is an instinctual natural drive for these things. We do harbor fear, anxiety, worry, regret, guilt and judgment. Through yoga, meditation, acupuncture, massage, herbs, support group, connecting positively with other women and sharing stories, often sharing our pain, we can let it go.

I believe that journaling each and every day, a simple five minute journal entry, is helpful. Just write down how you are feeling. Then continue with working on the positive mantras of the day with meditation, which is really important. It can help. Studies by Ali Domar, of the mind body institute at Boston IVF have shown an increased success for patients who included a mind-body-spirit regimen with fertility treatments. Randine Lewis has shown with eastern treatments, significant improvements in outcomes that often do not require shots or pills or surgeries, both for the male and the female.

The fertility evaluation should start with sharing your story with your practitioner, whether it’s a Reproductive Endocrinologist, an OBGYN, family doctor or a Traditional Chinese practitioner. Share your story, or even if it’s with your partner or friend, share your story. There is guidance, there is assistance there.

Some blood work may be important for both the male and female. Patients may benefit from testing hormone levels, looking at immunologic factors, karyotyping and chromosomal factors. Performing a hysterosalpingogram to look at the fallopian tubes and uterine patency can add to the diagnostic picture. A pelvic ultrasound can be performed to look at the uterus, ovaries, ovarian reserve and fibroids. Additionally a laparoscopy and hysteroscopy could be recommended. These are operative procedures to look into the woman’s pelvic organs and uterine cavity. Through these procedures we are able to look for adhesions which may affect the transport of the egg and sperm. Both hysteroscopy and laparoscopy are out patient procedures, often done in the office.
Endometriosis is an infertility factor which we believe is the implantation of the glands from the endometrial cavity, either coming directly out of the fallopian tube or just spontaneously growing on the reproductive organs, causing inflammation and scar tissue and sometimes diminishing ovarian reserve. Via the laparoscopy, endometriosis and adhesions can be removed and increase a couple’s odds of delivering a baby.

It may be that the cycles are regular, the fallopian tubes are open and the semen analysis is normal. It may be as simple as trying a few timed clomiphene citrate cycles with intrauterine insemination, which will bump your delivery rate from about 1-5% per cycle to 5-10% per cycle. There are some side effects from medications. Clomid has an anti-estrogenic effect and can often cause some emotional upheaval, some depression, anxiety, PMS type symptoms, or premenstrual syndrome.

There are many options available to couples experiencing infertility, both invasive and non-invasive, Eastern and Western, and each offers some benefit to the patient guiding them closer to parenthood. I believe that doing something is always better than doing nothing, especially when trying to create a family. For more information about any of our services you can call CNY Fertility Center and CNY Healing Arts and speak with our highly knowledgeable staff.
Have a spectacular day!
Dr. Rob


Ovarian Drilling


Ovarian drilling with laparoscopy is a technique which may help women who have Polycystic Ovarian Syndrome (PCOS) or Polycystic Ovaries (PCO) to ovulate normally, thus increasing their chances of pregnancy. Ovarian drilling is typically considered after several attempts at ovulation induction using clomid, or an insulin-sensitizing medication, such as metformin. Polycystic ovaries are generally smooth and pearl colored, and have many small immature follicles along the outside lining of the ovary. Women with either condition may have higher levels of testosterone in their bodies, which inhibits ovulation.
Ovarian drilling cauterizes the stromal theca cells in the ovary. The reduction of this testosterone-producing tissue leads to reduced testosterone levels in the body. Studies have reported that approximately 80% of women who underwent this surgery began ovulating regularly. Post surgery, women who did not regain ovulation, and were previously resistant to clomid citrate, were then more receptive to medical protocols. Pregnancy rates after ovarian drilling are reported as around 50%.
Ovarian drilling with laparoscopy is an out-patient surgery. Anesthesia is administered to the patient, and three small incisions are placed in the abdomen. The abdomen is inflated with gas to allow the physician to view the ovaries using a laparoscope. The drilling is done by cauterizing different parts of the ovary, and removing the unwanted tissue. The physician is able to explore the reproductive system during the laparoscopy, to determine if any additional issues may be present. When the procedure is done, a super glue-like adhesive is administered to the incisions, and the patient is able to go home to heal, after recovering from anesthesia.