Posts

6
Sep

Becoming an Egg Donor: The Home Stretch

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Diane (not her real name) has embarked on the journey of becoming an egg donor at CNY Fertility Center and will share her thoughts during the process in her blog here. If Diane’s journey and stories that she shares compels you to look in to becoming an egg donor we would love to get you started. The first step is to fill out our Donor Eligibility Questionnaire – click here to begin.
The Home Stretch:

I am now officially in my final week of becoming an egg donor. On Monday I had another routine appointment; blood draw and ultra sound.  The ultra sound showed the follicles were about 13-14mm.  The nurse predicted I’d be ready for my egg retrieval on Friday, but we’d wait until Wednesday’s appointment to confirm.  For the next two days I was instructed to continue the 300 units of the FSHs and also the Cetrotide (which prevents premature ovulating).

On Wednesday I returned for another check up.  The follicles were now about 16-18mm.  The doctor and nurse decided Friday would be too early for the retrieval and instead to plan on Saturday morning.  Wednesday I would administer the FSH and Cetrotide again. Thursday morning I was instructed to only take the FSH, and in the evening take the hormone that would now tell my body to ovulate.  Then on Friday I don’t have to take anything, but Saturday morning I am scheduled to be in the office first thing in the morning for the surgery.  I can’t believe I’m almost done!   What a process this has been, I can’t believe I’m in the final stretch already.  I hope over the next few days I continue to feel as good as I do now, to be side effect free and that they successfully retrieve lots of eggs for the recipient!
Sincerely,
Diane

30
Aug

Becoming an Egg Donor: Days 5-7

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Diane (not her real name) has embarked on the journey of becoming an egg donor at CNY Fertility Center and will share her thoughts during the process in her blog here. If Diane’s journey and stories that she shares compels you to look in to becoming an egg donor we would love to get you started. The first step is to fill out our Donor Eligibility Questionnaire – click here to begin.
Days 5-7:
Wednesday was Day 5 of being on the FSH.  I had a check up at CNY Fertility Center.  We started out the regular way, with a blood draw to check my estrogen levels and then an ultra sound.  The ultra sound was far more interesting on this visit.  The follicles were significantly larger and actually a measurable size.  They measured about 8mm, and the nurse explained that once they were about 18-20mm the egg inside would be mature.  She said the size of mine was right on track with where they should be.  I would continue with taking the recently increased dose of FSH unless they called to tell me otherwise.  She asked how I was feeling and if I was experiencing any side effects yet.  I am happy to report that so far so good.  I do not feel that my abdomen is swollen at all and I have yet to experience any PMS symptoms (physical or emotional).  My next appointment is set for Friday, which will be day seven of taking the FSHs.

Just returned from my Day 7 check up.  Had another blood draw and fascinating ultra sound.  The ultra sound showed a thickening of the uterine lining, which is normal and expected.  The follicles were measured and had now increased to 12mm.  Because they are getting close to maturing I was now going to also have a second shot.  This other injection, called Cetrotide, would prevent my body from prematurely ovulating.  The nurse gave me my first injection of the Cetrotide while I was there.  This is also given around the belly button area.  I have to admit, this injection did sting more than the shot for the FSHs.  For the next two days I have to administer both the FSH and the Cetrotide to myself, then I have another appointment on Monday.   I am happy to report that I am still  side effect free, although the nurse said as my estrogen increases the PMS type side effects may still kick in.
This continues to be such an amazing experience.  I am learning so much and gaining a lot of perspective on what it means to couples creating families.  Just being an egg donor is an involved process and big commitment, I can only imagine what the recipient must also go through.  Again,  I am humbled by the dedication and perseverance of couples experiencing infertility and of the fertility staff guiding them on this journey.
Sincerely,
Diane

23
Aug

Becoming an Egg Donor: Stimulating!

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Diane (not her real name) has embarked on the journey of becoming an egg donor at CNY Fertility Center and will share her thoughts during the process in her blog here. If Diane’s journey and stories that she shares compels you to look in to becoming an egg donor we would love to get you started. The first step is to fill out our Donor Eligibility Questionnaire – click here to begin.
Stimulating!
Since my last appointment I have started taking the Follicle Stimulating Hormones.  I am currently on Day 3 and had another appointment today.  Let me first tell you about taking the FSHs.
The nurse explained how to give myself an injection at my last appointment.  I don’t think of myself as a squeamish person so I thought this would be no problem.   But I have to admit, giving myself that first injection was more challenging (mentally!) than I had anticipated.  When a nurse gives you a shot, they chat with you, and usually I look away so I don’t see what she’s doing.   They can distract you and it’s usually over before you even realize they’ve done it.  It’s impossible, I quickly realized, to distract yourself when you are the one giving the injection, to yourself.  The anticipation was worse than anything.  I had to psyche myself up way more than I thought.  After a deep breath and a big ONE, TWO, THREE! I realized the injection itself was painless.  As I said, the mental anguish and anticipation was way worse than the actual shot.  I felt sort of foolish afterwards for making such a big deal out of, what turned out to be, nothing!  The area of the injection (right around my belly button) was just a tad tender for a few minutes afterwards, but as of yet I am not experiencing any side effects.  So, now that I’m on Day 3, I fancy myself the injection expert and no longer torture myself with anticipation beforehand.
I felt quite proud of that as I walked into my check up today.  The nurse drew blood again.  But just one vial today instead of 4, which was what they drew the previous two visits.  She told me that depending on the results of the blood test today they may increase or decrease the dosage of FSH that I’m currently taking.  Then the second nurse came in to do the ultra sound.  The ultra sound showed that there were indeed follicles and she said they looked good.  Then we set up appointments for two days out, four days out, and seven days out.
The nurse did end up calling me a couple of hours later to tell me that we did need to increase the dosage of FSH by 75 units.  Although the follicles did look good my estrogen levels were still a bit low.  I would take the new increased dosage and see how things looked at my next check up in two days.
This entire experience is so educational.  I feel as if I’m taking an advanced biology course; learning about estrogen levels, follicles, injections, dosages of hormones, etc. and all within my own body!  Each day is a new fun experience and I eagerly await each new part of becoming an egg donor!
Sincerely,
Diane

14
Jun

Fertility Drugs: A Quick Overview of Gonadtropins

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The term gonad describes an organ that produces sex cells (or gametes) such as sperm or egg. Thus, a woman’s ovaries and a man’s testes are both called gonads. Gonadotropins are hormones secreted by your pituitary gland that stimulate the growth and activity of your gonads. Therefore, these hormones play a part in egg and sperm production, as well as the development of physical traits like your voice, muscle, hair and breasts.
Your body naturally produces two kinds of gonadotropins: follicle-stimulating hormone (FSH) and luteinizing hormone (LH). These hormones are necessary for ovulation – the production of eggs. A woman may naturally have low hormone levels and be unable to ovulate. To boost hormone levels, a patient undergoing fertility treatment is often given scheduled injections of gonadotropin fertility drugs.
There are three classes of these fertility drugs: human menopausal gonadotropin (hMG), recombinant human follicle-stimulating hormone (rFSH), and human chorionic gonadotropin (hCG). hMG contains natural amounts of FSH and LH, while rFSH is created in the laboratory. Both are used to aid in the development of eggs. Once this happens, hCG acts similar to LH and is used to stimulate ovulation.
Right now you’re probably wondering how the heck to process all of these names, so let me break it down for you. Without enough FSH and LH, a woman cannot ovulate properly and requires hormone supplements like hMG, rFSH and hCG. Unfortunately, when you are prescribed one of these supplements, it won’t go by its generic name, but by a specific brand name. The most commonly used hMG is Bravelle or Repronex, rFSH is Follistim or Gonal-F, and hCG is Novarell, Ovidrel or Pregnyl.
These hormone supplements are often used in combination with other fertility treatments such as in vitro fertilization or intrauterine insemination. For more information on the process of using gonadotropins, click here. For more on the side effects of using gonadotropins, click here.

25
Nov

The high cost of increasing age and FSH in IVF treatment

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This article is provided for patients who are trying to conceive and have concerns regarding the potential cost- effectiveness of IVF. It is written for patients who have an understanding of the basic concepts being discussed. For explanation of the significance of FSH values, please see articles on this website on IVF and prognosis, and low response. At CNY Fertility Centers, access to care is a concern addressed by offering low cost IVF options in Syracuse, New York, Rochester NY and Albany NY.

The age of a woman who is trying to get pregnant with IVF and her ovarian reserve as reflected in day 3 FSH values are good predictors of IVF outcomes. Henne and colleagues at Walter Reed Hospital and the NIH evaluated 1238 first IVF cycles of women between age 26 and 42 years and an FSH level of <13 miu/ml.  A cost analysis was applied and focused on these patients who by normal standard were good prognosis. Patients need to understand that statistics for overall success even with a specific age group may not apply if the FSH is higher than 12 as results would be even worse. At a cost of $10,803 per cycle costs soared to over $100,000 per baby born as FSH and age of the patient increased over age 38-39.
This is not surprising as Voorhis had estimated cost per baby of $89,981 for patients over 38. Trad calculated the cost to be about $75,000. Neumann, who used very low success rates estimated that in low prognosis patients, costs per baby could be as high as $800,000.

For comparison and for patients concerned about the high cost of donor egg treatment the delivery rates of the alternative must be considered. At a cost of $25,000 per cycle, and delivery rate of 51%, the cost per baby is $49,000. These costs will be dropping rapidly as egg banking becomes widely available. As a woman’s predicted delivery rate falls below 10%, the donor egg option becomes favored treatment economically. CNY Fertility Center offers multiple options to make IVF and donor eggs more affordable including a refund program for IVF and donor egg IVF, 0% financing, six cycle discount program, and Fall IVF specials.

References:
Henne, MB et al The combined effect of age and basal FSH on the cost of live birth at assisted reproductive technology Fertil Steril 2008; 89:104-10.
Neumann, PJ Johanesson M The willingness to pay for in vitro fertilization: a pilot study using contingent valuation. Med Care 1994; 32: 686-99.
Trad, FS et al In vitro fertilization: a cost effective alternative for infertile couples? J Assist Reprod Genet 1995; 12 418-21.
Van Voorhis BJ et al. Cost effectiveness of infertility treatments. Fertil Steril 1997; 67:830-6

12
Nov

IVF and Antral Follicle Count

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This information is provided for patients interested in their prognosis for infertility treatment. CNY Fertility Center in Syracuse NY, Albany, NY and Rochester, NY provide consultations, and treatments for couples trying to conceive.
The number of follicles, each containing one egg, which are available in the ovarian pool relates to the chance of success of In Vitro Fertilization (IVF). These numbers decline with age, and in some women decline abnormally fast. For couples who are trying to conceive and their care givers, methods of predicting the potential outcome of IVF can be important in making medical decisions.

One important tool for measuring the ovarian pool is a direct measure of the follicles as they emerge in a given month. The number of small follicles in the ovary during a menstrual period are observed using ultrasound. At this point there are no large follicles, and the pool of follicles which will emerge that month are beginning to grow. As the fluid accumulates, even a few milliliters (a teaspoonful is 5 ml) of fluid in the antral follicle can produce a measurable echo on the highly sensitive ultrasound machines used for transvaginal evaluation of the ovaries. Follicles between 2 and 5 mm can be visualized and counted. The antral follicle count (AFC) must be done when the follicles have not begun to grow. Thus it is scheduled day 2, 3 or 4 of the cycle prior to considering IUI or IVF therapy. Since there is not a huge variation from month to month, this test can give a good idea of the prognosis for the future.
antral follicle
Antral Follicle from www.DKImages.com
antral follicle ultrasound
Ultrasound image of antral follicles from www.healthline.com
Because not all of the follicles can be visualized , after stimulation by clomiphene or injectable gonadotropins, the number of follicles which eventually develop may be higher that the number of antral follicles in that particular cycle.

In a review of studies, Verkagen has concluded that the AFC is as good as any of the biochemical tests to determine ovarian reserve. In IVF treatment, if the AFC is less than 4, there is a much lower rate of successful pregnancies. Since this cut off is so low, this limits the value of the test. How high can it go? Egg donors or young infertility patients might have an antral follicle count of 17 or more. The typical mid-30 year old infertility patient will have 5-10 antral follicles. Sometimes in women with low ovarian reserve it is tempting to try to find a cycle with more antral follicles in order to get a slightly better result. However, there is low variability of the AFC from month to month (Jayaprakasan 2008) so waiting for another month is not likely to change much.

More indirect biomarkers of ovarian reserve include serum FSH, day 3 estradiol levels, inhibin B and anti-Mullarian hormone. These tests of ovarian reserve are covered in the section on IVF prognosis on this web site. In practice all available information is used for prognosis. Thus, the AFC is used in conjunction with the indirect tests of ovarian reserve.
For additional information and opportunities to get involved in infertility chat rooms, visit CNY Fertility Center’s patient discussion forums for medical questions or support.

Selected References
Verkagen et al Fertil Steril 2008
Jayaprakasan, K et al. Establishing the intercycle variability of ultrasonographic predictors of ovarian reserve. Fertil Steril 2008;90:2126-2151.
Edited by JBM on 9-26-09

IVF and antral follicle count.

This information is provided for patients interested in their prognosis for infertility treatment. CNY Fertility Center in Syracuse NY, Albany, NY and Rochester, NY provide consultations, and treatments for couples trying to conceive. For a glossary of terms please refer to www.fertilitylifelines.com

The number of follicles, each containing one egg, which are available in the ovarian pool relates to the chance of success of in vitro fertilization (IVF). These numbers decline with age, and in some women decline abnormally fast. For couples who are trying to conceive and their care givers, methods of predicting the potential outcome of IVF can be important in making medical decisions.

One important tool for measuring the ovarian pool is a direct measure of the follicles as they emerge in a given month. The number of small follicles in the ovary during a menstrual period are observed using ultrasound. At this point there are no large follicles, and the pool of follicles which will emerge that month are beginning to grow. As the fluid accumulates, even a few milliliters (a teaspoonful is 5 ml) of fluid in the antral follicle can produce a measurable echo on the highly sensitive ultrasound machines used for transvaginal evaluation of the ovaries. Follicles between 2 and 5 mm can be visualized and counted. The antral follicle count (AFC) must be done when the follicles have not begun to grow. Thus it is scheduled day 2, 3 or 4 of the cycle prior to considering IUI or IVF therapy. Since there is not a huge variation from month to month, this test can give a good idea of the prognosis for the future.

secondaryFollicle-thumb.jpg

Antral Follicle from www.DKImages.com

antral healthline .com

Ultrasound image of antral follicles from www.healthline.com

Because not all of the follicles can be visualized , after stimulation by clomiphene or injectable gonadotropins, the number of follicles which eventually develop may be higher that the number of antral follicles in that particular cycle.

In a review of studies, Verkagen has concluded that the AFC is as good as any of the biochemical tests to determine ovarian reserve. In IVF treatment, if the AFC is less than 4, there is a much lower rate of successful pregnancies. Since this cut off is so low, this limits the value of the test. How high can it go? Egg donors or young infertility patients might have an antral follicle count of 17 or more. The typical mid-30 year old infertility patient will have 5-10 antral follicles. Sometimes in women with low ovarian reserve it is tempting to try to find a cycle with more antral follicles in order to get a slightly better result. However there is low variability of the AFC from month to month (Jayaprakasan 2008) so waiting for another month is not likely to change much.

More indirect biomarkers of ovarian reserve include serum FSH, day 3 estradiol levels, inhibin B and anti-Mullarian hormone. These tests of ovarian reserve are covered in the section on IVF prognosis on this web site. In practice all available information is used for prognosis. Thus, the AFC is used in conjunction with the indirect tests of ovarian reserve.

For additional information and opportunities to get involved in infertility chat rooms, visit CNY Fertility Center’s patient discussion forums for medical questions or support.

Selected References

Verkagen et al Fertil Steril 2008

Jayaprakasan, K et al. Establishing the intercycle variability of ultrasonographic predictors of ovarian reserve. Fertil Steril 2008;90:2126-2151.

Edited by JBM on 9-26-09

9
Nov

Considering Infertility Treatments

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This information is provided to patients concerned with the issue of fertility. This problem affects up to 15% of all couples, and more often among women over the age of 34. CNY Fertility Center offers services in Albany, Syracuse, and Rochester, NY. CNY Fertility Center provides a range of diagnostic services. All treatment options are offered including IVF in a low cost setting.

If you are considering treatment in trying to get pregnant, you may be in discussion with your medical staff regarding your specific prognosis (diagnosis) or chances of success. In all situations the individual patient is a major factor in the outcome possibilities. For example after IVF, younger, good prognosis patients will often have extra high quality embryos which can be frozen. This gives them a low cost second chance at another pregnancy through the use of frozen embryos. Low prognosis patients rarely have extra embryos to be frozen.

The couple entering IVF treatment will be involved in an intense daily journey, and expectations for their outcome need to be realistic. The most important fact is to remember that assisted reproductive technology (ART) offers the highest chance for pregnancy. Typical monthly spontaneous pregnancy rates among infertile couples may be as low as 2% per cycle. For some couples, even low prognosis rates of 5-10% are an improvement on Mother Nature. IVF and related variations are available because of intense investigations in the field by many laboratory and clinical scientists since the mid 1970’s. All of this knowledge is available to help you in this journey. Success rates in one month can approach 40-50%, in the best circumstances.

Beginning ART treatments can be compared to watching the effects of rain in the desert. Most of the year the desert is harsh and dry and its beauty is subtle. Yet after a rain, many cacti and succulents bloom with colorful flowers in order to attract pollinating insects or birds. Awareness of the specific odds of success for the couple will be helpful emotionally.

The prognosis will be discussed with you by your doctor. This will relate to the data available in your situation, which predict the number of eggs and embryos which will be produced. More eggs and embryos translate to improved success. Lower numbers often parallels lower quality eggs and embryos as well. The most difficult problem is the positive pregnancy test that occurs in the low prognosis patient who also faces pregnancy loss rates as high as 50%.

The prognosis will determine the dosage of medications used in conventional IVF. It will also indicate if a cycle may need to be canceled. When the patients response is lower than expected it may be advised that treatment cease and another attempt be made. Overlain on all of the emotional stress are the financial aspects of the possible cost of multiple attempts to conceive.
Advanced age is well known as the major adverse factor, but since the average age of patients considering IVF is in the mid 30’s it is part of the reality for many of them. The age of the female partner generally reflects the quality of the eggs.

Other factors can be considered in making a prediction of level of success. The most time tested method of determining the prognosis for IVF or IVM is a consideration of a combination of the age of the female partner and certain hormone levels measured during the menstrual period. The serum estrogen levels can be elevated and will suppress the FSH and lead to a falsely low reading of the FSH level. The normal levels of estradiol, the dominant estrogen, are below 65 to 80 pg/ml.
FSH levels gradually rise as a woman nears menopause. The FSH level is the measurement is most often done on day 3 of the cycle, but may be done on day 2-4 and achieve the same results. Ideally this level in many centers is below 10 miu/ml, but this cut off number varies.

None of the studies on FSH have been able to identify an absolute value for prognosis, according to analysis of 21 studies (Bancsi, 2003). The upper end of normal is often stated to be 10 miu/ml but may range up to 15. This will vary from lab to lab. Thus your doctor cannot tell you exactly where you fit. In discussing prognosis, most often patients find themselves to be in a gray area. The higher the number is, the darker the shade of gray. Older women who have high FSH can be more certain that this test is spelling trouble. A fair number of younger women with high FSH can do well and conceive with IVF. The FSH is most predictive of the number of eggs available and less predictive of their quality.

Research into more direct assessment of the number of eggs in the ovaries has come to the forefront. The hormones inhibin and AMH have been correlated with IVF outcomes in pregnancy or embryo quality. All these complex measurement have been factored into an index by Reprosource. This Ovarian Reserve Index uses all the biochemical markers discussed, considers the age of the woman and distills the data down to one number. It is the least variable from month to month and if combined with the AFC should be the most reliable guide to prognosis.
There are a number of other measures which have been applied and depending on the doctors and clinics may or may not be used in your case. The clomiphene challenge test is an extension of the effort to identify women who have elevated FSH values. This is addressed in a separate article on this website. Ultrasound measures of antral follicle count and more recently, ovarian volume have been helpful.

These other measures of prognosis will be discussed separately and if interested you may click onto these sections.
The cost of IVF therapy for a woman age 35 can be estimated according to her FSH level. The cost of a live birth was estimated in 2002 at $28000 if the FSH was under 10 IU/L and $37000 if over that number. At age 42 with normal FSH the cost was estimated at $122,000 and $309,000 if over 10 IU/L. The numbers would be higher today, but the relationships would be similar. Low cost IVF options are needed for women in the lower prognosis category as well as the young ones.

Previous stimulation – If a patient has been through gonadotropin therapy for IUI or in a previous attempt to conceive by IVF, her doctor has the best possible predictor of her response in subsequent treatment. All bets are off once the number of follicles is counted and the numbers of eggs and embryos are available, then the predictor tests take a back seat to the reality show. How do these ovaries respond under pressure? Once this is established, the numbers mean less.

Selected referencesBancsi et al. Fertil Steril 2008
Sun W et al. A new approach to ovarian reserve testing. Fertil Steril 2008; 90: 2196-2201
Wunder Dm et al. AMH and inhibin B as predictors of pregnancy by IVF ICSI. Fertil Steril 2008; 90:2203-09
Jbm rev 9-22-09

11
Sep

Clomiphene Citrate

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Clomiphene Citrate (Clomid)

pills
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.

25
May

All About Injectables

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Injectable medications are used for IVF or IUI cycles. One of the main processes in an IVF or IUI treatment cycle is the controlled stimulation of the ovaries, to produce eggs. The medications used in ovulation induction are called gonadotropins. Brand names include Follistim, Gonal-F, Menopur, Bravelle, and Repronex. Gonadotropins are primarily used to treat two types of women: 1) those who do not ovulate, ovulate irregularly, or have failed to conceive using Clomiphene citrate (Clomid) and 2) women who ovulate on their own, but may need help in producing multiple eggs, and whose bodies would benefit from the enhanced hormonal environment.
How do they work?
Gonadotropins are natural hormones that trigger the ovaries to make eggs. They are generally safe to use, but do require experience and careful monitoring.In a natural menstrual cycle without any medications, a woman produces one or two follicles, which are fluid filled sacs that contain an egg. The growth of the eggs and their release from the follicles are influenced by the secretion of two hormones from the pituitary gland: Follicle Stimulating Hormone (FSH); and Luteinizing Hormone (LH), both known as gonadotropins.When a woman becomes menopausal, her pituitary gland secretes large amounts of these hormones in an attempt to stimulate the ovaries, which no longer function. Gonadotropins (other than Follistim and Gonal F) are manufactured by extracting FSH and LH from the urine of post-menopausal women. Menopur contains both FSH and LH, while Bravelle contains only FSH.For a woman going through infertility treatments, these extracts must be injected and cannot be taken orally, because they would be digested by the stomach.Recently, gonadotropins (Gonal-F, Follistim) have been manufactured in the laboratory using recombinant technology, which allows a pure form of FSH to be produced. This is not a human tissue or urinary by-product, it is a recombinant FSH. Since it is more pure, it may be self-injected, using a small needle just under the skin.