Infertility Treatments > Medical > Gonadotropins

THE GONADOTROPINS: Menopur, Bravelle,Repronex, Follistim and

Gonal-F

Menopur, Bravelle,Repronex, Follistim and Gonal-F are collectively known as gonadotropins. Menopur and Repronex are formulations of  LH and FSH, while Bravelle, Follistim and Gonal-F are FSH alone. For purposes of discussion, these hormonal preparations can be grouped together as the gonadotropins. There is very little difference in their action, and they can essentially be used interchangeably. We do, however, believe that there is a crucial role for LH. There is ever-increasing data to support this contention and we do, therefore, use predominantly Menopur as it contains both FSH and LH. This is particularly true when using GnRH agonists and antagonists, such as is typically done during ovulation induction for IVF.

The gonadotropins function by directly stimulating the ovaries. The pituitary normally produces FSH and LH to stimulate the ovaries; by using the gonadotropins, this level of stimulation is directly increased.

Gonadotropins can be used alone or in combination with a GnRH agonist (see below). Administration is begun between day three and five of the cycle and usually continued for a total of five to nine days depending upon the response. One of the primary goals of gonadotropin therapy is to induce multiple-egg development. The ovulation of multiple eggs and the resulting production of higher hormone levels explain the conception rates associated with the use of gonadotropins. Whereas the use of clomiphene typically results in the production of only one or two eggs, gonadotropins can induce any number of eggs to develop, from a couple all the way to thirty or more. Their use must, therefore, be carefully monitored and supervised by a physician familiar and comfortable with their use.

Monitoring Gonadotropins
The response to the gonadotropins is usually monitored with a combination of estradiol levels and pelvic ultrasounds. The ultrasounds allow the physician to see the number of follicles and eggs that are developing. When a follicle reaches a certain size, around eighteen millimeters in diameter, the likelihood is greatest that the egg contained therein is mature. Thus, we can get not only a good indication as to the maturity of the follicles and eggs, but ultrasounds also provide a very clear picture of how many are mature and capable of ovulation. The estradiol levels also give some indication as to the health and well-being of the developing follicles. When the follicles are mature size, hCG is given and ovulation will occur thirty-six to forty hours later. 
In contradistinction to clomiphene which works by tricking the pituitary to increase its stimulation of the ovaries, the gonadotropins act directly on the ovaries. Rather than any type of antiestrogen effect, therefore, estradiol levels and the effects of estradiol are actually dramatically increased with the gonadotropins. For example, the gonadotropins enhance rather than impair cervical mucus production. 

Risk Factors of Gonadotropins
There are relatively few side effects associated with the gonadotropins. Aside from the emotional roller coaster that all couples experience while attempting to conceive, there are no significant emotional side effects associated with the menotropins. The two most frequent problems are enlarged ovaries and multiple births. It is normal for the ovaries to be enlarged after the use of the gonadotropins; we have, after all induced three or four (and sometimes more) eggs to develop and ovulate.  Most of the symptoms associated with this enlargement occur after ovulation, during the luteal phase when three or four corpora lutea (plural of corpus luteum) are actively producing progesterone. Simply decreasing one's activity level is all that is usually necessary.  In more severe cases, hyperstimulation may occur.

Multiple Pregnancies. Anyone initiating treatment with the gonadotropins must realize that multiple pregnancy is a possibility. Twin pregnancies occur as frequently as twenty percent of the time in women who conceive on gonadotropins.  And everyone has heard the stories of women who have conceived far more than twins.  However, higher order multiple pregnancies (triplets or more) don't have to be a significant risk to women on gonadotropins. Remember, the response to the gonadotropins is monitored with ultrasound. The number of  follicles and eggs that are developing can be seen prior to giving hCG to trigger ovulation. If an unacceptable number of follicles develops, we simply don't give the hCG; ovulation doesn't occur and the cycle is wasted, but a canceled cycle is better than a litter! There is no hard and fast number that constitutes an acceptable number of follicles. That depends on many factors including the number of previous attempts, age and other factors involved. This is why one should have an expert monitoring their cycle, so these types of information can be considered and carefully thought out decisions made.

Ovarian Cancer.  There has been some concern raised that the use of the gonadotropins is associated with an increased risk of developing ovarian cancer. This issue has been very carefully evaluated, and the data does not support such an association. It does seem that there may be a group of women with ovulatory dysfunction who are at increased risk of developing ovarian cancer with or without treatment. However, for the average women using gonadotropins, there is no evidence that this use is associated with an increased risk of ovarian cancer.

Other Considerations
The two major drawbacks to the gonadotropins are expense and the fact that they must be administered by injection. These hormones are very expensive, and one cycle can cost as much as $1,000 or more.  Secondly, all of these hormonal preparations much be administered by subcutaneous injection.

There is little if any reason to record a BBT chart while on the gonadotropins. All of the other monitoring provides more than enough information about the cycle. Progesterone levels are also checked during the luteal phase, and the length of the luteal phase is easily determined since the time of ovulation is known. All of this data provides more than enough information about the adequacy of the cycle.

The gonadotropins should only be used every other month at most.  It is simply too much for the ovaries to use them every month; the ovaries need at least a month in between to recover. There is a lot of debate as to what is the maximal number of cycles one should attempt with the gonadotropins, but suffice it to say that the chances of successful conception make it hard to justify more than three attempts in most situations. If conception has not occurred within three attempts, an ART procedure should be considered.

© 2005 Jarrett Fertility Group