Fertility Medication Reference Guide

Published: 12/14/2015

This is a quick reference guide for the medications used at Arizona Center for Fertility Studies for your treatment cycles. It includes information on:

• which medications need to be refrigerated
• when to start and stop your medications during a cycle
• and some of the over-the-counter medications you may use when you become pregnant.

If you are not 100% sure what to do and if you still have questions, it is STRONGLY recommended that you call us ANYTIME at (480) 860-4792 (if after hours, push the number 2 when asked).

REFRIGERATED FERTILITY MEDICATIONS

There are some fertility medications that when purchased need to be refrigerated right away to preserve the potency and/or longevity of the drug. This list includes the following:

• Lupron

  Lupron or Leuprolide-full strength and microdose (this medication already comes pre-mixed by the pharmacy)

• Growth Hormone, HGH

  Growth Hormone, HGH, also known as Tevtropin or Protropin. This medication comes in boxes with a single vial of powder and a single vial of water that need to be mixed to provide you with 3 days' worth of medication per each vial of the drug. This is done by mixing 3cc's or 3mls of water (to the "3" mark on the syringe) to the entire powder and injecting yourself with 1cc or 1ml (to the "1" mark on the syringe) of the medication into your hip. Remember to always refrigerate all MIXED and UNMIXED vials of this drug.

• Progesterone

  Progesterone Suppositories come premade from the pharmacist. They are "waxy" in texture and will melt or stick together if not refrigerated.

• hCG

  hCG, also known as human chorionic gonadotropin, Ovridel, Pregnyl or Profasi, is used to trigger ovulation. When the full dosage of 10,000 units is reconstituted by mixing the entire vial of the powder with 2cc's or 2mls of the water (to the "2" mark on the syringe), the entire dissolved solution is given IM into the hip muscle, and no refrigeration is needed. If you are instructed by a staff member at Arizona Center for Fertility Studies to do a "booster" shot of hCG after a timed intercourse or IUI cycle, in which you stimulated the ovaries with HMG (Human Menopausal Gonadotropins), the dosage is 5,000 units IM and can be given at any time of the day exactly one week after the trigger shot was done. Not always is hCG available in 5000 unit vials, so many patients will purchase a 10,000 unit vial and reconstitute it as noted above and will then inject ½ of the amount or 1cc IM into the hip muscle. This will leave ½ the dosage or 5,000 units (1cc or 1ml) in the reconstituted vial, which can be dated and placed in the refrigerator for up to one month for use later if you have not conceived on that cycle and wish to try another cycle the following month.

• Follicular Stimulating Hormone

  Follicular Stimulating Hormone or FSH is also known as Follistim, Gonal–F, Bravelle, Urofollitropin, or Fostimon. All unmixed vials can be stored at room temperature. If you have purchased either Follistim AQ or Gonal-F AQ cartridges for use with the pen, they need to be kept refrigerated at all times. Once the cartridge is punctured after the first injection, it remains good for one month under refrigeration, and then it should be discarded. There are also multi-dose vials of some of the above brands of FSH available. Once a vial is reconstituted for use (the powder is mixed with the solution), it must be refrigerated.

FERTILITY MEDICATION TIME TABLE

• Prenatal Vitamins

  Prenatal Vitamins that contain folic acid and omega 3-fatty acids or DHA should be started when you are beginning the process of actively conceiving. They should continue throughout the pregnancy. Folic acid helps to decrease the incidence of birth defects and spina bifida by 50%. The omega 3-fatty acids help to improve brain and eye development and maximize fetal growth.

• Baby Aspirin

  Baby Aspirin 81 mg Tablets should be started when you are beginning the process of actively conceiving. They should be taken daily through 34 weeks of pregnancy. They are used to decrease the stickiness of platelets and to increase uterine blood flow.

• Parlodel

  Parlodel or Bromocriptine should be started when advised by Arizona Center for Fertility Studies. It is used to treat elevated prolactin levels.

• Progesterone Injections

  Progesterone Injections start prior to embryo transfer and continue to the 12th week of pregnancy unless otherwise directed by your doctor.

• Crinone 8% Gel

  Crinone 8% Gel starts prior to embryo transfer and continues to the 12th week of pregnancy unless otherwise directed by your doctor.

• HMG (Human Menopausal Gonadotropins)

  HMG (Human Menopausal Gonadotropins), also known as Repronex, Menopur, and Lepori, is started on the morning of day 3 and is continued until you are advised to stop. This is usually when the follicles reach a cumulative size of 16, 17, or 18mm's. This medication is a combination of your body's natural hormones FSH (Follicle Stimulating Hormone) and LH (Luteinizing Hormone) and is used to make 2-4 egg follicles, in low dosage for IUI, and in higher dosage for IVF to stimulate the ovaries to make multiple follicles.

• FSH (Follicle Stimulating Hormone)

  FSH (Follicle Stimulating Hormone), also known as Bravelle, Follistim, Gonal F, and Fostimon, is started in the evening of day 3 and continued until you are advised to stop. This is usually when the follicles reach a cumulative size of 16, 17, or 18mm's. This medication is one of the body's natural hormones and is used to stimulate the ovaries to make multiple follicles.

• Human Chorionic Gonadotropin (hCG)

  Human Chorionic Gonadotropin (hCG), also known as Profasi, Ovridel, and Pregnyl, is given when advised by Arizona Center for Fertility Studies to "trigger." It is given at a specific time to cause the exact timed release (ovulation) of the oocytes (eggs) from the follicles. It allows the oocytes in the follicles to undergo the final maturation process before being released from the ovaries. It also gives us a specific window of when ovulation will occur so that timed intercourse, IUI, or Transvaginal Aspiration of Eggs can be performed.

• Human Growth Hormone

  Human Growth Hormone, also known as Tevtropin, Protropin, and Serostim, is given in the AM's starting on day 1 or 2 of a stimulated cycle. It is continued until advised by Arizona Center for Fertility Studies to stop. This is usually on the day that we decide you are ready for "trigger." It is used to help potentially improve oocyte quality.

• Metformin or Glucophage

  Metformin or Glucophage is a medication that is started after confirming insulin resistance. This is done by a simple fasting blood test that measures the ratio of glucose to insulin. The dosage of the medication ranges from 500mg Bid to 1500mg Tid. It is taken daily as directed and is discontinued when you become pregnant. It helps to allow for better stimulation with fertility medications.

NEEDLE AND SYRINGE GUIDE

The following medications are given subcutaneously (SQ) with BD Ultrafine Insulin Needles:

• Lupron or Leuprolide
• Micro Lupron
• Heparin

The following Medication is given subcutaneously (SQ) using the Pre-filled syringe it is supplied in:

• Antagon or Ganirelix

The following medications are given intramuscularly (IM) using a 3cc syringe with an attached 23gauge 1½ inch needle. An 18gauge 1½ inch needle is first attached to the 3cc syringe to draw up and mix the medication. The 23gauge 1½inch needle is then reattached to the 3cc syringe, and injected into the muscle:

• Human Chorionic Gonadotropin (HCG), Profasi, Pregnyl, Profasi, Ovridel
• Human Menopausal Gonadotropin (HMG) Menopur, Repronex, Lepori
• Follicular Stimulating Hormone (FSH), Bravelle, Gonal F, Fostimon
• Human Growth Hormone (HGH), Tevtropin, Protropin, Serostim

The following medication is given intramuscularly (IM) using a 3cc syringe with an attached 22gauge 1½ inch needle. An 18gauge 1½inch needle is first attached to the 3cc syringe to draw up and mix the medication. The 22gauge 1½ inch needle is then reattached to the 3cc syringe and injected into the muscle:

• Progesterone in oil

The following medications are given subcutaneously (SQ) using prefilled aqueous cartridges. They are administered by using a Pen device provided by the manufacturer:

• Follistim or Gonal F

MEDICATIONS YOU CAN TAKE IN PREGNANCY

In pregnancy, Category B medications have been shown to have no adverse effect on the fetus. Category C and D medications are associated with an increased risk of birth defects, category D being much worse than C. Before taking any prescription medications, consult either Arizona Center for Fertility Studies or your obstetrician/provider first. With any prescribed medication, you need to weigh the risks versus the benefits of continuing to take the medication. You should always consult with the prescribing physician to see if there are other medications you can take instead, or if you can safely go off the medication during the pregnancy.

Over-the-counter medications are generally safe to take during treatment and in pregnancy, but make sure to read the label first, and if there are any questions or doubts, please call Arizona Center for Fertility Studies before taking any medications.

Antibiotics that can be taken during pregnancy:

• Amoxil (Amoxicillin)
• Ampicillin
• Augmentin
• Bicillin L-A (Penicillin)
• Ceclor CD
• Ceftin
• Cleocin (Clindamycin)
• Ery-Tab (Erythromycin)
• Flagyl (Metronidazole)
• Keflex (Cephalexin)
• Macrobid (Nitrofurantoin)
• Macrodantin (Nitrofurantoin)
• Zithromax (Azithromycin)

HEALTHY START: RECOMMENDATIONS FOR PREGNANCY

"Arizona Center for Fertility Studies wishes you a healthy, safe, and wonderful pregnancy and delivery! It was our pleasure to assist you in achieving your most cherished dream. Please come by and show off your new "miracle of love and science" when your life calms down. We would love to see you all. Wishing you both all the love and joys of parenting."

— From all of us at Arizona Center for Fertility Studies.

Congratulations, You're Expecting!

From now until you deliver, you should be nourishing yourself and your developing baby by keeping a healthy and balanced diet, taking time to relax, and maintaining your physical health. Below are some recommended guidelines:

Nutrition

What you eat supplies the nutrients your baby needs to develop, so it is crucial to eat regularly, at least three nutritious meals and two healthy snacks a day. Your daily diet should include a balanced diet of grains, vegetables, fruits, milk products, and proteins.

The United States Department of Agriculture's website offers a great program that will help you construct a personalized food pyramid according to your daily dietary needs during pregnancy:

We recommend the following nutrition guidelines:

• The United States Public Health Service recommends that pregnant women take a prenatal vitamin or a multivitamin supplement daily that contains 400 mcg (0.4 mg) to 1000 mcg (1mg) of folic acid. Women in intermediate to high-risk categories for neural tube defects should take 4000 mcg (4 mg) to 5000 (5 mg) of folic acid daily. You should also take 5 mg of folic acid if you have been diagnosed with elevated levels of homocysteine. Folic acid has been shown to decrease the incidence of fetal neural tube (spina bifida) defects. The recommended daily dose can decrease the occurrence of birth defects and neural tube defects by 50%. Folic acid can also be obtained naturally through dark green leafy vegetables, citrus fruits, nuts, legumes, whole grains, and fortified bread and cereals. If you do not eat enough of these foods then you should folic acid supplements.
• Eat foods rich in omega 3-fatty acids or take supplements. Omega 3's have been shown to maximize the baby's eye and brain development, and also to maximize fetal growth.
• Drink plenty of non-caffeinated fluids, especially water, milk, and natural fruit juices, to stay hydrated and to help prevent constipation. Water is a great example but make sure to avoid untreated water (which is rarely found in the United States but may be found in underdeveloped countries) that has not been chemically treated, filtered, or boiled to eliminate infectious bacteria, viruses, and parasites. Decaffeinated coffee, colas, and tea can be safe to consume, but remember, they still contain small amounts of caffeine.
• Eat foods rich in iron (e.g., dried fruit, meat, dark green leafy vegetables, and legumes).
• Avoid "ready to eat" meats, poultry, and seafood (e.g., hot dogs, deli meats, refrigerated pates, meat spreads, and smoked seafood), and do not consume soft, unpasteurized cheeses (e.g., feta, brie, camembert, queso blanco, and queso fresco) and other unpasteurized dairy products. These products are more likely to carry Listeria monocytogenes, a harmful bacterium that causes listeriosis. Pregnant women and their unborn children are 20 times more susceptible to listeriosis than healthy adults, and 1/3 of all listeriosis case involves pregnant women. Infection can lead to preterm labor, low birth weight, mental and physical disability, or even death. Canned meat such as pates, spreads, and cooked seafood, along with pasteurized milk or foods containing pasteurized milk, are safe to consume.
• Do not eat undercooked or raw meat and fish, especially pork, lamb, or venison, and avoid raw foods such as oysters or sushi. Be extra careful to not touch your mouth after handling undercooked meat. Raw and undercooked meat can contain Toxoplasma gondii, a parasite that can cause toxoplasmosis. This disease can affect a baby by causing hearing loss, mental retardation, and/or blindness. Symptoms of toxoplasmosis include swollen glands, fever, headache, muscle pain, or stiff neck. Toxoplasmosis can be difficult to detect, but if you experience any of these symptoms, you should see your doctor or healthcare provider immediately.
• Do not eat fish known to contain high levels of mercury; mercury is toxic and can damage the nervous system, especially that of a developing fetus. Examples of fish to avoid include sharks, swordfish, king mackerel, tilefish, and large species of tuna. As long as the fish contains low-mercury levels, the Food and Drug Administration (FDA) and Environmental Protection Agency (EPA) strongly recommend you incorporate fish with low-mercury levels in your diet, as they are rich in high-quality protein and omega- 3 fatty acids and contain low levels of saturated fat. The FDA and EPA provide the following tips:
• 1. Eat up to 12 ounces (2 average meals) a week of a variety of fish and shellfish that are lower in mercury.
  2. Five of the most commonly eaten fish that are low in mercury are shrimp, canned light tuna, salmon, Pollock, and catfish.
  3. Albacore ("white") tuna, another commonly eaten fish, has more mercury than canned light tuna. So, when choosing your two meals of fish and shellfish, you may eat up to 6 ounces (one average meal) of albacore tuna per week.
  4. Check local advisories about the safety of fish from local lakes, rivers, and coastal areas. If no advice is available, limit intake to 6 ounces (one average meal) per week of fish caught in local waters, but don't consume any other fish during that week.
• Minimize your caffeine intake: do not drink more than 12 ounces of coffee per day. This stimulant can inhibit the body's absorption of iron and calcium.

For more nutrition and food guidelines, visit the FDA's "Food Safety for Mom's to Be" webpage.

Precautions:

For your health and the health of your baby, avoid:

• Alcohol. The amount of alcohol consumption that puts a fetus at risk is unknown. Therefore, the guidelines recommend the cessation of any alcohol intake throughout the entire pregnancy. Alcohol abuse can lead to fetal alcohol syndrome or other physical and mental birth defects. Arizona Center for Fertility Studies recommends absolutely no alcohol use during the entire pregnancy.
• Drugs. This includes illicit drugs but also certain legal drugs such as herbal and dietary supplements, prescription drugs, and over-the-counter drugs. Accutane (also known as Isotretinoin) and certain psoriasis drugs such as Soriatane are known teratogens (agents which can cause birth defects), especially during the first few weeks of pregnancy. You should receive clearance from your healthcare provider before taking any medications.
• Tobacco. A fetus receives less oxygen if the mother is smoking. This can lead to low birth weight, preterm labor, increased risk for miscarriage, or other pregnancy complications. Therefore, you should avoid smoking and exposure to secondhand smoke. Arizona Center for Fertility Studies recommends absolutely no smoking during the entire pregnancy.
• Hazardous substances. Examples include carbon monoxide, mercury, lead, paint thinner, benzene, formaldehyde, solvents, paint, cleaners, and pesticides.
• Cat litter boxes. A litter box may contain the parasite Toxoplasma gondii, which can cause toxoplasmosis. When possible, have someone else handle cleaning the litter box. If you are handling the litter box by yourself, make sure to use rubber gloves and a facemask when cleaning.
• Saunas and hot tubs. Your body temperature should not rise above 100 degrees F for a sustained period of time.

Healthy Exercise:

At appropriate physician-approved levels, exercise during pregnancy can benefit your health in a multitude of ways. It can reduce backaches, constipation, bloating, and swelling, elevate your energy and mood, reduce your risk of developing gestational diabetes, and help you sleep better.

• If you exercised regularly and were physically active before you became pregnant, most likely you can continue moderate exercise throughout your pregnancy. Regardless, before you begin or resume exercise activity during pregnancy, consult with your physician to obtain clearance for your intended regimen.
• If you did not exercise regularly prior to pregnancy, you should consult your physician to see what types and levels of physical activity are appropriate. As long as you do not have certain medical conditions, most likely you will be able to initiate exercise with a slow and gradual regimen.
• Women who possess risk factors for preterm labor, experience vaginal bleeding, or have had premature rupture of membranes should NOT exercise during pregnancy.
• Determine with discretion what exercises and sports are safe for you and the baby. Walking, running, hiking, dancing, swimming, and stationary bicycling are generally considered safe activities for most pregnant women. Many aerobics and yoga centers now offer classes geared specifically towards pregnant women.
• Always wear light clothing and drink plenty of fluids before and after exercises. Make sure you consume the daily extra calories you need during pregnancy.
• Keep your heart rate at an acceptable level. As long as you can talk normally while exercising, you should be fine. Exercise increases the flow of oxygen and blood to the muscles being worked and away from other parts of your body, so you do not want to over-exert yourself.

Unhealthy Exercise:

Not all physical activities are safe, especially if you have not exercised regularly before your pregnancy. To keep you and your baby safe, we recommend a few precautions:

• Avoid heavy lifting and jerky, bouncing motions since joints and ligaments are at a greater risk for injury during pregnancy.
• Do not exercise in hot and humid weather.
• Avoid any impact exercise and contact sports that pose a risk of trauma to the abdomen (e.g., kickboxing, soccer, and volleyball).
• Avoid exercise if you are ill.
• Your center of gravity changes throughout pregnancy, so avoid exercises that require delicate balance or that increase the likelihood of falling.
• Sporting activities not considered safe for pregnant women include horseback riding, diving, scuba diving, skiing, water-skiing, and motorsports like snowmobiling.
• Do not do any exercises on your back after your first trimester of pregnancy.

Stop exercising immediately and call your physician if you experience vaginal bleeding, dizziness, increased shortness of breath, chest pain, headache, muscle weakness, calf pain or swelling, uterine contractions, decreased fetal movement, or fluid leaking from the vagina.

Suggestions for Dealing with Nausea:

During pregnancy, you may experience nausea and vomiting because of changes in your hormone levels. This nausea is often called "morning sickness," but can occur throughout the day and/or night. Not all women have morning sickness, and it usually goes away after the first few months of pregnancy. Here are a few tips for minimizing nausea and vomiting:

• Get up slowly in the morning, since sudden movement can exacerbate nausea. Eating crackers or another light snack can potentially help ease nausea if eaten right before rising from bed.
• Eat small but nutrient-rich meals.
• Eat high-protein snacks.
• Avoid long periods without food.
• Drink fluids between, not with, meals.
• Avoid foods that are greasy, fried, fatty, or highly spiced.
• Avoid pungent and unpleasant odors. Get fresh air when you can.
• Rest when you are tired.
• Avoid reclining immediately following meals.
• Try ginger, chamomile tea, red raspberry leaf capsules, and/or tea.
• 500-1500 mg of time-released vitamin B pills from the health food store.
• If all else fails, call Arizona Center for Fertility Studies or your OB. Certain medications are safe and effective in early pregnancy to help decrease nausea. They include Tigan, Zofran, and Phenergan (also in suppository form).

If you have any of the following symptoms due to intense nausea, call your healthcare provider:

• Inability to retain food for more than 24 hours.
• Weight loss.
• Dark-colored or concentrated urine.
• Inability to urinate every 4-6 hours.
• Accelerated pounding heartbeat.
• Blood in vomit.

A Few More Tips…

• In general, there are no restrictions to having sexual intercourse unless you have a high-risk pregnancy (in which case, you should discuss the matter with your healthcare provider). There is no danger to the baby as it is protected by the cervix, amniotic fluid, and by the mother's abdomen.
• Sexual relations should be avoided if you experience spotting, bleeding, or cramping, or if you have been instructed to avoid intercourse by your healthcare provider.
• Spotting is very common in pregnancy and generally does not lead to problems. Matter of fact, up to 23% of women spot and/or bleeding in early pregnancy. It is usually "scary,” and you should call Arizona Center for Fertility Studies, any time of the day or night when it happens. Be sure to continue all your medications, especially progesterone, if you have spotting or bleeding; because most of the time, it does not indicate a miscarriage. However, if you experience vaginal spotting or bleeding, pelvic rest may be recommended (e.g., no intercourse, tampons, and tub baths). Consult Arizona Center for Fertility Studies or your healthcare provider if you experience any of these symptoms.
• Hair dying during pregnancy, whether through the use of natural products or chemicals, is considered safe, but should be done with caution. The amount of chemicals used in the hair is not potent enough to create a risk for either you or your child. Just to be safe, use gloves, do not leave dye in your hair longer than the instructions indicate, and dye your hair in a well-ventilated room. Arizona Center for Fertility Studies recommends NOT dyeing your hair in the first trimester of pregnancy just to be safe.
• Flying in an airplane and/or traveling to high elevations has not been proven to increase the risk of miscarriage. Arizona Center for Fertility Studies recommends not traveling in the first trimester unless it is important. It is troublesome to be having heavy bleeding with a miscarriage at 37,000 feet and another 3-hour plane ride to go. Also, even though the flight did not cause you to miscarry, you will not easily forgive yourself for going.
• Avoid hot tubs greater than 99 degrees.
• Avoid getting acrylic nails/artificial nails in the first trimester because of the toxic fumes in the salon.

Please do not hesitate to call us, at any time, at Arizona Center for Fertility Studies if there are questions or concerns.