Clomiphene & Tamoxifen
Clomiphene (Clomid & Serophene) and Tamoxifen (Nolvadex) are both what are termed "fertility drugs". The aim of using these drugs is to increase the prospect of achieving pregnancy either by bringing on ovulation or increasing the number of eggs that are ovulated.
What happens to you - The procedure
These drugs are both anti-oestrogens. Normally, as an egg develops in the ovaries, the surrounding cells produce increasing amounts of oestrogen. The oestrogen stimulates an area in the brain (known as the hypothalamus) which then, when there is a sufficient level of oestrogen, triggers the release of another hormone (luteinising hormone) which then in turn causes ovulation. When ovulation is not occurring or it is inefficient, these fertility drugs trick the brain into thinking there is no oestrogen available and so it releases greater concentrations of hormones (follicle stimulating hormone and luteinising hormone) to push the ovary to ovulate.
What you have to do
Clomiphene: The starting dose is 1 tablet daily for 5 days just after the commencement of a menstrual period. For example, 1 tablet daily from day 5 to 9 (or 2 to 6) of the cycle, where day 1 is the first day of menstruation. The dose is increased from 1 to 2, and then to 3 tablets daily for 5 days should the lower dose not lead to ovulation. Ovulation is confirmed by a blood test on day 21 to 23 of the menstrual cycle. This confirmation is usually only done until it is apparent that regular ovulation is occurring and appropriate levels of ovulation hormone (progesterone) have been achieved.
Tamoxifen: The starting dose is 2 tablets daily from day 5 to 9 of the cycle until ovulation occurs. Tamoxifen is increased from 2 to 4 to 6 tablets daily if ovulation does not occur. The progesterone level is measured in exactly the same manner as for Clomiphene.
Benefits & Advantages
If you are not ovulating you may benefit from one or both of these drugs. About 70% of women with PCOS will respond appropriately and ovulate. Women with hypothalamic problems respond less well to these drugs.
Clomiphene and Tamoxifen are sometimes also used in ovulating women in order to increase the number of eggs that are available. If more eggs are available this increases the chance of sperm meeting an egg to lead to fertilization and pregnancy. However in this situation the increase in pregnancy rates is small.
Side Effects & Complications
Side effects are uncommon and generally short lived. Occasional hot flushes, visual blurring, stomach bloating or lower abdominal cramps can occur. Menstrual periods are often slightly more painful and heavier than previously. Ovarian cysts are common and a normal effect of these drugs. The type of ovarian cysts caused by these drugs are usually only a problem if there is a complication of the cyst such as bleeding or twisting of the cyst. Rarely the ovaries dramatically over-respond to these drugs and, if this occurs, there is the possibility of twins or triplets. The risk of twins is 5%, the risk of triplets is slightly less than 1%, and high multiple pregnancies are extremely rare.
Carbergoline & Bromocriptine
What happens to you - The procedure
These tablets are known as Dopamine agonists. They are used to treat the problem of excessive Prolactin release from the pituitary gland. They do so by mimicking the messages that come from the brain to reduce Prolactin production. They are usually highly effective and provided that an ovulation problem is the only factor limiting conception, pregnancy rates are excellent.
What you have do to
With Carbergoline (Dostinex) you take a tablet once or twice a week. With Bromocriptine (Parlodel) you take tablets 1 or 2 times a day.
Benefits & Advantages
Reduced Prolactin levels. Recommencing normal ovulation and hopefully pregnancy.
Side Effects & Complications
Nausea, vomiting, dizziness, low blood pressure with fainting and blocked nasal passages can occur. You are advised to take the tablets initially at night before going to bed and be careful when getting out of bed the next morning in case you feel faint. Taking the medication with food or milk might be of assistance. Sometimes, if nausea is severe placing the tablet in the vagina can be of great assistance.
Injectable Hormone treatment
When ovulation normally occurs, one egg is released from the ovary. The aim of the hormone injections is to make the ovary produce an egg. On every day of your reproductive life (from birth to approximately 50 years) many eggs are available for ovulation. If the right set of hormonal signals are present, some of these eggs start to develop towards ovulation. The best, most advanced egg becomes dominant and it produces hormones into the surrounding ovary which suppresses the remaining susceptible eggs. The hormone that stimulates the ovary to produce an egg is called Follicle Stimulating Hormone (FSH).
What happens to you - The procedure & methods
There are two types of hormone / drugs used to produce ovulation:
- Follicle Stimulating Hormone (brand names - Puregon and Gonal F). This hormone is given daily by injection, which is different to its natural pattern of release. Given in this fashion the FSH forces the ovary to make available more eggs than would normally be the case.
- Human Chorionic Gonadotrophin (HCG) (brand names - Profasi and Pregnyl). Normally a hormone known as luteinising hormone (LH) is released from the pituitary gland to finally make the ovary release an egg. HCG is very similar in chemical structure to LH and is used to mimic this message. It promotes final maturation of the eggs, which have developed as a result of FSH treatment.
What you have do to
FSH (Puregon & Gonal f) requires daily injection.
These injections are subcutaneous, that is just underneath the skin, and can be administered by yourself or your partner. If preferred you may attend the Fertility Centre for these injections.
HCG (Profasi & Pregnyl) requires an intra-muscular injection that is deeper into the arm, buttock or thigh.
Monitoring treatment response
There are two types of monitoring used to see how the ovary is responding to FSH treatment. These are blood tests for hormone levels, which assess how well the ovary is functioning, and ultrasound to see how the follicles are developing.
- Hormone blood testing is usually performed every 1 to 3 days throughout your treatment. A test is carried out the day prior to the commencement of treatment and again on the 4th and 8th day of FSH therapy. Thereafter hormone tests are performed as necessary depending on response to FSH therapy. These tests measure the levels of the hormones Oestradiol, Progesterone and Luteinising Hormone (LH) in your blood. Essentially the higher the Oestradiol level the greater your response to treatment. As a rough guide one egg is produced for every 1000 units of Oestradiol measured in the blood.
- Ultrasound monitoring is performed on the 8th day of FSH therapy and then on one or two more occasions just prior to the egg collection procedure. The ultrasound is performed using the trans-vaginal approach. An instrument is placed in the vagina which will produce a picture on the ultrasound screen. The number of follicles being produced by the FSH therapy can be visualized. The higher the number of follicles the greater the number of eggs that might be produced and the higher the risk of multiple pregnancy. Not all follicles contain eggs however. Individual response is highly variable.
Benefits & Advantages
Without ovulation pregnancy cannot occur. FSH ovulation induction is mainly used in women who do not ovulated naturally. Occasionally it can also be used for women with unexplained infertility to increase the number of eggs available for the sperm to fertilise. These drugs are also used to stimulated the ovaries during a cycle of IVF treatment.
Side effects & Complications
The single most important complication of ovulation induction with injectable hormone therapy is multiple pregnancy. Twins, triplets and even quadruplets and quintuplets can occur. Great care is taken in an effort to avoid this risk but individual response is so variable that it cannot be avoided all together. Twins occur in 20% of pregnancies. Triplets or higher in 5%.
As with IVF Hyperstimulation syndrome can occur, although much less commonly.
This involves the passage of large amounts of fluid out of the ovary and surfaces of the abdomen into the abdominal cavity. As the condition progresses it can lead to fluid around the lungs, swelling of the hands, feet and skin and a reduction in blood flow to the kidneys and an overall decease of fluid in the blood stream. In its most severe state, if left untreated, it could lead to kidney failure and widespread clotting in the blood stream (deep venous thrombosis, stroke and pulmonary embolus). While there have been no reported deaths from this condition in Australia, deaths have occurred in other countries. Symptoms of Hyperstimulation syndrome include nausea, vomiting, abdominal distention and pain, poor urine output and difficulty breathing. None of these symptoms should ever be ignored in the days following ovulation induction. They should always be reported to the nursing staff at the Fertility Centre.
Other side effects and complications of hormone treatment are rare. Allergic reactions to medications, general sensations of being unwell and a range of other non specific problems can occur. Do not hesitate to bring suspected side effects to the attention of the nursing staff at Sydney IVF Newcastle.