Fertility Treatments 101

Fertility Treatments 101. Injectables, a primer.

….and it’s lovely to be back on Raising Twins, writing more stuff to the Internet-at-large. This piece is the third in a series of articles designed to take the reader through the oftentimes confusing world of infertility, its diagnosis, and common treatment approaches. For those who haven’t read the rest of the series, most of the big headings (diagnosis, common oral medications, IUI and IVF and the odds of multiples with each) have been touched upon already. In this article I plan to back up and fill the empty corner labelled ‘Injectables’ before moving on at a future date to the other side of a positive pregnancy test, namely the risks and management of multiple pregnancy and the hectic early days of Raising Twins, especially if premature as half of all twins will be (and my twins were). You can read about me here, or to save the click in summary I am a medical practitioner, but I am first and foremost, simply a parent of twins.

Before I begin, I’ll address the fairly obvious question of why it is appropriate to discuss fertility treatments on a website devoted to all things twins. The answer, I hope, is fairly obvious in that (as most people know these days, especially with some very high profile high order multiple families in the media), fertility treatments are a common cause of multiple birth, although it must be remembered there is one more old fashioned way that does still happen! Parents of ‘natural’ twins would be only too familiar with the assumption that they did IVF in order to conceive their children.

But whatever the mode of conception, twins and multiples in general invoke curiosity, lots of it. If you happen to be reading because you yourself are undergoing any of the previously or currently discussed treatments and wonder what it might be like to have multiples, there is a wealth of information available on this site. If it helps, I also write on Mission Impossible Infertile my own bloggy home about the crazy-making-zaniness that life with young twins conceived with the aid of IVF brings. The short summary would be that the experience of infertility, loss and failed treatments was hard beyond belief, my pregnancy was not without significant risk and there are days when both children scream to be picked up all day (teeth, I shall not say more) and I want to join them on the floor and cry myself, because two arms are not enough consolation for more than one baby at a time. But the rewards are also double. I simply cannot imagine life without my multiples, even if it meant I would get significantly more sleep than I now do.

To begin again, properly, previously I’ve had the great pleasure of the invitation to write about several aspects of the confusing place that is the fertility-treatments world in the context of A: how they work and B: how they sometimes lead to multiples, most commonly twins (a subject rather close to my own heart, you will be unsurprised to note). You can read about Clomid, IUI, as well as my experience with IVF as well as the nuts and bolts of a typical IVF cycle on this website. You can find those articles here and here and here.

The topic of this article is injectable medications, and how they work.

The obvious question to pose is where in all they myriad of pills, potions, lotions, sperm laden catheters and ultrasound scans of the infertile world do needles fit? The answer is as follows:

Most fertility treatments follow a fairly predictable cascade, starting at the least expensive/ invasive and moving up the scale as required if success (a pregnancy) does not occur. Commonly this means that a couple will become familiar with timed intercourse, Clomid/Femara, IUI, Injectables and then IVF, unless there is a good reason to omit some of the earlier steps. Examples of straight-to-IVF situations include things such as severe male factor infertility, or known blocked fallopian tubes, but there are many more. In some countries financial considerations inevitably become important, also.

It is always best to discuss the pros and cons of each fertility treatment option with your own caregiver when deciding when to move onto another treatment strategy and how long to persist.

At the risk of becoming repetitive, all fertility treatments come with an increased chance of conceiving multiple babies. This is by virtue of the fact that treatments either tend to result in more eggs being ovulated than normal or placing more sperm in the vicinity of the eggs (eg IUI), or both, in order to overcome barriers to conception and increase the odds of a pregnancy. So, without further ado:

How Injectables work.

To some degree, an injectables cycle works similarly to an IVF cycle (previously covered here), except that there is no downregulation/suppression of the woman’s ovaries beforehand and the eggs are not retrieved via minor surgery to be fertilised in vitro (simply a slightly fancy way of saying fertilisation occurs in the laboratory), but are allowed to mature and are ovulated in vivo (meaning inside the woman’s body in the normal fashion). Additionally, the emphasis is to grown only one to two mature sized follicles with each treatment cycle, as compared with IVF. This is because if many eggs are grown and allowed to ovulate, there is an unacceptable risk of high order multiples (three babies at once or more), a situation that can put the mother and babies at significant risk of serious health problems both in the short and long terms.

An injectables cycle begins with a menstrual period, called cycle day one by convention with the first day of full flow. This period may be spontaneous (i.e. be allowed to come on its own, the easiest option in women with more regular cycles), or induced by giving the woman progesterone beforehand (especially useful if the woman has infrequent or absent periods).

Medications that contain a drug known as Follicle Stimulating Hormone (FSH) are then given by injection each day to stimulate the ovaries to produce egg(s). These injections are usually subcutaneous (given with a tiny needle just under the skin) and only mildly uncomfortable. Additionally, many of the products now come in injection pens for ease of use, similar to the pens that diabetics use to give insulin. The number of units of drug is simply dialled up on the pen and the injection given without having to resort to syringes and needles and mixing vials.

As discussed above, the emphasis is on developing only a small number of eggs with each cycle and therefore the dose of medication is usually smaller than for IVF, thus less total medication is required. The number of eggs growing is monitored with regular vaginal ultrasounds, looking for the size of the black-appearing fluid -filled follicles that contain a growing egg.

Adjustments in the dose of medication may be made based upon the results of the scan.

Occasionally there will be an unexpectedly high number of follicles developing, and in this situation there are generally two options: either converting to an IVF cycle, or cancelling the treatment cycle. Cancellation is often very, very disappointing news to receive, but it is safer than continuing with IUI in the presence of many follicles.

The duration of stimulation depends on the response to the medication, but is typically in the range of ten to fourteen days. At the end of this phase when there the follicles are of a mature size an injection of HCG may be used to artificially mimic the natural hormonal surge of LH that would occur to trigger final maturation of the eggs and ovulation. Alternatively, the woman may be allowed to ovulate naturally. Generally a follicle can be expected to contain a mature egg capable of fertilisation when they reach approximately 18-22mm in size. Follicles that are either much smaller or bigger usually do not contain a fertilisable egg.

After this, the couple may simply have timed intercourse, or an IUI (intrauterine insemination) with the man’s sperm. After ovulation, progesterone medications or further ‘booster’ HCG injections may be used to support the second half of the cycle, but this step is not essential.

Finally, a urine or blood pregnancy test will be performed two weeks after ovulation to determine if the treatment has been successful. Returning to the twins focus of this website, the chance of conceiving multiples with injectable treatment is commonly quoted as 20-30%. If a cycle does not result in pregnancy, the woman can expect to have a menstrual period, and potentially begin treatment again the next cycle. Once again, I hope that this article is helpful. For more information on IVF procedure and infertility, you can visit Mission Impossible Infertile Also recommended is Stirrup Queens for further information regarding fertility treatments and for support of others who have been in similar situations.