It is well known that fertility drugs can play a crucial role in assisting individuals and couples to achieve a successful outcome during Fertility Treatment.
Dr Bart Kuczera, Fertility Consultant, Beacon CARE Fertility
We asked Dr Bart Kuczera, Fertility Consultant at Beacon CARE Fertility, to provide an overview of the different types of fertility drugs available, their function, possible side effects and advice he has for pharmacists.
1. What Are The Different Types Of Fertility Drugs?
There are three main categories of Fertility Drugs, each serving a specific purpose.
A) Ovarian Stimulation:
One category of Fertility Drugs is designed for ovarian stimulation. Medications such as Gonadotropins (hCG, LH and FSH) stimulate the ovaries to produce multiple eggs during a single menstrual cycle.
Both FSH alone and in combination with LH are used for this purpose. Different variants of highly purified menopausal or recombinant FSH are currently available. The hCG is used in females to trigger oocyte maturation and ovulation.
Occasionally, hCG is used for luteal phase support after fresh embryo transfer, or in cases of male hypogonadism, to stimulate sperm production (either alone or in addition to FSH).
B) Ovulation Inhibitors: Another class of fertility drugs focuses on preventing spontaneous ovulation. By carefully controlling the timing of ovulation, these drugs help optimise the chances for successful egg retrieval and reduce the risk of untimely ovulation. Medications such as GnRH agonists (e.g. buserelin, nafarelin) and antagonists (cetorelix, ganirelix) are used to suppress the release of eggs prematurely by preventing LH surge.
The agonist class works through selective pituitary flare-andexhaustion action in repeated doses and either requires pre-treatment before stimulation (hence the term “long protocol”) or, indeed flare protocols when they are commenced alongside the stimulation to take the benefit of the surplus FSH release.
The flare effect after the first/ single dose of GnRH agonist is often used to trigger ovulation safely as a means of prevention from OHSS in both IVF and egg freezing cycles.
The GnRH antagonists are of pure inhibitory action. Interestingly, recent advances in stimulation protocols employ progestogens in this role too, following their successful use in the progestogenonly-pill. They are, however suited only for treatments where no fresh embryo transfer is planned (e.g. egg freezing, elective embryo freezing).
C) Enhance Environment for Conceiving: In addition to drugs that stimulate and regulate ovulation, sex hormones are also utilised in various roles.
Progesterone and progestogens are used to plan the onset of menstrual bleeding (i.e., in cycle programming), control the endometrial growth in sequential hormonal replacement therapy for a frozen embryo replacement, or support endometrial maturation after oocyte collection and facilitate maintenance of a conducive environment for early pregnancy, or suppress the menstrual cycle for a few months in women with endometriosis.
2. What Are Common Side Effects Of Medication?
Fertility medications are generally well tolerated, but they may present some potential side effects, albeit rarely and typically of a mild nature.
Historically, ovarian hyperstimulation syndrome (OHSS) was a relatively frequent complication associated with IVF and fertility medication (hCG). However, advancements in protocols and strategies have significantly reduced its occurrence, which is now very rare.
One common side effect associated with fertility treatments involves the method of administration, particularly with injectable medications. Bruising at the injection site is a somewhat common and generally minor side effect, resulting from the use of needles for subcutaneous or intramuscular injections.
Some people also occasionally experience a rash due to an allergic reaction to the medication. This is typically a benign side effect that requires little to no intervention.
Lactose intolerant patients may experience some side effects due to the composition of the drug (and not the main substance of the drug itself).
Lastly, some individuals may experience mild symptoms such as headaches, bloating, swelling (water retention) or mood swings during the course of fertility treatments.
3. What Advice Would You Give Pharmacists regarding Fertility Medication?
From a supply perspective, I would suggest having some extra medication in stock (if possible). Oftentimes, a patient will need a “top up” of their fertility medication. If Pharmacies don’t have more than the initial prescribed dose in stock, it may cause an issue for the patient, especially if she requires the extra dosage over the weekend.
When counselling patients, I suggest emphasising the importance of remaining adequately hydrated (above normal levels) when taking fertility medication, as the ovaries will utilise an increased volume of water compared to that of a normal cycle.
Proper hydration or haemodilution is a strategy that helps prevent clots that can occasionally be caused due to the higher estradiol levels. Lastly, provide guidance on proper storage of the medication to ensure they maintain their efficacy, and suggest that the patient takes the medication around the same time each day.
4. What OTC Should Patients Avoid When Taking Fertility Medication?
Vitamin A, Retinoids and nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are generally discouraged during fertility medication regimens, due to potential interactions and adverse effects on reproductive health.
Excessive intake of vitamin A, can lead to toxicity and negatively impact embryonic development. NSAIDs may interfere with or prevent ovulation and could compromise the effectiveness of ovulation induction. NSAIDs used regularly may also hinder implantation.
It should be noted that patients typically “over supplement” when undergoing fertility treatment, and an excess of vitamins and herbs should equally be avoided.
5. Are there supplements that pharmacists can recommend that are OTC?
On the male side, multivitamins are available specifically for male fertility. Their role is well established for enhancing IVF outcomes by helping to improve semen parameters and reduce oxidative stress in seminal plasma, thus lowering sperm DNA damage.
For women aiming to conceive, folic acid is commonly advised. The role of vitamin D in female fertility is currently under extensive investigations and studies. It’s important to note that eggs are formed before birth and this limits the impact of any “enhancers”. By contrast, the production of sperm is continuous since puberty and prone to changes triggered by deficiencies, life style and supplementation.
