Yesh Tikva
A Jewish Fertility Community
Fertility Roadmap
Module 4
Understanding Hormones
The Menstrual Cycle:
According to The American College of Obstetrics and Gynecology (ACOG): “A menstrual cycle is defined from the first day of menstrual bleeding (called day 1) of one menstrual period to the first day of menstrual bleeding of the next. An average menstrual cycle lasts 28 days.”
How it works:
The brain (specifically the hypothalamus and pituitary gland) and the ovaries “talk” to each other with signals called hormones. These hormones control the menstrual cycle. The hypothalamus in the brain releases a gonadotropin releasing hormone (GnRH), which then signals the pituitary gland to produce follicle stimulating hormone (FSH) and Luteinizing hormone (LH). FSH and LH both allow the egg to develop, mature and be released from the ovaries, as well as increasing the estrogen hormone. Estrogen is important in allowing the egg to mature. The egg is released in a process called ovulation. This brings the mature from the ovary to the fallopian tube where it can meet with sperm. Once ovulation occurs estrogen and progesterone hormones are made to thicken the lining of the uterus for implantation of an embryo which could result in a pregnancy. If an egg successfully “meets sperm” then progesterone is made until the embryo is 10 weeks. If the egg does not meet the sperm, estrogen and progesterone are no longer made, and the lining of the uterus is released, called menstruation. The low estrogen signals the hypothalamus to release GnRH… and the cycle continues.
Summary:
Low levels of estrogen causes the brain to produce GnRH, which leads to the making of FSH and LH, which are important in egg development and increasing estrogen. Once an egg matures, ovulation occurs and there is an increase in estrogen and progesterone, which prepares the lining of the uterus for a fertilized egg. If there is no fertilized egg, a decrease in estrogen and menstruation occurs.
Hormone Treatments:
Based on our understanding of the menstrual cycle, you can now see why hormones can be a vital part of infertility treatments. The main goal of hormone treatments is to allow for egg maturation and ovulation. Mature eggs that begin the process of ovulation means an increased chance of getting pregnant.
Oral Hormones
Clomiphene Citrate:
Brand Names: Clomid, Serophene and Milophene
What do They do? These drugs block estrogen and stimulate ovulation by causing the pituitary gland to release more luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which stimulate the growth of an ovarian follicle containing an egg. They are typically prescribed for women with irregular menstrual cycles or to stimulate the development of more eggs. These drugs are either used as the primary treatment, or in combination with IUI or timed intercourse.
How it’s Used? The doctor typically prescribes a single does once a day for 5 days. You usually take the first pill on the third, fourth, or fifth day after you start your period. It typically causes ovulation 7 days after the last dose. It is often trial and error, so if it’s not effective the first time, your doctor will likely increase your dose the following cycle. It is usually not recommended for longer than 6 months.
Side effects: hot flashes, blurred vision, nausea, bloating, and headache
Letrozole:
Brand Name: Femara
What do They do? Letrozole is used off-label for fertility treatment, currently only FDA approved for breast cancer treatment.
This drug also stimulate ovulation by suppressing estrogen (know as aromatase inhibitor) leading to an increase in follicle-stimulating hormone (FSH) production, which stimulates the ovarian follicles (eggs) to mature.
It is typically prescribed for women with PCOS with irregular menstrual cycles to stimulate the development of more eggs. This drug is either used as the primary treatment with timed intercourse, or in combination with intrauterine insemination (IUI).
How it’s Used? The doctor typically prerscirbes 5 days of this orally administered drug. Usually you begin to take the first pill on the third, fourth, or fifth day after you start your period. It typically causes ovulation 7 days after the last dose. It is often trial and error, so if it’s not effective the first time, your doctor will likely increase your dose and the length of time it is perscribed for. It is usually not recommended for longer than 6 months.
Side effects: headaches, fatigue and dizziness
Injected Hormones
Injected Hormones:
How are They Used? These are typically shots, the dose depends on use, and previous responses. You can get injections in the stomach, upper arm, upper thigh or buttocks. Depending on the hormone being administered, some you start injecting on the second or third day in your cycle, for 7-12 days, then given another shot to cause ovulation, others are given throughout the pregnancy. Sometimes hormonal injections are combined with clomid.
Side effects and risks: tenderness, swelling, or bruising at the injection site. Also a risk of ovarian hyperstimulation, which is when your ovaries respond too much to the medication, and swell. This can lead to fluid leaking into the body, which can result in hospitalization and bed rest.
What do They do? These medications are used to control the menstrual cycle, to optimize egg retrieval and embryo transfers. These medications often contain FSH alone, or FSH and LH together. These hormones are important for egg maturation and ovulation.
Why is it Used? If clomid was unsuccessful or if you are preparing for ART procedure (like IVF or IUI), your doctor may prescribe gonadotropins.
Ovarian Stimulation:
Follicle Stimulating Hormone – FSH:
Brand Names: Gonal-F, Follistim, Bravelle, and Fertinex
What does it do? Stimulate the ovaries directly to produce multiple eggs with an increase in naturally occurring hormone FSH.
How are They Used? Administered by subcutaneous injection (videos on how to admisiter in hyperlinks above). Prescribed for IVF as well as in more aggressive protocols for IUI.
Human menopausal gonadotropin (hMG):
Brand Names: Menopur, Metrodin, humegon, and Pergonalm Repronex
What does it do? A combination of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) stimulate the gonads in the ovaries for follicle development.
How are They Used? Administered by subcutaneous injection. Prescribed for IVF.
Ovulation Suppression
Gonadotropin-releasing hormone antagonist (GnRH antagonist):
Brand Names: Ganirelix, Cetrotide, Antagon and Orgalutran
What does it do? Prevents early ovulation before egg retrieval. It blocks the pituitary gland from producing follicle-stimulating hormone (FSH) and luteinizing hormone (LH) causing the ovaries to stop producing estrogen and progesterone to prevent premature.
How are They Used? Administered by subcutaneous injection. Typically used in conjunction with FSH and HCG. Prescribed for IVF.
Gonadotropin-releasing hormone agonist (GnRH agonist):
What does it do? prevents early ovulation before egg retrieval.
AKA: Lupron, Synarel , Suprecur, Zoladex
Ovulation Stimulation:
Synthetic Human Chorionic Gonadotropin – HCG
Brand Names: Ovidrel, Pregnyl, Novarel and Profasi
What does it do? Similar in structure to luteinizing hormone (LH), hCG triggers the mature follicle to fully mature and be released by stimulating LH surge, inducing ovulation.
How are They Used? Administered by injection intramuscularly. Prescribed for IVF and in some IUI cycles.
Uterine Lining:
Progesterone
What does it do? Prepares the uterine lining for implantation. Taken before embryo transfer and frequently continued afterward to support the uterine lining and maintain the pregnancy.
Progesterone in oil (PIO)
Brand Name: Generic- Progesterone Injection USP, 50 mg/mL
How are They Used? Administered by intramuscular injection.
Progesterone suppositories
Brand Name: Endometrin
How are They Used? Administered by vaginal suppository
Estrogen
Brand Name: Estrace or Estradiol
What does it do? Grows the endometrium of the uterus to prepare for pregnancy.
How are They Used? Administered orally or by suppository. Generally prescribed prior to an embryo transfer and continued after the transfer to support the uterine lining and maintain the pregnancy.
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