Who Doesn’t Want Half and Half in Their Coffee? IVF Stimulation Medications

Calories, shmalories… We like our half and half! In fact, the lighter the better (sweet is good, too!). Half and half gives coffee that creamy taste that is not replicated by any amount of whole or skim milk. The same can be said for ovarian stimulation medications—the ovaries of most women like half FSH and half LH. In many cases without this combo, the response is bland and lackluster.

But before we go any further, let’s take it back to the “beans” (a.k.a. the basics). While FSH and LH are hormonal medications used in IVF, they are also hormones produced naturally in the brain. It is the steady production of FSH and LH throughout the menstrual cycle that results in egg production and ovulation.

Because in a natural cycle you never see FSH without LH, many fertility doctors prefer to keep this dynamic duo intact when selecting IVF stimulation medications. As a result, combined protocols (as we call them in fertility medicine) are definitely leading in the fertility polls. Most of us have seen better ovarian response, better egg quality, and hence, better embryo development when the two are mixed. But taking it back to the beans (a.k.a. the basics), FSH and LH are two hormones that are normally made in the brain.

Great, now they want me to take two shots? Unfortunately, yes, we do. And while we would love to minimize the number of times you have to stick yourself, doubling up will likely do your ovaries wonders. When we stimulate ovaries for IVF, as unnatural as it feels, we are trying to mimic a natural cycle as much as possible. Nature happens for a reason! By giving both FSH and LH together, we are coming closer to what happens when we are not there. These two were paired together before we got there—it seems silly to separate them!

Yes, there are certain women who do better with straight whole or skim milk or even black coffee. For example, women who suffer from hypothalamic amenorrhea (no periods due to low hormones from the brain) need LH. Their ovaries will sit on the runway all day without a blast of LH. On the flip side, women with the real deal PCOS do better with minimal LH in their stimulation. Their ovaries see LH all the time (been there, done that), so it’s better not to put fire on an already flammable situation.

The debate over whether to use FSH alone or FSH + LH has gone on longer than the Coke vs. Pepsi debate. There is evidence on both sides to support combo protocols vs. straight FSH or LH. While doctors may have a preference for one (and can certainly find evidence to support it), most large reviews have demonstrated that (like us) two are better than one. When sitting down with your doctor, before you start the shots, ask them what you are getting, why they are giving it to you, and why they like this for you. Asking questions will quell some of the confusion and anxiety that those bags of needles and boxes of medicines bring upon their arrival.

Your choice of cocktails is very personal. Trust us, we get it. While some of us are vodka soda fans, others like to mix with cranberry juice. And then we have the more elaborate amongst us who go for Cosmos, Long Island Iced Teas, and Mojitos. (Watch out the next day: sugar hangovers are the worst!) Whatever you like to mix with your alcohol, you probably have a reason for it. Same goes for your ovaries and us. Everything we do has a purpose. The difference is, we’re helping make babies, not Bellinis. Here’s to your success, your health, and your fertility. Cheers!

What’s Your Recipe? The Various Ways to “Bake” an Embryo

Disclaimer: we are not cooks, chefs, bakers, or anyone who knows how to make much besides pasta, PB & J, and scrambled eggs. So while we don’t recommend seeking out our advice on the best ways to cook your Thanksgiving turkey or how to get your soufflé to rise, we are going to take a page out of our foodie friends’ recipe book to explain IVF protocols. We want you to think of the medications as the ingredients, the needles and syringes as the mixers and pans, and the eggs/embryos as the final project (a.k.a. the cake). And while you will likely never see either of us on the Food Network or competing on Top Chef, you will hear us use the cake baking reference frequently. It helps for visualization and in many ways is pretty spot on.

Think back to the last time you baked or, more likely, watched Paula Dean do it on TV! On almost all occasions, when setting out to bake a cake you need some core ingredients: sugar, flour, eggs, and butter. These basics are pretty standard. What varies is the amounts, the order in which they are added, and the “other” ingredients. Some recipes call for chocolate chips, some for oatmeal, and some for cinnamon and nutmeg. So pull out your rollers, put your apron on, and let’s get cooking.

Step 1: Think of the hormones and the needles as “your basics.” Every protocol requires injectable gonadotropins (FSH, LH) to stimulate the ovaries to produce multiple follicles/eggs. However, the dosages and the formulations can vary. If you have been through this process before or know a friend who has, you are probably pretty familiar with the likes of Follistim, Gonal-F, and Menopur (brand names of the hormonal medications). Just like Duncan Hines, Toll House and Betty Crocker, they are similar products produced by different companies. And although one may claim to be fluffier and the other moister, in many ways, just like the medications, those chocolate cakes taste pretty much the same!

Step 2: While some of us like to create our menu and set out our ingredients days before we get started, others of us get the ball rolling just moments before the party starts. Again, the same can be said for the medications. While some protocols call for “day 2 of your period’s start” others require you to begin the injections about a week before your period arrives. Some even have you take preparatory medications (patches or pills) for a full MONTH before you start.

Step 3: For most cakes, butter, eggs, sugar, and flour alone are not going to cut it. Yes, the batter will be tasty, but the cake will be somewhat bland. Similarly, you can’t just give FSH and LH (Gonal F, Follistim, Menopur) alone. While they will certainly provide needed motivation to make the follicles grow, they won’t prevent ovulation. High estrogen + big follicles = Impending ovulation. Therefore, to prevent this, we must add an extra ingredient to prevent ovulation from happening before it is time for the retrieval. It is with this “anti-ovulation” agent that we can spice our recipe up and give it some flair. By varying the “anti-ovulation” medication (examples include Lupron, “Micro-dose” Lupron, Ganirelix, Cetrotide), we tailor the recipe to your taste buds (a.k.a. ovaries!).

Step 4: It’s time to put your masterpiece in the oven, but how long do you set that timer and how high do you set that oven? Here, again, we see variability. While some chefs may like to turn that burner off when the browning process begins, some might prefer a more charred look. The same can be said for when the final trigger shot (a.k.a. ovidrel, hCG, or Lupron) is administered; while some doctors prefer a shorter stimulation course and smaller follicles, others like to let things go longer and push the size of the follicles.

The basics behind the various stimulation protocols are almost always the same—stimulate the ovaries to produce multiple high-quality mature eggs. And just like in the kitchen, we don’t always achieve perfection on the first attempt. We learn a lot from past trials and improve on future endeavors—add a little more cinnamon, add a little less sugar, cut down on the time in the oven…In the same vein, protocols change between cycles—add a little more FSH, add a little less LH, cut down on the length of stimulation. And although doctors and chefs make it look simple, neither baking nor achieving a perfect stimulation is just not “as easy as pie.”

Oops, Shoot, Sh-t: What to Do When You Have a Medication Error

No matter how you choose to say it, either PG or double-X rated, medication errors can make you nuts. Depending on when and where they happen in your cycle, they can cause major anxiety. The fear of knowing if you tanked your IVF cycle can be overwhelming, to say the least! And while some errors can be cycle ending, most are no more than a minor blip (and one that we can fix pretty easily). The best advice we can give you is to take a deep breath, gather your thoughts, WRITE down what you took and when you took it, and contact your doctor’s office. Going on the Internet to see how serious of a snafu it was or panicking is not going to solve any problems. Letting us know and letting us help you fix it will.

As fertility doctors, we give A LOT of medications—both oral and injectable. While the orals are pretty straightforward (most of us have been swallowing pills for the entirety of our adult lives), the injectable ones can get a bit dicey. Sure, you can miss a pill, and that can set you into a panic. But most of the time, we tell you to double up or simply skip what you missed. No harm; no foul. With the injectable ones, there is a little bit more to it. First, you have to learn how to not only inject but also mix medications. Problems on both ends can result in a medication error. Most fertility centers will have you sit through a class or take an online course to review the process. And while there are no grades and no pop quizzes, we recommend that you don’t snooze through this class. It will be important down the road. Often, when something seems to go awry or you are having a memory lapse, going to an online source, be it the fertility clinic site, YouTube, or a Facebook group, can be helpful. It can get you back on course. But again, take it from girls in the know…call your doctor!

Although we don’t want to raise your blood pressure, we don’t want to give you a preview into what might go wrong. Here are the six most common mistakes we have seen:

  1. I gave myself the wrong dose (too much or too little).
  2. I gave myself the wrong medication.
  3. I left my medication out on the counter overnight.
  4. didn’t mix the medication correctly.
  5. I injected, but a lot of the water leaked out.
  6. I took my medication at the wrong time.

Again, we are not sharing them to stress you out (if you on the verge of doing IVF) but to bring you solace. You are not alone if you mess up—you are certainly not the first to have done it and definitely won’t be the last.

Although we likely won’t be the ones to pick up the phone when you do make that mistake, here is what we would say (in the order we wrote them above):

  1. Most over- or under-dosing (if caught quickly) can be remedied without so much as a hiccup. And while no one wants to be running at half-mast, the ones that make us cringe are the dangerous-, you-can-get-seriously-sick ones—women who have ovaries with tons of follicles are generally put on a low dose of hormones to prevent ovarian hyperstimulation syndrome (OHSS). If they accidentally triple their dose, they are seriously increasing their risk for OHSS.We can usually remedy the problem by reducing the dose, but it’s VERY important to call once you identify the mistake. Most of the times dosage errors happen when you didn’t get the right instructions or dialed up the pen incorrectly (for those formulations using a “pen” to administer). The best way to solve this is to write your instructions down in a SAFE place (not on your crumpled napkin from lunch) and to carefully set that dial. If you are getting an “I dunno type of feeling” when you are about to dial in the dose, phone a friend (a.k.a. your doctor) before you inject.
  2. Many of the medication names read like foreign languages. Most of us have never heard of Follistim or Gonal-F, let alone human chorionic gonadotropin (hCG). Swapping Follistim for Menopur or Gonal-F for Follistim is NO big deal (it’s like drinking Coke instead of Pepsi). However, giving yourself hCG instead of Ganarelix can be a big no-no. Our suggestion to ensure that this doesn’t happen is the following: become acquainted with all of your medications BEFORE the cycle starts. Open up those many boxes, and lay all of the contents out on your kitchen counter. While it may sound overwhelming, it will let you know what you have (and what you don’t have). Check it like you would a packing list with the list of instructions you got at the outset of the cycle. If something is missing, let your doctor know ASAP. Knowing what you have and what you are missing will not only let you prepare for the cycle in its entirety, but it will also make interpreting the daily medicine instructions a bit easier. It will be like hearing a foreign language a couple of times before traveling to that country!
  3. There are a lot of medications that come with an IVF cycle. They can turn your fridge into a pharmacy! Some medications need to be kept in a cold place. Make sure you are aware of which prefer the hotter climates and which like colder ones before you run out and leave all of the drugs on the counter. In reality, unless you are in the Deep South in the dead of summer, even if you left the “cold-blooded” ones out of the fridge for a night or two, you would be totally fine. However, prepping for what goes where will make the organizational aspect of things a whole lot simpler.
  4. Mixing can get people all mixed up! IMs, ccs, syringes, and needles; it’s like a baking experiment gone wrong. And unfortunately, more than one of the medications we use needs to be mixed. Our solution to this is practice—a test run before the big day. It will alleviate a lot of anxiety and clear up some of the confusion. If you are confused by what to mix with what and how much to pour where, make sure to ask before the oven timer goes off!
  5. The leakage effect is all in effect when it comes to shots. There will be water going in and going out after you administer a shot. The out part is usually what gets people freaked out and thinking that they must have done something wrong. Let the leaking go! It is highly unlikely that you lost a substantial amount of the medication in that trickle. Focus on what you did get in and how fierce you are to take shots two, sometimes three times, a day!
  6. Set an alarm clock. Set two alarm clocks. Set three if you need to! Timing for fertility medications is important, particularly for the last shot (a.k.a. the trigger shot). That final injection is timed to precede the retrieval by about 34–36 hours. While being off in the grand finale by minutes is nothing to lose sleep over, being off by hours can be pretty dramatic. Although we can usually match your time to ours, it’s best to be as in sync with our show time as possible.

There are medication errors that matter and those that don’t mean all that much. You won’t know what’s yours is unless you ask. Take copious notes when you get your instructions, and if something is unclear, press pause and ask the person on the other end to repeat. It may save you a major error and some major anxiety. And even if you do make the error of all errors, it was an accident. We all make mistakes—how we handle them is what determines the outcome. Think of it this way: you certainly won’t make that same mistake again!