It can be said that modern ART is only possible because of the advances made in basic sciences and especially pharmacology. The medications used for infertility treatment can be derived from (1) natural sources, i.e. human menopausal gonadotropins; (2) be produced using recombinant technology, i.e., FSH or LH; or (3) be of purely synthetic origin, i.e., gonadotropin-releasing hormon agonists/antagonists. A major new development has been the introduction of recombinant gonadotropins (FSH, LH, hCG). The recombinant technology is discussed on page 96. Recombinant FSH (r-FSH) is more expensive than urinary FSH (u-FSH). Based on current data r-FSH is more effective than u-FSH in achieving clinical pregnancy and is more cost-effective as well because less of it is used in the course of an IVF treatment cycle. Recombinant LH and r-hCG have not been used long enough to compare them to the urinary products. As mentioned earlier in the chapter, gonadotropin-releasing hormon agonists are used to suppress the endogenous production of FSH and LH. This takes 7-14 days to achieve and involves initial ‘flare-up’ during which preformed and stored FSH and LH are released. The flare-up is used in some clinics with a so-called ‘short protocol’ but the pregnancy rates are lower. Therefore, the ‘long protocol’ is preferred. In recent years, gonadotropin-releasing hormon antagonists have been developed. Unlike gonadotropin-releasing hormon agonists, the antagonists do not induce an initial stimulation of gonadotropin release. The reason is that gonadotropin-releasing hormon antagonists competitively bind to the gonadotropin-releasing hormon receptor without receptor activation or initial stimulation. Rapid (within a few hours) and reversible suppression of gonadotropin secretion ensues. Stopping the agonist leads to a quick recovery of the pituitary function. During COH, administration of gonadotropin-releasing hormon agonist is required only around the time of the expected LH surge. This allows a switch from the ‘long protocol’ to the ‘short protocol’. In the ‘short protocol’ FSH is started from day 2-3 of the menstrual cycle and after 6 days gonadotropin-releasing hormon antagonists are started. Both are administered for a further 4-5 days, until the day of hCG trigger. The average length of this protocol is 1-11 days and a lower total dose of FHS is required. The overall length of the COH cycle using gonadotropin-releasing hormon antagonists instead of gonadotropin-releasing hormon agonists is about 7-10 days less. The experience with gonadotropin-releasing hormon antagonists is limited and it is not possible to tell if they are superior in terms of live birth rates or complications like OHSS. Some medications used in ART are listed in Table Medications used in assisted reproductive technologies.

Table Medications used in assisted reproductive technologies

Medication Trade name Description Dose
Buserelin Suprecur Synthetic gonadotropin-releasing hormon agonist 100 times more potent than the natural hormone 150 μg as a nasal spray four times a day
Nafarelin Synarel As above 200 μg nasal spray three times a day
Triptorelin Decapeptyl As above 3.0 mg SC one a day
Cetrorelix Cetrotide Synthetic GnRH 3.0 mg SC as a single
antagonist dose or 0.25 mg/day SC
Ganirelix human menopausal Orgalutran Menogon As above
Purified extract from
0.25 mg/day SC
75-225 IU SC or IM
gonadotropins (hMG) Menopur menopausal urine containing FSH and LH in a ratio of 1:1 daily
Urofollitropin, high purity (HP) Metrodin HP Extract from menopausal urine containing FSH but virtually no LH 75-225 IU SC or IM daily
Follitropin alpha Gonal-F Recombinant FSH 37.5-150 IU SC daily
Follitropin beta human chorionic gonadotropin (hCG) Puregon Choragon Pregnyl Profasi As above
An extract from the urine of pregnant women containing hCG secreted from the placenta
50-200 IU SC daily
10 000 IUSC for triggering of ovulation
1500-2000 IU SC every 2-3 days for luteal support
Lutropin alpha Luveris Recombinant LH for use in patients with severe (< 1.2 IU/1) LH deficiency 75 IU SC daily
Progesterone Crinone Vaginal gel containing 8% progesterone delivering 90 mg of progesterone per application One applicator of 8% gel daily for luteal support
Gestone Progesterone for injection (50 mg/ml) 50-100 mg daily IM

FSH, follicle-stimulating IM, intramuscular hormone; GnRH, gonadotropin-releasing hormone; LH, luteinizing hormone; SC, subcutaneous;

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