If IVF was a movie, the medications would be the villainous sidekicks. Not the menacing bad guy, but all the annoying, unwanted plot points along the way. Even when you know they're essential to the journey, you still wish you could skip to the end without encountering them.
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How did in vitro fertilization (IVF) medication get such a "bad guy" reputation? Maybe you’ve heard injection horror stories from a friend or colleague or you’ve seen people posting updates featuring a mountain of used syringes on social media.
With all these images swirling in your mind, you grit your teeth, prepare for the worst, and give yourself the first injection…only to realize that it’s not that bad. As the days progress, you may go from feeling anxiety to, believe it or not, a sense of empowerment.
How could that be? Well, let’s dig into how IVF meds work and what they actually do.
Depending on the type of medication, fertility meds come in many forms: pills, patches, nasal sprays, and injections. Oral medications are usually the first step for those proceeding with fertility treatment like ovulation induction or intrauterine insemination (IUI), but they are not strong enough to provide the robust ovarian response we need to see during an IVF cycle.
Once you make the decision to move forward with IVF, you'll need to use injectable medications that directly stimulate the ovaries to produce multiple dominant follicles.
What are follicles? Follicles are the little fluid-filled sacs that contain eggs (you may have seen them on an ultrasound - they look like black circles). The ovaries typically only produce one dominant follicle (egg) per cycle, meaning one keeps growing, while the rest are reabsorbed into the body.
Gonadotropin-releasing hormone (GnRH) injections are taken during IVF to directly stimulate the ovaries to produce multiple eggs, prior to an egg retrieval. Common brand names include Gonal-F, Follistim, Menopur, Pregnyl, and Novarel.
What you receive will depend on what your insurance covers.
The injections are subcutaneous (similar to insulin shots), and utilize a small needle that goes right under the skin, into the fatty layer. Your fertility nurse will teach you how to administer them in your abdomen before you begin IVF.
FYI: The exact puncture site doesn’t need to be precise, so most patients can administer their own shots, even if they've never injected themselves in the past.
Every patient is different, but these are some commonly reported side effects:
In rare cases, these injections may cause something called Ovarian Hyperstimulation Syndrome (OHSS), a rare condition that can develop during the egg retrieval phase of IVF.
OHSS is a medical complication that affects approximately 3% (or less) of patients undergoing in vitro fertilization (IVF) each year. This can occur when the ovaries have an abnormally robust response to fertility medications. A large number of egg follicles grow, the ovaries continue to swell, and eventually leak fluid into the pelvis.
Thankfully, most cases of OHSS are mild and cause temporary discomfort.
IVF stimulating medications aren’t the only thing you must take. Additional medications are prescribed so that you don’t ovulate prematurely – we don’t want to make a bunch of eggs only to have them be released into the fallopian tubes where we can’t retrieve them!
You will be closely monitored by your provider with regular ultrasounds (to visualize each follicle as it develops) and blood work (to check hormone levels).
Once your eggs are the perfect size, you will administer what's called a "trigger shot," which contains a condensed amount of a naturally-occurring hormone called human chorionic gonadotropin (hCG).
This causes ovulation to occur in 34-36 hours so that we can precisely time your retrieval to fall just before that window. This assures us that your eggs are as mature as they can be without missing the window to retrieve them before your body ovulates.
The purpose of this injection of hCG is to trigger the final maturation and release of eggs from your ovaries after growth. It may cause side effects such as:
If you are having an embryo transfer this cycle, we will prescribe progesterone injections and suppositories and estrogen pills for you to take, at least until your pregnancy test - since they may help prevent pregnancy loss.
Why? The cyst(s) that remain after ovulation are usually in charge of providing progesterone and estrogen, essential implantation hormones that make the uterus thick and cozy for an embryo to implant. Since we disrupted their normal functionality by giving you medication to prevent ovulation, we can’t rely on them to do their job, so we help them out with progesterone and estrogen supplementation.
The progesterone in oil (PIO) injections are intramuscular, and we show you how to administer these as well. Since they should be given in a large muscle (usually the butt or hip), most patients ask for help with these shots. These shot will contain the hormone, as well as a little bit of natural oil for dissolving purposes.
Note: If you become pregnant after embryo transfer, you will continue taking these medications for a few weeks, until the placenta "takes over" hormone production.
Here's what you may experience while on progesterone shots:
And on both progesterone and estrogen:
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We know this is a lot of information to take in, and you'll likely have some follow-up questions. Let's tackle a few of the most common concerns we hear from IVF warriors:
This is a common (and logical) question, because women are born with a finite amount of eggs. Every egg counts! Thankfully, the short answer is no - IVF won't deplete your supply.
In a typical menstrual cycle, the body "recruits" a bunch of follicles from the ovaries each month. The amount of follicles recruited will be different in each person's body, and can even vary from month to month.
In an (unmedicated) menstrual cycle, one of the follicles becomes dominant around Day 5 and uses up all of the hormone called follicle stimulating hormone (FSH). The other follicles cannot continue to grow without it, so they stop growing and get reabsorbed by the body.
However, all of them are still withdrawn from your egg supply.
If we have you take the proper hormones before dominant follicle formation, then we can salvage as many follicles as possible by "distributing" FSH to them as well. Remember: FSH is the hormone necessary for follicular growth, so the eggs can mature and be fertilized.
You will also take luteinizing hormone (LH) which signals the body to prepare for ovulation. FSH and LH are both normal in a typical cycle, but are devoted to developing only one follicle. During an IVF cycle, higher levels of these hormones help mature as many follicles as possible.
In summary, we are not withdrawing additional follicles from your ovarian "bank" that month – we are just helping you "keep the change."
The ovarian stimulation stage of IVF is necessary to give you the best chance of success.
Here's why: we want your ovaries to create many follicles (stimulated by all those injections) so that when you have your egg retrieval, your surgeon is able to collect as many mature, healthy eggs as possible.
Those retrieved eggs will then be combined with designated sperm to fertilize and create embryos. The embryos that develop into blastocysts (around Day 5-7, the best stage for implantation), are eventually implanted in the uterus to try and achieve pregnancy.
Note: There is a high rate of attrition in IVF - from the amount of eggs retrieved to blastocysts available for transfer, so we want to start with as many eggs as possible.
Your unique starting dose depends on many factors (such as your age, weight, and results of ovarian reserve testing) and might be increased or decreased during your cycle depending on your response.
Remember: No two people or treatment cycles are alike, so be aware that your dose and medications may be different than a friend's - even if you are the same age.
One of the worst feelings during a fertility treatment cycle is the lack of control you may feel over its outcome.
When you have to rely on your fertility team (and technology) to help, it can be frustrating, especially if you believe that if you just work hard enough, you'll be able to accomplish your goals. Unfortunately, the world of infertility doesn’t always work that way.
The good news? Shifting your perspective can be empowering. Here's what to focus on:
Injecting IVF meds at night and being able to see your body's response in the next day or two (as your estrogen levels rise and those little black circles increase in size and number) is incredibly fulfilling. It helps you feel that you are actually doing something.
Many patients report feeling surprised at how brave and resilient they became during the IVF process, even if they were initially terrified by the thought of daily injections.
Partners, friends, or family members will want to know how they can help as you move through IVF treatment. They, too, feel helpless. Allowing others to help administer injections gives them a tangible way for them to support you, particularly if you are someone who doesn’t normally like asking for help.
Many people are also able to find humor in the situation and find that they develop an even deeper relationship, with increased connection and communication.
In summary, do you want to take injections in your spare time for fun? No. Are those injections as bad as most people make them out to be? Also no!
In fact, there is a silver lining in that you can tap into your internal resources that you didn’t know you had until you were asked to do some hard stuff. Also, allowing a partner, friend, or family member to help you navigate through your IVF cycle can enrich your relationship, as they most likely want to help you, but aren’t sure how.
Sometimes, all it takes to make the switch from fear to empowerment is believing you can do this. Remember, undergoing an IVF cycle can be tough, but so are you.