In vitro fertilization
In Vitro Fertilization is a fertilization process that is applied on the
egg that is combined with the body's sperm but outside it as it is made into
glass. This process includes many procedures such as monitoring the ovulatory
status of the woman and it removes an egg from her ovaries in order to make
them fertilized by the sperm in liquid and the process is made in the
laboratory. IVF is a kind of reproductive technology that is assisting in
treatment on infertility where a fertilized egg is being implanted in the
uterus of the surrogate and then the result is a child that is not related
genetically to the surrogate. This process is banned in some countries and
others regulate it. (Hansen et al, 2017)
Medications
There are many fertility drugs that are used lonely as basic types of
treatment for inducing ovulation. They may fail as therapy to be used solely so
then assistance reproductive procedures can be used with them. Examples are in
vitro fertilization for producing more eggs.
There are main three types of fertility drugs which are:
• Medications for Ovarian Stimulation:
There is the Clomiphene that can be Clomid, Serophene, generic. There is
also Letrozole that is referred to as
Femara, ]; human menopausal gonadotrophin (hMG) [Humegon, (FSH) [Follistim,
Gonal-F, Bravelle]; and luteneizing hormone (LH) [Luveris. (Mayoclinic, 2017)
• Medications for Oocyte Maturation:
Human chorionic gonadotropin (hCG)
[Profasi, APL, Novarel, Pregnyl and
Ovidrel
The following table shows treatment for infertility
based on the patients' cycle using Clomid:
Figure 2
• Medications to
Prevent Premature Ovulation:
GnRh agonists [leuprolide
(Lupron, generic), goserelin (Zoladex)]; nafarelin (Synarel), Gn RH
antagonists, ), cetrorelix (Cetrotide )]. [ganirelix (Antagon.
Clomiphene
Clomiphene citrate referred to as (Clomid, Serophene, generic) is always
used at first and it is mainly prescribed for the women suffering infrequent
periods and or suffering long menstrual cycles. This drug is gentler than other
potent drugs which are usually used in superovulation as it is based on
blocking estrogen and tricking the pituitary through the production of
follicle-stimulating hormone as well as the production of luteinizing hormone
(LH). This is important in follicle growth and eggs releasing.
Clomiphene that is usually taken orally through the mouth, very
inexpensive, and it bears multiple births risk estimated with a percentage of
(about 5%, mostly twins) which is a percentage that is lower than its
possibility with the usage of other drugs.
The following conditions can make the women have better chances with
this drug:
• Polycystic ovarian syndrome (PCOS
• having ability for menstruation but their menstrual
cycle is irregular.
While the following conditions can make women have low chances with the
drug:
• Infertility but having normal ovulation
• Having Low estrogen levels
• Suffering Premature ovarian failure
The patient takes one or two daily tablets and this continues for five
days and it begins after two to five days of the period. After a week of taking
the last pill, ovulation occurs. In case that there is no ovulation, the
patient should take higher dose in the next cycle. When this system is not
effective too, there should be more prolonged treatment and the patient should
take additional drugs and medicines as 6 cycles are the limited period
suggested for this treatment by doctors. The quality and amount of cervical
mucus can be reduced by Clomiphene as this can make the uterine lining thinner.
In this case, the patient should take different drugs to retain thickness. This
drug has some side effects such as headache, fatigue, weight gain, hot flashes
and nausea.
figure 3
Figure 4
Metformin9,12
Polycystic ovary syndrome (PCOS) is a known hormonal condition that makes women
produce higher increasing amount of androgens that then leads to irregular, or
no ovulation. Metformin has been used for restoring cyclic ovulation and menses
in some cases of women who are suffering from PCOS, though it is lowering the
higher increasing blood glucose levels. AEs of metformin has within increased
gastrointestinal discomfort, and that medication is contraindicated in some
specific patients with the renal dysfunction. (Fodina et al, 2016)
Gonadotropins
This drug is another choice instead of Clomiphene or if it is not
effective with the patient, Gonadotropins contain many kinds of drugs based on
the FSH as a lonely component or on either combination of follicle-stimulating
hormone (FSH) and luteinizing hormone (LH). It works in an indirect way to make
the ovaries able to produce the multiple follicles.
Gonadotropins are given to the patients through injection and it
includes the following components:
• Human Chorionic Gonadotropins (hCG)
• Human Menopausal Gonadtropins (hMG),
that is also referred to as menotropins
• Follicle Stimulating Hormone (FSH)
• Gonadotropin-releasing hormone (GnRH)
analogs, which include GnRH agonists and GnRH antagonists
Gonadotropin can be natural compounds that are got from the urine or
they can be synthetic compounds formed mainly in a laboratory with the help of
recombinant DNA.
Human Menopausal Gonadotropin (hMG).
These drugs are also referred to as menotropins. They include different
components such as the LH and FSH and all are derived from postmenopausal women
urine. It is taken as injections in series after the start of the period with
2-3 days. The period of giving the
injections to patients is about 7 to 12 days. If there is no ovulation, time is
extended.
Human Chorionic Gonadotropin (hCG).
Human chorionic gonadotropin
(hCG) resembels LH. It is like the LH surge that urges the follicle for eggs
releasing. Natural hCG drugsare repared from pregnant women urine and they
include Pregnyl, Profasi, Novarel, and APL.
The only existed genetically modified hCG drug is Ovidrel which has
lower side effects as being injected, it is more able for control than the
natural drugs. It is usually used after the usage of either hMG or FSH for
stimulating the follicles final maturation stages.
Follicle Stimulating Hormone (FSH).
Urofollitropin referred to as (Bravelle, Fertinex) is a form of FSH
which is purified, it is deriving from postmenopausal women urine. Follitropin
drugs (Gonal-F, Follistim) are considered synthetic versions of FSH. Sometimes
these drugs are presented for patients aligning with an hCG drug.
GnRH Analogs (Agonists or Antagonists).
Gonadotropin-releasing hormone
(GnRH) is a type of hormone that is produced in the brain at the hypothalamus.
This drug works to stimulate the pituitary gland to make it form LH and FSH.
GnRH is based on synthetic drugs which are considered either antagonists or
agonists. They have similarities with the natural GnRH but work differently.
Although the natural GnRH stimulates both LH and FSH, the analogs prevent them from surge that happens exactly
prior to ovulation. This prevents the releasing eggs prematuraly before they
can be harvested for helping the reproductive technologies.
Figure 5
•GnRH agonists include leuprolide (Lupron, generic),
nafarelin (Synarel), and goserelin (Zoladex).
• GnRH antagonists
include ganarelix (Antagon) and cetrorelix (Cetrotide).
GnRH antagonists suppress FSH and
LH more than GnRH agonists. Perhaps they need fewer injections.
Figure 6
Complications of Superovulation
Multiple Births:
The follicle overproduction may cause enlargement of the ovarian and
this raises the multiple births with a percentage of 25%.
Ovarian Hyperstimulation Syndrome:
The Ovarian Hyperstimulation Syndrome is considered the most serious
complication related to superovulation as it is associated with having enlarged
ovary and there is not any known cause for this. This then can lead to having
dangerous fluid as well as electrolyte imbalances that may cause damage to
liver and can cause damage to kidneys. It is also associated with other
symptoms such as high pressure of blood, breathe shortness, nausea, vomiting
and abnormal bloating which can endanger the life of the patient.
Bleeding and Rupture of Ovarian Cysts.
If the follicles overproduction is not checked, there could be rapture
of ovarian cysts and bleeding. This shows that there is a possibility that
clomiphene and gonadotropins can raise the breast and ovarian cancer risks.
There isn't clear evidence for that but some studies suggest the relationship
between the drug and breast cancer. Other studies suggest that it may reduce
the risk for cancer in fact.
Other Drugs Used or Under Investigation
Letrozole and Aromatase Inhibitors.
Letrozole (AKA Femara)
Chemical Name: 4,4′-((1H-1,2,4-triazol-1-yl)methylene)dibenzonitrile
Molecular Weight: 285.303 g/mol
Formula: C17H11N5
Original Manufacturer: Novartis
Half Life: 2 – 4 days
Detection Time: 2 weeks
Anabolic Rating: N/A
Androgenic Rating: N/A
Aromatase is blocked by the aromatase inhibitors as the aromatase is an
enzyme that is mainly responsible for estrogen production in the tissues of the
women bodies outside of their ovaries. These drugs can include some main
components such as letrozole (Femara) and anastrozole (Arimidex). Inspite of
the fact that letrozole is not agreed as an infertility treatment, it is
ususally used in theis purpose in the past few years.
Progesterone.
Progesterone is mainly a hormone that the human body produces in the
menstrual cycle. They are given to the women who have suffered miscarriages.
The miscarriages are signs of deficiency in the progesterone as the drug of it
can be presented to the woman after her retrieval of eggs in the period of in
vitro fertilization in order to make the uterine lining thicker and help it be
more able to be ready for holding the egg in the next implantation.
Tamoxifen.
Tamoxifen (Nolvadex, generic) is a type of drug referred to also as a
selective estrogen-receptor modulator (SERM). It is used for treating or
preventing diseases like breast cancer in some specific cases of women. It has
been examined in fertility treatments for ovulation inducing. Tamoxifen works
in a way that resembles the work of clomiphene but it is different as it may
lead to more health hazards with the risk for uterine cancer and blood clots.
(Jordan et al, 2016)
Glucocorticoids.
Glucocorticoids drugs are steroid hormones mainly used associated with
IVF and intracytoplasmic sperm injection (ICSI) for helping them make the
uterus lining more responding to the implantation of the egg. Yet there are
other reviews made recently that say that glucocorticoids do is not effective
in improving the success of pregnancy and its rates and there is no need for
using them routinely with assisted reproductive technologies. (Melo et al,
2015)
Figure 7 fertilization and implantation
Lifestyle Changes
There is not a specific diet that women should follow in order to have
good levels of fertility but there are some basic lines for a healthy life
style that should be followed to avoid infertility based on passive life styles
and these are some tips:
- Keep a
reasonable healthy weight: Women
who are not following rules to keep having healthy weight may be
overweight or underweight and this makes them at risk for fertility
problems, such as having lower opportunities to succeed in fertility
procedures.
- Don't smoke: Smoking can raise the infertility risk
in both males and females so it is good to avoid smoking that is active or
passive.
- Avoid extra
exhausting sporting exercise if it hurts the menstrual cycle. Yet it is
important to practice some simple and regular exercise such as aerobe or
walking.
- Reduce the usage
of caffeine and alcohol.
- Don't take any
unneeded medications. (Nazni, 2014)
The role of pharmacist in dispensing these drugs (advices
to the patients)
Patients who suffer infertility can be advised by the pharmacist about
their cases through educating them about many channels such as the information
found on media channels as TV and the internet. There are different online
surveys and consulting services for infertility but the patients shouldn't
investigate and deal with these sites all unless they are well known
scientifically by a pharmacist, written by a special person or health
organization and they have to be evidence based and peer reviewed. They may be
misleading and inaccurate if found online in different sites that may not be
educational or scientific. Systematic reviews can be effective and useful, they
are advised to read them and make use of the information in them. Patients are
also advised to consult doctors early as they have to consult doctors if they
feel problems in the menstrual period or in being pregnant or even if they are
women who are over 35 and still not pregnant. Pregnancy tests are essential to
be made by patients regularly. There is a great role for the pharmacist in
dispensing these drugs and managing the infertility in patients as he has to
put great attention to the relevant details to the treatment regimens of
infertility and advises the patients to do so. A pharmacist can also can be a
good source for information of infertility patients, he can tell them about the
reliable online sites for information and can also educate them and give them
the medication counseling in things and issues such as training on techniques
for injection and managing any relevant diverse effects. The pharmacist can
also provide patients with assistance with financial considerations related to
treatment of infertility and tests needed such as copay savings or prior
authorization relevant to the different costs of infertility therapy. (Barnes and Wiemer, 2015).
Conclusion
In conclusion, infertility is a case of inability to give birth or be
pregnant for longer than a year after regular sexual contact. it is important
to focus on the important of fertility and discovering infertility and its
reasons early as this helps women treat it effectively and avoid many other
relevant health problems. There are many signs and symptoms that can tell the
patient should ask a doctor about fertility levels and if the patient suffers
infertility and what treatment should be applied with each patient such as the
older age than 35 or the irregular menstrual cycle. There are many types of
infertility and the doctor can decide this via different measurements and
testing. There are many associating risk factors for infertility such as age,
weight, smoking and others. The patient can receive different types of
treatment and medicines based on the needs and the success of the treatment
received by the patient. It is necessary to follow a healthy life style in
order to avoid infertility that is related to some bad habits such as smoking
or taking too much caffeine or alcohol.
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