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Dr. Eric Daiter

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Dr Eric Daiter has served Monmouth and Middlesex Counties of New Jersey as an infertility expert for the past 20 years. Dr. Daiter is happy to offer second opinions (at the office or over the telephone) or new patient appointments. It is easy, just call us at 908 226 0250 to set up an appointment (leave a message with your name and number if we are unable to get to the phone and someone will call you back).


"I always try to be available for my patients since I do understand the pain and frustration associated with fertility problems or endometriosis."


"I understand that the economy is very tough and insurance companies do not cover a lot of the services that might help you. I always try to minimize your out of pocket cost while encouraging the most successful and effective treatments available."

NJ Center for Fertility and Reproductive Medicine - Infertility Tutorials

Menotropin Therapy (detailed)
Menotropins are a powerful group of medications in which the most active ingredient in terms of ovulation induction or enhancement is follicle stimulating hormone (FSH). The unit of measurement for FSH is the International Unit (IU) which is based on an international reference preparation (IRP). One ampule of lyophilized (freeze dried) FSH generally has 75 IU of FSH (some have 150 IU of FSH so you should read the label).

Some menotropins, such as Pergonal and Humegon, also contain 75 IU (or 150 IU if there is 150 IU of FSH) of LH. LH stimulates the production of estrogen's precursor hormones (androstenedione and testosterone) in the ovary. Many women secrete adequate LH, making the addition of LH in these medications unnecessary. If the anticipated estrogen production is quite large, such as when heavily pushed to maximally produce mature eggs in IVF cycles, then many infertility specialists prefer to have additional LH available. Also, there are some women who do not produce LH in adequate amounts and these women benefit from the additional LH.

The basic infertility evaluation should be completed prior to the use of menotropins.

Menotropins are contraindicated in women with no ovarian reserve (menopause). A woman with early ovarian failure will occasionally have a spontaneous recovery of ovulation (for unknown reasons) but attempts at ovulation induction or enhancement in these women are usually unrewarding. Ovulation induction can be considered if the FSH concentration is less than the LH concentration and/or the estradiol concentration is greater than 40 pg/ml (the amount required for a withdrawal flow).

There should always be documentation of tubal patency and availability of sperm prior to initiating treatment with menotropins. I often recommend a laparoscopy to assess and optimize the pelvis prior to menotropin therapy. An exception is when the only finding on evaluation is a clear-cut ovulation disorder. The appropriateness of laparoscopy should be individually discussed with each couple considering menotropins.

Menotropins can be used for either ovulation induction, ovulation enhancement in a process referred to as "controlled ovarian hyperstimulation" (COH) or "assisted reproductive technology" (ART, including IVF).

Menotropins are injectable medications. Most of these have considerable contamination with other proteins and are given as intramuscular injections deep into the upper outer quadrant of the gluteus maximus muscle (rear end). Fertinex is an exception in that it has been highly purified through affinity chromatography so that it can be self administered subcutaneously (under the skin) in the upper thigh. Recombinant forms of menotropins are also highly purified and can be administered subcutaneously.

In my experience, the partner of the woman being treated is the most reliable and caring person to give the intramuscular injections once taught the proper technique (to prepare and administer the medication). The shot is given at night (occassionally twice a day) in a dosage that may change from day to day.

There are several protocols commonly used for ovulation induction and enhancement with menotropins. The physician in charge of your COH or IVF cycle should be experienced in the use of these medications to optimize your response and limit complications. Common features of appropriate protocols include:

(1) perform an ultrasound exam prior to initiating a cycle.

* There should be no large cysts within the ovary at the onset of a stimulation cycle. Cysts greater than 2 cm (and possibly 1.5 cm) are relative contraindications for starting the medication. Larger cysts may interfere with optimal stimulation either by producing hormones locally to disrupt the surrounding follicular development or by mechanically interfering with follicular development due to their size. I will generally advise that the patient with a large ovarian cyst return the following month for an ultrasound and may start stimulation if the cyst has gone away. Most of these cysts seem to be residual (corpus luteum) cysts from the prior cycle and are removed by the body within days to weeks. Selected patients will be allowed to initiate a cycle despite a large ovarian cyst if the circulating estrogen concentration is found to be low (indicating that the cyst is not functioning hormonally). If a larger cyst in the ovary persists over several months then further evaluation and probably removal would be recommended. Removal of persistent nonfunctional large cysts of the ovary is primarily to rule out serious pathology (such as cancer).

(2) menotropins are started in the early part of the cycle

* a "standard" protocol for COH is 2 ampules of menotropin per day starting on cycle day 2, 3 or 4. The first day of heavy flow is cycle day 1. Medications are usually given in the evening at about the same time each day. Monitoring bloodwork for estradiol concentration is initiated after 3 days of medication. This estrogen level allows adjustment of the medication dosage and determination of when to return to the office for additional bloodwork (and possibly an ultrasound). Once additional testing with ultrasounds is begun, monitoring is usually more frequent and may even be required each day. On average, a "typical stimulation" may take 7-12 days of medication and the patient will have returned to the office on 3-5 occasions for monitoring.

(3) dosing of menotropins may be changed from cycle to cycle

* some patient's ovaries are difficult to stimulate with menotropins. If 2 ampules per day results in a poor response, then increasing the dosage of medication is considered. Increasing from 2 to 4 ampules per day is common. Generally I do no use greater than 6 ampules per day since I have not seen reasonable success in achieving a pregnancy with greater doses. Some patient's ovaries will respond by maturing too many follicles at once. If there is a larger than desired response to 2 ampules per day, then decreasing the amount of medication to 1 ampule or 0.5 ampule is considered.

(4) GnRH agonists may be used for ovarian suppression or "a flare"

* GnRH agonists are a type of medication often used with menotropins in stimulated cycles. Their most common indications are when more even development of follicles is desired. If a prior stimulated cycle resulted in maturation of only 1 or 2 mature eggs despite the presence of multiple other follicles then use of a GnRH agonist may be helpful. In these situations, the GnRH agonist is started about a week prior to the expected menses to suppress any early development of follicles (the follicles are at a common baseline of development when the menotropins are started). Also, use of agonists allows for greater control and the ability to push follicles to larger sizes at the end of the stimulation cycle.

* the GnRH agonists may be administered in a variety of ways, including as injectable medications or taken as an intranasal spray. There are many different GnRH agonists available and each has a different half life (duration of effectiveness). Thus, these medications may need to be taken either once or twice a day depending on the particular product chosen.

* GnRH agonists will initially result in the release of stored FSH and LH from the pituitary gland. This stimulatory response to these medicines lasts for the first few days. GnRH agonists also suppress the production of new FSH and LH so that once the stored hormones have been released the circulating FSH and LH is very low. Therefore, following the initial few days of stimulation there is a suppression of the ovary for the duration of administration of the medication. Since these medications deplete stored LH the brain is also incapable of triggering ovulation via an LH surge .

* a "flare" protocol exists, for which the GnRH agonist is started at (about) the same time as the menotropins. This flare protocol takes advantage of the initial release of pituitary FSH and LH, which may further enhance egg development. With the flare protocol there will be pituitary and ovarian suppression by the time of ovulation so there is an inability to mount the LH surge (signal to ovulate).

(5) menotropins are commonly used during IVF

* higher doses of menotropins along with a relatively strong GnRH agonist (such as lupron) are generally used for In Vitro Fertilization (IVF). A standard IVF protocol would consist of lupron (initiated on idealized cycle day 21 of the prior cycle) and 4 ampules of menotropins per day (initiated early in the next cycle). Both GnRH agonist and menotropins are continued until ovulation is desired, then the LH surge is simulated with hCG (profasi).

(6) polycystic ovaries are often difficult to stimulate

* Polycystic ovaries are characterized by a large number of follicles arrested in early to mid development. When stimulating polycystic ovaries, the goal is to avoid excessive numbers of small follicles with very high circulating estradiol concentrations since this can result in severe forms of ovarian hyperstimulation syndrome. Protocols to avoid excessive development differ dramatically from one another. Some start with a high dose of menotropins and cut back once a few follicles have begun to develop. Others start with a low dose of menotropins, hoping that only a small number of follicles will respond. Still others administer 1-3 months of birth control pills to suppress follicular development and then use a GnRH agonist to continue to suppress abundant follicular development until menotropins are started. There is usually a considerable learning curve (trial and error period) to customize the menotropin strategy for patients with PCOS since the ovaries generally respond uniquely and unpredictably. Trying several different menotropin protocols might be required before settling on an ideal protocol for a particular patient's ovaries.

(7) giving steroids may suppress excessive androgenic hormone production

* If a woman has abundant circulating androgenic hormones these can interfere with follicular development. Androgenic hormones are associated with male pattern hair growth and occasionally dark irregular discoloration of the skin usually in areas of creases (such as arm pits, neck, under breasts). Blood hormone studies can usually (but not always) confirm high circulating levels of these hormones. If the androgens are elevated or if there are clearcut signs of excess androgens then consideration of concurrent low dose glucocorticoid steroid medication (such as dexamethasone or prednisone) is considered.

(8) GnRH pumps are available

* As an alternative to menotropin therapy these pumps will infuse the releasing hormone, GnRH, in preset amounts and time intervals. GnRH will directly stimulate release of FSH and LH from the pituitary gland. In my experience, patients do not like the concept of an indwelling catheter either placed under the skin or into a blood vessel. The catheter stays in place for weeks to months and works by means of a small pump (about the size of a transistor radio) that the patient carries.

Intensive monitoring is required to maximize appropriate egg development and minimize exposure to complications. This monitoring includes transvaginal ultrasounds and bloodwork for hormone (esp. estradiol) levels. Usually, I will perform a baseline ultrasound exam to rule out large ovarian cysts and then obtain bloodwork and ultrasounds every 1-4 days until there is full maturation. A typical cycle might involve 7-12 days of medication. At the end of the stimulation process, human chorionic gonadotropin (hCG, such as Profasi) is given into the intramuscular region to simulate the LH surge and trigger both the final maturational step in egg development and the release of the mature egg(s).

Human menopausal gonadotropins are expensive. For controlled ovarian hyperstimulation (COH) with intrauterine inseminations (IUIs) two to three (but up to six) ampules per day are taken for about 10 +/- 3 days, for a normal total of 20-30 ampules. For In Vitro Fertilization about twice as much medication may be normal. Since each ampule costs about 50 dollars the total for the medication is easily 1-2 thousand dollars per attempted cycle. In addition, the professional and other fees for monitoring can be expensive.

Obtaining menotropin medication can be difficult. Menotropins are not carried as routine stock in many pharmacies. Therefore, you should confirm that your pharmacy has actually received a supply for you prior to attempting to fill your prescription. If you are unable to identify a pharmacy that will order this medication for you, a local infertility center (such as my office) should be able to direct you. Menotropins are stable if stored at room temperature up until their stated expiration date.

There are few side effects to the human menopausal gonadotropins (menotropins). Stress associated with a cycle of IVF or COH can be intense and a free flow of communication between partners can be very effective at reducing this stress. Organization is important for working couples since monitoring may take 30-60 minutes in the morning, exclusive of travel time.


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Eric Daiter, M.D. - Edison, NJ - E-Mail: - Phone: (908)226-0250

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