Damien O’Brien MPSI synopsises conception, including IVF, medications and the role of the pharmacist
Conception is an increasingly important area of healthcare, with more patients seeking advice on pre-conception health, fertility optimisation and assisted reproduction. In Ireland, trends such as delayed parenthood, greater awareness of fertility issues, and the growing use of assisted reproduction have expanded the role of pharmacists at various stages of the conception journey.
Approximately 16 per cent of couples experience fertility issues. While conception is commonly associated with female reproductive health, fertility issues affect men and women equally. Typically, approximately 30 per cent of cases are attributed solely to male factors, 30 per cent solely to female factors, 30 per cent to a combination of both, and 10 per cent of cases remain unexplained.
Community pharmacists are among the most accessible healthcare professionals and are well positioned to provide evidence- based guidance, medication review and reassurance for patients. Pharmacists have an important role in identifying potential medication- related risks affecting conception, supporting lifestyle changes, and ensuring appropriate referral where necessary. They are also increasingly involved in supporting patients receiving fertility treatment, which often involves complex medication regimens requiring careful counselling regarding storage, administration and adherence.
This article will examine the background of conception and fertility, the role of pre-conception health
and lifestyle optimisation, pharmacy considerations regarding medications and conception, and the role of the pharmacist in supporting patients undergoing fertility treatment.
Background on conception and infertility
Conception occurs when a sperm fertilises an ovum. Ovulation typically occurs on day 14 in a standard menstrual cycle, although the cycle length and timing can vary widely. The ovum is viable for approximately 12-to-24 hours after ovulation, while sperm can survive in the female reproductive tract for up to five days. Therefore, the fertile window is considered to span five days prior to ovulation and the day of ovulation.
Female infertility may result from a range of factors affecting ovulation, fertilisation or implantation. The most important factor influencing female fertility is maternal age, due to declining ovarian reserve and oocyte quality, particularly after the age of 36. Ovulatory disorders such as polycystic ovary syndrome (PCOS) are another common cause. Endometriosis, tubal disease, fibroids, thyroid disorders, obesity and previous pelvic inflammatory disease may also negatively impact fertility. In some cases, no clear cause can be identified despite investigation.
Male factors contribute to a significant proportion of infertility cases and may arise from abnormalities in sperm production, motility or morphology. Common
The most important factor influencing female fertility is maternal age, due to declining ovarian reserve and oocyte quality, particularly after the age of 36
causes of male infertility include azoospermia (the absence of measurable sperm in the ejaculate), oligozoospermia (low sperm count), abnormal sperm morphology, retrograde ejaculation, blockage of the vas deferens, and poor sperm quality. Lifestyle factors including smoking, excessive alcohol consumption, obesity and recreational drug use that may negatively impact sperm quality.
The use of anabolic steroids or exogenous testosterone can also suppress spermatogenesis. Certain medications, acute viral infections or genetic conditions, such as cystic fibrosis, may also reduce sperm quality. Although the effect of age on male fertility is less pronounced than in women, sperm quality generally declines after the age of 45.
Infertility is typically defined as failure to achieve pregnancy after 12 months of regular unprotected sexual intercourse. However, earlier assessment is often recommended in women over the age of 35 or where known risk factors exist. Pharmacists are ideally placed to identify potential medication-related causes of infertility, provide advice regarding lifestyle factors and refer for further assessment where appropriate.
Pre-conception health and lifestyle optimisation
The period before conception provides an important opportunity to optimise health and reduce the risk of adverse fertility and pregnancy outcomes.
The management of chronic medical conditions should also be optimised during this period. Poorly controlled diabetes, thyroid disease, epilepsy and hypertension may adversely affect both fertility and pregnancy outcomes. Pharmacists can support adherence to treatment and ensure patients receive appropriate medical review before conception. As highly accessible healthcare professionals, pharmacists are well placed to provide guidance on lifestyle modification and pre-conception nutritional supplementation.
Folic acid supplementation is an essential consideration in this period to reduce the risk of neural tube defects. Women who are planning pregnancy should be counselled to take folic acid 400mcg daily for a minimum of three months prior to conception and continue throughout the pregnancy. A 5mg daily dose may be recommended for women at increased risk, including those with
a previous pregnancy affected by a neural tube defect, obesity, diabetes, certain malabsorption disorders
and concomitant use of medications known to affect folate metabolism.
Maintaining a healthy body weight is also an important factor in optimising fertility. Obesity is associated with reduced fertility in both men and women and may also increase the risk of miscarriage, gestational diabetes and other complications. Being underweight may also disrupt ovulation. A balanced diet rich in fruits, vegetables, whole grains and healthy fats may support reproductive health. Pharmacists can also counsel on nutritional deficiencies, including iron and vitamin D, in certain cases.
Smoking cessation is important in all individuals trying to conceive. In women, smoking is associated with reduced fertility and an increased risk of pregnancy complications, while in men it may impair sperm count, motility and morphology. Pharmacists can support smoking cessation through a range of pharmacological and non- pharmacological interventions. Alcohol consumption may also negatively affect fertility and pregnancy outcomes. Women planning pregnancy should be counselled that avoidance is typically recommended when trying to conceive. Caffeine intake should also be considered, with current recommendations generally advising limiting consumption to less than 200mg daily when attempting to conceive and during pregnancy.
Conception and medication
Medication review is an important aspect of pre-conception care, and pharmacists can make a significant contribution. Many individuals planning pregnancy may be taking prescription medicines, over-the- counter products or supplements that may affect fertility, conception or pregnancy outcomes. Pharmacists play an important role in ensuring that medication use is optimised before conception occurs through medication review, patient education and timely referral. Patients should be advised not to discontinue prescribed medicines without medical review as poor control of underlying conditions may itself adversely affect fertility and pregnancy outcomes.
Many medications require careful consideration when trying to conceive. Sodium valproate, topiramate and oral retinoids (isotretinoin and acitretin) are associated with a high risk of congenital malformations and should be avoided when trying to conceive. A formal Pregnancy Prevention Programme should be in place when these medicines are used in women of childbearing potential. Other medicines associated with foetal harm that require review prior to conception include angiotensin- converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), methotrexate and warfarin.
A medication review should also
While folic acid supplementation is recommended, excessive intake
of vitamin A should be avoided due to its teratogenic potential
include non-prescription products and supplements. Attention should be paid to vitamin supplementation. While folic acid supplementation is recommended, excessive intake of vitamin A should be avoided due to its teratogenic potential.
Fertility treatment
In certain cases, lifestyle modification and optimisation of underlying health conditions may be sufficient to achieve pregnancy. Others may require medical intervention to improve fertility before progressing to assisted reproductive technologies. Ovulatory disorders, particularly those associated with PCOS, are a common cause of female infertility. Letrozole is an aromatase inhibitor used to induce ovulation, while clomifene is a selective oestrogen receptor modulator. These medications are often taken early in the menstrual cycle to stimulate ovulation and increase the likelihood of conception without assisted reproductive technology.
Fertility supplements are often used in an attempt to improve fertility. Coenzyme Q10 (CoQ10), omega-3 fatty acids and antioxidants are sometimes used in both male and female infertility, while dehydroepiandrosterone (DHEA) may be used in women with diminished ovarian reserve. Some studies suggest benefits in selected patient groups. However, the quality
of evidence varies and routine use is not typically recommended.
In vitro fertilisation (IVF)
In some cases, pregnancy is not achieved despite appropriate lifestyle measures and medical intervention. Assisted reproductive technology may be considered in these circumstances. In vitro fertilisation (IVF) is an increasingly important treatment option for infertility.
This involves the fertilisation of an egg by sperm outside the body, followed by transfer of the embryo into the uterus. Successful treatment often uses medications to stimulate ovarian function, control ovulation and support implantation. As the use of fertility services continues to expand, community pharmacists are increasingly likely to encounter patients receiving IVF medications.
Gonadotrophins
Gonadotrophins are used in ovarian stimulation to promote the development of multiple follicles in the ovaries, increasing the number of mature oocytes available for fertilisation. Treatment is typically initiated early in the menstrual cycle. Follitropin alfa and menotropin are gonadotrophins commonly used in Ireland and are administered via daily subcutaneous injection.
Gonadotrophin-releasing hormone (GnRH) agonists and antagonists
These medications prevent premature ovulation during the ovarian stimulation process.
They suppress hormonal signals to allow close control of egg maturation and the timing of egg retrieval. Buserelin is a
GnRH agonist and cetrorelix is a GnRH antagonist commonly used in this process, both administered by subcutaneous injection.
Trigger medications
Trigger medications are used to induce final oocyte maturation by mimicking the body’s natural luteinising hormone surge. Once follicles have reached an appropriate stage of development, a trigger injection is administered. Egg retrieval is typically scheduled approximately 36 hours later, meaning the timing of administration is critical. Choriogonadotropin alfa and human chorionic gonadotropin (hCG) are examples of trigger medications.
Progesterone
Progesterone has a role in luteal phase support in IVF. It is used following embryo transfer to support endometrial development and facilitate implantation and may be continued for several weeks if pregnancy is achieved. Vaginal pessaries, vaginal gels and subcutaneous injections are common formulations used.
Clinical considerations
The use of IVF medications presents several important counselling points and clinical considerations for pharmacists. As the use of assisted reproductive technologies continues to increase, pharmacists are likely to encounter these treatments more frequently in community pharmacy. An in-depth knowledge of these medications and effective patient counselling enables pharmacists to provide valuable support throughout a complex treatment process.
Storage
Many fertility medications require refrigeration and careful handling to ensure stability. Pharmacists are responsible for ensuring appropriate storage within the pharmacy and can also provide practical guidance
Fertility medications are administered according to highly specific treatment regimens
to patients on the transport and storage of these medications.
Administration
Many IVF medications are administered parenterally, typically by self-administration. Patients should be thoroughly counselled on proper injection technique and the safe disposal of sharps. Progesterone preparations are often vaginal formulations and require counselling on administration. Patients should be advised that local irritation and discomfort are common and do not necessarily indicate treatment failure.
Adherence and timing
Fertility medications are administered according to highly specific treatment regimens. Small changes to the schedule may negatively affect treatment outcomes. Patients may find multiple injections and complex dosing schedules challenging. Pharmacists therefore play an important role in reinforcing adherence and helping patients manage these regimens, as treatment success often depends on dose timing.
Adverse effects
Ovarian hyperstimulation syndrome (OHSS) is one of the most significant adverse effects associated with fertility treatment. It is an excessive response to fertility medications, with symptoms ranging from mild abdominal discomfort and bloating, to severe abdominal pain, rapid weight gain, nausea, vomiting and shortness of breath. Other common adverse effects include bloating, pelvic discomfort, headache, breast tenderness, fatigue, nausea and injection-site reactions. Pharmacists should counsel patients regarding these adverse effects and provide reassurance where appropriate.
Emotional support and patient counselling
Infertility and fertility treatment can be associated with a significant emotional burden. Patients may experience anxiety, stress, uncertainty and disappointment throughout the treatment process. In these situations, community pharmacists can provide reassurance, answer questions and refer patients to additional sources of support where appropriate.
The role of the pharmacist
Pharmacists are ideally placed to contribute to positive reproductive health outcomes throughout the fertility journey, extending beyond the supply of medication. They can support smoking cessation, encourage healthy lifestyle modifications and advise on appropriate nutritional supplementation before conception. They can also review medications in patients with chronic conditions to help optimise treatment pre-conception.
There are many opportunities in community pharmacy to counsel patients receiving ovulation induction therapy and IVF treatment on storage requirements, administration techniques, the importance of adherence and adverse effect monitoring. As awareness of fertility and the use of assisted reproductive technologies continue to increase in Ireland, pharmacists have an important opportunity to provide evidence-based advice and patient- centred support during a significant stage of care.
References upon request
