hMG (Human Menopausal Gonadotropin) or menotropin is derived from the urine of postmenopausal women to stimulate the ovaries and testes.

hMG (human Menopausal Gonadotropin) or menotropin indications:

• It aids in the development of follicles and pregnancy in ovulatory women during the cycle of aided reproductive technology.
• Before treatment initiation, evaluate the male partner for the possible cause of infertility (azoospermia).
• Females should be evaluated for the underlying cause of infertility before the initiation of the treatment.
• A complete gynecologic examination, endocrine workup (rule out primary ovarian failure), and a pregnancy test should be done before the start of the treatment.

• Off Label Use of Menotropins in Adults:

  • It is used to stimulate spermatogenesis in males.

hMG (human Menopausal Gonadotropin) or menotropin Dose in Adults:

Dose in the treatment of Assisted reproductive technologies (females):

• It is administered as a subQ injection in a dose of 225 units once a day beginning on the second or third day of the menstrual cycle.
• It could be given along with urofollitropin. The combined dose of the medications shouldn't be greater than 225 units (menotropin 75 units Plus urofollitropin 150 units OR menotropin 150 units Plus urofollitropin 75 units).
• After five days, the dose should be changed in accordance with the serum estradiol levels or the ovarian response as revealed by an ovarian ultrasound.
• HCG should be injected as soon as a sufficient follicular response is observed.
• The dose should not be increased by greater than 150 units and not more frequently than once every 2 days.
• The total duration of the treatment should not exceed 20 days and the maximum dose of menotropin or menotropin Plus urofollitropin should not exceed 450 units.

Dose in the treatment of Spermatogenesis (males) (off-label):

• It is administered as an intramuscular injection after the administration of HCG.
• The usual dose is 75 units three times a week with twice-weekly HCG.
• The treatment is continued and semen analysis is done at 4 - 6 months of the treatment to see for sperms.
• HCG should be injected as soon as a sufficient follicular response is observed. Menotropins may be administered at a higher dose of 150 units three times a week for an additional six months if the response is insufficient after six months of treatment.

hMG (human Menopausal Gonadotropin) or menotropin Dose in Children:

Not applicable.

Pregnancy Risk Factor X

• It is not recommended for pregnant women.
• A pregnancy test must be performed before the treatment can begin.
• Menotropin is linked to multiple gestations and ectopic pregnancy.

Menotropins use during breastfeeding:

• It is unknown whether breastmilk contains menotropin.
• The manufacturer suggests that you stop breastfeeding because of possible adverse effects on the fetus.

Dose in Kidney Disease:

It has not been studied in kidney disease patients. The manufacturer has not recommended any adjustment in the dose.

Dose in Liver disease:

It has not been studied in liver disease patients. The manufacturer has not recommended any adjustment in the dose.

Side Effects of Menotropins (hMG):

• Endocrine & Metabolic:

  • Ovarian Disease
  • Ovarian Hyperstimulation Syndrome

• Infection:

  • Infection

• Gastrointestinal:

  • Abdominal Cramps
  • Vomiting
  • Diarrhea
  • Enlargement Of Abdomen
  • Gastrointestinal Fullness
  • Abdominal Pain
  • Nausea

• Central Nervous System:

  • Headache

• Genitourinary:

  • Multiple gestations (a common side effect)
  • Vaginal Hemorrhage
  • Pelvic Pain
  • Breast Tenderness
  • Ectopic Pregnancy

• Respiratory:

  • Dyspnea

• Local:

  • Injection Site Reaction
  • Swelling At Injection Site
  • Pain At Injection Site
  • Inflammation At Injection Site

Less common side effects of hMG:

• Cardiovascular:

  • Tachycardia

• Endocrine & Metabolic:

  • Ovarian Cyst
  • Ovary Enlargement

• Central Nervous System:

  • Dizziness

• Hematologic & Oncologic:

  • Hemoperitoneum
  • Ovarian Neoplasm

• Dermatologic:

  • Rash At Injection Site
  • Skin Rash

• Hypersensitivity:

  • Anaphylaxis

• Respiratory:

  • Flu-Like Symptoms
  • Tachypnea

• Local:

  • Irritation At Injection Site

• Miscellaneous:

  • Fetal Abnormality
  • Ovarian Torsion

Contraindication to Menotropins (Human Menopausal Gonadotrophins - HMG):

• Menotropine or any other formulation component allergies
• High levels of the follicle-stimulating hormone are a sign of primary ovarian failure.
• Nongonadal endocrine conditions (eg, pituitary, adrenal, thyroid) that are uncontrolled
• Tumors of either the hypothalamus or pituitary
• Reproductive tract tumors that are hormone-dependent
• Undetermined cause: Abnormal uterine bleeding
• Polycystic Ovarian Syndrome does not cause enlarged ovaries or an ovarian cyst.
• pregnancy.

Warnings and precautions

• Hypersensitivity

  • Menotropin administration has been linked to severe allergic reactions.
  • If a hypersensitivity reaction occurs, treatment must be stopped.

• Ovarian enlargement:

  • Ovarian enlargement may occur. To reduce the chance of abnormal ovarian growth, you should use the lowest effective dose.
  • If a patient is experiencing ovarian hyperstimulation syndrome, be sure to monitor them.

• Ovarian hyperstimulation syndrome:

  • It is an overreaction that starts 24 hours after receiving hCG treatment but can get worse 7 to 10 days later.
  • Ovarian hyperstimulation syndrome, or OHSS, is a rare condition that results from ovarian stimulation with menotropin.
  • Mild to moderate symptoms of OHSS are:
    • Abdominal distension
    • Abdominal discomfort
    • diarrhea,
    • Nausea and vomiting are common symptoms.
    • Mild to moderate enlargements of the ovarian cysts or ovaries.
  • Symptoms and signs that indicate severe OHSS include:
    • Extreme abdominal pain
    • Severe dyspnea
    • Hypotension
    • Anuria and oliguria
    • Ascites
    • Hydrothorax
    • Rapid weight gain
    • Venous thrombosis is a condition that can lead to venous embolism.
    • Large ovarian cysts
    • Nil and vomiting are intractable
    • Pleural effusion
  • Laboratory abnormalities in OHSS could include:
    • Hypoproteinemia,
    • Elevated liver enzymes
    • WBC raised
    • Electrolyte imbalances
    • A lower creatinine clearance
    • hemoconcentration,
  • The primary treatment is supportive and includes fluid management and pain relief as well as medications to prevent thromboembolic complications.

• Ovarian torsion

  • Menotropin use has been linked to ovarian torsion.
  • To avoid permanent ovarian damage, ovarian torsion must be immediately diagnosed and treated.
  • Patients at high risk include those with OHSS, patients with ovarian cysts, polycystic ovaries, previous abdominal surgeries, and patients with ovarian torsion.

• Effects on the pulmonary system:

  • It has been reported that the lungs can be toxic.
  • There have been reports of serious toxicities such as atelectasis and acute respiratory distress syndrome.

• Thromboembolism

  • Patients who have OHSS may experience thromboembolic events or treatment.
  • Patients with a history of thromboembolic events, such as morbid obesity or thrombophilia, are at greater risk.

Monitor:

• The follicular growth should be monitored by transvaginal ultrasound to determine follicular growth and the timing of HCG administration.
• Estradiol administration may also be useful in some cases.
• For at least two weeks following the delivery of HCG, the patients should also be under observation for ovarian hyperstimulation syndrome (OHSS).
• The patients may report symptoms of abdominal bloating, pain, rapid weight gain, and reduced urine output.
• Patients should be hospitalized if they develop moderate to severe symptoms of ovarian hyperstimulation syndrome.
• These patients should have serum albumin, serum electrolytes, hemoglobin, hematocrit,  and creatinine measured daily.
• Liver function tests should be measured weekly in patients with OHSS.
• Patients should also have a daily assessment of the degree of ascites, cardiac and respiratory status, fluid balance, hydration, urine output, urine-specific gravity, clinical features of thromboembolism, vital signs, and weight.
• In males, spermatogenesis should be monitored.

How to administer Menotropins (Human Menopausal gonadotropins - hMG)?

• It is administered as a subcutaneous injection in the lower abdomen.
• The site of injection should be rotated.

Mechanism of action of Menotropins (Human Menopausal gonadotropins - hMG):

FSH and LH (follicle-stimulating hormone and luteinizing hormone), which are taken from postmenopausal women's urine, are combined in a pure form.

It stimulates the testes and ovaries in males and aids in maturing ovarian follicles for females without primary ovarian failure.

It can also be used by males to treat spermatogenesis.

After multiple doses, FSH now has a half-life between 11 and 13 hours. 

Time is taken to get their peak serum concentrations takes 18 hours to finish a single dose of subQ. It is excreted primarily in the urine

International Brands of Menotropins (hMG):

• Menopur
• BSV-Humog
• M.G. Organon
• HMG
• HMG Lepori
• HMG Massone
• Humegon
• IVF-M
• Menodac
• Menogon
• Menogon 75
• Menogonal
• Menopur
• Merapur
• Merional
• Meropur
• Pergogreen
• Pergonal
• Pergonal 500
• Pergonal 75 75
• Progonadyl

HMG (Human Menopausal Gonadotrophins) Brand Names in Pakistan: