“Injections to ‘plump up’ our ovaries to get our eggs out.” “Hormone jacking up shots.” I hear these descriptions from my patients about IVF medications. I get it, but not exactly comforting to see that box of needles!
IVF medications fall into three groups: meds that stimulate your ovaries to make multiple eggs (FSH and LH, like Gonal-F, Follistim and Menopur), meds that prevent you from ovulating before egg retrieval (ganirelix, Cetrotide or Lupron), and a trigger shot (hCG, Lupron or both) that matures your eggs about 36 hours before retrieval. This is usually a 9–12 day course.
I’m Dr. Lucky Sekhon, double board-certified reproductive endocrinologist and infertility specialist in New York City. I’ve had multiple egg retrievals and given these shots myself. I make fertility medicine accessible and empathetic in my practice, my book The Lucky Egg, on Instagram and in The Lucky Egg Drop. Let’s break down your list of meds, go through a sample schedule and distinguish between evidence vs my clinical preferences.
I walk through the three parts of an IVF protocol in this video:
IVF medications do three jobs: stimulate, block ovulation, and trigger
The IVF protocol is the order and type of medications given leading up to egg retrieval. Though names of medications will differ, there are 3 fundamental jobs to do.
I often describe it to patients like this: The ovaries are a pantry. There is a smaller “kitchen” cabinet in that pantry which you have access to. In the pantry is the reserve of resting eggs. In the “kitchen cabinet” are recruited follicles (fluid sacs that contain the eggs) that are “available” for this cycle. Left to their own devices, typically 1 will become dominant and the rest will disappear. You want to salvage as many of the “available” as possible during stimulation – not steal eggs from future cycles!
FSH stimulates follicle growth, ovulation blockers keep follicles from premature release, and the trigger starts final egg maturation.
Notice how stimulating the follicle to grow and the egg to finish maturation is a different job. This is why we don’t substitute the trigger with stim injections.
Not all of these drugs will be taken and not all of the meds will be used for the entire stimulation period. There is prep done beforehand. Some of these meds may even be from the later transfer period like progesterone. My fertility acronym guide makes sense of all the alphabet soup.
The IVF medications list: what each drug does and when you take it
Think of this as a medication decoder, not a grocery list. Refer to your prescription sheet for the medications, dosage, formulation, injection route.
Table 1. IVF medications list
| Medication type | Common brand names | What it does | When in the cycle | How it’s given |
|---|---|---|---|---|
| FSH | Gonal-F; Follistim/Puregon | Stimulates follicle growth | During stimulation | Subcutaneous injection |
| FSH plus LH activity / hMG | Menopur | Supports follicle growth with both hormone activities | During stimulation | Subcutaneous injection |
| Low-dose hCG as an LH source | Prescribed diluted or compounded hCG | Supplies LH-like activity alongside FSH | During stimulation, when selected | Usually subcutaneous; prescribed preparation |
| GnRH antagonist | Ganirelix; Cetrotide | Blocks the premature LH surge | Added during stimulation | Subcutaneous injection |
| GnRH agonist: suppression or flare | Lupron / leuprolide | Initially stimulates, then suppresses pituitary signaling | Before and/or during stimulation | Short-acting subcutaneous injection |
| hCG trigger | Ovidrel; Novarel/Pregnyl | Initiates final egg maturation | At the assigned time before retrieval | Injection; route depends on prescribed product |
| Lupron trigger | Lupron / leuprolide | Prompts the pituitary to release an LH surge | At the assigned trigger time | Subcutaneous injection |
| Dual trigger | Low-dose hCG plus Lupron | Combines both trigger mechanisms | At the assigned trigger time | Separate injections; prescribed routes |
| Priming | Birth control pills; estrogen patches | Used for scheduling and attempted follicle synchronization | Before stimulation, when selected | Oral pills or skin patches |
| Oral boosters | Letrozole; Clomid | Alters estrogen feedback to increase the body’s hormone signaling | Selected stimulation protocols | Oral tablets |
| Progesterone support | Progesterone in oil (PIO); vaginal progesterone | Supports the uterine lining for transfer | After retrieval and/or during a transfer cycle | PIO intramuscularly; vaginal products vaginally |
Roles of medications according to ESHRE stimulation guideline & ASRM trigger guidance. Always consult the relevant medication-specific guidance for further details.
FSH and LH stimulation medications
FSH = follicle-stimulating hormone. LH = luteinizing hormone. Gonal-F and Follistim are sources of FSH. Menopur is a source of FSH and LH activity (it’s not just another brand of FSH). Human menopausal gonadotropin = hMG. It’s not that everybody needs to get everything injected. The need for more LH activity (if any) is patient specific.
GnRH antagonists
GnRH = gonadotropin releasing hormone.
This is the message from your brain to your pituitary.
Ganirelix and Cetrotide are “hold those eggs” drugs. These stop the hormonal message to ovulate early while stimulation continues.
Lupron
It can be used to block ovulation. Or it can be used to initiate a final maturation. It is a short acting med used in a retrieval protocol that is not equivalent to the longer acting depot. See my detailed guide to Lupron.
Trigger shots
Trigger is your last maturation instruction, not another day of stims. Your pituitary function and stim protocol, along with the possibility of hyperstimulation will play a role in which trigger you choose. Trigger selection.
Priming and oral add-ons
Birth control, estrogen could be prior to injections, clomid or letrozole can be used with them in some protocols (not that they are necessarily better if used together). ESHRE reviews these options separately.
Progesterone support
Progesterone is for the uterine lining, not for egg production. You use it, and how/whether you use it, depends on your transfer strategy. Read my progesterone injection guide for the practical details.
Stimulation injections (stims): Gonal-F, Follistim and Menopur
What is stims in IVF? Stims = ovarian stimulation. This is when we use medications to cause many follicles to grow. (We use FSH to cause follicular growth. LH activity to support ovarian hormone production that contributes to follicular growth.)
My initial prescription is based on your antral follicle count, AMH, hormone pattern, response history etc. Individualized medication dosing is based on ovarian reserve testing. (We’re trying to individualize medication dose/intensity so as to avoid overresponse. NOT maximizing what your insurance will pay for.)
My approach in clinic: someone with PCOS, relatively high baseline LH might get a more FSH heavy mixture. Someone with hypothalamic amenorrhea, very low pituitary LH, might need more LH support. Just some examples of treating the hormonal situation that I have before me. Not interchangeable diagnosis/universal cookie-cutter prescriptions.
More medication has a ceiling—not an egg-quality bonus
Established recommendation, based on low-certainty evidence: for predicted low responders, ESHRE does not recommend > 300 IU daily dose of gonadotropins. No benefit of higher dosage has been demonstrated. This is a population recommendation. This is not the dose you set for yourself. The clinic has to take into account the FSH activity of combined preparations as well. ESHRE dose recommendation.
Other concern is the possibility that higher doses are detrimental to eggs. Suggestive, inconclusive evidence: my own research found no overall correlation between the cumulative gonadotropin dose and the chromosome abnormalities in embryos of normal responders. In cycles stimulated past cycle day 12, there was a slight dose dependency. Obviously, the observational nature of this study doesn’t allow us to say with certainty that the abnormality in the embryos was caused by the medication.
But that is not the same as it being a proof that lower doses give better eggs. So I would not sell mini-IVF as an upgrade in egg quality. I might try lower doses for the recurrent poor responders, when I don’t really expect much more from adding the medication. Especially when the issue of cost comes into play. A practical clinical decision, not a guarantee of healthier embryos.
Low-dose hCG can stand in for Menopur
When Menopur was in short supply in 2022 I described a funky workaround – hCG works as an LH source because it works through the same receptor. (Small stimulation doses are not the same as an hCG trigger.) Evidence for LH supplementation.
Menopur has both FSH and LH activity. You need to account for both to substitute Menopur. ie LH activity, which you could substitute with a low dose of hCG, and you may have to modify the FSH prescription. It is not a DIY dilute at home situation. Your clinic and pharmacy need to manage substitution and prep.
Suggestive, not proof of equivalence: similar live-birth outcomes with hMG vs low-dose hCG supplementation (retrospective 2024 study). Smaller trials reviewed by ESHRE leave uncertainty. ESHRE does not recommend routine low-dose hCG supplementation. An individualized substitute is different from a proven upgrade.
Ganirelix, Cetrotide and Lupron keep you from ovulating early
“What does ganirelix do in IVF?” To stop premature LH surge which can cause premature release of eggs before you have a chance to retrieve them. The effect of ganirelix (and Cetrotide) is rapid blockage of GnRH receptors (in the pituitary). They’re antagonists. Meanwhile, the injected stimulation meds keep working on the ovaries.
In my practice I usually do flexible start once the lead follicle is around 14 mm or the E2 is around 600-700 pg/mL or so. Some places do fixed start stimulation day. The newer recommendations from ESHRE are to conditionally prefer a fixed start. (Often day 5/6 or so). This is based on low certainty evidence. It doesn’t necessarily mean your place is wrong if you get different start instructions. Fixed vs flexible protocols.
Often when I add in an antagonist, I will add in an extra vial of Menopur to compensate for lower levels of natural LH (unless I am trying to slow things down). This is my own clinical modification, not a suggestion to modify your prescription. (See my follicle size guide by day for how ultrasound features help me make decisions.)
Lupron does an initial flare of FSH/LH. And then with continued exposure the pituitary becomes less sensitive. “Numb” if you will. Constant exposure prevents ovulation. Short exposure to an appropriate pituitary can cause maturation. Various uses of Lupron.
If you miss a blocker, contact your clinic right away rather than waiting until you come in. Generally I suggest to try to make up missed dose ASAP. But it depends on the drug, time of day, etc. So follow what they say. Don’t double up or try to re-jigger things on your own.
The trigger shot matures the eggs 36 hours before egg retrieval
Trigger: This triggers the final maturation of the egg and helps it detach from the follicle wall. Think of it like peeling a banana: a ripe banana comes off much easier than a green one. Typically the egg will be retrieved 36 hours later or so (in a time range as determined by your clinic). Trigger-to-retrieval timing.
Typically, the egg ovulates ~38 hours post hCG. But this is just an average, not a hard and fast rule. The old study where the hour-by-hour ultrasound was done was IUI patients with stimulated cycles. Not universal IVF time. Ovulation timing study.
And the trigger time in your clinic is more important than an average from the internet.
hCG trigger directly provides an LH-like effect. The prolonged ovarian stimulation that comes from the trigger is one of the risk factors for ovarian hyperstimulation syndrome (OHSS). OHSS is a complication characterized by large ovaries and abnormal fluid shifts.
Lupron only trigger causes a transient release of your own hormones. Differences in triggers.
Established: use of GnRH agonists such as Lupron does lower the OHSS risk. ASRM recommends GnRH agonist triggers as a first-line approach to OHSS prevention for high risk patients. But there was also lower live birth rates when only the agonist triggers were used for fresh transfers in trials. Because the shorter hormone burst might not be enough to keep the uterine lining happy. Which is why it is important to know what you are doing with the embryos after – can you freeze them or do you have to do some nice planning for luteal support for a fresh transfer. Cochrane trigger review; ASRM recommendations.
Dual trigger. Combining Lupron with low-dose hCG. My practice has often been 40-80 units of Lupron and about 1,000 units of hCG (compared to 5,000-10,000 units for hCG only triggers). I have been a proponent of this approach. But that is clinical choice – not evidence of better results. ESHRE says dual triggering is probably not recommended for normal or low responders (ESHRE). And adding hCG still poses some OHSS risk more than not adding hCG. ESHRE; ASRM.
Not a good idea to use Lupron only trigger in situations where there is not enough LH surge from your pituitary gland. This may occur in hypothalamic problems or prolonged suppression with Lupron. Need a hCG-based approach in those cases. Pituitary response considerations.
Plan to set alarms, double check to make sure you have your medication, and immediately call on-call team if trigger is late, missed, or unsure. Don’t attempt to fudge it.
A sample IVF medication schedule, day by day
This IVF medication schedule example shows one common way of doing antagonist retrieval (where the embryos are frozen, not fresh transferred). It’s not a prescription. The medication schedule timing below reflects how I do things clinically. Check out the IVF timeline for how stims fit into the whole IVF process.
Table 2. Illustrative antagonist schedule
| Cycle/stim day | Medications | Monitoring |
|---|---|---|
| Before stims | Optional birth control or estrogen priming. In this birth-control example, pills stop about four days before injections; estrogen stop timing is individualized. | Clinic confirms the start plan. |
| Stim day 1, often cycle day 2–3 | FSH with or without Menopur, in the evening | Baseline ultrasound and bloodwork before starting |
| Stim days 2–4 | Continue prescribed stimulation medications | Follow the clinic’s instructions. |
| Stim day 5 | Continue; clinic may adjust doses | First follow-up ultrasound and estradiol check in this example |
| Stim day approximately 5–7 | Add ganirelix/Cetrotide once daily when instructed; Menopur may be adjusted | Flexible-start example: lead follicle about 14 mm or estradiol about 600–700 pg/mL |
| Stim days 7–10, or longer if needed | Continue stimulation and antagonist | Visits approximately every 1–2 days |
| Trigger night, often when the main follicle group is about 17–20 mm | Take the prescribed trigger at the exact time; stop other injections according to the clinic’s final instructions | Final scan/labs determine readiness—not the calendar alone. |
| Trigger plus approximately 36 hours | Egg retrieval | Procedure and recovery |
Here is a common example of this. Drugs, dose and days will vary for your clinic. You need to follow your protocol sheet.
Other clinics might vary the timing of the monitoring or washout of primes or fixed antagonist start. Plans for fresh transfers may be different. See ESHRE protocol guidance.
For me, I often find that the regular stims tend to fall all in the same night time frame (not to the one minute). Blockers are a big one to keep consistent on. And, the trigger has a specific date with your ovaries. We use ultrasounds and estradiol levels to determine what’s next. A dose change is a piece of information, not a report card on how good you are at IVF.
Here’s how I decide when it’s time to trigger:
Common IVF protocols: antagonist, long Lupron and microdose flare
IVF protocols explained: the major difference is how we stop ovulation and whether or not we take advantage of the initial flare of Lupron or the final suppression effect of Lupron
Table 3. Common IVF protocols compared
| Protocol | How ovulation is blocked | Usually chosen for | Trigger options | Trade-offs |
|---|---|---|---|---|
| GnRH antagonist, with optional priming or oral medications | Ganirelix or Cetrotide during stims | Broad use, including patients at elevated OHSS risk | hCG; Lupron-only when appropriate; selected dual trigger | Shorter treatment; lower OHSS risk than long agonist protocols |
| Long Lupron / down-regulation | Lupron suppresses pituitary signaling before and during stimulation | Selected patients based on synchronization goals and prior response | Full-dose hCG rather than relying on Lupron | Longer course; possible over-suppression; limits OHSS-reducing trigger options |
| Microdose Lupron flare | Early Lupron flare followed by continued suppression | Selected low responders in my practice | Full-dose hCG | Additional injections; uses the initial flare but is not a proven egg-quality upgrade |
Mechanics and patient selection as I explain clinically – comparative safety supported by Cochrane protocol review
Established: antagonist and long agonist protocols have similar live-birth outcomes, with less OHSS on antagonists. That’s an important difference. The safer protocol need not be the less effective protocol. Your individual risk depends on your response and prevention plan. Cochrane review.
Personally I like the flexibility of an antagonist protocol. You can use long Lupron to give advance suppression (I tend to do 10 units/day from ~ week after ovulation in my long protocols up until reduced dose 5 units when you start stimming) but for some who have a slower response this can be too much. I would consider microdose flare as another option for low response. Not necessarily more powerful/better protocol in all cases.
Priming is another issue that needs to be considered separately. I might use birth control/estrogen to synchronize, or to try to get more synchronized growth. But it’s important to note that ESHRE does not recommend 12–28 days of birth-control pretreatment in antagonist protocols (since it lowered efficacy in trials) and there’s no evidence to show estrogen pretreatment will improve outcome. Both okay for scheduling. Scheduling convenience and a higher chance of live birth are not the same outcome.
I personally assess a protocol based on number of eggs retrieved compared to basal follicles, and percentage that are mature. From my clinical perspective it’s about focusing on how to get more eggs available (mature eggs) vs. the promise of getting more intrinsic egg quality. I need to have a specific reason to change what meds you use. Longer list of ingredients does not a better med make.
IVF injections are subcutaneous, short-lived and more manageable than they sound
The vast majority of retrieval injections are just subcutaneous and not IM. When people ask where to inject IVF meds, I usually show them how to pinch up a bit of lower abdominal fat. I’ve done these injections on myself also. Knowing about the med and knowing how to inject it are two different things. Some require mixing. Pens are a set dose. Ask your nurse to show you exactly which products you have. You should rotate your injection sites as advised. Make sure you are doing what they prescribe, especially with hCG. Progesterone in oil is what comes to mind with transfer support i.e. that good old intramuscular you are familiar with. Different beast than stims. My PIO tips will tell you about that. No changing up without your team.
The side effects of IVF injections vary
I mostly see bloating, fatigue, headaches, bruising, sometimes mood swings.
Menopur can be painful. Ganirelix/Cetrotide sometimes result in a localized itchy welt.
Not everyone feels emotionally bad, some patients report feeling really good surprisingly.
These are observations. Not predictions for your cycle.
You might experience more bloating as your ovaries grow.
You might have lingering discomfort after retrieval until you heal.
Just let your clinic know. Don’t assume all symptoms are innocuous. ASRM outlines the range of ovarian enlargement and OHSS symptoms.
Emergency – get in touch with your clinic for severe/worsening abdominal pain, quick escalation of bloating, constant vomiting, low urine. Get emergency medical attention for breathing problems.
Sometimes these are not normal “discomfort” of stimming. OHSS red flags.
A localized minor welt is different from generalized hives or facial/throat swelling. If you experience breathing issues or facial/throat swelling following injection, get emergency help.
Activity: follow your team’s limitations. Read my thoughts on exercise during stims.
Every drug in your IVF protocol should have a reason
Not one right cocktail fits all- but there should be a reason for every drug. There should be a clear understanding of which drug stimulates follicles, which drug prevents ovulation and which drug is maturing your follicles. That way you are an active participant and not someone who’s supposed to blindly follow some mysterious calendar.
I’ve had a cycle called off due to low response. Then I did better after a change of protocol. That makes me remember it’s possible to make adjustments, and no change guarantees an outcome. It’s okay to do some trial and error. You’re not a failure because your protocol isn’t the same as your friends. Or because your ovaries work in a different way each time.
Retrieval injection stage is usually a small window in the whole process. And often only about 9–12 days of stimulation. Not months of the same injections. You deserve to understand the process that you’re going through. Follow me on Instagram for more explanations from both sides of the exam table. Or subscribe to The Lucky Egg Drop. Or check out The Lucky Egg.
You can book a consult with me if you are in the NYC area and you’d like to go over your protocol.
