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ENTRANT INFORMATION

*First Name
*Last Name
*Date of Birth
*Street Address
*City and State
*ZIP Code
*E-mail Address
*Daytime Phone
Evening Phone

*First Name
*Last Name
*Date of Birth

CHILD(REN) INFORMATION

For pregnancies with multiple births, please list each child separately.

CHILD 1
*First Name
*Last Name
*Date of Birth
CHILD 2
First Name
Last Name
Date of Birth
CHILD 3
First Name
Last Name
Date of Birth

BRAVELLE® (urofollitropin for injection, purified)

BRAVELLE® (urofollitropin for injection, purified), administered SC or IM in conjunction with hCG, is indicated for ovulation induction in patients who have previously received pituitary suppression. BRAVELLE administered SC in conjunction with hCG is indicated for multiple follicular development (controlled ovarian stimulation) part of an ART cycle in patients who have previously received pituitary suppression.

Important Safety Information

BRAVELLE is contraindicated in women who have: a high FSH level indicating primary ovarian failure, presence of uncontrolled non-gonadal endocrinopathies, tumors of the pituitary gland or hypothalamus, sex hormone dependent tumors of the reproductive tract and accessory organs, abnormal uterine bleeding of undetermined origin, ovarian cysts or enlargement of undetermined origin, not due to polycystic ovary syndrome, and a prior hypersensitivity to urofollitropins, purified. Hypersensitivity/anaphylactic reactions associated with urofollitropins for injection, purified administration have been reported in some patients. BRAVELLE is not indicated in women who are pregnant and may cause fetal harm when administered to a pregnant woman.

BRAVELLE should only be used by physicians who are thoroughly familiar with infertility problems. BRAVELLE is a potent gonadotropic substance capable of causing Ovarian Hyperstimulation Syndrome (OHSS), with or without pulmonary or vascular complications in women undergoing therapy for infertility. Ovarian torsion has been reported after treatment with gonadotropins. Serious pulmonary conditions and thromboembolic events have been reported with BRAVELLE. There have been infrequent reports of ovarian neoplasms both benign and malignant, in women who have had multiple drug therapy for controlled ovarian stimulation; however, a causal relationship has not been established. Multiple pregnancies, spontaneous abortion, congenital malformations and ectopic pregnancies have occurred following treatment with BRAVELLE.

The most common adverse reactions (≥5% incidence) in ovulation induction include: headache, hot flashes, OHSS, pain, and respiratory disorders. The most common adverse reactions (≥2% incidence) in ART include: abdominal cramps, abdominal fullness/enlargement, headache, nausea, OHSS, pain, pelvic pain, and post retrieval pain.

Please see full Prescribing Information for BRAVELLE.

MENOPUR® (menotropins for injection)

MENOPUR® (menotropins for injection), administered subcutaneously, is indicated for the development of multiple follicles and pregnancy in the ovulatory patients participating in an ART program.

Important Safety Information

MENOPUR is contraindicated in women who have: a high FSH level indicating primary ovarian failure, presence of uncontrolled non-gonadal endocrinopathies, tumors of the pituitary gland or hypothalamus, sex hormone dependent tumors of the reproductive tract and accessory organs, abnormal uterine bleeding of undetermined origin, ovarian cysts or enlargement of undetermined origin, not due to polycystic ovary syndrome, or prior hypersensitivity to menotropins or MENOPUR. MENOPUR is not indicated in women who are pregnant and may cause fetal harm when administered to a pregnant woman.

MENOPUR should only be used by physicians who are thoroughly familiar with infertility problems. MENOPUR is a potent gonadotropic substance capable of causing Ovarian Hyperstimulation Syndrome (OHSS), with or without pulmonary or vascular complications, in women undergoing therapy for infertility. Ovarian torsion has been reported after gonadotropin treatment. Serious pulmonary conditions and thromboembolic events have been reported with MENOPUR. There have been infrequent reports of ovarian neoplasms with MENOPUR. Multiple pregnancies, spontaneous abortion, congenital malformations and ectopic pregnancies have occurred following treatment with MENOPUR.

The most common adverse reactions (≥2%) in ART include: abdominal cramps; abdomen enlarged; abdominal pain; headache; injection site pain and reaction; injection site inflammation; OHSS.

Please see full Prescribing Information for MENOPUR.

ENDOMETRIN® (progesterone)

ENDOMETRIN® (progesterone) Vaginal Insert is indicated to support embryo implantation and early pregnancy by supplementation of corpus luteal function as part of an Assisted Reproductive Technology (ART) treatment program for infertile women.

Important Safety Information

ENDOMETRIN should not be used in individuals with any of the following conditions: previous allergic reactions to progesterone or any of the ingredients of ENDOMETRIN, known missed abortion or ectopic pregnancy, liver disease, known or suspected breast cancer, active arterial or venous thromboembolism or severe thrombophlebitis, or a history of these events.

The physician should be alert to earliest signs of myocardial infarction, cerebrovascular disorders, arterial or venous thromboembolism (venous thromboembolism or pulmonary embolism), thrombophlebitis, or retinal thrombosis. ENDOMETRIN should be discontinued if any of these are suspected.

Patients with a history of depression need to be closely observed. Consider discontinuation if symptoms worsen.

ENDOMETRIN should not be recommended for use with other vaginal products (such as antifungal products) as this may alter progesterone release and absorption from the vaginal insert.

The most common adverse reactions reported (greater than 5%) were post-oocyte retrieval pain, abdominal pain, nausea, and ovarian hyperstimulation syndrome.

Please see full Prescribing Information for ENDOMETRIN.

REPRONEX® (menotropins for injection, USP)

REPRONEX® (menotropins for injection, USP), in conjunction with hCG, is indicated for multiple follicular development (controlled ovarian stimulation) and ovulation induction in patients who have previously received pituitary suppression.

Important Safety Information

Only physicians thoroughly familiar with infertility treatment, including the risk of multiple births and adverse reactions, should prescribe REPRONEX. It is a potent gonadotropic substance capable of causing mild to severe adverse reactions in women. Gonadotropin therapy requires a certain time commitment by physicians and supportive health professionals, and its use requires the availability of appropriate monitoring facilities. In female patients it must be used with a great deal of care. REPRONEX, like all gonadotropins, is a potent substance capable of causing mild to severe adverse reactions, including OHSS (incidence of 3.5%), with or without pulmonary or vascular complications, in women undergoing therapy for infertility.

Please see full Prescribing Information for REPRONEX.

NOVAREL® (chorionic gonadotropin for injection, USP)

NOVAREL® (chorionic gonadotropin for injection, USP) is indicated for induction of ovulation and pregnancy in the anovulatory, infertile woman in whom the cause of anovulation is secondary and not due to primary ovarian failure, and who has been appropriately pretreated with urofollitropins or human menotropins.

Important Safety Information

NOVAREL should be used in conjunction with urofollitropin or human menopausal gonadotropins only by physicians thoroughly experienced with infertility treatment. Principal serious adverse reactions are: OHSS; enlargement or rupture of ovarian cysts with resultant hemoperitoneum; multiple births; and arterial thromboembolism. NOVAREL is contraindicated in women with precocious puberty, androgen-dependent neoplasm, and prior allergic reaction to HCG. HCG may cause fetal harm when administered to a pregnant woman. Combined HCG/PMS (pregnant mare's serum) therapy has been noted to induce high incidences of external congenital anomalies in the offspring of mice, in a dose-dependent manner. The potential extrapolation to humans has not been determined.

Please see full Prescribing Information for NOVAREL.

You are encouraged to report negative side effects of prescription drugs to the FDA.
Visit www.fda.gov/medwatch or call 1-800-FDA-1088.