Page What is IVF 3 Medication Suppression 5 Stimulation 10 Prepare for Retrieval 11
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Table of ContentsClick on an item below to go directly to that page. Once there, hit the arrow on the page to get back to the Table of Contents.
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What is IVF 3MedicationSuppression 5Stimulation 10Prepare for Retrieval 11Post operative 12AdministrationSC injections14IM injections15
Monitoring 16Daily Cycle Instructions21Preoperative appointment 22
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Day of egg retrieval 23Sperm collection 25Day after egg retrieval 28Day of embryo transfer 29Cycle Cancellation31 Complications 32Embryo Freezing 33Pregnancy test 34Emergencies 35Typical Cycle 36Consents 37Nurse Appointment 38
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What is IVF?
Stimulate the ovaries to mature many eggs
Surgically remove eggsMix with spermIncubate fertilized eggsReturn a few to the
uterus
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What is IVF?
Starts the month before the stimulation
Lasts approximately 8 weeksMedication for about 6 weeks
To start, call your nurse with your period
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Medications
Suppression Medicines•Begin the month before the
stimulation Birth Control pills Lupron Ganirelix Cetrotide Climera patch
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Medications
Suppression Medicine•Birth control pills
Start d1-3Suppress LH & FSH hormones
Regulate cycles, active pills only
Side effectsEarly pregnancy symptoms
Breakthrough bleeding
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Medications
Suppression Medicine•Lupron
Suppress LH, FSH, estrogen, and progesteroneBetter quality eggsStops ovulationOnce or twice a day injectionSide effects: hot flashes, insomnia, headacheUse condomsAllergy: local redness
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Medications
Suppression Medicine
•Ganarelix/Cetrotide Suppress LH immediately Once a day injection Fewer shots Side Effects: headache, nausea
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Medications
Suppression Medicine
•Climera patch Stabilizes and thickens the
uterine lining Skin patch placed anywhere
except the chest Changed every other day Side effects: headaches, breast
tenderness, uterine cramping and bloating. Rare: blood clots
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Medications
Stimulation Medicine•Gonal-F, Follistim, Bravelle
Repronex, Menopur Mature many eggs at once Once or twice a day injection Side Effects/risks:
Mood swingsBloatingOvarian hyperstimulation
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Medications
Preparation for Retrieval•HCG, Pregnyl, Novarel
Final maturing of eggs Given:
4 follicles (2 follicles with mean ≥17-18mm)
Estradiol level is at least 600 36 hours before egg retrieval Risk:
early ovulation, OHSS
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Medications
Post Retrieval Medicine•ProgesteroneSupports the lining of the uterus Injectable, vaginal suppository, vaginal gel
May delay periodContinue even if bleeding startsSide effects similar to pregnancy
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Medications
Post Retrieval MedicineDoxycycline - antibiotic
All patients Pills
• Estrace – Estrogen ICSI, AH, PGD patients Pills
• Medrol- anti-inflammatory ICSI, AH, PGD patients Pills
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Subcutaneous (small needle) injection
Clean the injection site with an alcohol wipe by rubbing in a circular motion. Remove the needle cap. Pinch the injection site with one hand. Using the other hand, quickly insert the needle straight in as far as it will go. Inject the medication by pushing the plunger down to empty the syringe. Remove the needle. Rub the area in a circular motion to massage the medication. Dispose of the syringe in a “sharps” container. If you see blood or a small amount of fluid at the injection site, simply wipe the site with the alcohol wipe and apply light pressure.
Medication Administration
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Intramuscular (big needle) injectionClean the injection site with an alcohol wipe by rubbing in a circular motion. Remove the needle cap.
Stretch the injection site with one hand and using the other hand, quickly insert the needle straight in as far as it will go.
Release the skin. With that hand draw back very gently on plunger; if no blood flows into the syringe, inject the medication. If blood is seen, the needle is probably in a vein - remove the needle and apply pressure to the needle site. Repeat the injection at another site after putting on a new needle. Remove the needle. Rub the area in a circular motion to massage the medication. Dispose of the syringe in a “sharps” container. If you see blood or a small amount of fluid at the injection site, simply wipe the site with the alcohol wipe and apply light pressure.
Medication Administration
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Monitoring Instructions
U/S and Blood work
•Vaginal probe U/S to check size and number of follicles (fluid sacs in the ovary containing the eggs)
•Male and female U/S technicians
•Blood test for estradiol and/or progesterone
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Monitoring Instructions
Where/when
•Weekdays 7-8a in U/S L-1 for U/S and bloods 7-9a 3rd floor for bloods only
•Weekends 7:30-8:30a in U/S L-1 for U/S and
bloods
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Monitoring Instructions
Standing order lab slip•Do not write on it•Filed in lab for 1 year•Tell lab tech what test you
need
Ultrasound slips•Given to you in ultrasound
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Monitoring Instructions
Fill out a call back sheet each time you test•Name and phone numbers•Voice messages: Yes or No•Have identifiers on your
answering machines•Leave room on the
answering machine for the longest incoming message available
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Monitoring Instructions
Satellite testing centers
•850 Boylston (weekdays only) Use BWH testing slips (see
Instruction booklet for times)
•Patriot’s Place, Foxboro (weekdays only) Use BWH testing slips (see
Instruction booklet for times)
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Daily Cycle Instructions
Daily orders are done by the doctors by 2p•Nurses call with new
instructions by 5p •If there is no call by 5p,
page the F&E Fellow on call 617-732-6660
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Pre-Operative Appointment
During the stimulationMeet with MD and
anesthesiologist to sign surgical consents
On a testing day if BWH patient
If testing at a satellite, test at BWH on the day of the pre-op appointment
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Day of Egg Retrieval (ER)Admission to 5C
•No eating/drinking after midnight the night before
•Bring hospital blue card•Arrive 5C 1 hr before ER•Admit to pre-op/recovery area•Change into a hospital gown•IV started•Couple together pre/post op
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Day of Egg Retrieval
Operating room
•Feet in stirrups•Anesthesia•U/S guidance, needle inserted into each follicle, fluid removed by suction
•Fluid passed to embryologists who remove eggs from the fluid
•By stretcher to the recovery room
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Sperm collection
In advance•If you need to be together or
produce at home notify your nurse
•If you anticipate a problem with production, consider freezing specimens before the cycle starts
Day of HCG shot•Ejaculation within 5 days before
the egg retrieval•Abstain after HCG shot
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Sperm collection
Day of Egg Retrieval•Bring hospital blue card and a picture ID
•Produce specimen Day of egg retrieval Private room on 5C Fill out paperwork and label specimen container
No lubricants
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Day of Egg Retrieval
Post op recovery
• 1 - 1 1/2 hours• Need a ride home• May feel groggy, sore,
backache• Pain medication prescription• Start antibiotics; also medrol if
ICSI, PGD, AH
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Day after Egg Retrieval
Post op recovery
•Fertilization call• Start progesterone (if Crinone start tomorrow); also Estrace if ICSI, PGD, AH
• Take it easy for 48 hours
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Day of Embryo Transfer (ET)
You will get a call the afternoon before the ET with the transfer time
Arrive 1 hour before transfer time
Do not empty your bladder
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Day of Embryo Transfer
MD will discuss the embryos with you
Couple can be together for the ET
10 minutes to recover Take it easy for 24 hours
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Cancellation
Poor response to medication• Few or no follicles; low estradiol
Estrogen level and follicle number don’t match
Missed testing or medication Ovulation before egg retrieval No fertilization Arrested development of
embryos
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Possible Complications of ART
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Multiple pregnancyOHSS
Infection at injection or operation site
Ectopic (tubal) pregnancy Ovarian torsion (twisting) Medication side effects Surgical risks
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Embryo Freezing
Sign consent and NECC contract
Freeze good quality embryosNotification if you have frozen
embryosCryo embryo transfer cycle
(CET)Insurance company may require
it
Liquid Nitrogen embryo storage tank
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Pregnancy Test
Approximately 18 days after the egg retrieval
If you have bleeding, do not stop progesterone
Cycle review after negative test or +FH
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If you have an emergencyCall 617-732-6660Ask for the F & E fellow on call Stay on the line or leave a
call back number and the physician will return your call
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Typical IVF Cycle
Call with your period Suppression therapy 7-21 days Baseline U/S and/or blood Start the stimulation 7-14 days later HCG 36 hours later egg retrieval 3-5 days later embryo transfer 16 days later pregnancy test
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Consents
Consent bookletMultiple consent
formsCannot start cycle without
signed consents Arrange to give them to
your nurse
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Nurse Appointment
If you need more assistance, call to make an appointment with your nurse to:
• Review your individual protocol• Discuss medications and
pharmacies• Learn how to do injections
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Multiple pregnancy Because several follicles containing eggs can mature and ovulate at the same time, it can result in a multiple pregnancy. Thus multiple implantation of embryo can occur. Usually, the number of fetuses can be determined by ultrasound at 6-7 weeks gestation (4 -5 weeks after the IUI). Fetal reduction may be possible in high order multiple gestation pregnancies.
Complications
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Ovarian Hyperstimulation Syndrome (OHSS) After ovulation, the follicles fill up with fluid and form cysts. This can lead to lower abdominal discomfort and bloating. Symptoms of OHSS may include: nausea and vomiting, shortness of breath, weight increase 2-3 pounds a day, low urine output. These can happen within 2 weeks after the HCG injection. The symptoms usually resolve within 1-2 weeks without treatment. Pregnancy can make it worse and last longer. Treatment may include cancelling the cycle before the HCG and in severe cases hospitalization for fluid management. Complications
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Infection at the injection site Symptoms of injection site infection can include redness and/or extreme tenderness at the site and fever (rare). You may be instructed to apply warm soaks to the site and/or be given antibiotic treatment.
Ectopic pregnancy (tubal pregnancy) You will have an early ultrasound to rule out ectopic pregnancy. Approximately 5% of Assisted Reproduction pregnancies become ectopic and resolve on their own or are treated with medication or surgery. Symptoms may include abdominal pain and/or irregular bleeding.
Complications
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Ovarian torsion (twisting) In less than 1% of cases, the enlarged ovary can twist on itself. This can decrease the blood supply to the ovary and result in significant lower abdominal pain. Surgery may be required to untwist or possibly remove the ovary.
Medication side effects Read the package inserts of your medications and discuss any possible side effects with your physician.
Complications
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Complications
Surgical risksInfection: Bacteria may be transferred into the abdominal cavity by the retrieval needle. Bleeding: The retrieval needle goes through the vaginal wall and into the ovary. These have blood vessels and there are other blood vessels nearby. Trauma: It is possible to damage nearby abdominal or pelvic organs.Anesthesia: Complications such as: allergic reaction, low blood pressure, nausea or vomiting. Failure: The egg retrieval could fail to get any eggs or the eggs may be abnormal or of poor quality and may not fertilize or produce a viable pregnancy.