IVF Informational Class

IVF Informational Class : 

The purpose of this class is to help familiarize you with the process of IVF. We will review a cycle from beginning to end and will include medications used in an IVF cycle, mixing and administering of these medications, and possible side effects. From the start of your cycle to your pregnancy test is approximately 4 weeks. We encourage you to review this information well before your IVF cycle begins and let us answer any questions which may arise or address any concerns you may have. IVF Informational Class

Welcome to DIRM! : 

Welcome to DIRM!

Overview : 

Overview

Table of Contents : 

Table of Contents Slide 1 Getting Started; your “Baseline Appointment” Slides 2-5 Introducing your Injectable Medications   Slides 6-10 The Egg Retrieval Process   Slides 11-13 The Second Half of your Cycle –”The Luteal Phase” Slide 14 Frozen Embryo Cycles Slide 15 Possible side effects of the IVF Procedure Slides 16-19 Medications used in an IVF cycle/Possible Side Effects.

Table of Contents cont. : 

Table of Contents cont. Slides 20-23 Frequently Asked Questions   Slide 24 Pregnancy Safe Medications   Slides 25-29 Administering and Mixing Medications Slide 30 Additional injection sites Slide 31 Bravelle/Menopur Video Slides 32-39 Follistim Pen/Ganirelix/hCG Videos

GETTING STARTED YOUR “BASELINE APPOINTMENT” : 

GETTING STARTED YOUR “BASELINE APPOINTMENT” Baseline appointment refers to the appointment you will make to be seen on cycle day 2 or 3 of a full flow. If your cycle begins on Friday, please schedule for Saturday, and if your cycle begins Saturday or Sunday, please call for a Monday or Tuesday appointment. Appointment times: Blood and scan are done Monday-Friday from 7:30 a.m. until 11 a.m. and Saturdays are 7:30 a.m. until 9 a.m. Baselines are never done on a Sunday. Baseline appointments are done in the Newark office only. Subsequent appointment s may be scheduled in the Milord office if this is more convenient for you.   You will be seen for an ultrasound and blood work. The purpose of this appointment is to make sure that your ovaries are free of any cysts and that your hormones levels are appropriate to begin.   Once your blood and scan is complete you will meet with an IVF coordinator to review the treatment plan designed specifically for you.   You will receive your voice mail box instructions and your medication dosage for the first three days of your stimulation.   Before you leave you will be asked to see one of our billing representatives. 1

Introducing your injectable medications : 

Introducing your injectable medications You will begin your stimulation with medications designed to stimulate your ovaries by increasing estradiol levels which in turn will cause multiple follicles to grow.   These medications may include: Bravelle, Menopur, and Follistim – depending upon the stimulation protocol designed for you – you may use one or more of these medications.   Injections are done between 7 and 9 p.m; some patients may be asked to do injections in the morning as well - between 7 and 9 a.m. Please try to be consistent with your injection time, trying not to vary more than 1 hour. 2

Injectable Medication Introduction cont… : 

Injectable Medication Introduction cont… At each appointment you will have an ultrasound and blood work to assess the growth of the follicles and to measure the estradiol level in your blood. Throughout your entire stimulation phase, we expect your estrogen level to rise and your follicle diameters to continually increase. If at any time during stimulation, including after your hCG injection, your estrogen level plateaus or drops, the cycle could potentially be cancelled.   Blood and scan results of the day are reviewed every afternoon by Dr. Russell and his IVF staff. Instructions regarding your medication dosage and any possible changes will be left on your voicemail at the end of the day. If no message has been left by 6 p.m., please call the main number and listen to the message to contact the IVF Coordinator. 3

Your next injectable medications : 

Your next injectable medications Cetrotide or Ganirelix: the purpose of this medication is to prevent a premature LH surge and rise in your progesterone level. Begins approximately 4-6 days into your stimulation and is to be done in conjunction with your other stimulating medications. Instructions regarding when to begin this medication will be left on your voicemail with your other instructions. 4

Your final injectable medication before retrieval : 

Your final injectable medication before retrieval Now that your follicles are almost mature, between 16 and18 mm., it is time to administer your hCG (human chorionic gonadotropin). This medication is designed to provide a surge of LH which will begin the maturation process, and will allow Dr. Russell to easily retrieve the eggs. HCG is the only injectable medication you will do on this evening; all other injectable medications are now finished. You will be given a specific time to administer this injection and this time cannot be varied. Your retrieval will occur approximately 34 hours later.   Your appointment the following day will be for blood work only unless Dr. Russell feels an ultrasound is necessary.   The lab will draw your blood and give you pre-retrieval instructions.   You will also be given anesthesia paperwork and you will be asked to take this home with you to complete and return the morning of your retrieval. The anesthesiologist will review this with you before your procedure. 5

Preparing for your Retrieval : 

Preparing for your Retrieval We will confirm on your voice mail the time of your retrieval and will remind you to begin preparing: you will need to do a douche and enema the evening before; take your first dose of antibiotics and begin your Medrol (Methylprednisilone), have nothing to eat or drink after midnight and then repeat the douche in the morning. If you are on oral medications for health issues you may take your a.m. meds with a small sip of water. 6

Arriving for your retrieval and what to expect : 

Arriving for your retrieval and what to expect REMEMBER TO AVOID USING FRAGRANCES SUCH AS HAIRSPRAY, PERFUME, DEODORANTS, POWDERS, COLOGNE, ETC. AS THESE FRAGRANCES MAY HAVE A TOXIC AFFECT ON THE THE EGGS AND EMBRYOS. We will ask that you arrive 30 minutes prior to your planned procedure. When you arrive you will be escorted to the retrieval room and asked to undress from the waist down and put on a gown   An anesthesiologist will be called to meet very briefly and review your medical history.   The medical assistant will position you and make sure you are comfortable before the anesthetist begins to sedate you.   The anesthetist will monitor your heart rate, pulse, blood pressure, oxygen level during your procedure.   Your husband/partner may stay with you until the anesthetist is ready to start your intravenous medication. Your husband/partner will then be asked to leave to collect his specimen. He will be escorted to our IVF waiting area and will join you after you are fully awake from your procedure. You also have the option of collecting this specimen at home and bringing it with you, as long as it is received within 45 minutes of collection (sterile specimen containers are available at the front desk). 7

The Retrieval Procedure : 

The Retrieval Procedure Dr. Russell will come in to begin the vaginal wash with warm soapy water.   The anesthetist will begin to sedate you and once asleep the procedure will begin. Dr. Russell will insert the vaginal probe with attached aspiration needle into the vagina; the aspiration needle is advanced through the back of the vaginal wall and under ultrasound guidance each follicle is then aspirated of its contents into a test tube. The test tube is then passed off to the embryologist who will pour the contents into a petri dish; the contents will be scanned under the microscope and the eggs counted.   Dr. Russell will continue this process until every follicle has been aspirated. Once all follicles have been aspirated the procedure is complete. 8

FYI… : 

FYI… It is important to note that the number of follicles seen on ultrasound may not result in the number of eggs retrieved:   Not every follicle may contain an egg.   Not every egg that is retrieved will be mature (only mature eggs can be inseminated and can result in an embryo)   Not every egg that is inseminated will result in an embryo and,   Not every embryo will continue to divide until your transfer. 9

Recovering from your procedure : 

Recovering from your procedure Once fully awake you will be taken to our recovery room. When you are able to empty your bladder your intravenous medication will be discontinued and you will be discharged to home. Recovery time in our office is usually 30 to 45 minutes. You will be given discharge instructions before you leave.   You will not be able to drive for 24 hours following the procedure, so in the event that your spouse/partner cannot stay for the entire procedure, please make arrangements for transportation home.   Vaginal spotting and some cramping are normal post-procedure symptoms; heavy bleeding, severe cramping and a fever of greater than 100.3 are not. If you have any problems following retrieval, you will need to page Dr. Russell. 10

The Luteal Phase of your IVF Cycle : 

The Luteal Phase of your IVF Cycle The IVF Coordinator will meet with you before you leave and will give you detailed instructions on which medications to resume and when to begin your progesterone support. You will be instructed to check your voicemail the following morning for fertilization results You will receive updates on your voicemail until the day of your transfer. Transfers are typically done 3 to 5 days after retrieval. 11

The Embryo Transfer Procedure : 

The Embryo Transfer Procedure We will ask you to prepare for transfer by drinking approx. 24 ounces of water a couple of hours prior; this allows for better visualization while Dr. Russell does the transfer under ultrasound guidance. Dr. Russell will insert a thin spaghetti like plastic catheter attached to a syringe through the cervix into the uterine cavity. When he is ready he will slowly push the plunger of the syringe which will expel the fluid containing the embryo (s) into the uterus. You may experience some very mild cramping and notice some spotting later. The IVF Coordinator will meet with you to review your transfer restrictions, medications instructions, and give you the dates to return for hormone checks and pregnancy test. 12

Pregnancy Test Day : 

Pregnancy Test Day With a positive pregnancy test you will be asked to continue all medications.   Schedule labs again two days later to evaluate the hCG level.   First ob scan will be approx. one week later to look for a sac in the uterus   Ultrasound the following week to look for fetal heart activity.   With a negative test you will be asked to discontinue your medications and schedule a consult with Dr. Russell to review your cycle. 13

FROZEN EMBRYO CYCLES : 

FROZEN EMBRYO CYCLES If you elect to the cryopreservation (freezing) of embryos, these embryos may be used after an unsuccessful fresh cycle, or stored until later for a future cycle. Frozen embryo cycles are much less involved than fresh cycles. You will be placed on Lupron (this is an injectable medication) for about seven to ten days before your period is expected to begin, and you will baseline on the second or third day of your period.   Instead of taking stimulating medications, you will begin taking estrogen pills. You will be required to come to the office for blood work and an ultrasound one or two more times prior to transfer to make sure that the uterine lining is developing appropriately. You will begin your progesterone supplementation about five days before your transfer. We will then thaw the embryos and give you a date for transfer. From the frozen embryo transfer to the pregnancy test, you will continue taking estrogen and progesterone. Your pregnancy test will be about 12 days after transfer. 14

Possible Side Effects with IVF : 

Possible Side Effects with IVF Infection - signs could include fever, chills, foul-smelling vaginal discharge, or pelvic pain. The chances of this occurring are slim due to the antibiotic, medicated douche, and the use of sterile technique. Internal bleeding (due to the use of a needle to aspirate the eggs - this is an extremely rare complication. Signs of internal bleeding may include dizziness, pelvic pain, or very heavy vaginal bleeding. Another risk associated with an IVF cycle is Ovarian Hyperstimulation. Ovarian Hyperstimulation occurs from a fluid volume shift within the body as fluids from the blood vessels are pooled into the pelvic and abdominal cavities. If hyperstimulated, the patient can experience one or more of the following symptoms: weight gain of more than five pounds, dizziness, shortness of breath, nausea, vomiting, decreased urination, and/or severe pelvic or abdominal pain. This is not directly related to your egg retrieval and becomes more prevalent after embryo transfer. Please contact the office if you experience any of these symptoms. If it is after hours, follow the instructions to have Dr. Russell paged. 15

MEDICATIONS USED IN AN IVF CYCLE : 

MEDICATIONS USED IN AN IVF CYCLE Please note: Most of these medications require mixing; A video is presented at the end of this class to demonstrate how to mix and administer these medications.   Bravelle, Menopur, Repronex, Follistim   These medications are used to stimulate your ovaries and cause numerous follicles to grow and mature..   Subcutaneous injections done in the thigh or abdomen.   Needle Size: 25 Gauge 5/8” size needle to inject.   Mixing is required for all but the Follistim 16

MEDICATIONS USED IN AN IVF CYCLE cont… : 

MEDICATIONS USED IN AN IVF CYCLE cont… Cetrotide and Ganarelix:   These medications are used to suppress your natural LH surge and rise in progesterone.   Subcutaneous injections done in the thigh or abdomen.   Needle Size: 25 Gauge 5/8” size needle to inject.   Mixing is required for the Cetrotide – no mixing for Ganarelix.   HCG (Human Chorionic gonadotropin)   This medication is used to provide the necessary LH surge which will complete the maturation process and allow the eggs to be retrieved easily from your ovaries. This medication is similar in composition to the luteinizing hormone (LH) released in a natural cycle; the administration of this medication begins the ovulation process; egg retrieval is scheduled before ovulation can occur. Mixing is required 17

MEDICATIONS USED IN AN IVF CYCLE continued… : 

MEDICATIONS USED IN AN IVF CYCLE continued… Progesterone in oil:   This medication is used to provide support to the endometrium and to prepare your endometrial lining for your upcoming embryo transfer. Mixing is not required.   This is a deep muscle injection in the gluteous maximus at least one inch below the hip bone.   Needle Size: 22 Gauge 1-1/2” needle to inject.   Progesterone Suppositories or Crinone:   These are vaginal preparations also used to support the endometrium and used in conjunction with the progesterone in oil.   Oral Medications used in your IVF cycle:   Antibiotics will be ordered for you and your husband/partner : Doxycycline and Azithromycin (Z-pack)   Your husband/partner will be asked to begin his antibiotic (usually Doxycycline) the same evening your stimulation begins; The purpose of this is reduce the amount of bacteria in the sperm which will prevent cross contamination of bacteria to your eggs.   Medrol (methylprednisilone) is a low dose steroid which will begin the evening before your retrieval. This medication will help reduce any inflammatory process which may occur within the uterus and help prepare the environment for embryo transfer. 18

Medication Side Effects : 

Medication Side Effects Side Effects of your stimulating medications are usually minor and may include: bloating, irritability, irritation at the injection site If you develop itching, redness, and raised areas like hives, please inform the nursing staff or Dr .Russell to be evaluated for a possible allergic reaction to the medication Mild headaches 19

FAQs during an IVF cycle : 

FAQs during an IVF cycle Q: Can I schedule my baseline appointment in the Milford office?  A: Baseline appointments must be scheduled in the Newark office; you may schedule the remainder of your monitoring appointments in the Milford office.   Q: What if my cycle begins after hours and I need to schedule my cycle day 2-3 appt.?   A: Please call the office and leave a message on extension 10 stating that you need to schedule for cycle day 2 or 3; if you are already cycle day 2 you need to be seen the following morning, so please leave a message that you will be in and arrive sometime between our blood and scan times: Monday-Friday 7:30-11:00 a.m. and Saturday 7:30- 9 a.m. (Remember we do not do baseline appts. On Sundays).  Q: May I exercise during my IVF cycle?   A: You may exercise during your stimulation; if you start to feel bloated and uncomfortable you should stop exercising. 20

FAQs continued… : 

FAQs continued… Q: May I continue to have intercourse during my IVF cycle? A: Intercourse is fine during your IVF cycle; when you are 2-3 days away from your retrieval we will recommend intercourse or ejaculation and then abstinence; this will provide a good semen sample for the day of retrieval; you will be asked to refrain from intercourse after your transfer.   Q: What type of pain medication can I take during my stimulation? A: Only Tylenol is permitted; no aspirin or Ibuprofen. Q: Are the injections I will need to do very painful? A: The subcutaneous injection is done with a very small thin needle and causes very little to no discomfort at the injection site. Because the intramuscular injection requires a longer thicker needle this injection will cause a bit more discomfort. Most patients imagine this to cause much more discomfort than it actually does.   Q: What can I do to minimize injection pain? A: For the intramuscular injection there are several things you can do: first you can ice the area for a few seconds; once the injection is complete, massage the area for a minute or so and apply moist warm heat to the site. 21

FAQs cont… : 

FAQs cont… Q: Can I receive vaccinations during my IVF cycle? A: No because it may take you body several weeks to fully develop antibodies to the pathogen (s) you have been vaccinated with.   Q: What If I become ill during my IVF cycle? A: Of course staying healthy during this treatment is always best, but of course that is not usually in our control: should you become ill or develop a fever, please contact the IVF department.   Q: What if something comes up and I cannot do my injection at the designated times? A: If you need to do your injection a bit earlier or later than planned, that is fine on occasion, do your best to keep to the schedule varying no more than one hour. 22

FAQs cont… : 

FAQs cont… Q: How long will I need to do my progesterone injections? A: You will continue your injections at least until you have had your second obstetrical ultrasound (approximately 2 weeks after your pregnancy test). Once Dr. Russell feels the pregnancy is progressing well he may stop or reduce the number of progesterone injections. Q: When will my transfer restrictions be lifted? A: Restrictions regarding intercourse, lifting and physical activity will remain until Dr. Russell feels the pregnancy is progressing normally and fetal heart beat activity has been identified (approximately 2 weeks after your pregnancy test). 23

OVER-THE-COUNTER MEDICATIONSAPPROVED TO BE USED IN PREGNANCY : 

OVER-THE-COUNTER MEDICATIONSAPPROVED TO BE USED IN PREGNANCY Many patients have questions about what medications they may use during pregnancy. The following is a listing of those over-the-counter medications which may be used in early pregnancy. If you need to see your OB-Gyn or Primary Care Physician for any treatment which requires a prescription, please advise them that you are pregnant.   Colds: Any Tylenol Products, Chlor-Trimeton, Contac, Ornex, Sinutabs, Sudafed   Cough: Robitussin (Plain or DM), Benylin (Plain or DM), Novahistine (Plain or DM)   Headache: Any Tylenol Products, Anacin 3, Datril   Sore Throat: Chloraseptic Spray or Throat Lozenge   Nausea and Vomiting: Emetrol   Laxative: Peri-Colace, Metamucil   Stool Softeners: Colace, Surfax   Diarrhea: Kaopectate   Hemorrhoids: Anusol, Preparation H Ointment or Suppositories    Please call the office 302-738-4600 if your temperature rises to 100 degrees or higher accompanied by any illness. 24

MIXING AND ADMINISTERING YOUR SUBCUTANEOUS INJECTIONS : 

MIXING AND ADMINISTERING YOUR SUBCUTANEOUS INJECTIONS Mixing Bravelle and Menopur: The following are instructions on mixing your powder vials of Bravelle and or Menopur: These medication can be mixed together to avoid numerous injections. You will use a syringe with a 5/8” needle for this injection.   Remember to always observe proper hand washing technique before beginning; make sure your work surface is clean; and always swab the top of your vial with alcohol before inserting the needle.   Pull back the plunger of the syringe to the 1 ml mark, inject this 1 ml of air into a vial of water,   Draw up 1 ml of water into your syringe, inject this 1 ml of water into your first vial of powder and mix gently (do not shake)   Now draw up all of this mixed medication into your syringe and inject into the next vial of powder (again mix gently) 25

MIXING AND ADMINISTERING YOUR SUBCUTANEOUS INJECTIONS cont… : 

MIXING AND ADMINISTERING YOUR SUBCUTANEOUS INJECTIONS cont… Continue mixing until you have incorporated all the vials of powder you are instructed to use   You may notice some air in the syringe; to remove flick the top of the syringe with your finger; (this will allow the air to rise and then you can expel the air before you inject).   Injection technique: A subcutaneous injection is done in the fatty layer of tissue just under the skin and is done with a 5/8” needle. Injection sites include Abdominal area ( about 1 inch below or to the left or right of the belly button), or the thigh.   Choose your injection site, swab with alcohol and allow to dry, grasp about an inch or two of fatty tissue, using a dart like motion inject at a 90 degree angle; Inject the medication slowly and remove needle in the same direction it was inserted.   You can rotate your injection sites as many times as you like between your thighs or abdominal area. 26

ADMINISTERING YOUR INTRAMUSCULAR INJECTION : 

ADMINISTERING YOUR INTRAMUSCULAR INJECTION Progesterone in oil does not require mixing. This is dispensed as a multi use vial; Use one vial until empty and then open a new vial.  Remember to always observe proper hand washing technique before beginning; make sure your work surface is clean; and always swab the top of your vial with alcohol before inserting the needle. You will use a syringe with a 1-1/2” needle for this injection. 27

Intramuscular Injection Procedure : 

Intramuscular Injection Procedure Preparing for the Injection: Make sure you have all of the items that you will need (eg, syringe, medicine, and cleaning materials). Wash hands with warm, soapy water before giving the injection. Select a site for injection. This should be an area on your body with a large muscle (e.g. upper hip/buttock. Cleanse the area with an alcohol wipe, allow to dry. Giving the Injection: Remove the needle cap. Smooth the skin with one hand. Hold the syringe the way you would a pencil. Insert the needle at a 90° angle to the skin with a darting like motion until the needle is all the way in the skin. Hold the syringe with one hand. With the other, pull back the plunger to check for blood in the syringe. If you identify blood in the syringe do not inject; remove needle and choose new site. If you do not see blood, slowly press down on the plunger until it stops. 28

Intramuscular Injection Procedure cont… : 

Intramuscular Injection Procedure cont… Remove the needle from the skin. If there is bleeding at the site of injection, apply a bandage. Immediately put the syringe and needle into a container that is puncture-proof.  Will It Hurt? Depending on the medicine, there is usually some discomfort at the injection site. Soreness in the muscle is also common. Tips for minimizing pain include: Inject medicine that is at room temperature. You may wish to ice the area for a few seconds first. Remove all air bubbles from the syringe before the injection. Relax the muscles in the injection area. Quickly break through the skin. Do not change the direction of the needle as it goes in or comes out. Firmly rub the injection site for a minute or so and apply moist heat. Do not reuse disposable needles. 29

Injection Sites : 

Injection Sites 30

Bravelle & Menopur Video : 

Bravelle & Menopur Video 31

Follistim Pen Video pt.1 : 

Follistim Pen Video pt.1 32

Follistim Pen Video pt.2 : 

Follistim Pen Video pt.2 33

Follistim Pen Video pt.3 : 

Follistim Pen Video pt.3 34

Follistim Pen Video pt.4 : 

Follistim Pen Video pt.4 35

Follistim Pen Video pt.5 : 

Follistim Pen Video pt.5 36

Follistim Pen Video pt.6 : 

Follistim Pen Video pt.6 37

Ganirelix Video : 

Ganirelix Video 38

Pregnyl Video : 

Pregnyl Video 39