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Patient Instructions


INTRODUCTION
We recommend that you read these instructions entirely as soon as you can, making notations in the margins about any area where you have questions. As you approach each step, we suggest that you re-read that particular section and ask any questions at that time. This will prevent you from becoming confused with too many answers at one time.

It is important to remember that each patient has her own unique response to the medications she receives and that each ART cycle is different. This means that not only are you unlikely to respond as others do, but you may actually respond differently from one cycle to the next. For this reason, you will find that your treatment and testing differ from those of other patients. Please do not compare your test results and medication plans with others going through treatment. Although you may find much in common with other patients here, please keep in mind that IVF is a very private matter and that some patients do not feel comfortable discussing this.

PRE-CYCLE COUNSELING
We recommend that you contact the IVF nurse coordinator at (404) 843-2229 when your period begins for the cycle preceding the one in which you will undergo in vitro fertilization. At this time, arrangements will be made to complete any pre-cycle testing, provide you with the necessary prescriptions for medications, complete the appropriate informed consent documents, and review and clarify your financial obligations. Separate consent forms are available for IVF, embryo freezing and micromanipulation. All consent forms must be signed by you and your partner prior to initiating the treatment cycle. You will have an IVF teaching appointment at which time you will meet with both the doctor and nurse to review the consent forms and have any questions answered. You are to avoid the possibility of pregnancy during this cycle by using contraception.

MAXIMIZING CHANCES FOR SUCCESS

Females:

  • Avoid all medications other than Tylenol and prenatal vitamins. If you are taking other prescription medications, check with us prior to beginning your treatment cycle
  • No smoking or alcohol use. Studies show both can result in lower pregnancy rates and a greater risk of miscarriage.
  • No more than two caffeinated beverages per day.
  • Avoid changes in diet or weight loss during IVF cycle. A healthy well-balanced diet works best.
  • Refrain from intercourse three to four days prior to egg retrieval and following embryo replacement until pregnancy determination is made.
  • Normal exercise may continue unless enlargement of your ovaries produces discomfort.
  • Avoid hot tubs or saunas.
Males:
  • Fever greater than 100.4°F one to two months prior to IVF treatment may adversely affect sperm quality. If you are sick, please take your temperature and notify us of any illnesses.
  • Sitting in hot tubs and saunas is discouraged. Even a single episode in the hot tub can adversely affect sperm function. Please refrain from this for at least three months prior to treatment.
  • Drugs, alcohol and cigarette smoking should be avoided for three months prior to treatment and at all times during the ongoing IVF treatment cycle to get the best results.
  • If you have a history of genital herpes infection, you must report any pre-herpes symptoms, active lesions or healing herpes lesions. The occurrence of any of these stages in either the male or the female will require cessation of the IVF treatment.
  • Do not begin any new exercise, sport or marathon training within three months of planning IVF. If you are a runner, please decrease jogging to a total of less than 20 miles a week.
  • Refrain from wearing tight underwear.
  • Abstain from intercourse for at least three days, but not more than seven days prior to collection of semen for egg collection and during treatment.

IVF TREATMENT
Treatment may begin in the cycle preceding your planned cycle of treatment. Most patients will be given birth control pills (BCP) to suppress ovulation and assist in the timing of the IVF cycle. Those patients who are not taking BCP will be given an ovulation testing kit to monitor your LH levels. When an LH-surge (color change) is noted, call the office. You will be asked to report to the office for an ultrasound examination to evaluate the mid-cycle development of the uterine lining and for a trial transfer. This procedure consists of a pelvic examination and placement of a tiny catheter inside the uterus to determine the direction and length of the uterine cavity prior to your treatment cycle. This procedure minimizes trauma to the uterine lining during your actual IVF treatment cycle and may enhance pregnancy rates.

You are to avoid the possibility of pregnancy during this cycle by using barrier contraception. Approximately seven days after the surge, you will begin therapy with subcutaneous Lupron or Synarel nasal spray. This will continue for a period of about ten days, sometimes longer if necessary. You may be asked to return to the office for an estradiol value and ultrasound examination. If these tests are normal, you will initiate gonadotropin injections (Repronex, Pergonal, Follistim, Gonal-F or Bravelle) within several days. Although the trial embryo transfer is usually performed before scheduling IVF, in some situations your physician may choose to delay the trial transfer until you have begun Lupron therapy. Alternatively, you will be asked to begin a month of oral contraceptives prior to starting Lupron, which you will begin taking approximately three weeks later. After finishing the pack of oral contraceptives, the baseline ultrasound will be scheduled.

Each patient's treatment is individualized. The recent availability of the medications Antagon and Cetrotide has provided physicians with another option. Like Lupron or Synarel, Antagon and Cetrotide prevent the release of the stimulated eggs before the retrieval procedure. After reviewing your blood tests results, your physician will determine on or about the sixth through eighth day of gonadotropin injections to begin Antagon or Cetrotide injections. This medication will be continued until the day of the hCG injection.

The first day of medication will be considered day one of your cycle. All consent forms must be signed and deposits paid prior to receiving approval to start medication and further instructions. Your treatment may stop at any stage if the medical team feels that successful completion of treatment is unlikely. A credit or refund may be due if you do not complete your treatment cycle. Specific instructions regarding drug doses and upcoming appointments will be given.

OVULATION INDUCTION
The purpose of "super ovulating drugs" is to stimulate the ovaries to produce more than one egg. Bravelle, Repronex, Pergonal (hMG),Follistim and Gonal-F (FSH) are given as an injection once or twice a day to recruit multiple eggs. This will require you to make arrangements with someone (partner or friend) to give you your injections. Arrangements should be made prior to initiation of your therapy to teach him/her how to mix the drugs and give the injections.

After receiving injections for approximately five days, a transvaginal ultrasound will be performed at Georgia Reproductive Specialists. You will be asked to empty your bladder and proceed to the examining room, where you will undress from the waist down. A vaginal transducer will be inserted into your vagina. You may experience some vaginal discharge after the procedure as transmission gel is used on the vaginal probe, but the procedure itself should not cause discomfort.

Ultrasound is a process whereby high-frequency sound waves, not radiation, are transmitted through tissue. As the ultrasound waves strike the tissues, they project a white image on the ultrasound screen. Follicles are round sacs of fluid within the ovaries. Therefore, the follicles appear as dark circles on the ultrasound screen. Hopefully, each follicle contains an egg; however, the eggs cannot be seen during the ultrasound. In some cases, the follicle has no eggs and in others the follicle contains more than one egg. The number of follicles, therefore, does not correspond to the number of eggs. We monitor follicular growth and also the number of follicles being produced.

Beginning approximately treatment day 6, you will undergo daily blood sampling to determine your estradiol level. This level is used to individualize your medication treatment for that afternoon and the following morning. Estradiol is produced by the lining of the follicle (fluid filled structure where the egg develops). In addition, a progesterone and LH determination may be made if your estradiol level is rising rapidly. If your progesterone level is also rising, administering hCG a day earlier may be advisable.

It is very important for you to be on time in the morning in order for your lab results to be available for physician review early in the afternoon. After review, you will be notified of any change in your medication dosages. It is very important not to quote numbers with other patients. This may cause you unnecessary anxiety. Each person is going to respond differently. We are not looking for specific numbers when we perform ultrasounds and run blood work. We are looking for the relationships between the blood work and the ultrasound findings. Your physician will review your results and notify you immediately if there is any problem.

When your physician determines that you are ready for retrieval, you will be given an injection of hCG (Pregnyl, Novarel). This injection is given late in the evening approximately 37 hours prior to retrieval. This medication ripens the developing eggs and initiates ovulation. Ovulation occurs about 42 to 48 hours from the time of injection if you do not have an egg-retrieval procedure. Many patients experience abdominal discomfort after the hCG due to ovarian enlargement and are convinced that they are ovulating. Rest assured that we are monitoring you very closely and the chance of ovulating prior to retrieval is extremely slim, and almost zero if you are receiving Lupron, Synarel, Antagon or Cetrotide.

Sexual abstinence too long before retrieval (more than five days) or relations too close to retrieval (24 hours) could possibly decrease the quality of the semen sample. If you did not have sexual relations the day before hCG, we recommend that you do the day of hCG. If your husband has a low sperm count you may need a four to five day period of abstinence. Discuss this with your physician early in your cycle.

MEDICATIONS
Lupron (leuprolide acetate) is an analog of gonadotropin releasing hormone (GnRH). When given as a subcutaneous (just below the skin) injection, it will stimulate the "turning-off" of your pituitary gland. We are able to take advantage of the suppressive actions to improve the recruitment of multiple follicles and prevent premature ovulation. Room temperature storage is advised. Be sure not to keep each vial past the expiration date. One vial will provide approximately four weeks of injections.

Side effects are short term. Hot flashes may be felt when your estrogen level lowers and will disappear when you begin gonadotropin injections. Occasionally, patients experience headaches as well.

A consistent time within the same hour each day should be chosen to give the injection. Lupron comes in a kit with alcohol wipes, small syringes, and one container of medicine. The supplies can be carried in your purse and the shot can be conveniently given in a couple of minutes.

Lupron Injection Instructions:

  1. Wash and dry hands thoroughly.
  2. Assemble supplies: two alcohol wipes, one tissue, one syringe, medication.
  3. At first use, remove and discard plastic cap off the medication.
  4. Clean the Lupron vial with an alcohol wipe.
  5. Remove cap from syringe exposing needle.
  6. Pull the syringe plunger back until its tip is at the proper dose mark. Insert needle straight and firmly into the rubber center of the vial and push the plunger all the way in.
  7. Turn the vial upside down.
  8. Pull the syringe plunger down filling the medication slightly below the line adding 0.2cc (or 0.1cc if that is your dose) and remove from the vial.
  9. Hold the syringe needle up and flick with finger to remove any air bubbles.
  10. Hold the syringe and new alcohol wipe in the right hand.
  11. Choose injection site, rotating sides daily. Pinch the skin gently with the left hand.
  12. Wipe area then save wipe to wipe the area again after the injection.
  13. Holding the syringe like a dart, perpendicular to the skin, briskly insert small needle quickly and entirely into the skin.
  14. Slowly inject all medication, release the pinch and remove syringe. Cover the area with alcohol wipe then with tissue.
  15. When you begin gonadotropin injections, Lupron dosage will usually decrease to half (0.5mg) or be discontinued. Medication may continue through the day of hCG administration or may be terminated when you begin gonadotropin injections.

Antagon and Cetrotide (ganirelix acetate) are antagonists (blocks the action) of gonadotropin releasing hormone (GnRH). Its effect action is similar to Lupron in that Antagon and Cetrotide prevent premature ovulation. Antagon or Cetrotide injections are begun later in the treatment cycle and duration of treatment is usually three or four days. As a drop in estrogen level may be associated with the start of Antagon or Cetrotide injections, your physician may modify the gonadotropin dose and medication prescribed.

Side effects are infrequent, minor and usually limited to redness or soreness at the site of injection. The medication comes in pre-filled syringes

  1. Hold the syringe and alcohol wipe in the right hand.
  2. Choose injection site, rotating sides daily. Pinch the skin gently with the left hand.
  3. Wipe area then save wipe to wipe the area again after the injection.
  4. Holding the syringe like a dart, perpendicular to the skin, briskly insert small needle quickly and entirely into the skin.
  5. Slowly inject all medication, release the pinch and remove syringe. Cover the area with alcohol wipe then with tissue.
Injectable Gonadotropins: Repronex and Pergonal are brand names for hMG. T hMG is a combination of the hormones FSH (follicular stimulating) and LH (luteinizing). Follistim & Gonal-F contain only pure FSH. They affect the ovaries directly to rescue multiple follicles before normal selection of a single dominant follicle. Follistim and Gonal-F may be given as a less painful subcutaneous (under the skin) injection.

Side effects may include abdominal distention/discomfort, bloating sensation, mood swings, fatigue or restlessness. In most cases, the side effects are relieved by follicular aspiration. Multiple births may occur with this medication.

The medication comes in ampules or vials of powder which need to be diluted with water. Several such ampules or vials are combined into just one syringe with water (diluent).

Repronex/Pergonal Intramuscular Injection:

  1. Wash and dry hands thoroughly.
  2. Assemble supplies: one 3cc syringe, one 25-30 gauge 1.5"needle, one 22 gauge 1.5" needle, two alcohol wipes, one tissue, one ampule of water, and the designated ampules of medication.
  3. Unwrap supplies.
  4. Attach syringe to a 22 gauge 1.5" needle.
  5. Using an alcohol wipe, cover finger and thumb and snap open all glass ampules. For Repronex , remove the plastic protective caps and wipe the rubber stopper. Insert the needle through the rubber stopper.
  6. Remove needle cover and draw 1cc of water into the syringe, then distribute between the powder and ampules. It dissolves immediately.
  7. Fill the syringe with all the medication by inserting the needle as far into the ampule as possible and at an angle, then pulling back the syringe plunger. Stop before it reaches the end of the syringe, even if there is more medication. Push the syringe straight up and flick firmly with the finger. Remove all excess air in syringe.
  8. Change needles to the thinner 25 gauge 1.5"needle and express a drop of medication.
  9. Holding the syringe and new alcohol wipe in the right hand.
  10. Select injection site, rotating sides for comfort. Pinch your skin gently with the left hand. Standing on the opposite leg relaxes the muscle to be used.
  11. Wipe skin with alcohol then slide under left thumb.
  12. Hold syringe like a dart, perpendicular to the skin, insert needle quickly to 1 1/2" of depth to pass the skin and fat to the muscle.
  13. Slowly inject medication and withdraw the needle swiftly.
  14. Slide alcohol wipe over the area then wipe area with a Kleenex.
  15. All supplies are discarded in a milk carton or strong containers after single use. You may also place all needles in a glass jar with a dilute bleach solution.

Gonal-F / Follistim / Bravelle Subcutaneous Injection:

  1. Wash and dry hands thoroughly.
  2. Assemble supplies: one 3cc syringe, one 25 gauge 1.5"needle, one 25 gauge 5/8"needle, two alcohol wipes, one tissue, one ampule or vial of water, and the designated ampules of medication.
  3. Using an alcohol wipe, cover finger and thumb and snap open all glass ampules or remove the plastic cover over the vial's rubber stopper.
  4. Remove needle cover and draw 0.5cc of water (1 cc for Follistim) into the syringe then distribute between the powder and ampules. It dissolves immediately.
  5. Slowly turn the vial upside down, the medication will not run out. Fill the syringe with all the medication by inserting the needle as far into the ampule as possible and at an angle then pulling back the syringe plunger. Stop before it reaches the end of the syringe, even if there is more medication. Push the syringe straight up and flick firmly with the finger. Remove all excess air in the syringe.
  6. Switch to the shorter (5/8 th inch) 25 gauge needle.
  7. Hold the syringe needle up and flick with finger to remove any air bubbles.
  8. Hold the syringe and new alcohol wipe in the right hand.
  9. Choose injection site rotating sides daily. Pinch skin gently with the left hand.
  10. Wipe area then save wipe to wipe the area again after the injection.
  11. Holding the syringe like a dart, perpendicular to the skin, briskly insert small needle quickly and just under the skin.
  12. Slowly inject all medication, release the pinch and remove syringe covering area with alcohol wipe then with tissue.
Follistim AQ Pen Subcutaneous Injections:
  1. Wash and dry hands thoroughly.
  2. Assemble supplies: one Follistim AQ Cartridge, one Follistim Pen, one BD Micro-Fine Pen Needle, one alcohol wipe and one tissue.
  3. Pull off the protective cap from the pen and set aside on a clean, dry surface.
  4. Unscrew the pen body from the cartridge holder. Place the cartridge holder and the pen body aside on a clean, dry surface.
  5. Take a Follistim AQ Cartridge out of its package and clean the rubber stopper on the cartridge with an alcohol pad. Insert cartridge into the cartridge holder by placing the metal-rimmed cap end first.
  6. Screw the pen body onto the cartridge holder. Make sure there is no gap between the pen body and the cartridge holder. The blue arrow on the cartridge holder should point to the middle of the yellow alignment mark on the blue pen body.
  7. Clean open end of the cartridge holder with an alcohol pad.
  8. Your Follistim AQ cartridge will contain either 300 IU or 600 IU. Record the Follistim AQ Cartridge content in your personal log. For doses of 50 IU up to 450 IU, turn the dosage knob until the dot beside the correct number on the dosage scale is sitting in the middle of the dosage window.
  9. If, by mistake, you dial past the correct number, do not try to turn the dosage knob backward to fix the mistake. Continue to turn the dosage knob in the same direction past the 450 IU mark as far as it will turn. The dosage scale must move freely. Push the injection button in all the way. Start to dial again starting from the "0" upwards.
  10. Clean the open end of the cartridge holder with an alcohol pad. Pick up your BD Micro-Fine Pen Needle. Peel off the protective paper shield. Do not touch the needle or place an open needle on any surface.
  11. Push the end of the cartridge holder into the outer needle shield. Screw them tightly together. Place your Follistim pen with the attached needle, flat on a clean dry surface.
  12. Swab the skin at the injection site. Pinch the already swabbed area of the skin between two fingers. With the other hand, insert the entire BD Micro-Fine Pen Needle straight into the skin. Press the injection button all the way in to make sure you give yourself a full injection. Wait for 5 seconds before pulling the needle out of the skin. The middle of the dosage window should display a dot next to the "0". If the injection button does not push in all the way, and the number in the dosage window does not read "0", it means there is not enough medication left in the cartridge. The number in the dosage window will give you the amount of medicine needed to complete the prescribed dose. Write down this number. This will be the number you dial for the completion of your dose. Start over with a new Follistim AQ Cartridge and a new needle and follow all the instructions up to this step. Make sure you choose a different injection site to complete your dose of Follistim AQ Cartridge.
  13. Pull out the BD Micro-Fine Needle and firmly press down on the injection site with a tissue. Rub gently.

Gonal-F 450 IU and 1200 IU Multi-Dose (MD) Subcutaneous Injection:

  1. Wash and dry hands thoroughly.
  2. Assemble supplies: one multi-dose kit, two alcohol wipes, and one tissue.
  3. Flip the protective cap off of the Gonal-F MD vial.
  4. Rub the top of the vial with an alcohol swab.
  5. Carefully remove the rubber cap from the pre-filled syringe of bacteriostatic water. To prevent contamination, avoid contact with the needle.
  6. With the vial face up, insert the pre-filled syringe needle straight down through the center of the circle on the rubber stopper of the vial. Slowly inject the water into the vial. Do not shake.
  7. After all the water has been injected, release your finger from the plunger of the syringe. Allow the plunger to rise to its original position, releasing pressure in the vial. Withdraw the syringe and dispose.
  8. Wipe the rubber stopper of the vial of the Gonal-F MD with an alcohol swab.
  9. Remove the wrapper from the 27-gauge syringe provided.
  10. Carefully pull the plastic cap from the needle and avoid touching the needle.
  11. With the Gonal-F vial on a flat surface, insert the needle straight through the marked center of the rubber stopper.
  12. Keep the needle in the vial as you lift the vial and turn it upside down with the needle pointing upward.
  13. Slowly pull back the plunger until the syringe fills to slightly more than the unit marking for your prescribed dose of Gonal-F. Then push the plunger slowly toward your prescribed dose. This prevents bubbles from forming.
  14. Carefully remove the syringe from the vial and recap the needle. The syringe is now filled with the prescribed dosage of Gonal-F and is ready for administration.
  15. Wipe the skin and save wipe to wipe the area again after the injection.
  16. Holding the syringe like a dart, perpendicular to the skin, briskly insert the needle quickly and just under the skin.
  17. Slowly inject all medication, wait 3 seconds, release the pinch and remove syringe, covering area with tissue. Rub gently.

Gonal-F RFF Pen Subcutaneous Injection:

  1. Wash and dry hands thoroughly.
  2. Assemble supplies: one Gonal-F RFF Pen, one needle, one alcohol wipe and one tissue.
  3. Priming the Pen: FIRST TIME USE ONLY - Attach needle as follows: remove pen cap and wipe threaded tip with alcohol wipe. Remove peel tab from outer needle cap. Press threaded tip of pen into open end of outer needle cap. Remove outer needle cap. Set dose at 37.5. Pull out injection button as far as it will go. Remove inner needle cap and hold pen so needle points upward. Tap pre-filled reservoir to let any air bubbles rise to the top. It is normal if a few small air bubbles remain.
  4. Keep needle pointing upward and push in injection button completely. Hold until you hear a click. A small amount of liquid should appear from needle tip. If no liquid comes out, reprime the pen until it does. Replace inner needle cap.
  5. Set the dose as follows: Turn dosage dial so your prescribed dose is lined up with the black dose arrow. CONFIRM THAT THE CORRECT DOSE ON DOSAGE DIAL IS LINED UP WITH THE BLACK DOSE ARROW BEFORE PROCEEDING. IF THE DIALED DOSE IS TOO HIGH OR TOO LOW, RESET BEFORE PULLING THE INJECTION BUTTON.
  6. Load and confirm as follows: Load the dose by pulling out injection button as far as it will go. Confirm correct dose by looking at red dosage confirmation scale. The last visible flat red arrow indicates the loaded dose. If loaded dose is lower than set dose, there is not enough drug to complete the dose. Use new Gonal-F RFF pen to complete dose.
  7. If set and loaded dose is too low, turn dosage dial to correct dose and pull out injection button again. If set and loaded dose is too high, discard dose by pushing liquid out into safety container and repeat step 5.
  8. Inject as follows: Clean recommended injection site with alcohol swab and let air dry. Remove inner needle cap. Do not touch needle or allow it to touch any surface. Inject needle into skin at a 90 degree angle and push injection button until it stops clicking. After last click, release pressure. Keep needle in the skin for at least 5 seconds. Remove needle and apply pressure as needed with tissue. Rub gently.

Low Dose hCG Administration

  • Add 10 cc/ml of fluid to the HCG 10,000 unit vial of powder (the 3cc/ml syringe will need to be filled several times in order to transfer all of the fluid into the powder).
  • Each line (small or large) on the syringe is equal to 10 units of Low Dose HCG once the medication is mixed. So, if your doctor orders 30 units of Low Dose HCG you will draw up enough medication to fill the syringe to the 3rd line. See the drawing below as an example
  • Disregard the writing at the bottom of the syringe regarding units as this does not measure the medication you are taking.
  • Your doctor will decide the dose you will take each day when you monitor and the nurse will give you those instructions.
  • You may continue to use this mixture for up to 30 days, but remember to keep it REFRIGERATED after mixing.

BEGIN TAKING _________UNITS LOW DOSE HCG ON ____________

Human chorionic gonadotropin (hCG, brand name Pregnyl, Novarel) is a hormone closely similar in its biologic effect to LH, which normally induces ovulation. hCG initiates follicular changes, triggering ovulation approximately 42 to 48 hours later. Retrieval must occur before ovulation or the follicles will be empty. hCG is also secreted by the placenta during pregnancy. hCG is available by intramuscular or subcutaneous injection. Room temperature storage is adequate prior to dilution. The powder is diluted just prior to injecting.

Side effects similar to those encountered with the above mentioned medications may be briefly noticed.

hCG Intramuscular Injection:

  1. Timing of hCG is critical and should be performed within 30 minutes of the designated time.
  2. Wash and dry hands thoroughly.
  3. Assemble supplies: one 3cc syringe, one 22 gauge 1.5" needle and one 25 gauge 1.5"needle, 2 alcohol wipes, one tissue, and medication.
  4. Remove all wrappings, snap off plastic caps from medication.
  5. Attach syringe and needle. Pull the syringe plunger back until its tip is at the proper dose mark. (1cc or 1ml).
  6. Wipe each vial with alcohol wipes.
  7. Remove cover from the needle, insert straight and firmly into the center rubber top of the water. Push the plunger all the way in.
  8. Turn the vial upside down.
  9. With the tip of the needle in the liquid medication, pull plunger of syringe to fill to 1cc of water then remove.
  10. Insert water into the powder and gently roll between hands with needle inside. The powder dissolves rapidly. Holding the vial upside down, slowly pull back on the plunger to obtain all the medication, then remove the needle. Do not let the plunger reach the end of the syringe.
  11. Remove air bubbles from the syringe by firmly flicking with a finger.
  12. Change needle to a 25 gauge 1.5"needle.
  13. Choose injection site, as done for injectable gonadotropins, and pinch skin with the left hand.
  14. Hold syringe and alcohol wipe in right hand.
  15. Wipe skin and slide alcohol wipe under left thumb.
  16. Holding the syringe like a dart, perpendicular to the skin, inject 1 1/2" and quickly inject medication then withdraw needle briskly.
  17. Slide alcohol wipe over the area then with tissue.
  18. Dispose of supplies safely in a strong container.

Continued
 


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