EGG RETRIEVAL
You should have nothing to eat or drink in the eight hours prior to your retrieval. This procedure begins in the same fashion as a vaginal ultrasound. You will receive small doses of medication given intravenously, which will make you relaxed and sleepy.

Recovery from these drugs, for most patients, is rapid and generally nausea is minimal. Your vagina will be cleaned to minimize the risk of infection. The vaginal transducer is inserted into your vagina, and the eggs are retrieved with a needle inserted through the vaginal wall under the guidance of ultrasound. No abdominal incisions are required.

PRE-RETRIEVAL INSTRUCTIONS:
Report to GRS at your assigned time. DO NOT EAT OR DRINK ANYTHING AFTER MIDNIGHT. When you arrive, tell the clerk that you are an IVF retrieval patient and let her know what time you are posted for surgery. Please make sure to arrive without jewelry, nail polish, make-up, or contact lenses. You may wear your wedding rings.

Shortly before your retrieval, an attendant will escort you to the preparation area. Please note that usually no preoperative sedatives are administered. While you are in the preparation area, please try to empty your bladder completely. If an epidural anesthesia is planned, the anesthesiologist will confer with you and answer any questions you may have regarding your anesthesia. When all is ready, you will be taken into the procedure room and asked to lie on the procedure table. If you do not yet have an intravenous line, one will be started. Next, you will receive medication to make you feel relaxed and drowsy, or you will receive medication to put you to sleep (as discussed earlier under anesthesia). The procedure will last about 25 to 45 minutes.

Your partner will be asked to provide a semen specimen before or immediately after the time of your retrieval. Following your initial recovery your partner may be with you. The time you will be required to remain for observation will vary between patients. IVF retrieval patients will generally stay approximately 60 minutes while patients who have had an epidural block will remain for approximately two or three hours. When the nurse feels that your condition is stable, you will be discharged. Patients are not allowed to drive themselves home after retrievals. Following your retrieval, you may eat or drink when you feel well enough. At this point, following your procedure, you should begin taking your antibiotic if you have not been instructed to start them earlier.

Sometimes when immature eggs are retrieved, male factor fertility is present, or if fertilization does not occur, your husband may be required to provide a second semen sample. This generally will occur the day after retrieval, but may occur later the same day. Arrangements will be made to contact him the morning following retrieval if this is necessary.

POST-RETRIEVAL INSTRUCTIONS
Following transvaginal ultrasound retrieval you may experience some pelvic area tenderness and feel tired or sleepy from the medications you have received during the procedure. You will also have some light vaginal spotting. This bleeding should be scant and may be red to brown in color.

The medications used during your egg collection may not be eliminated by your body for up to 24 hours. You may feel "hung over" or just not your normal self. During this period we ask that you do not:

1. Drive a car or operate machinery or power tools.
2. Drink any alcoholic beverages.
3. Make any important decisions.

Antibiotic therapy (tetracycline) is administered to minimize the risk of infection following this procedure. An antibiotic is usually given four times daily immediately after your retrieval for a total of seven days.

Medrol, a steroid hormone, is given daily for a period of four days to assist pre-embryo implantation. This is given orally twice a day for a total of four to seven days.

Progesterone is a hormone produced by the remains of the ruptured follicle (corpus luteum). Progesterone helps the lining of the uterus become thick and is therefore essential for the implantation of the pre-embryo. As estrogen levels are higher in stimulated ovarian cycles, it is necessary to administer natural progesterone supplements to establish a normal estrogen/progesterone ratio. Therefore, hCG or additional progesterone supplements may improve the uterine lining and enhance the possibility of pre-embryo implantation. You will be instructed by the IVF nurse on the exact route and administration of natural progesterone supplementation assigned to your physician. The progesterone can be administered through a vaginal suppository or an IM injection. The FDA has released a warning about the use of synthetic progesterone during pregnancy; however, the natural progesterone supplements used in conjunction with an IVF cycle are recognized as safe.

You will be contacted by the nurse on the day following your egg retrieval and given the status report on your eggs and sperm. At this time, fertilization will be seen in most cases, but embryo replacement can only be confirmed when the fertilized egg divides normally, usually after one additional day. As you know, although rare, one of the risks of IVF is lack of fertilization. Sometimes the reason for this is understood but many times no reasons are apparent. If this occurs, monitoring will be discontinued. You will be given an opportunity to meet with your physician and or the embryologist regarding the implications of this finding. Having intercourse between retrieval and transfer is suggested and may improve implantation.

You should abstain from sexual intercourse for two weeks after the embryo transfer. Your physician may advise sexual intercourse after egg retrieval. You should also abstain from strenuous physical activity during those two weeks. If you have any questions about a particular activity, please contact your physician.

Please contact your doctor if any of the following occur:

• Fever greater than 100.4°F that lasts for more than two hours
• Excessive vaginal bleeding
• Unusual and increasing pelvic area discomfort
• Difficulty with urination or change in bowel activity
• Nausea, vomiting or diarrhea
• Sharp or shooting pains
• Pain or burning during urination
• Abdominal swelling
• Unusual back pain

The pre-embryo transfer procedure is similar to a pap smear. A speculum is inserted into your vagina. An abdominal ultrasound examination is performed. Then a catheter and guide is inserted into the cervical canal, and the catheter is fed into the uterus. Occasionally, you may feel some cramps as the catheter is placed into the uterine cavity. The pre-embryos are then placed into the uterus. The embryologist then inspects the catheter under a microscope to make sure that all the pre-embryos were transferred.

Pre-embryo transfer is usually a very short procedure. There is generally very little discomfort, if any at all. So RELAX! Following pre-embryo transfer, you will be able to dress and leave after the "ok" is given by the embryologist.

Following the procedure, you may get dressed and be driven home. You will NOT be able to drive yourself home. Please take things easy for the next few days. Please remember that you are to continue your progesterone (and any other prescribed medications such as heparin, estrogen, or baby aspirin) until we have the results of your pregnancy test. Following transfer, some patients may pass a small amount of bloody fluid or air from the vagina. Please do not worry about this, it does not mean that you are expelling the embryo(s). From the time of transfer until your pregnancy test, you can resume most of your regular activities.

It is normal to blame yourself or something you may or may not have done during this time if your pregnancy test is negative. Therefore, in general, try not to do anything for which you will blame yourself if you are not pregnant. In general, the following guidelines are offered:

• No tub baths or swimming for 48 hours after replacement
• No douching
• No tampons
• No intercourse or orgasms until the fetal heartbeat is seen on ultrasound, or the pregnancy test is negative
• No jogging, aerobics, tennis, skiing, mountain climbing, etc. (You get the idea)
• Do not begin any new physical activity
• Do not taken any non-prescription medications or other prescribed medications without the approval of the IVF team
• No heavy lifting
• You may return to "work" after 24 hours
• Try to keep busy; remaining mentally distracted will help the ten to twelve days pass easier

PREGNANCY TESTING
Quantitative hCG pregnancy testing will be done fifteen days after egg retrieval. If, however, this falls on a weekend, a Saturday test would be done on Friday, and a Sunday test would be done on Monday. Arrangements will be made to have your blood drawn at GRS between 7:30 a.m. and 9:00 a.m. If you live out of town, this may be done at your private physician's office and reported to us. We will call you with the results as soon as possible, usually in the afternoon.

Most of the testing reveals either positive or negative results; however, occasionally we see a test that is "weakly positive." If you have a "weakly positive" pregnancy test, it is caused by one of the following four scenarios:

1. Late but normal implantation of the embryo
2. Discontinued pregnancy
3. Ectopic pregnancy
4. Lab error

An ultrasound examination will be performed approximately three to four weeks after your retrieval. This early ultrasound is critical to evaluate the possibility of miscarriage, ectopic pregnancy, and multiple pregnancies. An ectopic (tubal) pregnancy can occur in 2-4% of IVF pregnancies. If diagnosed early, this unfortunate complication may be treated as an outpatient with medication. Once we determine the presence of fetal heartbeat, we will refer you back to your obstetrician. If you do not have one, we will be happy to make a recommendation.

If your pregnancy test is negative, you may stop taking progesterone. You will get a period within three to five days, if you have not already started bleeding. This period may be different from your normal period (lighter, heavier, shorter, longer). If you do not get a period within one week, please call and return for blood work.

After investing so much time and money for your ART treatment, failure to have fertilized eggs or a negative pregnancy test can be an abrupt shock. You may wish to make an appointment to meet with your physician to review your treatment and discuss your feelings with us. All that it may take to achieve your IVF success is time and another attempt.

TELEPHONE CALLS
The answering service has been instructed not to page the on-call staff after hours and on weekends unless you consider your call an emergency. However, patients who have had retrieval or surgery that day or the day prior and are experiencing bleeding, temperature elevation, nausea and vomiting, or difficulty urinating should not hesitate to call and are considered emergencies. Calls regarding the beginning of your period, questions concerning instructions, prescription refills and appointments are not considered emergencies. Calls regarding the scheduling of appointments will not be returned after office hours.

Please keep in mind that some days are extremely busy and phone calls will be returned as soon as possible. However, some phone calls may not be returned until after hours or the next day. Our office hours are from 7:30 a.m. until 4:30 p.m. When leaving a phone message, please let us know how long you will be available at that number and provide us with a number to reach you later in the day. If your call is emergent in nature, please keep your phone line open for a return call.