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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

What is IVF?

Stimulate the ovaries to mature many eggs

Surgically remove eggsMix with spermIncubate fertilized eggsReturn a few to the

uterus

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

Medications

Suppression Medicines•Begin the month before the

stimulation Birth Control pills Lupron Ganirelix Cetrotide Climera patch

Medications

Suppression Medicine•Birth control pills

Start d1-3Suppress LH & FSH hormones

Regulate cycles, active pills only

Side effectsEarly pregnancy symptoms

Breakthrough bleeding

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

Medications

Suppression Medicine

•Ganarelix/Cetrotide Suppress LH immediately Once a day injection Fewer shots Side Effects: headache, nausea

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

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

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

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

Medications

Post Retrieval MedicineDoxycycline - antibiotic

All patients Pills

• Estrace – Estrogen ICSI, AH, PGD patients Pills

• Medrol- anti-inflammatory ICSI, AH, PGD patients Pills

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

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

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

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

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

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

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)

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

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

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

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

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

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

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

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

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

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

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

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

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

Pregnancy Test

Approximately 18 days after the egg retrieval

If you have bleeding, do not stop progesterone

Cycle review after negative test or +FH

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

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

Consents

Consent bookletMultiple consent

formsCannot start cycle without

signed consents Arrange to give them to

your nurse

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

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

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

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

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

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.