HRC Fertility`s Guide To

Transcription

HRC Fertility’s Guide To
HOPE
HRC ’S ORGANIZED PATIENT EDUCATION
Table of Contents
1 Introductory Information
40
Ganirelix Acetate (Antagon)
1
To Our Patients
41
Lupron
2
Planning Calendar
42
Luteal Lupron
3
Patient Bill of Rights
43
Microdose Lupron
4
Frequently Asked Questions
44
Gonadotropin Medications
Bravelle, Follistim, Gonal-F,
Menopur, Repronex
47
Follistim Pen and Follistim
AQ Cartridge
51
Reconstituting Gonal-F RFF 75 IU Vial
52
Gonal-F Multi-dose 450 IU Vial
53
Gonal-F Self-injection RFF Pen
55
Luveris
58
hCG Injections: Novarel or Pregnyl
60
Ovidrel
62
Estradiol Valerate (E2 Valerate)
63
Progesterone
64
Heparin
10 Tests
10
Clomiphene Citrate Challenge Test
11
Diagnostic Hysteroscopy
12
Hysterosalpingogram (HSG)
13
Sonohysterography (SHG)
14
Endometrial Biopsy
15
Post Coital Test
16
Semen Analysis
17
Test Yolk Buffer
18 Procedures
18
Intracytoplasmic Sperm
Injection (ICSI)
19
Embryo Assisted Hatching (AH)
20
Intrauterine Insemination (IUI)
65 Financial
21
IVIG Therapy
69 Resources
23
Laparoscopy
69
Abbreviations
25
Preimplantation Genetic Diagnosis
and Screening (PGD/S)
70
ASRM Information
72
ASRM Glossary of Terms
77
Counseling
27 General Information
27
Cycle Monitoring
78
Family, Friends and Social Situations
28
Ectopic Pregnancy
80
How Family and Friends Can Help
29
IVF Cycle Overview
81
31
Gender Selection
How to Reduce Stress
During Infertility
32
Ovarian Hyperstimulation
82
Preconception Guidelines
87
Relaxation Techniques
88
Resources
33 Administration of
Injections/Medications
33
General Information
96
Suggested Reading
36
Preparing & Administering Injections
97
Thoughts and Considerations
37
Cetrotide
99
You and Your Partner
HRC HOPE 08/03/11
To Our Patients
W
elcome to HRC Fertility. We are dedicated to providing you with the best fertility
care and treatment available through our physicians, nursing, laboratory and
administrative team. Because we want to make your experience with us as pleasant
as possible, we have designed this Resource Guide with you in mind. We like to refer to it as
our patients’ “Guide to HOPE” (HRC’s Organized Patient Education), and think you will find it
helpful in answering some of your questions.
Our HOPE Resource Guide is designed to help you learn more about fertility and your
treatments. You will find descriptions of tests and procedures you may be undergoing,
information on medications you may be taking, a step-by-step guide on how to self-administer
injections, coping strategies such as relaxation techniques, and several resources including
books, associations and web sites.
We know there are emotional and stressful issues when patients struggle with fertility, our
center strives to develop new and unique ideas to help us understand our patients’ needs.
We welcome all your recommendations and/or suggestions for how to improve this Resource
Guide for future patients. You, our valued patient, ultimately know best what is most beneficial
and useful when experiencing all the emotions, questions and frustrations you feel when trying
to turn your dreams into realities.
We will make every attempt to answer all your questions and address your concerns and make
your experience at HRC Fertility a positive one.
Wishing you all the best in our journey together,
The Physicians and Staff at HRC Fertility
HRC HOPE 08/03/11
1
Planning Calendar
For purposes of planning your cycle, please indicate any dates you will be unavailable.
Thank you.
Name of Patient: __________________________
Month of: ________________________________
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Month of: ________________________________
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
HRC HOPE 08/03/11
2
Patient Bill of Rights
Y
ou have important rights to ensure that you receive the health care you deserve. You are
entitled to these rights without regard to your sex, race, culture, economic, educational,
or religious background. You also have responsibilities to be an informed patient and
health care plan participant.
Patient Rights:
• Receive appropriate care, treatment and consideration.
• Be treated with dignity and respect.
• Participate actively in decisions regarding health care, including refusing treatment, if desired
(to the extent permitted by law).
• Receive full consideration of privacy and confidentiality during health care consultation,
examination and treatment.
• Receive complete information about your health condition, proposed treatment and
alternatives, including non-treatment, or second opinion, in order to give informed consent or
to refuse treatment.
• Leave the hospital at any time, even against medical advice.
• Know the cost (co-payment, deductible and coinsurance) of care and treatment and receive an
explanation when required.
• Be informed of continuing health care requirements following discharge from the hospital
or office.
• Change primary care physicians when desired, subject to the waiting period and continuing
care consideration.
Patient Responsibilities:
• Know the benefits and exclusions of your health care coverage.
• Carry your health care identification card with you at all times.
• Know how to access health care services in routine, urgent and emergency situations.
• Cooperate with your physician’s advice.
• Make preferences known clearly – ask for clarification of anything not understood.
• Contact your health care member services immediately for questions and assistance.
HRC HOPE 08/03/11
3
Frequently Asked Questions
New Patients
Q. I just got my period. What do I do next?
A. Look at the instructions that were given to you by your coordinator. You may need to have
screening testing scheduled. If you are unsure, call your coordinator for guidance.
Spa / Exercise / Intercourse
Q. Can I have my hair colored? Can I get a permanent? Can I have my nails done?
Laser hair removal?
A. Yes, until the embryo transfer, and then as advised by your obstetrician.
Q. How much exercise and to what point?
A. No strenuous exercise, including aerobics, once you have been on stimulating medication
for about five to six days.
Q. Can I take a tub bath, sauna or jacuzzi? Can I go swimming?
A. It is not recommended after the embryo transfer. It is important not to change your core
body temperature immediately following your embryo transfer because it may affect embryo
growth prior to implantation. Once you have been referred to your obstetrician, follow
his/her recommendation(s).
Q. Can I get a massage?
A. Yes, prior to the embryo transfer. There is no data on deep tissue massage after an embryo
transfer, but we generally do not recommend it.
Q. Are there any restrictions in having sexual intercourse?
A. We recommend that you abstain from intercourse after your embryo transfer until the
pregnancy test. If you have any other questions, please contact your physician’s office.
Food / Drink
Q. Can I have a glass of wine or alcohol during the cycle?
A. Alcohol decreases the efficacy of any medication. It is recommended not to have any alcohol
after the embryo transfer due to possible harmful effects on the baby.
Q. Can I eat shellfish or sushi when I am pregnant?
A. It is not recommended because there can be parasites in raw fish and mercury in shellfish.
HRC HOPE 08/03/11
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Intrauterine Inseminations/Semen Analysis
Q. How long should we abstain from sex before my partner brings in his sample?
A. A minimum of two days, but no longer than seven days, is recommended.
Q. How are Intrauterine Inseminations (IUI’s) done?
A. The physician or nurse uses a small catheter to insert the specially prepared sperm into
the uterus.
Medications
Birth Control Pills
Q. I am having nausea while on the pill, is this normal?
A. Some patients do have this side effect. Try taking it in the evening at bedtime, and it may
not occur.
Q. Why am I taking birth control pills?
A. To coordinate your cycle and to plan your calendar and timing dates for your
treatment cycle.
Q. Do I take the placebo pills in my packet of birth control pills?
A. No, you do not need them.
Q. Is spotting / bleeding normal on the pill?
A. This may occur with some patients and is called breakthrough bleeding. It is common, if
you do not take the pill at the same time every day or if you miss a day. Continue taking
your pills. If you have questions or concerns, please call your coordinator.
Q. Will I gain weight from the medication? Will I be moody?
A. There may be a temporary weight gain, and often patients do mention that they have
mood swings. While on the stimulating medications, you may experience bloating, breast
tenderness and mood swings. The symptoms usually subside about one to two weeks after
being on the stimulating medications. In some patients it may take longer.
Q. How long will I be on stimulation medications?
A. Depending on the patient’s response, usually between eight to twelve days.
Lupron (Leuprolide Acetate)
Q. What does the Lupron do? Are there any side effects?
A. It helps to prevent premature ovulation. Some patients may experience dry skin, spotting,
hot flashes, headache and fatigue. These symptoms usually subside once a patient begins
the stimulating medication.
HRC HOPE 08/03/11
5
Q. Will this one bottle of Lupron be enough?
A. Yes. Although it looks like a small amount, the multi-dose vial is enough for two weeks of
daily injections.
Clomid (Clomiphene Citrate)
Q. What is the difference between Clomid and injectable medications?
A. Clomid is an oral medication that is less expensive than injections and is often prescribed
prior to injection therapy.
Progesterone
Q. How can I help prevent lumps from my progesterone injections?
A. This is a common occurrence. Massage the injection site gently with clean gauze or cotton
ball for about one minute after the injection. Use moist moderate heat on the area for ten
minutes after the injection. Walking around helps absorption as well.
Q. Is Progesterone safe to take when it states not to take during pregnancy?
A. Daily Progesterone is usually used to supplement the hormonal status after ovum aspiration.
The use of intramuscular or vaginal Progesterone is usually used to maintain the uterine
lining. The Progesterone used is naturally occurring and is similar to that which is normally
produced by the ovary; there is no evidence of an increased risk of birth defects.
Antibiotics
Q. The medication that I received (Doxycycline) states “Do not take if you are trying to get
pregnant.” Will this hurt the pregnancy?
A. Doxycycline can be used only during early pregnancy. After six weeks of pregnancy, there
may be problems with its use.
Yeast Infection Medication
Q. Can I use medication if I get a yeast infection?
A. Yes, before your embryo transfer. After your embryo transfer, use Monistat or Gyne-Lotrimin
cream on the outside of your vagina three times daily. Do not insert the applicator into
the vagina.
HRC HOPE 08/03/11
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Can I take any of the following medications / injections / immunizations during a cycle or
after an embryo transfer?
Medications
During
Treatment Cycle
After Documented
Pregnancy
Amoxicillin, Ampicillin
Bactrim
Doxycycline
Erythromycin
Flagyl
Headache medications (Fioricet, Fiorinal)
Prozac, Zoloft, Celexa
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Ativan, Xanax
Prednisone
Yes
Yes
Anaprox, Motrin, Aleve, Advil
Benadryl
Cold medications (Sudafed, Tylenol-Cold)
Regular-Strength Tylenol or Robitussin
GI Medications (MOM, Colace, Immodium, Pepcid)
Echinacea, St. John’s Wort
No
Yes
Yes
Yes
Yes
No
Yes
No
No
Yes
No
No
Consult your
prescribing physician
No
Consult your
No
Yes
No
Yes
Yes
No
During
Treatment Cycle
After Documented
Pregnancy
Yes
Consult your dentist
Yes - only if inactivated
virus vaccine
Yes - only if at risk of
acquiring the disease
No
No
Yes
Yes
No
Yes - only if inactivated
virus vaccine
Yes - only if at risk of
acquiring the disease
No
No
No
No
Consult your
Injections/
Immunizations
Lidocaine/Xylocaine
(used for dental procedures)
Flu Injection
Hepatitis Vaccine
Chicken Pox Vaccine
Rubella Vaccine
TB (tuberculosis) test – PPD
Tetanus Injection
Allergy Injections
This list is only to be used as a guide. Please check with your physician prior to taking any
medication. Please check with your pharmacist regarding any drug interactions.
HRC HOPE 08/03/11
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IVF and Additional IVF Procedures
Q. What are your success rates for IVF cycles?
A. Success rates vary with the age of the female. Please ask your physician what he/she thinks
your prognosis will be with IVF.
Q. What is Intracytoplasmic Sperm Injection (ICSI)?
A. ICSI is a procedure that is performed to increase fertilization. ICSI is done on the day of
egg retrieval in the laboratory by the embryologist and involves selecting one sperm and
injecting it into the center of an egg.
Q. What is Assisted Hatching (AH)?
A. A procedure that is done on the day of embryo transfer performed in the laboratory by the
embryologist to aid in implantation.
Q. Do you do Preimplantation Genetic Diagnosis or Screening (PGD/S)?
A. Yes, we offer both.
Q. What is PGD?
A. The ability to perform a genetic evaluation on the embryo or oocyte prior to your embryo
transfer for specific inheritable diseases or for tissue type (HLA) matching.
Q. What is PGS?
A. It is the ability to screen embryos for chromosome # errors, perform sex selection or screen
for translocations (piece of one chromosome attached to another).
Cycling Patients
Q. Am I ovulating early? I have noticed increased discharge.
A. The increasing hormone levels can sometimes cause more discharge than you are used to
having. It is a common occurrence.
Q. Can I fly while I am in fertility treatment?
A. You may fly while you are on the stimulating medications, but it is a good idea to hand-carry
your medications in case of travel delays, lost luggage, etc.
Q. Can I have dental work done?
A. Yes, but no general anesthesia after the embryo transfer. Preferably, have your dental work
prior to starting treatment.
HRC HOPE 08/03/11
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Following Embryo Transfer
Q. What activities can I do after the embryo transfer?
A. No strenuous exercise, tub baths, jacuzzis, saunas, swimming, or intercourse until after an
ultrasound confirming a heartbeat.
Q. Can I travel more than four to six hours in a car after my embryo transfer?
A. Yes, if you stop every one to two hours to stretch and walk around.
Q. What does bed rest mean?
A. To stay off your feet as much as you can for 48 to 72 hours. It is okay to get up to go to the
bathroom and to walk to the car after the embryo transfer.
Q. What can I do for nausea during pregnancy?
A. Crackers and eating small, frequent meals (watch the spicy foods) usually helps.
Q. What if I have spotting/bleeding and I am pregnant?
A. Spotting/bleeding is very common in early pregnancy. Remember: no strenuous exercise if
you are spotting/bleeding. Abstain from intercourse until you receive permission from your
physician’s office. If bleeding heavily, call your physician’s office.
Q. How long am I followed at HRC when I am pregnant?
A. Until approximately eight weeks, if there are no complications.
Egg Donation
Q. How can I find an egg donor?
A. There are agencies that coordinate egg donors, as well as surrogates. Your physician’s office
will be able to provide you with recommendations.
Financial
Q. How much does it cost for IUI’s?
A. Our financial counselor will provide that information for you.
Q. How much does In Vitro Fertilization (IVF) cost?
A. Our financial counselor will provide that information for you.
Q. I have an HMO. Which ones do you belong to?
A. You will need to call your health plan for that information.
Q. Are my pregnancy follow up appointments covered by insurance?
A. Not usually. We can courtesy bill your insurance, but we will collect a fee for each
service provided.
HRC HOPE 08/03/11
9
Clomiphene Citrate Challenge Test
C
lomiphene Citrate (Clomid) Challenge Test is a test that is being performed to check
your ovarian reserve (to determine how well your ovaries are functioning). Ovarian
reserve, along with female patient age, is an important predictor of treatment success.
1
Call the office on Day 1 of your menstrual flow (not spotting). If this is on the weekend,
please call Monday morning.
2
You will come into the office to have your blood drawn for an E2 (Estradiol) level and
FSH (Follicle Stimulating Hormone level) on Day 2, 3 or 4 of your menses (period).
3
You will begin Clomid — 100mg per day on Day 5 of your menses. This will be two tablets,
50mg each, which are taken together at the same time each day.
4
You will take the tablets cycle Days 5 to 9, and you will return to the office on cycle Day 10 or
11 (after five days of Clomid). The FSH level will be repeated on Day 10 or 11.
5
You will be notified by your coordinator or your physician regarding your lab results, within
one day of having your blood work drawn (unless it is a weekend or holiday).
6
You will need to sign the Clomid Consent Form, which lists the possible side effects, before
starting the medication.
HRC HOPE 08/03/11
10
A
hysteroscopy is an important tool in the study of infertility, recurrent miscarriage, or
abnormal uterine bleeding. Diagnostic hysteroscopy is used to examine the inside
of the uterus, also known as the uterine cavity, and is helpful in diagnosing abnormal
uterine conditions such as internal fibroids, scarring, polyps, and congenital malformations.
A hysterosalpingogram (an x-ray of the uterus and fallopian tubes) or an endometrial biopsy
may be performed before or after a diagnostic hysteroscopy.
The first step of diagnostic hysteroscopy involves slightly stretching the canal of the cervix
with a series of dilators. Once the cervix is dilated, the hysteroscope, a narrow lighted viewing
instrument, similar to but smaller than the laparoscope, is inserted through the cervix and into
the lower end of the uterus. Carbon dioxide gas or special clear solutions are then injected into
the uterus through the hysteroscope. This gas or solution expands the uterine cavity, clears
blood and mucus away, and enables the physician to directly view the internal structure of
the uterus.
Diagnostic hysteroscopy is usually conducted at HRC and local anesthesia is a possibility.
Diagnostic hysteroscopy is usually performed soon after menstruation because the uterine cavity
is more easily evaluated and there is no risk of interrupting a pregnancy. A mock transfer or trial
of transfer may also be done at this time.
Permission granted for reproduction by the American Society for Reproductive Medicine
www.asrm.org
HRC HOPE 08/03/11
11
Hysterosalpingogram (HSG)
A
hysterosalpingogram (HSG) is an x-ray study to diagnose blockage of the fallopian tubes
and abnormalities of the uterus and cervix. A radiopaque dye is injected through the
cervix into the uterus and fallopian tubes. Pictures are displayed on a monitor as the
dye travels through the reproductive system. In the case of normal (unblocked) fallopian tubes,
the dye fills the uterus and spills out the ends of the tubes. If the flow of the dye stops, an
obstruction is indicated. The total procedure takes approximately one half hour. If the HSG
demonstrates an abnormality, the radiologist may choose to extend the length of the test to
conduct a more detailed evaluation of the uterus and/or tubes. A tubal catheterization or
selective salpingography may be used to open fallopian tubes that are blocked.
Patient Instructions:
1
Contact our office on Day 1 (the first day of full flow) or Day 2 of your menstrual cycle.
If this occurs on a weekend or holiday, please call the next business day. HSGs are
performed on Days 7 to 10 of the cycle, after bleeding has ended, but before ovulation
occurs. HSGs are done at selected offices only. You will be told where to go when you
schedule the procedure. You will be asked to sign an informed consent form acknowledging
your understanding of the procedure and giving the physician permission to perform
the test.
2
At the time of scheduling, advise a team member if you have: a) any drug allergies or
allergies to shellfish, or b) a mitral valve prolapse, heart murmur, or any other condition
that requires antibiotic treatment before a medical procedure. At the time of scheduling,
you will be given an antibiotic prescription. Start the antibiotic the day before your HSG.
3
Reschedule your HSG appointment if you have not stopped bleeding on the day it is
scheduled. The test cannot be performed while you are actively bleeding.
4
It is recommended that someone accompany you to the office for the test and take you
home afterward.
5
Plan to arrive at the radiology center one half hour before the HSG is scheduled. You may
take one to two tablets (200mg tablets) of Advil or Anaprox approximately 20 minutes before
the procedure to minimize pain from uterine cramping. You may also receive local anesthesia
(an injection into the cervix) to numb the opening of the uterus prior to the test.
6
Some cramping and spotting may occur after the HSG. If you develop a fever, if bleeding is
as heavy as the heaviest flow during your menstrual period, or if you have severe cramping,
call our office immediately. After hours or on weekends or holidays, call the answering
service and have the on-call physician paged.
HRC HOPE 08/03/11
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Sonohysterography (SHG)
S
onohysterography (SHG) is an ultrasound study to diagnose abnormalities of the
uterus. A small volume of sterile saline is injected via a sterile catheter through the cervix
into the uterine cavity and images are displayed on an ultrasound as the saline travels
through the reproductive system. This procedure is especially sensitive for evaluating the
uterine cavity for uterine polyps, adhesions, submucous (fibroids) and uterine cavity anomalies.
The total procedure takes approximately 15 minutes. If the sonohysterography demonstrates an
abnormality, the physician may choose to perform an office hysteroscopy to conduct a more
detailed evaluation of the uterus.
A mock transfer or trial of transfer may also be done the same day as sonohysterography.
1
Contact our office on Day 1 (the first day of full flow) or Day 2 of your menstrual cycle. If this
occurs on a weekend or holiday, please call the next business day. Sonohysterographies
are generally performed before the 14th day of the cycle, before ovulation occurs. You
will be asked to sign an informed consent form acknowledging your understanding of the
procedure and giving the physician permission to perform the test.
2
At the time of scheduling, advise a team member if you have: a) any drug allergies or
allergies to shellfish, or b) a mitral valve prolapse, heart murmur or any other condition
that requires antibiotic treatment before a medical procedure.
3
Reschedule your sonohysterography appointment if you have not stopped bleeding on the
day it is scheduled. The test may be compromised if you are actively bleeding.
4
Plan to arrive at the office one half hour before the sonohysterography is scheduled. You
may take one to two tablets (200mg tablets) of Advil or Anaprox approximately 20 minutes
before the procedure to minimize pain from uterine cramping.
Some cramping and spotting may occur after the sonohysterography. If you develop a fever,
or if bleeding is as heavy as the heaviest flow during you menstrual period, call our office
immediately. After hours or on weekends or holidays, call the answering service and have
the on-call physician paged.
HRC HOPE 08/03/11
13
Endometrial Biopsy
A
n endometrial biopsy involves scraping and examining a sample of tissue from the
lining of the uterus (endometrium). The procedure makes it possible for the physician to
determine if ovulation has occurred, and whether the lining of the uterus has undergone
the changes necessary for the implantation of a fertilized egg and the support of an early
pregnancy. An endometrial biopsy can also detect an infection or inflammation of the
endometrium (endometritis).
The procedure is usually performed one to four days prior to the onset of menstruation. In a
woman with a 28-day cycle, it is usually scheduled for Days 24 to 26. From start to finish the test
takes about five minutes. The physician begins by inserting a speculum into the vagina. The
cervical area is cleansed with cotton swabs and antiseptic and an antiseptic solution containing
iodine. Please advise a team member if you have an allergy to iodine or shellfish. An instrument
called a tenaculum may be used to stabilize the cervix. This may cause a brief, slight cramping
sensation. A narrow plastic instrument is passed into the uterus to collect a small sample of
tissue from the side wall of the uterus. During the 60 seconds the tissue is collected, minimal
to severe cramping may be experienced. This will subside spontaneously after a few minutes.
The tissue is evaluated by a pathologist who will “date” the tissue according to an ideal
menstrual cycle. In order to interpret the results, you need to notify your physician’s office on the
day that your menstrual period begins following the test. The lining is considered “in-phase” if
the progesterone is in a certain range and the lining has thickened to the degree expected on
a specific day of the cycle. A biopsy that is “out of phase” suggests a lag in the growth of the
lining and an inability of the endometrium to support an early pregnancy.
The time frame between Days 24 and 26 of the cycle is too early to perform a pregnancy
test. However, a woman undergoing an endometrial biopsy does not need to worry about
disturbing a pregnancy. Studies involving large numbers of women who had the procedure
performed during the cycles when they conceived showed no greater incidence of birth
defects or miscarriage.
1
Call our office to schedule the endometrial biopsy. You will be asked to sign an informed
consent form acknowledging your understanding of the procedure and giving the physician
permission to perform the test.
2
If the test is for diagnosis of hormonal imbalance, you will need a progesterone level
approximately one week after ovulation. The biopsy can be scheduled when the
progesterone level is within the normal range.
3
You may take one to two tablets (200mg tablets) of Advil, Motrin or generic ibuprofen one
hour before the procedure. There are no special diets or restrictions either before or after
the endometrial biopsy. It is rare that home rest is required after the test.
HRC HOPE 08/03/11
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Post Coital Test (PCT)
T
he post coital test (Sims-Huhner test) is a quick, painless procedure which enables the
physician to evaluate the interaction between a woman’s cervical mucous and her
partner’s sperm. The test is performed just shortly before or at the time of ovulation.
In a woman with a 28-day menstrual cycle, it is usually done on Days 12, 13 or 14. Timing is
essential for this test; it is only for a limited time, right around ovulation, that the amount
and characteristics of the mucous permit the sperm to migrate.
The patient and her partner engage in sexual relations following a 36 to 48 hour period of sexual
abstinence. About two to eight hours later, a sample of the cervical mucous is removed. In most
cases, the procedure causes no discomfort. The quantity and clarity of the mucous is assessed
in addition to its ability to stretch (spinnbarkeit). The mucous is examined microscopically to
determine the number, motility and progression of the sperm. Results are known immediately.
An adequate post coital test implies that pre-ovulatory hormonal activity and coital technique
are satisfactory. It suggests adequate sperm number and motility, and that there is no significant
antisperm immunity factor (“allergy” to sperm).
An abnormal or “poor” test may be due to bad timing of the test, a male factor, an infection
in either partner, a hormonal imbalance in the woman, or incompatibility between the sperm
and the mucous. In the case of poor results, it may be necessary to repeat the test. Additional
testing may be recommended including a semen analysis, cultures for infections, and a more
extensive infertility workup.
1
Your physician will determine when your post coital test should take place. Physicians differ
in their recommended period of sexual abstinence and the exact timing of the procedure.
You will be given specific instructions by our office when you make your appointment.
2
Have sexual intercourse when instructed based on the time the post coital test is scheduled.
3
You (the woman) may shower afterwards, but do not bathe or douche prior to the test.
HRC HOPE 08/03/11
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Semen Analysis and Sperm Penetration Assay
T
he semen analysis (SA) and sperm penetration assay (SPA) are used to evaluate the
fertility of the male partner. Information including the number of sperm, their motility and
morphology, penetration and the volume of the semen sample is obtained. Additional
tests can be performed when indicated to culture the semen for infection, and to detect
antisperm antibodies.
The laboratory is equipped with a collection room for comfort and privacy. Patients are
encouraged to use this facility, or the patient may collect at home in a sterile container and
deliver the specimen to the lab within one hour.
Payment in full is due at the time of service. Our office does not bill the insurance for
these services without prior authorization. We will supply an itemized statement for
insurance purposes.
1
The semen analysis is done by appointment. The SPA is done only on selected days between
11 am and 12 pm. Please contact our office to schedule an appointment.
2
Abstain from ejaculation for at least two days, but not more than seven days, before
producing the specimen.
3
The specimen should be obtained by masturbation. Do not use a condom or withdrawal.
Do not use any soaps, detergents, creams or lubricants to aid collection. These agents can
damage the sperm.
4
Obtain a sterile container from our office if collection at the lab is not possible. Write
your name and your partner’s name, your social security number, date of birth, and your
physician’s name on the container. Please fill out the appropriate information sheet that you
will receive from our lab technician. Samples that are not collected in sterile containers or
properly labeled cannot be accepted. Keep the container tightly capped and carry it in an
inside pocket or under your arm to keep the specimen at body temperature. Do not expose
the container to direct heat. The specimen must be delivered to the lab within 60 minutes
of collection.
5
Ejaculate directly into the specimen container. If there is any spillage, let the lab know if it
occurred toward the beginning or end of the collection. If you are asked to produce a split
ejaculate, collect the specimen in two portions in two separate containers. Check with our
office for specific instructions.
Note: Semen samples for certain tests including semen culture and retrograde ejaculation must
be collected at the office.
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Instructions for Mixing Test Yolk Buffer with
Semen at Home
1
Remove Test Yolk Buffer vials from freezer, allowing to thaw at room temperature completely
(approximately one to two hours).
2
Collect specimen in a sterile 4oz. cup. Let specimen liquefy at room temperature for
half an hour. (Specimen will become watery. If not, then let it sit for another half hour).
3
By using a plastic pipette, transfer specimen to orange cap tube to measure the volume.
4
Add Test Yolk Buffer until the volume is doubled (e.g., if specimen volume is 3.0ml, add
Test Yolk Buffer up to 6.0ml).
5
Gently invert the tube three to four times and place in a cup filled with room
temperature water.
6
Place the cup in the refrigerator (not freezer).
7
To transport specimen, place the tube inside a thermos filled with cool water (4ºC).
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Intracytoplasmic Sperm Injection (ICSI)
I
n 1992 a Belgian group introduced a new technique known as ICSI. This procedure has
revolutionized the treatment of male infertility. ICSI is a remarkable breakthrough because it
requires only a single sperm for fertilization to occur. Fertilization takes place in the lab where
embryologists insert a single sperm into the cytoplasm of the egg.
For many infertile couples, the inability to achieve fertilization is the principal problem. This
process increases the likelihood of fertilization when there are abnormalities in the number,
quality, or function of the sperm. However, ICSI is generally unsuccessful when used to treat
fertilization failures that are primarily due to poor egg quality.
ICSI
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Embryo Assisted Hatching (AH)
S
ince 1996, HRC has increasingly employed a technique known as assisted hatching (AH)
selectively in women 35 and older. Patients who may benefit from AH are those whose
embryos have thicker zonas, patients whose Day 3 FSH level is elevated and those
who have failed IVF two or more times. Microembryonic hatching is a technique whereby
microscopic holes are created in the embryonic shell to facilitate easier release of the embryo
into the endometrial cavity, thereby improving the chances of implantation. At HRC, we have
performed a considerable number of hatching procedures and have found an increase in
pregnancy rates, especially in women over 40 years of age.
Holding Pipette
Zona Drilling
Hole in Zona
Hatching Blastocyst
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I
ntrauterine insemination (IUI) is a procedure in which semen is processed and the sperm is
placed into the uterus through a catheter. The male partner produces a semen sample by
masturbation. The sperm are then separated from the seminal plasma, white blood cells,
prostaglandins and other “debris” with a density gradient. A speculum is inserted into the
woman’s vagina and a catheter with a syringe containing the concentrated sperm is inserted
through the cervix into the uterus. The sperm is injected and the catheter and the speculum
are removed. An IUI is usually not a painful procedure.
1
IUIs are done during certain hours by appointment only. Contact our office for details and
to schedule an appointment. You will schedule one or two inseminations, depending on
the protocol.
2
Collection instructions for the male partner:
a
Abstain from ejaculation for at least two days, but no more than seven days before
producing the specimen.
b
The specimen should be obtained by masturbation. The lab is equipped with a collection
room for comfort and privacy. You are encouraged to use this facility. Ejaculate directly
into the sterile specimen container. Do not use a condom or withdrawal. Do not use any
soaps, detergents, creams or lubricants to aid specimen collection. These agents can
damage the sperm.
c
Obtain a sterile container from our office, if collection at the lab is not possible. Write
your name and your partner’s name, your social security number, date of birth and your
physician’s name on the container. The date and time the specimen was produced and
the number of days of sexual abstinence must also be written on the label. Samples that
are not collected in sterile containers or properly labeled cannot be accepted. Keep
the container tightly capped and carry it in an inside pocket or under an arm to keep
the specimen at body temperature. Do not expose the container to direct heat. The
specimen must be delivered to the lab within an hour of collection. The specimen must
be available one hour prior to the scheduled insemination.
3
Plan to be at the office for approximately one hour. You will be given an appointment time
for the actual insemination, which takes only a few minutes to perform. Afterwards, you will
rest for five to 10 minutes before being discharged.
4
Some cramping and spotting may occur after the insemination. This is normal. If the
cramping becomes severe, the bleeding is as heavy as the heaviest flow during your
menstrual period or you develop a fever, call our office immediately. After hours or on
weekends or holidays, call the answering service and have the on-call physician paged.
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Intravenous Immunoglobulin Therapy (IVIG)
I
mmunoglobulin is used to prevent or treat some illnesses that occur when your body
does not produce enough immunity. IVIG is also used to treat idiopathic thrombocytopenic
purpura (ITP), a disorder associated with increased platelet breakdown. Low platelet level
increases the risk of bleeding and IVIG is used to prevent this bleeding by increasing the
number of platelets. Although IVIG is produced from the pooled blood of many individuals,
it does not contain hepatitis virus or immunodeficiency virus.
High dose intravenous immunoglobulin (IVIG) therapy is clinically beneficial and not
experimental in a variety of immune disorders associated with human reproductive failure and
pregnancy. Examples include: autoimmune diseases, Rh sensitization, hypogammaglobulin
recurrent fetal loss and infertility associated with antiphospholipid antibodies, intrauterine
growth retardation and idiopathic thrombocytopenia.
The beneficial effects of this medication are documented in the literature involving treatment
for autoimmune disorders, organ transplant, bone marrow rejection and autoimmune disorders
associated with infertility and pregnancy. Its use can no longer be labeled as experimental.
IVIG can be given at a local infusion center or by a home health agency.
Side effects
If any of the following side effects occur, notify your physician immediately. Some side effects
may include:
• Fever/chills
• Redness of face
• Unusual tiredness or weakness
• Dizziness
• Chest tightness
• Nausea/vomiting
• Sweating
Rare side effects are:
• Fast heartbeat
• Wheezing
• Troubled breathing
• Lightheadedness
• Bluish coloring of lips/nailbeds
The majority of side effects are generally mild and may go away during treatment as your body
adjusts to the medicine. However, check with your physician if any of the following side effects
continue or are severe:
• Backache or pains
• Joint pain
• General feeling of discomfort
• Leg cramps
• Muscle pain
• Headache
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Precautions
• Patients who have had an allergic or unusual reaction to immunoglobulin products should
use IVIG with caution.
• Vaccinations should be avoided for at least 14 days prior to and three months after
receiving IVIG.
• IVIG should be used with caution in pregnant or breast-feeding women. It is not known
whether IVIG can cause fetal harm.
Your physician will discuss the risks versus benefits of IVIG therapy in your individual case.
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Laparoscopy
A
laparoscopy is a surgical procedure that allows the physician to see the outside of the
uterus, ovaries and fallopian tubes. The woman is given general anesthesia and her
abdominal cavity is inflated with carbon dioxide to provide a better view of her pelvic
organs. A laparoscope (a small scope with a fiber optic lens) is inserted through a small incision
in the navel. Additional smaller incisions in the pubic hairline may be necessary. If endometriosis
or adhesions are discovered, the physician may elect to actively operate to treat the condition.
A laparoscopy can last from 45 minutes to several hours depending on the findings. The
procedure is performed at a hospital or outpatient surgery center, usually on an outpatient basis.
1
Contact our office on Day 1 (the first day of full flow) of your menstrual cycle to schedule
your surgery. If this occurs on a weekend or holiday, please call the next business day.
Laparoscopies are usually done during the first half of the menstrual cycle, before
ovulation occurs.
2
Please check to see if your insurance requires preauthorization.
3
Do not eat, drink or smoke after midnight the night before surgery.
4
Report to the hospital or surgery center at least two hours before the surgery is scheduled.
5
Wear loose comfortable clothing. Do not wear jewelry, fingernail polish or bring
any valuables.
6
You may be at the hospital or surgery center for three to six hours. You cannot drive for
at least 24 hours after you are discharged. Please arrange in advance for a ride home.
7
For the first 24 hours following the surgery:
•
Do not drink any alcoholic beverages.
•
Do not take any medication not prescribed by your physician.
•
Do not operate any heavy equipment.
•
Do not smoke.
•
Do not sign any important papers or documents.
8
The carbon dioxide used to inflate your abdomen can cause pain in the shoulder area
following surgery. Take Advil, Tylenol or Nuprin for pain relief. DO NOT TAKE ASPIRIN.
9
You may experience moderate vaginal bleeding for two to six days. Refrain from intercourse
until bleeding has stopped.
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10 The stitches used to close the incisions are dissolvable and covered by small adhesive
bandages. Take showers daily and let water splash on the incisions. This keeps them clean
and encourages healing.
11 Call our office immediately if you experience any of the following symptoms:
•
Bleeding as heavy as the heaviest flow during your menstrual period.
•
Severe pain.
•
A temperature of 100° or above.
•
Difficulty urinating.
•
Any heavy discharge from the navel.
After hours or on weekends or holidays, call the answering service and have the on-call
physician paged.
12 Call your coordinator a few days after your surgery to schedule a post operative visit with
your physician.
Diagnostic Laparoscopy
Permission granted for reproduction by the American Society for Reproductive Medicine
www.asrm.org
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Preimplantation Genetic Diagnosis and
Screening (PGD/S)
W
ell before IVF became a reality, people dreamed (and worried) about the possibility
of one day being able to determine genetic features of a person before pregnancy
is established. Today, through the miracle of Preimplantation Genetic Diagnosis and
Screening (PGD/S), this dream is a reality. These approaches combine the technology of assisted
reproduction with the exploding advances in genetics.
To accomplish PGD/S, couples undergo IVF and typically, three days after the egg retrieval,
a single cell is removed from each normally dividing embryo. Using a variety of techniques to
explore the chromosomal (PGS) or genetic (PGD) makeup of the cells, healthy and unhealthy
embryos can be distinguished. Healthy embryos that reach the blastocyst stage of
development are transferred to the woman’s uterus five days after egg retrieval.
PGD/S is used in three different situations:
1
Chromosomal Analysis. As women age, they produce increasingly higher numbers of eggs/
embryos containing abnormal numbers of chromosomes. Abnormal chromosome count is
known as aneuploidy. This problem accounts for a significant portion of IVF failures and
increased miscarriage rates for women in their latter reproductive years. Checking for
aneuploidy allows for the transfer of lower numbers of embryos with less chance for
chromosomal abnormalities, and hence, potentially lower miscarriage rates. Aneuploidy
studies, for example are ideal for couples who want to limit their risk of having a baby
with Down Syndrome or other chromosomal anomalies, without having to terminate an
established pregnancy. Chromosomal analysis can also be used to determine the sex of the
embryo, in order to achieve accurate sex selection. HRC performs sex selection to eliminate
sex-linked genetic disorders, and for social reasons, under strict guidelines. Translocations
are also screened out using this approach.
2
Genetic Traits. A wide array of genetic probes have been developed that detect genes that
cause diseases like cystic fibrosis, Tay-Sachs, sickle cell anemia, and Huntington's disease,
to name a few. Using a process called polymerase chain reaction (PCR), thousands of copies
of DNA from a single cell can be quickly generated and analyzed with DNA probes and/or
using DNA microarrays. Embryos that develop normally to Day 5 and are not affected by
the disease in question are then transferred to the mother.
3
Translocations. A rare condition known as chromosomal translocation occurs when a piece
of one chromosome becomes detached and attaches itself to another chromosome. The
person carrying the translocation is normal, but a large percentage of the eggs or sperm
they produce carry unbalanced amounts of chromosomal material. Resulting embryos
either do not implant, miscarry, or occasionally produce children with conditions like
Down Syndrome. Through a special variation of PGD, only embryos that will produce
healthy children can be selected for transfer.
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HRC is proud to announce an affiliation with Gene Security Network (GSN), a more complete
way of bringing PGD/S into mainstream diagnostics. This is the first commercially available test
to leverage bioinformatics to inform IVF transfer decisions by identifying potential abnormalities
across all 24 chromosomes from a single embryonic cell. Test results are available within 24 hours
and have an accuracy rate exceeding 99% for the cell tested.
This new technology uses genetic information from both the mother and father – obtained via
a simple cheek swab – as well as data from the Human Genome Project, to create an accurate
reconstruction of the genetic makeup of each embryo prior to conception. As the ultimate goal
of any IVF cycle is a healthy pregnancy, technologies that stand to improve IVF success rates,
such as GSN’s All Chromosome Aneuploidy Screening test, hold great promise for couples
facing infertility.
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Cycle Monitoring
P
atients undergoing cycle stimulation at HRC are closely monitored by ultrasounds and
laboratory tests. Blood hormone levels and the size of the ovarian follicles are used
to track responses to medication and to predict when ovulation is likely to occur.
Appointments for blood tests and/or ultrasounds must be scheduled. Blood tests and
ultrasounds are usually performed early in the morning.
You will have a vaginal ultrasound performed during your initial consultation. Ultrasound has
been used extensively in gynecology to provide detailed images of a woman’s reproductive
organs. Its safety has been confirmed by many large studies; unlike an x-ray, ultrasound involves
no radiation. An instrument called a transducer is used. It bounces high frequency sound waves
off internal organs and converts them into pictures displayed on a monitor. This transducer is
shaped like a tampon. It is covered with a condom, lubricated with a sterile gel and inserted into
the vagina. You will be given the option to insert the transducer yourself or to have the physician
insert it. Using this technique, the eggs developing in the ovaries can actually be counted and
measured. In most instances, an ultrasound causes little or no discomfort.
Your principle contacts during a monitored cycle will be your physician and your coordinator.
The physicians review the blood test results and ultrasounds daily and your coordinator will call
with your results and instructions later that same day. It is not necessary to get confirmation
of your instructions from a physician. Please ask to speak with a physician only if you feel it is
absolutely necessary. In less urgent situations, please call the following morning to schedule
a consultation.
Receiving and carefully following your instructions is very important. If you cannot be reached
at home, let the office know where you will be or where a message can be left. If you have not
received a call by 5 pm, call the office and ask to speak to the nursing team.
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Ectopic Pregnancy
A
n ectopic pregnancy is a pregnancy that implants outside of the uterus. It can occur in a
fallopian tube, on an ovary, or in rare instances, inside the pelvic cavity. The pregnancy
cannot develop normally and may rupture, causing bleeding and damage to the tube or
ovary. An ectopic pregnancy can be life threatening if not treated.
An ectopic pregnancy occurs in approximately 1% of pregnancies. Women with a history of
ectopic pregnancy, chlamydia, pelvic inflammatory disease, gonorrhea and/or tubal adhesions
are at higher risk. Diagnosis of an ectopic pregnancy is usually made with ultrasounds and blood
hormone studies. In some instances, the drug methotrexate can be used to treat the condition.
More commonly, a laparoscopy must be performed to surgically remove the pregnancy.
As an infertility patient, you are at a statistically increased risk for an ectopic pregnancy. If you
become pregnant, your blood hormone levels will be monitored, and an ultrasound will be
scheduled early in the pregnancy to verify that implantation has occurred in the uterus.
Ectopic Pregnancy Warning Signs:
• Uterine cramping
• Lower back pain
• Sharp lower abdominal pain, usually on the right or left side
• Light headedness or fainting
• Cold sweats
• Shoulder pain
• Irregular or abnormal menstrual bleeding
• Rectal pressure
Call our office immediately if you experience any of the symptoms listed above. After hours or
on weekends or holidays, call the answering service and have the on-call physician paged.
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IVF Cycle Overview
Timing
An IVF cycle is approximately six weeks, depending on your menstrual cycle. Your treatment will
begin once all necessary lab screening/diagnostic testing has been completed, consents have
been signed, fees have been paid/insurance benefits have been verified, and (if participating
in a Low Cost Two-Cycle or Three-Cycle or the HRC Refund Guarantee Program) qualification
and approval has been met. The treatment cycle is started with your menses. Most often, the
physician may use oral contraceptives for females with irregular or long cycles or to assist
with the timing of events.
Monitoring
An ultrasound is done prior to starting gonadotropins, which are the stimulating medications.
These are injectable medications that stimulate the ovaries to recruit several eggs for laboratory
fertilization and ultimate embryo transfer.
Once the gonadotropins have begun, we will do frequent ultrasounds to monitor the follicle
size and estradiol blood tests to monitor the estrogen level. Typically, the average length of
Gonadotropin injections is 10 days. Gonadotropins stimulate the ovaries to produce multiple
follicles and may cause some abdominal bloating and tenderness. It is important for you and
your partner to keep a flexible and low stress work schedule. Most patients continue to work
throughout the cycle.
Once the ultrasound and estradiol levels confirm mature follicles, the physician will determine
when you are ready to receive the next injection called human chorionic Gonadotropin (hCG),
which completes the maturation process of the eggs and readies them for fertilization.
Egg Retrieval
Your physician will perform your egg retrieval under ultrasound guidance. A special needle
is used to go through the vaginal wall and into each ovary to remove the eggs. You will be
informed of the number of eggs retrieved following the egg retrieval. The egg retrieval is done
under anesthesia, so you will feel no discomfort during the procedure. You will recover for
approximately 30 minutes after the procedure, and you will need someone to drive you home.
You will not be able to work the day of the procedure.
Embryo Transfer
You will be notified the day after the egg retrieval with the fertilization results (the number of
eggs that became an embryo). Transfer of the embryos is usually scheduled three to five days
later. The number of embryos transferred varies with each individual, and your physician will
discuss the recommended number to transfer.
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Pregnancy Test
A pregnancy test will be done by a blood test 12 to 14 days after the embryo transfer. When the
test is positive, you will continue some of the medications for the first trimester of pregnancy.
Support
An IVF procedure can be stressful emotionally, physically and financially. We encourage you to
seek support from family, friends or a counselor that specializes in fertility.
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Gender Selection
G
ender selection has become a popular option for couples desiring to choose the sex
of their children. HRC offers gender selection for both “Family balancing”, and gender
linked genetic diseases. Gender selection is effectively performed with pre-implantation
genetic diagnosis (PGD) or MicroSort. Currently the MicroSort process is only available to new
patients for gender linked genetic diseases while the FDA finalizes that data obtained from a
ten-plus year clinical trial.
HRC Fertility has many years of experience helping couples with family balancing through IVF
with PGD. PGD can be performed with an in vitro fertilization (IVF) cycle to determine the sex
of the embryos and enables our physicians to determine which embryos will most likely result
in a healthy, ongoing pregnancy. PGD can determine the gender of the embryo with a 99.9%
accuracy for those looking to balance their family.
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T
he fertility drugs used for stimulation, whether used in IVF or non-IVF settings, usually
cause the ovaries to enlarge. In some cases, the ovaries are so sensitive to these
medications they enlarge four or five times the normal size, producing very high levels
of estradiol (the main ovarian estrogen). Sometimes (not often), additional substances may be
produced in excess and cause the fluid to leak from the blood vessels and capillaries. The
fluid may collect in the abdomen which causes swelling and discomfort. This is called ovarian
hyperstimulation syndrome (OHSS). Signs and symptoms can occur within seven days after egg
retrieval. The physicians at HRC strive to prevent hyperstimulation by closely monitoring our
patients with serial ultrasounds and laboratory testing(s).
Notify a coordinator if any of the following symptoms occur:
1
Excessive bloating. A slight amount of bloating is normal.
2
Lower abdominal pain. Excessive bloating, unusual abdominal tenderness or pain. (Some
mild bloating or cramping is normal.) Sometimes abdominal pain is accompanied by nausea,
vomiting and/or diarrhea. Please call the office and report these signs and symptoms to the
coordinator or the physician on-call.
3
Weight gain. A sudden, rapid gain of two or more pounds on any two consecutive days.
4
Urine output. Noticeable increase or decrease in urination. Please report this immediately
to your coordinator.
5
Nausea. Report nausea and inability to take routine meals or fluids.
6
Shortness of breath. Call the office immediately.
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Administration of Injections
D
uring the preoperative appointment, the clinical team gives individualized instruction
about taking Lupron,® and gonadotropins Bravelle,® Gonal-F,® Follistim,® Menopur® or
Repronex® to stimulate follicular development.
Each couple/individual is responsible for the administration of their medications that are
necessary for ovarian stimulation. The majority of couples/individuals undergoing IVF learn how
to give their own injections (the partner gives the injection to you or you administer the injection
to yourself). Occasionally, a friend or relative can be taught to give the medication.
We understand that some couples or individuals may not be able to give their own injections
for various reasons. The patient is responsible for arranging injections as needed throughout
the week, weekends and holidays, including the hCG injection. The hCG injection is given at a
specific time, approximately 36 hours prior to your procedure.
Some options available to administer injections include: utilizing a visiting nurse service, a 24hour medical care facility or a local emergency room. Please ask your nurse for a written order
if you plan to use an outside agency. Injections may be given by the nurses at HRC during
business hours. A nominal fee will be charged for this service.
One of the possible risks of any Gonadotropin is ovarian enlargement which, when excessive,
is called ovarian hyperstimulation syndrome. When ovaries get very large in association with
excessive weight gain due to water retention, hyperstimulation can become a more serious
problem. Some ovarian enlargement is expected with Gonadotropin treatment. Notify your
coordinator, if any of the following symptoms occur:
1
Excessive bloating. A slight amount of bloating is normal.
2
Lower abdominal pain. Excessive bloating, unusual abdominal tenderness or pain. (Some
mild bloating or cramping is normal.) Sometimes abdominal pain is accompanied by nausea,
vomiting and/or diarrhea. Please call the office and report these signs and symptoms to the
coordinator or the physician on-call.
3
Weight gain. A sudden, rapid gain of two or more pounds on any two consecutive days.
4
Urine output. Noticeable increase or decrease in urination. Please report this immediately
to your nurse coordinator.
5
Nausea. Report nausea and inability to take routine meals or fluids.
6
Shortness of breath. Call the office immediately.
After hours an HRC physician is on-call for emergencies from 5 pm to 9 am, seven days a
week. If you need assistance, call our office and leave a number where you can be reached with
the answering service and the physician will return your call.
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A Note about Ovarian Cancer
Ovarian cancer is in fact one of the least common forms of cancer that affect women overall.
Unfortunately, this rare disease may be more frequent in women with infertility and/or women
who have never borne children. Several retrospective epidemiological studies have reported a
possible association with ovarian cancer and fertility drugs. However, it is not known whether
infertile women who have taken these medications are truly at a greater risk than infertile
women who have not utilized these therapeutic interventions. Indeed, it may be a result of the
risk a woman with infertility poses, not necessarily the use of these fertility enhancing agents.
Nonetheless, until further studies are published, a possible linkage may exist. Please inform your
physician of any known family history of ovarian cancer or any past history of ovarian tumors.
Risks of Fertility Medications
While life-threatening risks are rare, more common risks include multiple births with substantial
problems for both mother and children, cysts of the ovary which usually heal, mood changes
and skin and hair growth changes (usually reversible). Like pregnancy, fertility medication
creates hormone changes that may aggravate underlying conditions such as migraines, immune
disorders, joint pains, etc. Please make sure you have given your physician a complete medical
history, as well as a list of all medications you are currently taking.
Monitoring Tests
Blood Work
Measurement of estradiol (E2), secreted by the follicles in the ovary, provides an excellent
estimation of ovarian function and adequacy of the follicle. Therefore, an estradiol blood test is
obtained frequently throughout the stimulation cycle to monitor the response of the ovaries to
gonadotropins. Testing usually begins on about Day 7 of your cycle.
Ultrasound
Ultrasound is particularly valuable in tracking follicular growth when used in conjunction with
estradiol testing. No preparation is needed before an ultrasound, and the examination takes
between five and 20 minutes to perform. A probe is easily introduced into the vagina with little
or no discomfort. Sound waves emitted from the probe travel through the body to the ovary and
allow visualization and measurement of the follicles by the ultrasonographer.
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Cycle Modification
1
About 15% of patients who begin taking medication are canceled prior to the procedure.
Some of the reasons for cycle cancellation are follicles not developing properly, inadequate
blood hormone levels and less than three follicles maturing simultaneously. If a cycle is
cancelled, medication may be modified in subsequent cycles in an attempt to improve your
response. Such issues are discussed by the physician during the post treatment visit.
2
Occasionally, the estradiol (E2) level is too high and the risk of hyperstimulation may be
aggravated if a pregnancy does occur. In such cases, we recommend that all the embryos
be frozen, if possible, and transferred a month or two later. If it is necessary to freeze all
embryos due to the high risk of hyperstimulation, we would also recommend avoiding
intercourse as well.
A Note to Satellite Patients
HRC offers ultrasound and blood testing at various sites throughout Los Angeles and Orange
County to reduce long commutes. Please note that satellite patients are responsible for calling
the satellite facility to schedule ultrasound tests and blood tests. Also, it is critical to call your
coordinator at your main office and notify them when your cycle starts, and prior to arriving for
any blood work you may need drawn.
A guide for mixing and the administration of injectable medication follows. Please contact your
coordinator if you have further medication questions.
Beginning of Menstrual Flow
If menstrual flow begins between 9 am and 5 pm (on any day), you should call your coordinator
at the office and let her know that your cycle has started. Then, you will schedule appointments
for blood tests and ultrasounds. If menses begins after 5 pm, you should call your coordinator
the next day. If your menses starts on a Friday night, Saturday or Sunday, please leave a
message with the answering service and a coordinator will call you back. Sometimes a blood
test is required on Day 3 of the cycle.
We suggest that you contact your pharmacy to fill your prescriptions one to two weeks before
starting your cycle to be sure that you have all medications on hand. Many pharmacies are
not open weekends and holidays. Please make sure you have enough medication to cover
weekends and holidays.
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Directions for Preparing and Administering
Subcutaneous and Intramuscular Injections©
Subcutaneous Needle
Ask your health care provider (physician,
coordinator or pharmacist) about disposal
when the container is full.
Intramuscular Needle
• Your injection material must be sterile and
cannot be reused again.
• Never leave needles lying around where
others can pick them up.
Getting Ready
Supplies needed:
• Vials of medication
• Vials of diluent such as
Sodium Chloride Injection (USP),
bacteriostatic water or bacteriostatic saline
(if needed)
• Syringes and needles (Use the proper type
and size recommended by your physician,
coordinator or pharmacist)
• Gauze and adhesive bandages
• Cotton balls and alcohol; or alcohol swabs
• Sharps container
• Antibacterial soap
Preparation of the Area
• Choose a flat surface such as a kitchen or
bathroom counter.
• Clean the flat surface with alcohol and
let air-dry.
• Never reuse a needle. Not only does a
needle need to be sterile each time you use
it, but today’s needles are thinner and more
delicate for greater comfort, so reusing the
needle can damage the tip and cause injury
and greater pain.
Pain Management
Discomfort can be minimized in several
different ways.
• Rotating injection sites can prevent areas
from becoming too sore. Ask your
coordinator about rotation.
• Warm compresses can sooth soreness
of injection.
• Applying ice 30 to 60 seconds before and
after an injection can numb the nerves.
• Inject at room temperature.
• Remove all air bubbles from syringe
before injecting.
• Wait until alcohol on skin has evaporated.
• Wash your hands with antibacterial soap.
• Make sure your muscles are relaxed.
• Set up supplies on a flat surface.
• Try not to change the direction of the
needle while under the skin.
Clean Up
• Use a quick dart-like motion.
• Discard used needles, syringes and vials into
your sharps container.
• Your sharps container is classified as medical
waste and must be disposed of properly.
These are general procedures. It does not
replace instruction given to you by your
physician or other health care provider.
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Cetrotide®
C
etrotide® is a medication used to
provide immediate suppression of the
LH surge, which is an important part
of the ovarian stimulation cycle. It is available
in two doses (follow your coordinator’s
instructions and see below) and is injected
subcutaneously. Your physician has chosen
the regimen that best meets your individual
needs. Since no luteal phase pretreatment is
required, suppression can be completed in
days. This allows the egg to reach the level
of development needed and results in fewer
injections for patients.
syringe and remove the cover over the
needle. Do not touch the needle. If you
do touch the needle, use a new one.
4
We will advise you when to start Cetrotide,
which is usually after you have been taking
the stimulating medication injections for a
few days.
We will advise you when to stop Cetrotide
when you are ready for ovulation to
be triggered.
Mix the medication using the following
method:
a
Wipe the top of the vial with an
alcohol swab. Do not touch the top
after wiping with anything other than
the needle.
b
Push the needle through the middle of
the rubber stopper on the vial. Inject
the bacterisostatic water into the vial
by slowly pushing on the plunger.
c
Push the plunger all the way in.
d
Leave the syringe in the vial and
gently shake the vial until the solution
is clear and without residue. Avoid
forming bubbles.
e
Draw all of the solution in the vial into
the syringe. If liquid is left in the vial,
invert the vial, pull back the needle
until the opening of the needle is
just inside the stopper. Look through
the side of the vial to control the
movement of the needle and the
liquid. It is very important to make
sure you withdraw all the solution
in the vial.
f
Withdraw the needle from the vial.
Cetrotide 3mg
Please note: Cetrotide 3mg is a one-time
injection that is designed to slowly release
over several days. At the end of the time
allotted, your physician’s office will decide if
you need additional Cetrotide. Additional
Cetrotide is injected in daily doses of .25mg.
Opening Medication
1
Use a new sterile syringe and needle
provided in the package each time
you inject.
2
Carefully flip the lid of the vial off.
Wipe with an alcohol swab.
3
Take the injection needle with the yellow
mark and remove the wrapping. Take the
pre-filled syringe and remove its cover.
Place the unwrapped needle on the
5
Take off the needle from the syringe and
lay it down. Remove the wrapping from
the injection needle with the gray mark.
Put this needle in the syringe and remove
its cover.
HRC HOPE 08/03/11
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6
7
Tap the syringe with the needle pointed
up to cause any air bubbles to rise.
Slightly press the plunger until a drop of
liquid appears at the top of the needle.
You are now ready to administer
the injection.
Injecting the Medication
For Subcutaneous Injection:
Choose an injection site (abdomen, thigh,
or upper arm as directed by your physician,
coordinator or pharmacist) and swab the area
with alcohol. Allow to air dry.
1
Pinch a fold of skin with one hand and
insert the syringe with the other hand.
Use a quick dart-like motion. Depress
the plunger.
Cetrotide .25mg
Please Note: Cetrotide .25mg is a daily
injection that your physician or health care
provider may prescribe after Cetrotide 3mg.
Choose a different injection site each day
to minimize discomfort.
Opening Medication
1
Use a new sterile syringe and needle each
time you inject.
Carefully flip the lid of the vial off. Wipe
with an alcohol swab.
3
Take the injection needle with the yellow
mark and remove the wrapping. Take the
pre-filled syringe and remove its cover.
Place the unwrapped needle on the
syringe and remove the cover over the
needle. Do not touch the needle. If you
do touch the needle, use a new one.
4 Mix the medication using the following
method:
2
Release the skin.
3
Pull the needle out and discard syringe
and needle in your sharps container. If any
bleeding occurs, apply gentle pressure.
4
Choose a different site each time you
inject (or as directed by your health care
provider). Good sites for subcutaneous
injections are the upper arm, the outer
thigh, the hips and abdomen.
Special Storage Instructions
Store Cetrotide 3mg in a cool dry place
protected from excess moisture and heat. The
recommended storage temperature is 25°C
(77°F) but it can be exposed to temperatures
ranging from 15 - 30°C (59 - 86°F).
a
the needle.
b
Push the needle through the middle of
the rubber stopper on the vial. Inject
the bacterisostatic water into the vial
by slowly pushing on the plunger.
c
d
Leave the syringe in the vial and gently
shake the vial until the solution is clear
and without residue.
HRC HOPE 08/03/11
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e
f
5
Draw all of the solution in the vial into
the syringe. If liquid is left in the vial,
invert the vial, pull back the needle
until the opening of the needle is
just inside the stopper. Look through
the side of the vial to control the
movement of the needle and the
liquid. It is very important to make
sure you withdraw all the solution
in the vial.
Withdraw the needle from the vial.
Take off the needle from the syringe and
lay it down. Remove the wrapping from
the injection needle with the gray mark.
Put this needle in the syringe and
remove its cover.
6
7
the injection.
Choose an injection site (abdomen, thigh, or
upper arm) as directed by your coordinator
and swab the area with alcohol. Allow to
air-dry.
1. Pinch a fold of skin with one
hand and insert the syringe
with the other hand. Use
a quick dart-like motion.
Depress the plunger.
2. Release the skin.
3. Pull the needle out and discard syringe
4. Choose a different site each time you
provider). Good sites for subcutaneous
injections are the upper arm, the outer
thigh, the hips and abdomen.
Special Storage Instructions
Cetrotide .25mg must be refrigerated at a
temperature of 2 - 8°C (36 - 46°F). Keep the
packaged tray in the outer carton. This will
protect it from light.
To view an instructional video, go to:
http://www.fertilitylifelines.com/serono/products/cetrotide/instructions.jsp
HRC HOPE 08/03/11
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Ganirelix Acetate® (Antagon)
G
anirelix Acetate® is a medication used
to provide immediate suppression of
the LH surge, which is an important
part of the ovarian stimulation cycle. It is
available in prefilled syringes and is injected
subcutaneously. Since no luteal phase pretreatment is required and Ganirelix Acetate
works quickly, suppression can be completed
in days. This allows the eggs to reach the level
of development needed and results in fewer
injections for patients.
We will advise you when to start Ganirelix
Acetate, which is usually after you have been
taking the stimulating medication injections
for a few days.
We will advise you when to stop Ganirelix
Acetate when you are ready for ovulation to
be triggered.
Opening Medication
1
Use a new disposable, pre-filled, sterile
syringe and needle each time you inject.
2
Carefully unwrap the Ganirelix Acetate
package without depressing the plunger.
Hold the syringe with one hand and point
the needle up. With the other hand,
remove the needle cover.
3
4
the injection.
Choose an injection site (abdomen, thigh, or
upper arm) as directed by your coordinator
and swab the area with alcohol. Allow to
air-dry.
1
Pinch a fold of skin with one
hand and insert the syringe
with the other hand. Use
a quick dart-like motion.
Depress the plunger.
2
Release the skin.
3
4
inject (or as directed by your coordinator).
Good sites for subcutaneous injections are
the upper arm, the outer thigh, the hips
and abdomen.
http://www.follistim.com/Consumer/GanirelixPregnyl/GanirelixAcetateInjection/
AboutGanirelixAcetateInjection/index.asp
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Lupron®
L
upron® is a medication to improve
follicular development and control
ovulation. If ovulation were to occur
prematurely, the cycle would need to be
cancelled. With Lupron, the likelihood of
premature ovulation and cycle cancellation
is reduced.
With the long protocol your period may be
delayed; notify the coordinator if your period
is delayed more than one week. Also,
sometimes the physician may request that
you take a smaller than standard dose twice
daily, which is the “microdose” regimen.
We will advise you when to start Lupron.
The following is the “long” or
“luteal” protocol.
The first dose of Lupron is started a week after
ovulation (often Day 21 of the cycle) in the
preceding menstrual cycle. Contraception
must be used during this cycle. You may be
given birth control pills prior to your Day 21.
To learn more about Lupron and view an instructional video, go to:
http://www.education.designrx.net/PatientPortal
and search under medications for Lupron
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Luteal Lupron®
• 2 week kit
• Multi-dose vial
• 14 syringes included in the kit
• No mixing required by patient
• Store in the refrigerator
• Once open, may be used
for six months
• Subcutaneous injection
(into the fatty tissue)
1
Wash hands with soap and water and use
a clean surface for preparing the injection.
2
Remove Tuberculin syringe or Insulin
syringe — either type may be used,
(27 gauge 1/2” needle), from the wrapper.
3
For first-time use, remove the metal cap
from the vial.
4
Clean rubber stopper and metal ring on
vial with alcohol prior to each use.
5
Remove plastic cap from syringe. Pull
the plunger back until the tip is at the
proper mark.
6
Place the vial on a clean, flat surface, and
push the needle through the center of the
rubber stopper on the vial. Push the
plunger all the way in.
7
Keep the needle in the vial. Lift the vial
and turn it upside down. Check to see that
the needle tip is in the liquid.
8
With the needle tip in the liquid, slowly
pull back the plunger until the syringe fills
to the proper mark.
9
Remove the syringe from the vial being
careful not to touch the needle.
10 Holding the syringe at eye level with the
needle pointing up, tap the barrel of the
syringe with finger.
11 Depress plunger to clear air bubbles from
the needle and the barrel.
12 Place the cap back on the needle while
preparing the injection site.
13 Recommended areas for injection include
the upper 2/3 of the outer thigh, lower
abdomen (2” from the navel), or
triceps area (back of the upper arm).
14 Remember to alternate sites daily.
15 Clean selected site with alcohol and allow
to air-dry.
16 After removing the cap from the needle,
grasp the site (pinch an inch) between
thumb and forefinger and insert the entire
needle into the subcutaneous skin at a
90° angle.
17 Release the skin and inject medication.
18 Withdraw the needle at the same angle it
was inserted.
19 Gently rub the site with a dry cotton ball
or gauze in a circular manner to facilitate
absorption. Apply Band Aid, if desired.
20 Without recapping the needle, dispose of
the syringe in a sharps container. Use the
disposable syringe only once.
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Microdose Lupron®
• Prepared only by pharmacies
specializing in fertility
medications
• Multi-dose vial
• No mixing required by patient
• Syringes are ordered separately
• Store in the refrigerator
• May be used up to six months
• Subcutaneous injection
(into the fatty tissue)
• Dose - 0.2 cc (20 units) twice
daily, usually between
7 am and 9 am and
between 7 pm and 9 pm
1
Wash hands with soap and water and use
a clean surface for preparing the injection.
2
Remove Tuberculin syringe or Insulin
syringe — either type may be used,
(27 gauge 1/2” needle), from the wrapper.
3
For first-time use, remove the metal cap
from the vial.
4
Clean rubber stopper and metal ring on
vial with alcohol prior to each use.
5
Remove plastic cap from syringe. Pull
the plunger back until the tip is at the
proper mark.
6
Place the vial on a clean, flat surface, and
push the needle through the center of the
rubber stopper on the vial. Push the
plunger all the way in.
7
Keep the needle in the vial. Lift the vial
and turn it upside down. Check to see that
the needle tip is in the liquid.
8
With the needle tip in the liquid, slowly
pull back the plunger until the syringe fills
to the proper mark.
9
Remove the syringe from the vial being
careful not to touch the needle.
10 Holding the syringe at eye level with the
needle pointing up, tap the barrel of the
syringe with finger.
11 Depress plunger to clear air bubbles from
the needle and the barrel.
12 Place the cap back on the needle while
preparing the injection site.
13 Recommended areas for injection include
the upper 2/3 of the outer thigh, lower
abdomen (2” from the navel), or
triceps area (back of the upper arm).
14 Remember to alternate sites daily.
15 Clean selected site with alcohol and allow
to air-dry.
16 After removing the cap from the needle,
grasp the site (pinch an inch) between
thumb and forefinger and insert the entire
needle into the subcutaneous skin at a
90° angle.
17 Release the skin and inject medication.
18 Withdraw the needle at the same angle it
was inserted.
19 Gently rub the site with a dry cotton ball
or gauze in a circular manner to facilitate
absorption. Apply Band Aid, if desired.
20 Without recapping the needle, dispose of
the syringe in a sharps container. Use the
disposable syringe only once.
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Gonadotropin Medications
Bravelle,® Follistim,® Gonal-F,® Menopur® and Repronex®
B
ravelle,® Follistim,® Gonal-F,® Menopur®
and Repronex® are the brand names
of injectable medications known as
gonadotropins. These medications are used
to stimulate the ovaries to produce multiple
follicles. They are very similar in their efficacy
and often can be used interchangeably.
The first dose is usually given in the evening.
Individual dosages are determined by the
physician before the cycle starts. Blood
and ultrasound testing (after a few days of
gonadotropins), and each evening’s dosage
is determined by the physician based upon
that morning’s tests. Your coordinator may
call in the afternoon, if any changes are made
in that day’s dosage. At times, she may give
dosages for several consecutive days in one
phone call.
An additional risk is multiple births. Because
these medications cause many follicles to
develop, numerous eggs may be fertilized,
creating more embryos than are required for
transfer. When many embryos are transferred,
multiple births may result. Multiple births
may also occur with insemination or timed
intercourse when fertility drugs are used.
If for some reason you have questions or have
not heard from your coordinator by 4:30 pm,
please check your answering machine or voice
mail. If there is no message, call the office
immediately to obtain your instructions. The
office closes at 5 pm. Calls received after that
will be returned the following day.
Side effects of gonadotropins are generally
minor but may include:
• Local discomfort at the injections site
• Mild fatigue
• Slight mood swings
• Headaches
• Ovarian hypersensitivity
HRC HOPE 08/03/11
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Bravelle,® Menopur® or Repronex®
Reconstitution and Subcutaneous Administration
Your doctor has prescribed Bravelle® and /or Menopur® – or – Bravelle®
and /or Repronex® for subcutaneous injection.
This instruction sheet will help you prepare and inject your medication at
home. If you have any questions, don’t hesitate to call your doctor or nurse.
Before You Start
Wash your hands with antibacterial soap and use alcohol to clean the surface
where you will be working.
Have These Supplies Ready:
- A vial (or vials) of Bravelle® and/or Menopur® – or – Bravelle® and/or
Repronex,®, and a vial of Sodium Chloride 0.9% (sterile diluent) that is
conveniently packaged with your medicine.
- A sterile syringe and needle.
- Q•Cap™ (for exclusive use with Ferring fertility products) that is conveniently
packaged with your medicine.
- Alcohol pads, rubbing alcohol, gauze and a needle disposal container.
Preparing Your Medicine
and Filling the Syringe
Remember: Only the Sodium
Chloride (sterile diluent) provided
may be used to reconstitute
Bravelle® and/or Menopur® – or –
Bravelle® and/or Repronex.®
• Remove the syringe from the
wrapper (as directed by your
doctor or nurse). If there is a
capped needle on the syringe,
remove the needle by twisting
it counterclockwise. Open one
Q•Cap™ by peeling back the label
and set the blister pouch with the
Q•Cap™ aside. Do not take the
Q•Cap™ out of the blister pouch
at this time. Do not touch the
ends of the Q•Cap.™
• Remove the plastic caps from
the tops of the vials of the sterile
diluent and Bravelle® and/or
Menopur® – or – Bravelle®
and/or Repronex.®
• Wipe the tops of the vials with
alcohol. Don’t touch the tops of the
vials once you have wiped them.
Spike End
• Withdraw the syringe plunger to
the volume of diluent that is to
be removed from the vial. This
is normally 1mL, but be sure to
follow your doctor’s instructions on
the amount of diluent to use. Hold
the syringe and place the spike
end of the Q•Cap™ over the top
of the sterile diluent vial. Push the
tip of the Q•Cap™ into the rubber
stopper of the vial until you feel a
slight resistance. Be careful not to
push down on the syringe plunger
by mistake during this step.
Luer End
Connector
• Push the syringe plunger down
to transfer the air from the syringe
into the vial. Keeping the syringe
and Q•Cap™ together, turn the vial
upside down and pull back on the
syringe plunger to withdraw the
desired amount of sterile diluent
from the vial, as directed by
our doctor.
• Place the vial on the counter.
Remove the Q•Cap™ and syringe
from the vial by pulling up on
the syringe barrel. Discard the
diluent vial.
• Place the sterile diluent vial on the
counter. Remove the Q•Cap™ from
the blister pouch by grasping its side.
Carefully twist the syringe onto the
Luer end (connector) of the Q•Cap™
until you feel a slight resistance.
Do not touch the spike end of
the Q•Cap.™
HRC HOPE 08/03/11
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• Hold the Bravelle®/Menopur®/
Repronex® vial in one hand. Grasp
the sides of the syringe with your
other hand and place the tip of the
Q•Cap™ over the top of the vial.
Push the tip of the Q•Cap™ into t
he rubber stopper of the vial until
you feel a slight resistance. Be
careful not to push down on the
syringe plunger by mistake during
these step.
• Slowly inject the sterile diluent
into the vial containing Bravelle®/
Menopur®/ Repronex® powder.
Gently swirl until the powder is
completely dissolved. Do not
shake the vial because this will
create bubbles.
• As soon as the powder has
completely dissolved, turn the vial
upside down and withdraw all of
the Bravelle®/Menopur®/Repronex®
into the syringe.
Note for patients who need
multiple vials: The Bravelle®/
Menopur®/Repronex® solution may
be used to dissolve up to five
additional vials, for a total of six
vials in 1mL. After reconstituting
the first vial of Bravelle®/Menopur®/
Repronex® with sterile diluent, use
the solution already in the Q•Cap™
syringe to reconstitute the additional
vials of Bravelle®/Menopur®/
Repronex®. When reconstituting
additional vials, follow the same
instructions used to reconstitute the
first vial of Bravelle®/Menopur®/
Repronex®. When you have finished
reconstituting all the vials for this
injection, proceed to the next section.
Removing the Q•Cap™
and Adding the Needle
• When you have finished reconstituting the last vial necessary for
your injection and have withdrawn
all the medication into the syringe,
twist the syringe counterclockwise
while holding the Q•Cap™ steady
to remove the syringe from the
Q•Cap.™ Discard the Q•Cap™ with
the attached medication vial.
• You are now ready to attach the
injection needle to the syringe of
your injection. Please follow your
doctor’s instructions on which
needle to use and where to make
your injection.
• While holding the syringe
pointing upward, twist the small
(subcutaneous) needle clockwise
onto the syringe.
• Hold the syringe straight up. Draw
back slightly on the plunger and
tap the syringe so that any air
bubbles rise to the top. Slowly
press the plunger until all the air
is out of the syringe and a small
drop of solution forms at the tip
of the needle.
• Tap the syringe to remove the drop
of solution at the tip of the needle.
• Carefully recap the needle to keep
it sterile. The solution is now ready
for injection.
If an uncapped needle EVER comes
into contact with anything other than
Bravelle®/Menopur®/Repronex® or
sterile diluent, do not inject yourself
with it. Immediately remove the
needle and replace it with a new
sterile needle.
Injecting your Medicine
• Bravelle®/Menopur®/Repronex®
should be injected into skin on your
abdomen a few inches below your
navel – left or right. Each day use
the alternate side of your abdomen
to help prevent soreness.
• Carefully clean the injection site
area with an alcohol pad and allow
the site to air-dry.
• Remove the needle cap from
the syringe.
• Hold the syringe in one hand.
Use your other hand to gently
grasp the skin in the injection site
area between your thumb and
index finger.
• Hold the syringe perpendicular (at
a right angle) to the skin like a dart
and quickly insert the needle all the
way into the skin.
• Depress the plunger of the syringe
with a steady motion until all the
fluid is injected beneath the skin.
• Release the skin and pull the
needle straight out.
Disposing of the Syringe
and Needles
• Recap the needle and discard
the syringe and the needle into a
needle disposal container with a lid.
• Discard any opened vials of
diluent or opened vials of
medication. After you finish
your course of treatment,
ask your healthcare
provider how to properly
dispose of the needle
disposal container.
After the Injection
• If any bleeding should occur, simply
place a small piece of gauze over
the injection site and apply gentle
pressure to stop the bleeding.
• If the injection site becomes sore,
applying ice for brief intervals may
help relieve any discomfort.
http://www.ferringfertility.com/medications/trainingguide.asp
HRC HOPE 08/03/11
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Follistim Pen™ and Follistim® AQ Cartridge
Instructions
Subcutaneous (Sub Q) Injection
Storage
• The Follistim® AQ Cartridge comes refrigerated from the pharmacy and may be stored
refrigerated at (36º- 46ºF) for three years or until expiration date.
• Once the cartridge is at room temperature (77ºF), it is good for three months or
until expiration.
• Once the rubber stopper of the cartridge is pierced by a needle, the product can be stored
for a maximum of 28 days, either refrigerated or at room temperature.
• Due to weather conditions, in Southern California, it is recommended to store the drug
refrigerated until it is needed.
• Do not use after the expiration date.
• Do not freeze the cartridge.
• Protect the cartridge from light.
• Injecting cold medication is likely to cause discomfort. Bring medication to room temperature,
which takes approximately 20 minutes.
Follistim Pen™ Injection
• Ready:
– Put Follistim® AQ Cartridge into Cartridge Holder and attach Pen Body.
– Make sure blue triangle is lined up with yellow rectangle.
– Swab skin area with alcohol and let dry for five seconds.
• Set:
– Set dosage amount at window.
– Attach needle.
– Remove both shields on needle. Look for prime (drop of medication).
• Inject:
– Inject.
– Remove needle from skin after a count of five seconds. This insures a full delivery
of the dose.
– Check the window to see that it reads “0.” This tells you that the pen delivered your dose.
If it says another number, i.e. 150 IU, remove the cartridge and insert new cartridge to
complete your dose.
HRC HOPE 08/03/11
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Additional Points
• Attach the needle (only use the Micro-Fine™ Pen Needle) just before the injection.
• Use a new needle for every injection.
• ALWAYS dial the pen towards you. If you pass your desired dose, don’t worry. Continue to dial
towards you (all the way past 450 IU) until you feel the mechanism release. With the palm of
your hand, push the dosage knob back in. Begin dialing again to your desired dose.
– The pen self-primes before every injection. A drop of medication will be at the tip of the
needle (you do not pay for the extra medication that is supplied).
• Look at page 9 of your Follistim Pen Instructions for Use Booklet for more information.
• While dialing your dose you will hear three clicks of the pen for every 25 IUs passed.
• Your Follistim Starter Kits and Pens are provided to you by HRC. If you need one due to
an emergency, call the pharmacy where you received your medication.
• Use a sharps container to dispose of used needles.
HRC HOPE 08/03/11
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Instructions
Using the Follistim Pen™
Follow these steps:
• Before you use the Follistim Pen™ for the
first time
• When you replace the cartridge
Note: Always wash your hands thoroughly
with antibacterial soap and water before you
use the Follistim Pen™ or when you replace
the cartridge.
1 While holding the Pen
Body firmly with one hand,
pull off the Protective Cap
with your other hand. Put
the cap aside on a clean,
dry surface.
2 Unscrew the entire Pen Body
from the Cartridge Holder. Place
the Cartridge Holder and the
Pen Body aside on a clean,
dry surface.
Loading the Follistim Pen™
3 Take a Follistim® AQ Cartridge out of its package.
Do not use the Follistim® AQ Cartridge if the medicine
contains particles or it is not clear. Make sure the
medicine is at room temperature before using. Clean
the Rubber Stopper on the cartridge with an alcohol
pad. Pick up the Cartridge Holder and place the
cartridge into the Cartridge Holder. Insert the Metal
Rimmed Cap end first.
4 Pick up the Pen Body and lower it into the Cartridge
Holder. The black rod must press against the Rubber
Piston on the cartridge. Screw the Pen Body fully
onto the Cartridge Holder. Make sure there is no gap
between the Pen Body and the Cartridge Holder. The
arrow s on the Cartridge Holder should point to the
middle of the yellow alignment mark n on the blue
Pen Body.
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Instructions
Attaching the BD Micro-Fine™ Pen Needle
5 You must use a new BD Micro-
Fine™ Pen Needle with each
injection. Never reuse a needle.
Attach a BD Micro-Fine™ Pen
Needle after you make sure there
is a Follistim® AQ Cartridge in the
Cartridge Holder. Clean the open
end of the Cartridge Holder with
an alcohol pad.
6 Pick up your BD Micro-Fine™ Pen
Needle that is in an Outer Needle
Shield. Peel off the Protective
Paper Seal. Do not touch the
needle or place an open needle
on any surface.
7 Hold the Outer Needle Shield
firmly in one hand while holding the
Cartridge Holder firmly in the other
hand. 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.
Preparing the Injection Site
8 The best place for injection is in the abdomen, which is the stomach area
below the belly button (navel) or in the upper leg. Your healthcare provider
can show you other places where you can inject Follistim® AQ Cartridge.
Change your injection site a little bit with each injection to lower your
chances for skin reactions.
9 Use a swab moistened with alcohol
to clean the skin area where the
needle will enter to remove any
surface bacteria. Clean about two
inches around the injection site
where the needle will be inserted.
Let the alcohol dry on your skin for
at least one minute before injecting
the medicine.
http://www.follistim.com/Consumer/FollistimPen/index.asp
HRC HOPE 08/03/11
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Reconstituting Gonal-F® RFF 75 IU Vial
Gonal-F®
RFF 75
IU Vial
27G 1/2”
Injection
18G 11/2”
Mixing
Needle
4 Remove the safety seal cover of
the 18G 11/2” needle Push the
needle on the prefilled syringe until
it is tightened. Holding the hub,
or base, of the needle, secure the
needle on the tip of the prefilled
syringe and remove the needle cap.
1 Flip the protective plastic cap off
of the Gonal-F® RFF vial.
8 Gently pull the
plunger back to
allow a small air
space. Recap the
needle. Twist
and pull off
needle from the
syringe and
discard in your
sharps container.
9 Remove the
safety seal cover
of the 27G 1/2”
needle for
injection. Push
the needle on
the prefilled
syringe until it
is tightened.
Holding the hub,
or base, of the needle, secure the
needle on the tip of the prefilled
syringe and remove the needle cap.
5 With the vial of the Gonal-F® RFF
powder on a flat surface, insert the
needle of the prefilled syringe
straight down through the marked
center circle of the rubber stopper.
Slowly inject the water into the vial.
DO NOT shake.
2 Wipe the top of the vial with an
alcohol swab.
3 Hold the barrel of the prefilled
syringe of Sterile Water in one hand.
Firmly hold the plastic cap between
the thumb and forefinger of the
other hand and with a downward
motion, gently snap and pull off the
cap. If the gray cap remains, simply
remove it.
RFF: Revised Formulation Female
10 With the syringe pointing upward,
gently tap on the syringe and slowly
push the plunger until
all air bubbles are gone and a drop
of liquid appears on the tip of
the needle.
6 Invert the vial and pull back the
18G 11/2”needle as far as needed
and withdraw the entire contents of
the vial. Remove the syringe from
the vial.
7 If your dose requires more than
one vial of Gonal-F® RFF 75 IU,
use the mixture in the syringe to
reconstitute the next vial of Gonal-F®
RFF 75 IU powder. Use the same
18G 11/2” needle and syringe to
reconstitute additional vials.
11 Recap the needle. The administration syringe is now filled with the
prescribed dose of Gonal-F® RFF and
is ready for administration.
Use reconstituted Gonal-F® RFF 75
IU vial immediately.
http://www.fertilitylifelines.com/serono/index.jsp
HRC HOPE 08/03/11
51
Reconstituting Gonal-F® Multi-dose 450 IU Vial
Gonal-F® Multi-Dose
custom dosing injection
syringe (IU FSH)
Prefilled syringe of
Bacteriostatic Water
for Injection, USP
(0.9% benzyl alcohol)
1 mL
Gonal-F®
Multi-Dose
450 IU Vial
1 Flip the protective plastic cap off of
the Gonal-F Multi-Dose vial.
®
8 With the vial
of reconstituted
Gonal-F® on
a flat surface,
insert the needle
straight down
through the
marked center
circle of the
rubber stopper.
4 With the vial of Gonal-F® powder
on a flat surface, insert the needle of
the prefilled syringe straight down
through the marked center circle of
the rubber stopper. Slowly inject the
water into the vial. DO NOT shake.
9 Without
removing the
needle from
the vial, turn it
upside down so
that the needle
points upward.
5 After all of the water has been
injected into the vial, remove your
finger from the plunger, allowing
the plunger to rise to its original
position. Withdraw the needle
safely and dispose of it in a
sharps container.
10 Slowly pull the plunger back until
the syringe fills to slightly more than
the unit marking that corresponds to
your prescribed dose. Keeping the
needle in the vial, slowly push the
plunger to your prescribed dose.
This will clear any air bubbles.
alcohol swab.
alcohol swab.
3 Carefully twist and pull off the
rubber cap from the prefilled syringe
of Bacteriostatic Water. To prevent
contamination, avoid contact with
the needle.
7 Remove the
wrapper from
the custom
dosing injection
syringe.
Carefully loosen
and pull the
plastic cap from
the needle and
avoid touching
the needle.
11 Carefully remove the syringe from
the vial and recap the needle. The
custom dosing syringe is now filled
with the prescribed dose of Gonal-F®
and is ready for administration. Once
reconstituted, store remaining
solution at room temperature or
refrigerate for up to 28 days.
HRC HOPE 08/03/11
52
Self-Injecting With Gonal-F® RFF Pen
4 Easy Steps
Priming the Pen
(First use only)
1 Attach Needle
Remove pen cap and wide threaded
tip with alcohol swab. Remove peel
tab from outer needle cap. Press
threaded tip of pen into open end
of outer needle cap. Twist pen
clockwise until needle is securely
attached. Remove outer needle cap.
2 Set the Dose
Turn dosage dial so your prescribed
dose is lined up with the black
dose arrow.
Recheck that correct dose on the
dosage dial is lined up with black
dose arrow before proceeding.
If the dialed dose is too high or
too low, reset before pulling the
injection button.
Pen Cap
Outer
Needle
3 Load and Confirm
Load the dose by pulling out
injection button as far as it will go.
Find the last fully visible flat red
arrow on the injection button. It
confirms the dose that is loaded and
ready to be injected. (If the loaded
dose is lower than the set dose,
there is not enough drug to complete the dose. Use a new Gonal-F®
RFF Pen to complete dose. See next
page for more detailed instructions.)
4 Inject
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
90º angle. Push the injection button
until it stops clicking. After the last
click, keep the needle in the skin
for at least 5 seconds. Remove the
needle and apply pressure as
needed with gauze pad.
Removable
Needle
Inner
Needle Cap
Prefilled
Reservoir
Threaded
Tip
Dose
Arrow
Injection
Button
Dosage
Dial
Follow instructions for Step 1: Attach
needle. Set dose arrow 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 prefilled reservoir to let any air
bubbles rise to the top. (It’s normal
if a few small air bubbles remain.)
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.
Disposal
Hold pen firmly by drug reservoir
and replace outer needle cap. Grip
outer needle cap firmly, and unscrew
pen from needle by turning pen
counterclockwise. Dispose of needle
in safety container.
Storage: After use, replace pen cap
and store pen at room temperature
or in refrigerator up to 28 days.
HRC HOPE 08/03/11
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Gonal-F® RFF Pen
When you need to complete a dose with a new pen
When you pull out the injection button, if the last visible flat red arrow
shows a number less than the dialed dose, you do not have enough
medication to complete your prescribed dose. In this case, follow the
directions below.
1
In the shaded area of the chart, find the dose remaining in your
current pen.
2
Find your prescribed dose in the column on the left.
3
Find the intersection of “Dose Left in Current Pen” and “Prescribed
Dose.” The number at this intersection indicates the dose you need
to dial on a new pen to complete your prescribed dose.
1
Dose Left in Current Pen
Prescribed Dose
2
450
412.5
375
337.5
300
262.5
225
187.5
150
112.5
75
412.5
375
337.5
300
262.5
225
187.5
150
112.5
75
37.5
375
337.5
300
262.5
225
187.5
150
112.5
75
37.5
337.5
300
262.5
225
187.5
150
112.5
75
37.5
300
262.5
225
187.5
150
112.5
75
37.5
262.5
225
187.5
150
112.5
75
37.5
225
187.5
150
112.5
75
37.5
187.5
150
112.5
75
37.5
150
112.5
75
37.5
112.5
75
37.53
75
37.5
37.5
3
HRC HOPE 08/03/11
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Luveris® 75 IU
Review these Steps
Before you Administer
Luveris®
4 Wipe the rubber stoppers with an
alcohol swab. The rubber stoppers
should not be touched once wiped.
Get ready
1 Make sure you have all the
necessary materials assembled in
a clean area: one Luveris® 75 IU vial,
one vial with sterile water (diluent),
one syringe, two needles, alcohol
swabs, gauze, bandage and sharps
bin. (The syringe, needles, alcohol
swabs, gauze, bandage and
sharps bin are not included in
the Luveris® package).
Luveris®
diluent
Luveris®
powder
Syringe, Reconstitution and
Administration Needles
Sharps Bin and Alcohol Swabs
2 Wash your hands thoroughly.
3 Remove the plastic caps from
the vial of Luveris® powder and the
vial with the diluent, with your thumb.
Inject Air into the Vial of
Sterile Water
8 Place the vial of diluent on a hard,
flat surface
9 Carefully insert the needle through
the center of the rubber stopper
into the vial of sterile water (diluent).
Keep the syringe in a straight, upright position as you insert the needle or it maybe difficult to depress
the plunger.
Allow the Luveris® diluent to
adjust to room temperature
before you administer
your injections.
Check that the Luveris®
diluent is clear. Do not use if
it contains any particles.
Filling the Syringe with the
Luveris® Diluent
10 Gently inject the air into the vial
by depressing the plunger on the
syringe (the injected air creates
pressure and makes it easier to
withdraw the solution).
Draw Air into the Syringe
5 Remove the wrapping from the
syringe and reconstitution needle.
6 Attach the needle onto the syringe
and carefully pull or twist off the
needle cap of the reconstitution
needle. Do not touch the needle or
allow it to touch any surface.
7 Draw some air into the syringe by
pulling the plunger approximately to
the 1mL/1cc mark.
AIR
Fill the Syringe with Diluent
11 Without removing the needle,
turn the vial upside down and
withdraw all of the diluent into the
syringe, making sure that the tip
of the needle remains in the water
(diluent ) by slowly backing it out
of the vial.
12 Remove the needle from
the vial.
DILUENT
HRC HOPE 08/03/11
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Reconstitution Luveris®
Inject the Diluent Into the Luveris®
Powder
13 Place the vile containing the
Luveris® poser on a hard, flat surface.
14 Insert the needle through the
center of the rubber stopper into
the Luveris vial. Keep the syringe
in a straight, upward position as
you insert the needle or it may be
difficult to depress the plunger.
Draw the Luveris® Solution Back
into the Syringe.
17 When all the powder has
dissolved, without removing the
needle, turn the syringe and vial
upside down and gently withdraw
all the Luveris® solution back into
the syringe.
Remove Air Bubbles
21 To remove any air bubbles, point
the needle upwards and gently tap
the syringe.
DILUENT®
22 When all the bubbles rise, slightly
push the plunger until a small drop
appears from the tip of the needle.
15 Slowly inject the sterile water
(diluent) into the vial with Luveris®
powder by depressing the plunger
on the syringe.
Make sure that the tip of the needle
remains in the solution by slowly
backing the needle out of the vial
to withdraw as much of the solution
as possible.
To control the movement of the
needle in the solution, look from the
side of the vial through the gap in
the rubber stopper.
18 Carefully remove the needle
from the vial.
Preparing the Administration
Change Needles
19 Recap the reconstitution needle
(1). Twist the cap and needle off the
syringe (2).
Obtain a Clear Solution
16 Leaving the needle in the vial,
gently rotate the vial between your
fingers until all of the powder is
dissolved. Do not shake.
2
1
23 Recap the syringe needle.
Now you are ready
to administer your
Luveris® 75 IU injections
Injecting your Dose
Prepare the Injection Area
24 Choose an injection site as
directed by your nurse, doctor or
pharmacist. Alternate the injection
sites each day.
20 Remove the wrapping from the
administration needle. Twist the
needle onto the end of the syringe
(3) and carefully remove its cap (4).
4
3
HRC HOPE 08/03/11
56
25 Carefully clean the injection site
with an alcohol swab and allow it to
air-dry.
Remember that your
injection materials must be kept
sterile and cannot be reused.
Administer Your Injection
26 Uncap the syringe needle.
Holding the syringe with one hand as
you would hold a pencil, pinch the
skin of the chosen injection site with
the other hand and hold firmly.
27 Inset the entire length of the
needle into the skin at an upward
angle of about 45° to 90°. Do not
inject into a vein.
28 Release the hand pinching the
skin and depress the plunger in a
slow, steady motion until all the
medication is injected. Do not inject
into a vein.
30 Apply gentle pressure to the
injection site using sterile gauze.
Put a small adhesive bandage strip
over the injection site if desired.
Discard used materials
31. Do not recap the needle. Discard
the used needle and syringe into
your sharps bin.
29 Gently withdraw the needle.
These are common instructions for administering your injection.
However, you should always follow the advice given by your nurse or doctor.
Use the Luveris® solution only if all the powder has dissolved and the liquid is clear and
colorless. Inject your Luveris® dose immediately upon reconstitution.
Storage of Luveris® 75 IU
Important: Luveris® is stored either refrigerated at (36°- 46°F/2°- 8°C) or at room temperature (up to 77°F/25°C) in its
original package. Protect from light. Do not freeze. Do not store above 77°F (25°C). Do not use after the expiration
date shown on the vial or the carton. Keep out of reach of children.
Side effects may occur with the use of infertility drugs and, therefore, should only be prescribed by physicians who are
thoroughly familiar with infertility problems and their management. Ovarian hyperstimulation syndrome (OHSS), with
or without vascular and pulmonary complications, can occur with the use of infertility drugs. Reports of multiple births
have been associated with gonadoptrophin treatments. The most common side effects in women using Luveris®
include headache, abdominal pain, nausea, OHSS, breast pain and ovarian cyst. Please see Full Prescription
Information (PI) for product details.
HRC HOPE 08/03/11
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hCG Injections: Novarel™ and Pregnyl®
W
hen three or more follicles approach the 15 to 20mm range and the estrogen
level is above 500, it is likely that each of these follicles contains a mature, fertilizable
egg. The patient is then ready to receive an injection of hCG, human chorionic
Gonadotropin (Pregynl or Novarel). This natural hormone stimulates and induces final maturation of the eggs, preparing them for fertilization.The patient may also have follicles less than
15mm, which may not contain a mature egg.
Specific instructions will be given as to when to administer the injections. It is important that
hCG be taken at the time designated. If the injection cannot be given within 30 minutes of
that time, notify the coordinator when receiving instructions. On the morning following hCG
injection, usually no blood sample or ultrasound is obtained. Approximately 36 hours following
hCG administration, the doctor performs the egg retrieval or gamete intrafallopian transfer
(GIFT) procedure.
HRC HOPE 08/03/11
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Administration of hCG: Novarel™ and Pregnyl®
General Instructions for Both Dosages:
For 10,000 Unit Dosage:
1
1
Pull the syringe plunger back to the
1cc mark.
Assemble equipment:
–
3cc syringe with needle
–
11/2” 25g needle
2
Inject 1cc of air into the vial of diluent.
–
Alcohol preps
3
–
1 box of hCG and diluent
Draw out 1cc of diluent and inject the
diluent into the vial of hCG powder.
4
Draw out the entire contents from the vial
(1cc) and administer intramuscularly.
2
Remove pop-top from both vials and swab
both rubber stoppers with alcohol.
3
One vial contains sterile water (diluent);
the other contains hCG powder.
4
Discard diluent vial immediately after
adding to the powder. Inject 1cc of sterile
water into hCG powder.
5
Gently rotate the vial and allow time for
the powder to dissolve. Do not shake.
6
Turn vial upside down to remove diluent
and to remove mixed medication.
7
Put a new sterile needle (11/2” 25 gauge)
on the syringe prior to the injection.
8
The eye of the needle must be in the
liquid in order to remove the contents
from the vial.
9
Expel air bubbles.
10 Be Very Careful to inject the mixed
medication and not the diluent.
11 Injection is to be given intramuscularly in
the upper outer quadrant of the buttocks.
For 5,000 Unit Dosage:
1
Pull the syringe plunger back to the
2cc mark.
2
Inject 2cc of air into the vial of diluent.
3
Draw out 2cc of diluent and inject the
diluent into the vial of hCG powder.
4
Draw out 1cc of the mixed medication from
the vial and administer intramuscularly.
5
Discard the remaining vial of mixed
medication.
NOTE: It is VERY IMPORTANT to give
the injection at the time stated.
_____________ n am n pm
12 It is very important to give the injection at
the time stated by the physician’s office.
To view an instructional video about Novarel, go to:
http://www.ferringfertility.com/medications/novarel/injecting.asp
To view an instructional video about Pregnyl, go to:
http://www.follistim.com/Consumer/ganirelixPregnyl/Pregnyl/
PregnylInstructionalVideo/index.asp
HRC HOPE 08/03/11
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Ovidrel® Prefilled Syringe
Get ready
Ovidrel® Prefilled Syringe
(choriogronadotropin
alfa injection) is the only
recombinant, liquid, readyto-inject human chorionic
Gonadotropin (r-hCG)
approved in the world.
It is manufactured using the
recombinant human DNA
technology, which provides
high purity and consistency
from batch to batch.
2 Wash your hands thoroughly.
1 Make sure you have all the
necessary materials assembled
in a clean area: Ovidrel® PreFilled
Syringe, alcohol swabs, gauze,
sharps-disposal container.
Please allow the prefilled syringe
to adjust to room temperature
before you administer your
injection.
Prepare Your Ovidrel® Prefilled Syringe
3 With the needle pointing
up-wards, carefully remove the
needle cap from the syringe. Do not
touch the needle or allow it to touch
any surface. Keep materials sterile.
4 To remove any air bubbles, point
the needle up and gently tap on the
syringe until all the bubbles rise to
the top.
5 Push the plunger carefully until a
small drop of liquid begins to appear
from the tip of the needle.
Prepare the Injection Area
6 Chose an injection site in the
lower abdominal area, preferably
around the belly button but at least
1” away.
7 Carefully clean the injection site
on the stomach with an alcohol swab
and allow it to air-dry.
HRC HOPE 08/03/11
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Storage of Ovidrel®
Prefilled Syringe
Important: Ovidrel® Prefilled
Syringe should be stored
refrigerated (36°- 46°F/
2°- 88°C) to allow the product
to be used until the expiration
date shown on the syringe or
carton. Alternatively, the
Ovidrel® Prefilled Syringe may
be stored by the patient for
no more than 30 days at room
temperature (up to 77°F/25°C)
and in this case must be used
within those 30 days. Protect
from light. Do not freeze.
Administer Your Injection
8 Holding the syringe with one
hand the way you would hold a
pencil, pinch the skin on the chosen
injection site with the other hand
and hold firmly.
Always take your injection
exactly as your doctor
instructed.
9 Insert the entire length of the
needle into the skin at an upward
angle of about 45 to 90°, as
indicated by your doctor or nurse.
Review these instructions
carefully. If you have
questions, do not hesitate
to contact your healthcare
provider.
Discard Used Materials
You can also call Serono
Fertility Lifelines toll-free at
1-866-LETS TRY
(1-866-538-7879) or visit
www.seronofertility.com.
10 Release the skin and push the
plunger in a slow, steady motion until
all the medication is injected. Take as
much time as you need to injection
all the contents.
11 After injecting all the contents,
gently withdraw the needle.
12 Apply pressure to the injection
site with a gauze pad. If bleeding
does not stop within a few minutes,
place a piece of clean gauze over
the injection site and cover it with
an adhesive bandage.
13 Discard the syringe in your
sharps-disposal container.
Remember that injection materials
must be kept sterile and cannot
be reused.
http://www.fertilitylifelines.com/serono/products/ovidrel/instructions.jsp
HRC HOPE 08/03/11
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Estradiol Valerate® (E2 Valerate)
E2 Valerate is a form of estrogen administered by intramuscular injection. It is usually prescribed
for the female patient during various types of assisted reproductive treatment cycles to stimulate
or enhance the endometrial (uterine) lining.
The most common possible side effects of this medication are mood swings, headaches,
abdominal bloating, increase of vaginal secretions and irritation at the site of the injection.
Patients using this medication may feel some, all or none of these side effects. Presence or
absence of these side effects is not an indication of how well the drug is working or whether or
not the patient is pregnant. It is important to report any unusual side effects to your physician.
This medication is administered by intramuscular injection once every three days. It is measured
in small doses ranging from .1cc (ml) to .6cc for E2 Valerate labeled 20mg/ml. You will be using
a small 1.0cc or tuberculin (TB) syringe to measure and inject the E2 Valerate. The use of an
incorrect syringe may result in medication errors that will adversely affect your cycle.
If you have any questions, please ask the clinical team. Thank you.
Administration of Estradiol (E2) Valerate® (Delestrogen)
• Estradiol (E2) Valerate is to be administered every three days.
• Use a 1.0cc or Tuberculin (TB) syringe to measure the dose.
• If available, use an 18 gauge, 11/2” needle to withdraw the
liquid from the vial.
• When the correct dose is measured, pull the needle out of the
vial, then pull back on the plunger to empty the needle of fluid.
• Replace the 18 gauge needle with a 22 gauge 11/2 ” inch needle.
• Inject by an intramuscular (IM) injection into the upper outer quadrant of the buttocks.
This is a 1.0cc or TB Syringe
2mg = .1cc (.1ml)
4mg = .2cc (.2ml)
6mg = .3cc (.3ml)
Dosaging
These instructions apply to E2 Valerate labeled
20mg/ml. If your medication shows a different
concentration, it is crucial to show it to your
physician or nurse to calculate your specific dosage.
Failure to do so may result in medication errors.
8mg = .4cc (.4ml)
Specific Patient Instructions:
HRC HOPE 08/03/11
62
Progesterone™
Progesterone™ is prescribed to supplement the progesterone already present in the body,
and to cause the uterine lining to be more receptive to embryo implantation. Beginning the
day after the egg retrieval, or the GIFT procedure, progesterone is administered either by IM
injection, vaginal gel (Crinone 8%), vaginal suppositories or sublingual tablets, as instructed
by your physician. Injectable progesterone medication is produced in an oily solution to
ensure slow, even release into the bloodstream. Individual dosage and administration
method will be discussed beforehand.
Possible side effects of progesterone include weight gain, mood swings, slight discomfort
at injection sites and breast tenderness.
Please discard any progesterone in oil that you have not used within 30 days from the date
of opening the vial. Progesterone may delay the menstrual cycle. Progesterone medication
carries a warning regarding birth defects. The progesterone prescribed is a natural formula,
which has not been known to increase the risk of birth defects.
• Wash hands with soap and water and use a clean surface for preparing
the medication.
• If available, use an 18 gauge, 11/2” needle to withdraw the liquid from
the vial.
• When the correct dose is measured, pull the needle out of the vial, then pull
back on the plunger to empty the needle of fluid.
• Replace the 18 gauge needle with
a 22 gauge 11/2” needle.
• Inject by an intramuscular (IM) injection
into the upper outer quadrant of
the buttocks.
• This is a 3.0cc syringe.
To learn more about Progesterone and view an instructional video, go to:
http://www.education.designrx.net/PatientPortal
and search under medications for Progesterone
HRC HOPE 08/03/11
63
Heparin
Opening Medication
1
Use a new sterile syringe and needle each
time you inject.
2
Carefully flip the lid of the vial off.
3
Carefully twist the needle
cover (and plunger cover, if
necessary) off of the syringe.
Do not touch the needle. If
you do touch the needle, carefully recap
the needle, twist the needle off and
replace with a new needle. Twist the
needle on the syringe. Remove cover.
Needles are no longer sterile after
being touched.
4
5
6
You are now ready to administer the
injection.
Choose an injection site (abdomen, thigh,
or upper arm as directed by your physician,
coordinator or pharmacist) and swab the area
with alcohol. Allow to air-dry.
1
Pinch a fold of skin with one hand and
insert the syringe with the other hand.
Use a quick dart-like motion.
Draw the diluent into the syringe using
the following method:
a
the needle.
b
Draw air into the syringe by pulling
the plunger back until the mark of the
amount of medication you are going
to withdraw.
2
Depress the plunger all the way in a
slow, gentle motion until all the
medication is injected.
3
Release the skin.
c
Insert the needle into the vial through
the rubber stopper.
4
d
e
Turn vial upside down without
removing the needle. Withdraw the
amount needed making sure the tip
of the needle remains in the solution.
If the bleeding does not stop, place clean
gauze over the injection site and cover
with an adhesive bandage. Do not rub
the site or bruising may occur.
f
Withdraw the needle
from the vial.
5
provider). It is recommended that you use
the abdomen. Ask your coordinator if you
have further questions.
HRC HOPE 08/03/11
64
Financial Considerations
HRC Policy Regarding Insurance
HRC has always been sensitive to the high cost of infertility treatment. We strive to keep our
costs competitive and to help our patients maximize their insurance benefits.
Most patients have an incredible array of paperwork on what is covered by their insurance and
what is not. For some, it is all treatments, for others it is none and for others yet, it is a confusing
hybrid of partial coverage and non-coverage. Over the years, HRC has had patients who have
requested that we bill their insurance with a diagnosis that is covered under their plan as
opposed to infertility, which is not a covered benefit. Patients often tell us that their previous
physician billed in this fashion or that their friend had gone to a center that was amenable to
pursuing this billing strategy. However, as sympathetic as HRC is to patients’ plight regarding
their lack of insurance coverage, HRC will not engage in such billing practices as insurance
carriers may view this as fraudulent. HRC has always been proactive in developing payment
options for patients to enable them to pursue infertility treatment regardless of their insurance
benefit status.
As a courtesy, we are happy to assist our patients by verifying insurance coverage. However,
we cannot assure you that the information we are given is correct, as no insurance will ever
guarantee payment. All insurance payments are subject to review of medical necessity and
HRC will not be responsible should your benefits change or if your insurance denies payment.
Regardless of insurance coverage, you are ultimately responsible for the full payment of
your account.
Before we can bill your insurance for any type of treatment, you must first obtain a written
pre-certification of coverage from your insurance carrier. If your plan is an HMO, please make
sure your authorization has been obtained prior to each visit. Your estimated co-payment will
be collected up front. All services will be billed out on a fee-for-service basis. You will be billed
for any remaining balances, or non-covered services, after the insurance payment has been
received. We must receive pre-certification before you start your cycle. HRC can assist with
this process, but it is the patient’s responsibility to obtain the insurance pre-certification.
Financial Consultations
All of our patients must contact one of our financial advisors to schedule a financial
consultation prior to initiating treatment. This is the opportunity for an open discussion about
costs, insurance coverage and payment policies that will allow you to make the best choice.
This consultation is an important part of the entire process you will experience when you visit
us for treatment. Payment is required in full prior to the start of medications. We hope with the
various financial options we are able to help more couples afford their treatment at HRC.
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Diagnostic Testing
Prior to initiating treatment you will be asked to complete pre-cycle diagnostic testing, such
as uterine imaging, infectious disease screening, semen analysis, etc. If you and your partner
decide to have your laboratory testing performed at HRC, it will be on a fee-for-service basis.
Unless these pre-cycle diagnostic tests are covered benefits, we cannot bill your insurance
company. However, we will provide you with a receipt to submit to your insurance carrier. Please
understand that you can ask your nurse coordinator for a prescription to have the laboratory
testing done at an outside facility. Over the years, we have found that insurance companies
deny our claims for tests such as HIV, Hepatitis Panel, infectious disease screenings, etc., but
our patients have shared that if they go through their primary care physician, their insurance
company will, at times, cover their claims for these tests.
Insemination Cycles
If you do not have insurance coverage for an insemination, payment will be collected at the time
services are rendered. We will not bill the insurance for the ultrasounds and laboratory test(s) if
your policy does not cover inseminations. If your policy does cover insemination, we will need
written pre-certification or pre-authorization from your insurance.
Note: It may be recommended that you do back-to-back inseminations. If so, you will incur costs
for two inseminations. Please note that insurances may count the second insemination as an
attempt. This could affect your coverage if your insurance benefit has a limit on the number of
attempts they will allow.
Prices are subject to change without notice.
Package Pricing
The package price or global fee is a flat rate that cannot be itemized. The package price option
is utilized when a patient does not have insurance benefits for fertility services. If the insurance
covers infertility, all services must be billed on a fee-for-service basis, and the Package Price fees
would not apply.
The Package Price Includes:
• Ultrasound and estradiol monitoring of egg
development from start of birth control pills
or Lupron
• Egg retrieval
• IVF laboratory work including sperm
preparations
• Egg identification
• Culture and fertilization
• Embryo incubation and monitoring
• Transfer preparation
• Embryo transfer
• One BhCG level after transfer
Only services provided at an HRC facility are
covered by these financial options.
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The Package Price Does Not Include:
• Consultations
• PGD/S
• Pre-cycle lab work and procedures such as
semen analysis or cultures
• ICSI
• Infectious disease screening
• Embryo freezing
• Vaginal cultures
• Frozen embryo storage fees
• Mock transfer
• Frozen embryo transfer cycle
• Estradiol or Progesterone
• Pregnancy monitoring
• Sonohysterogram or hysteroscopy,
medications
• MicroSort® West fees
• With donor and surrogacy cycles,
administrative fees, recruitment, screening
and payments to the donor or surrogate
are not included
• Invasive procedures for obtaining sperm
(PESA, TESA, TESE, MESA)
Please refer to listing of prices for
additional services.
• Anesthesia
• AH
Canceled or Dropped Cycles
If for any reason your cycle is canceled, all services will be itemized to the point of termination,
and the balance of those services must be paid prior to proceeding with the next cycle. If you
should decide not to continue with treatment, you may have the services deducted from your
cycle deposit and request a refund of the remaining credit.
Financing Options
Over the years, HRC has worked hard trying to keep the costs associated with assisted
reproductive treatment as low as possible. We sincerely understand the emotional toll our
patients go through when trying to figure out how they will pay for their treatment. We offer
a variety of financial options for qualified patients undergoing in vitro fertilization such as our
One-Cycle option, Low Cost Two-Cycle* and Three-Cycle* options and our HRC Refund
Guarantee Program.*
Your treatment will begin once all necessary lab screening/diagnostic testing has been
completed, consents have been signed, fees have been paid, insurance benefits have been
verified, and (if participating in a Low Cost Two-Cycle or Three-Cycle or the HRC Refund
Guarantee Program) qualification and approval has been met.
HRC accepts most major credit cards, checks and cash, and additionally we are able to offer our
patients other financing options. Although HRC does not offer an in-house lending program, we
are now associated with several organizations to give our patients more payment options.
* Please note that qualification for these programs
is subject to approval.
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MicroSort® West* Fees
Please refer to www.microsort.com for their current list of fees.
* Caution: This procedure uses an investigational device. Limited by federal law to
investigational use.
RSA Surgery Center
RSA Surgery Center will bill you or your insurance for the facility fee for any procedure
performed in the RSA facilities with the exception of those procedures included in your
cycle packages.
Pregnancy Services
We hope all our patients are successful and have healthy pregnancies. When you achieve a
pregnancy, we will monitor you for a few weeks into the first trimester (please consult your
physician and/or nurse coordinator). The pregnancy ultrasounds and pregnancy laboratory
testing will also be fee-for-service. Unfortunately, we cannot bill your insurance company for
these services as the majority of the insurance carriers feel we should send you to your
obstetrician immediately after confirming pregnancy. Frequently, our claims for pregnancy
services are denied because the insurance carriers feel they are not medically necessary.
However, we will give you a receipt with a diagnosis to submit to your insurance carrier as
our patients have shared that in some cases they are reimbursed.
Please ask your financial counselor if you have any questions regarding this information.
We wish you the very best today and always!
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Abbreviations
ACOG
American College of Obstetricians
and Gynecologists
IVF
In Vitro Fertilization
AH
Assisted Hatching
LH
Luteinizing Hormone
ART
Assisted Reproductive Technology
MAX
OOP
Maximum Out of Pocket
ASA
Antisperm Antibody
MESA
ASRM
American Society for
Reproductive Medicine
Micromanipulation Epididymal
Sperm Aspiration
Mona
Monarch
BBT
Basal Body Temperature
OCP
Oral Contraceptive Pill
BhCG
Beta Human Chorionic
Gonadotropin
OHHS
Ovarian Hyperstimulation Syndrome
OI
Ovulation Induction
CCT
Clomid Challenge Test
OPK
Ovulation Predictor Kit
CF
Cystic Fibrosis
PCO
Polycystic Ovarian Disease
DED
Deductible
P4
Progesterone
DI
Donor Insemination
PCT
Post Coital Test
DS
Donor Sperm
PGD/S
E2
Estradiol
Preimplantation Genetic
Diagnosis/Screening
EEJ
Electroejaculation
PCP
Primary Care Provider
PPO
Preferred Provider Organization
PRL
Prolactin
Rx
Prescription
REI
Reproductive Endocrinologist &
Infertility Specialist
SA
Semen Analysis
SART
Society for Assisted Reproductive
Technologies
Endo Bx
or EMB Endometrial Biopsy
ET
Embryo Transfer
FET
Frozen Embryo Transfer
FSH
Follicle Stimulating Hormone
GIFT
Gamete Intrafallopian Transfer
Gn or
GnRH
Gonadotropins
H&P
History and Physical
hCG
Human Chorionic Gonadotropin
HMO
Health Maintenance Organization
HRC
HRC Fertility
HSG
Hysterosalpingogram
ICSI
Intracytoplasmic Sperm Injection
IM
Intramuscular
IUI
Intrauterine Insemination
IU
International Units
SHG or
Sono
Sonohysterogram
STDs
Sexually Transmitted Diseases
SUB-Q
Subcutaneous
TESA
Testicular Sperm Aspiration
TESE
Testicular Sperm Extraction
TSH
Thyroid Stimulating Hormone
US
Ultrasound
ZIFT
Zygote Intrafallopian Transfer
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ASRM Information
The following is a list of helpful fact sheets and information available through the
ASRM website (www.asrm.org).
These fact sheets and booklets are archived in PDF format and may be viewed with a free
Adobe® Acrobat® Reader.
n Adoption
n Complications and problems associated
with Multiple Births
n Diagnostic Testing for Male Factor
n Infertility
n Intrauterine Adhesions
n Laparoscopy and hysteroscopy
n Managing Pelvic Pain
n Medications for Inducing Ovulation
n Ectopic Pregnancy
n Multiple Pregnancy and Birth: Twins,
Triplets, and Higher Order Multiples
n Endometrial Ablation
n Older Female Patients
n Endometriosis
n Genetic Screening for Birth Defects
n Hirsutism and Polycystic Ovarian
Syndrome
n Hydrosalpinx
n Hysterosalpingogram
n Infertility: An Overview
n Infertility Counseling and Support:
n When and Where to Find It
n Intracytoplasmic Sperm Injection (ICSI)
n Prediction of Fertility Potential in
n Ovulation Detection
n Risks of In Vitro Fertilization
n Sexual Dysfunction and Infertility
n Side Effects of Gonadotropins
n Smoking and Infertility
n Stress and Infertility
n The menopausal Transition
(Permimenopause)
n Weight and Fertility
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The following booklets are available at the ASRM website (www.arsm.org) in
Spanish.
n Adherencias Intrauterinas
n Agentes sensibilizadores a la insulina
y SOP
n Complicaciones de la Gestacion Multiple
n Consumo de tabaco e infertilidad
n Disfunción sexual e infertilidad
n Estrés e infertilidad
n Fármacos para la fertilidad y riesgo de
embarazo múltiple
n Gestacion Multiple y Reduccion
Embrionaria
n Hirutismo y Sindrome de Ovarios
Poliquisticos
n Peso y Fertilidad
n Tecnologías de Reproducción Asistida
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ASRM Glossary of Terms
Anejaculation
A condition in which no semen is expelled from
the penis during sexual arousal.
Anorexia Nervosa
An eating disorder associated with a distorted
body image that is caused by a mental disorder.
Inadequate calorie intake results in severe
weight loss.
Assisted Reproductive Technology (ART)
Procedures in which pregnancy is attempted
through gamete manipulation outside of the
body, such as in vitro fertilization (IVF) or
gamete intrafallopian transfer (GIFT).
Azoospermia
A cause of male infertility in which no sperm
are present in the semen.
Biological Father
The man whose sperm fertilized the ovum from
which a child developed and who is therefore
genetically related to that child.
Chlamydia
A sexually transmitted infection caused by the
microorganism chlamydia trachomatis, which
if left untreated in a woman may cause pelvic
inflammatory disease (PID), pelvic adhesions
and tubal blockage.
Cryopreservation
A special freezing technique used to preserve
embryos and sperm for future use in an
ART procedure.
Cryptorchidism
A cause of male infertility in which one or both
testes have not descended into the scrotum after
the first year of life.
Dilatation and Curettage (D&C)
A procedure in which the cervix is gradually
widened and the lining of the uterus is gently
removed by scraping or suction.
Biological Mother
The woman from whose ovum a child
developed and who is therefore genetically
related to that child.
Disease
A disease is defined as any deviation from
or interruption of the normal structure or
function of any part, organ, or system, or
combination thereof, of the body that is
manifested by a characteristic set of symptoms
or signs. Dorland’s Medical Dictionary 1988: 481.
Bulimia
Bulimia is an illness characterized by uncontrolled
episodes of overeating usually followed by selfinduced vomiting.
Dyspareunia
A condition in women in which intercourse
is uncomfortable or painful due to a medical
problem or emotional issues.
Cervix
The lower, narrow end, or neck, of the uterus,
which opens into the vagina.
Ectopic Pregnancy
A pregnancy in which the fertilized ovum has
implanted in a location other than inside the
uterus, usually in a fallopian tube.
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Embryo
The fertilized ovum after it has begun the process
of cell division.
Endometriosis
A condition in which tissue resembling the
lining of the inside of a woman’s uterus is found
elsewhere in the body (usually in the pelvis).
Endometrium
The tissue lining the inside of a woman’s uterus,
in which a fertilized egg implants at conception.
Epididymis
A structure that covers part of each testis and
is the storage place for mature sperm cells.
Estrogen (Estradiol)
A hormone that is produced in a woman’s
ovaries and plays a role in regulating ovulation
and endometrial development.
Fallopian Tubes
The two narrow, hollow structures located
on either side of a woman’s uterus in the lower
abdomen, extending to an ovary on each side.
Fetus
In medical terms, an embryo becomes a fetus at
about the end of the seventh week of pregnancy,
after major structures (head, torso, limbs, etc.)
have formed.
Follicle
A structure within the ovary containing the egg
that is extruded at ovulation.
Gamete Intrafallopian Transfer (GIFT)
A variation of ART in which unfertilized
eggs and sperm are placed together in
the woman’s fallopian tubes, with fertilization
taking place in the tube instead of a
laboratory dish.
Germ Cells (Gametes)
The sex cells — oocytes (eggs) and spermatozoa.
Gestational Carrier
Mother in a surrogacy arrangement, the woman
who carries a pregnancy to term and delivers a
baby, which may or may not be genetically
related to her.
Gonorrhea
A sexually transmitted infection caused by the
microorganism Neisseria gonorrhea, which if
left untreated in a woman may cause pelvic
inflammatory disease (PID), pelvic adhesions,
and tubal blockage.
Hypothalamus
A structure located at the base of the brain that
secretes hormones that regulate the pituitary
gland which in turn regulates various bodily
functions, including ovulation in women and s
perm production in men.
Implantation Bleeding
Light bleeding or spotting that sometimes
occurs when a fertilized egg (embryo) implants
in the uterus.
Impotence
A condition in which a man cannot achieve or
sustain an erection long enough to ejaculate inside
a woman’s vagina.
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In Vitro Fertilization (IVF)
A form of assisted reproduction in which an egg
and sperm are combined in a laboratory dish
and the resulting embryo (sometimes called a
preembryo) is subsequently transferred into a
woman’s fallopian tube.
Incompetent Cervix
A condition in which a pregnant woman’s cervix
begins to dilate too soon, causing miscarriage.
Infertility
The absence of conception after at least one year
of regular unprotected intercourse.
Intracytoplasmic Sperm Injection (ICSI)
A technique in which a single sperm cell is injected
through a microsurgical needle directly into the
cytoplasm of an egg to facilitate fertilization.
A technique in which sperm are introduced
directly into a woman’s cervix or uterus to
produce pregnancy, with or without ovarian
stimulation to produce multiple ova.
Luteal Phase
The second half of the menstrual cycle, beginning
at ovulation (Day 14 in an average 28-day cycle)
and ending with menstruation.
Miscarriage
Spontaneous loss of a pregnancy before twenty
weeks of gestation.
Motility
In a semen analysis, the degree to which sperm
cells are able to spontaneously propel themselves.
Oligospermia
A cause of male infertility in which fewer than
forty million sperm are present in the semen
from one ejaculation.
Oocyte
An ovum; the egg before it is released
at ovulation.
Ova
The female sex cells, or eggs, which are
produced in the ovaries.
Ovaries
Two small organs on either side of a woman’s
lower pelvis which produce ova, or eggs,
and hormones.
Ovulation Induction
A procedure in which medication is used to
stimulate a woman’s ovaries to produce
multiple mature follicles and ova.
Pelvic Inflammatory Disease (PID)
Inflammation of the female upper reproductive
tract (uterus, tubes, and ovaries) usually resulting
from infection with chlamydia and/or gonorrhea.
Penis
The male reproductive organ, through which
semen exits during ejaculation.
Perinatologist
An obstetrician/gynecologist specializing in
the care of pregnant women and their babies
during pregnancy.
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Pituitary
A gland located at the base of the brain that
is stimulated by hormones released from the
hypothalamus to secrete hormones that regulate
various bodily functions, including ovulation in
women and sperm production in men.
Placenta
The thick pad of tissue inside a pregnant woman’s
uterus that provides nourishment to and disposes
of waste from the growing fetus.
Polycystic Ovarian Syndrome (PCOS)
A condition in which an excess number of multiple
small cysts form on both ovaries. Women with this
condition don’t ovulate on a regular basis.
Postcoital Test
A test used to evaluate the interaction between a
man’s sperm and a woman’s cervical mucus.
Premature Ejaculation
A condition in which ejaculation occurs before
the penis enters a woman’s vagina.
Prostate Gland
A gland that is located just below a man’s bladder
and secretes fluid that helps sperm pass through
the urethra.
Reproductive Endocrinologist
An obstetrician/gynecologist who specializes
in diagnosing and treating infertility.
Scrotum
A saclike pouch containing the testes at the base
of the penis.
Secondary Infertility
Infertility in a woman who has had one or more
pregnancies.
Seminal Vesicle
A small gland that is located just behind the
bladder in the male and stores sperm prior
to ejaculation.
Sexually Transmitted Infection (STI)
An infection that is spread by sexual contact.
Also called a sexually transmitted disease (STD).
Premature Ovarian Failure
A condition in which a woman’s ovaries stop
producing estrogen and cease ovulation before
the age of 40.
Sperm Cells
The male sex cells (spermatozoa), which are
produced in the testes.
Primary Infertility
Infertility in a woman who has never had
a pregnancy.
Sperm Count
An assessment of the number of sperm
present in each milliliter of semen.
Progesterone
A hormone that is produced in a woman’s ovaries
and that stimulates the endometrium to thicken in
preparation for possible pregnancy during the
latter part of the menstrual cycle (luteal phase).
Sperm Penetration Assay
A test examining the ability of sperm to penetrate
and fertilize a modified hamster egg.
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Sperm Washing
A procedure used to remove components other
than sperm from a semen sample prior to being
used for intrauterine insemination.
Testes
Two small organs that are located at the
base of the male’s penis and in which sperm
are produced.
Testosterone
A hormone that is produced by a man’s
testes and helps to maintain the production
of sperm.
Thyroid
A gland located at the base of the neck, which
secretes hormones influencing metabolism.
Tubal Ligation
A type of female sterilization in which the fallopian
tubes are cut, clipped, or tied in order to prevent
pregnancy.
Ultrasound
A procedure in which sound waves are used to create an image of the internal structures and organs.
Unexplained Infertility
Infertility for which the cause cannot be
determined with currently available
diagnostic techniques.
Urethra
A narrow, tube like structure through which urine
passes on its way from the bladder to the outside
of the body in both sexes. In males, it is also a
passageway for sperm.
Uterine Fibroids
Abnormal, benign (noncancerous) growths of
muscle within the wall of a woman’s uterus.
Uterine Polyps
Abnormal, benign (noncancerous) growths
attached to a short stalk that protrudes from
the inner surface of a woman’s uterus.
Uterus
The hollow, muscular organ in a woman’s lower
abdomen, in which a developing fetus grows
during pregnancy.
Vagina
The elastic, muscular passageway leading from
the cervix to the outside of a woman’s body.
Varicocele
A cause of male infertility in which varicose veins
are present in the blood vessels above the testes.
Vas deferens
The long, narrow tube through which sperm
pass on their way from the testes to the
seminal vesicles.
Vasectomy
A procedure for male sterilization, in which
a small segment of each vas deferens is
surgically removed to prevent sperm from
entering the ejaculate.
Zona Pellucida
The outer protein coat (shell) of an ovum,
which must be penetrated by a sperm cell for
fertilization to take place.
Permission granted for reproduction by the American
Society for Reproductive Medicine, www.asrm.org.
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Counseling
I
nfertility can be overpowering. It can compromise your life goals and identity. It affects
relationships with your partner, family member(s), friends and co-workers. A counselor can
help you understand and deal with your feelings, communicate with your partner, work
through treatment decisions and explore family building alternatives.
Should you consider counseling? Feelings of depression, guilt, anger, anxiety and loss of control
are common reactions to infertility. In situations where these feelings become unmanageable,
the empathy and objectivity of a counselor can be extremely helpful, even if only for a couple
of sessions. Don’t wait until you are in a crisis to seek professional help. Use counseling as a
resource, not as a last resort!
Choosing a Counselor
Select a counselor with care. You may need to interview several to find the right match. Your
financial resources, schedule, physical limitations and level of comfort are all considerations. Ask
for recommendations from people you trust and investigate local organizations that provide
counseling services. Referral resources can include your physician, insurance company or HMO,
social service agencies and your minister, priest, rabbi or other pastoral counselor. Consider
the counselor’s educational background and training. Are you looking for a psychiatrist?
A psychologist? A social worker? Think about whether individual, couples or some other
form of therapy is most appropriate. Other questions to ask include:
• Does the counselor have experience treating infertile couples?
• What is the fee per session? Is it fixed or based on a sliding scale?
• Is the counselor part of your HMO or PPO? Is there a deductible and/or co-payment?
• Is there a limit to the number of sessions covered?
• Is counseling covered by your insurance plan? What qualifications does the counselor need
for his/her services to be covered? How is billing handled? Is there a limit to the number of
sessions covered?
• Is there a charge for missed or cancelled appointments?
• How long is each session?
• What is the accessibility to the counselor between sessions?
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Family, Friends and Social Situations
F
amily gatherings and social situations, such as a baby shower, Christmas with nieces and
nephews or a company picnic, can be difficult for couples struggling with infertility. Such
child-centered events can stir up feelings of jealousy, sadness and resentment. Though
these emotions can cause you great pain, and may be difficult to tolerate and control, they are
universally shared by couples experiencing infertility. Awareness and recognition of your real
thoughts and feelings, and working to express them appropriately, are the best ways to cope.
Give yourself permission to be selective about attending emotionally charged social gatherings.
Arrive late and leave early. Redirect or excuse yourself from uncomfortable conversations, and
be prepared with some responses for people who insist on asking when you’re going to start a
family. Is there a trusted relative or friend who can help you if social situations become difficult?
You don’t have to be on the front lines of every struggle with infertility.
Try not to isolate yourselves from your family and friends. A strong and cohesive support
network is essential. You may need to raise the awareness and sensitivity of those significant
to you. Remember, before your treatment began how much did you know about infertility? Try
to keep your explanations brief and factual. Consider each individual’s level of comprehension
and your investment in the relationship.
Family, friends and co-workers inevitably say things that may seem thoughtless and uncaring.
It is important to keep in mind that the majority of these remarks are made by well-meaning
people who have little understanding of infertility or what you are going through. The following
responses to several of the more common (not to mention irritating) questions and comments
are suggestions only. Create a few of your own. It is up to you to choose a response that feels
right depending on your relationship with the speaker and the situation.
Responses for insensitive things even well-meaning people say:
“Just relax. You’ll get pregnant in no time.”
Responses
“Relaxation will not open my tubes/fix my hormone imbalance/increase
sperm count.”
“Relax? If I relax anymore I won’t be able to get up for work!”
“Have you tried wearing boxer shorts?”
Responses
“I don’t wear underwear.”
“No, I haven’t. But my wife has.”
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“Lie on your back with your feet in the air after you have sex.”
Responses
“I wish getting pregnant were that simple, but we have some medical problems.”
“Sex? We’re supposed to have sex?”
“If you adopt a baby you’ll get pregnant for sure.”
Responses
“Couples adopting a baby are no more likely to get pregnant. Those are just the people you
hear about.”
“That would be terrific. Then we’d have two kids.”
“Your job is pretty stressful. Maybe you should quit.”
Responses
“I don’t think cutting our income in half is going to help me relax.”
“No good scientific research has been able to prove that stress causes infertility, but I can
tell you that infertility definitely causes stress!”
“When are you going to start a family? You’re not getting any younger.”
Responses
“A baby is a gift, not a given.”
“I check the mailbox everyday.”
“Thank you for your interest, but our family planning is a personal matter that
I’d rather not discuss.”
“You’re so lucky you don’t have kids. They’re so much trouble. Do you want mine?”
Responses
“I’m sure you don’t mean that. Imagine what your life would be like
without them.”
“No, to be perfectly honest, I don’t want your kids.”
“I hope that we’ll be grandparents someday.”
Response
When we’re pregnant, you’ll be the first to know because we love you so much.”
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How Family and Friends Can Help
Y
our family and friends may have little understanding of infertility, what you are going
through, or how they can help you. Remember, before you began treatment how much
did you know about infertility? You may want to share the following suggestions with
people significant to you. Their understanding and sensitivity can form a strong and cohesive
support network for you and your partner.
Learn About Infertility
For most couples experiencing infertility, making a baby does not include passion or romance.
Their only hope for a biological child lies with medical treatment that can be very stressful, time
consuming and expensive. Infertility is a medical condition that cannot be cured by relaxing,
taking a vacation or adopting a baby.
Be Sensitive
Invite the couple to all social gatherings and family functions. Even if the occasion is a baby
shower, let them make the decision to attend or not. Be understanding if they choose not to
go or if they leave early.
Be sensitive. Try not to center conversations around children or pregnancy. Avoid infertility
clichés like “just relax and you’ll get pregnant for sure” or “think of all the fun you have
trying.” Such comments are often perceived as thoughtless and uncaring by couples
experiencing infertility.
Show the couple you care about them and sympathize with the difficulties they have had trying
to get pregnant. Let them talk about their fertility problems if they choose. Don’t press for
details or offer unsolicited advice.
Ask how you can help. A ride to a physician’s visit, a casserole or an invitation to a movie can all
show you care. Baby sitting would certainly help a couple experiencing secondary infertility. At
times, all they need is a good listener or a hug.
Maintain Confidentiality
If the couple has shared their fertility problems with you, respect their confidence. They need to
know they can trust you.
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How to Reduce Stress During Infertility
1
Give yourself and your spouse permission to have and express negative feelings. This
includes such feelings as anger, sadness, envy and guilt. These are often not easy to tolerate
in ourselves or others, but are real and important feelings. Crying is a part of expression.
2
Communicate feelings to each other. This means talking about fears, angers and insecurities
about yourself and your partner. Because it is difficult and risky to do, it is tempting to avoid
this, but avoidance tends to create hurt and misunderstandings, which can be more painful
than facing difficult feelings.
3
Respect each other’s differences. Every person’s coping style is individual. Do not judge
yourself by your partner, because you are not the same.
4
Recognize that you may get or give less because you are both stressed at the same time. Try
to find other sources for getting needs met so as to increase your chances of getting what
you need. This will help lessen guilt and anger when you can’t get or give what is needed
to each other.
5
Remember that you are partners who share the same dilemma. It is easy to focus anger on
each other when no other target seems handy. At those times, it is important to try to
remember that you are on the same side.
6
Ask for what you want and need from each other. Many people worry about burdening their
spouses, which limits what they get, and which overlooks the possibility that their spouse
could say “no” if necessary. The chances for getting what you want or need are greater when
you ask, especially since no one can read minds.
7
Don’t get polarized by extreme positions. People often have mixed feelings about things. If
one spouse takes one position, it is easy for the other spouse to take the other position and
never find a middle.
8
Try not to protect each other. This often backfires in unexpected ways and can create
more misunderstanding than it does good.
9
Try to talk about and understand the stress on the sexual relationship. There are ways to
fight back against the effects infertility has on sexual aspects of a relationship, and it is
important to try to remember that they are of a temporary nature.
10 Don’t lose each other in the process of infertility. Remember that you and your spouse are
a family. You chose each other to love and to share your life with for reasons beyond having
children. Infertility is enough of a loss without losing each other.
By Barbara Gastwirth, CSW Sept/Oct, 1992
Pittsburgh Area RESOLVE, Inc.
P.O. Box 11203; Pittsburgh, PA 15238
National Office
1310 Broadway; Somerville, MA 02144
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Preconception Guidelines
W
henever a couple commits to medical treatment for infertility, it is a substantial
financial and emotional investment. As conscientious health care providers,
it important for us to recommend certain preconception testing and precautions.
Alcohol and Drug Use
Fetal alcohol syndrome is characterized by mental retardation and cranial facial deformities.
It has been known to occur in infants where the mothers drank even lightly during their
pregnancies. For this reason, we advise abstaining from alcohol use while you are trying to
conceive and during pregnancy. New evidence also suggests that men who consume alcoholic
beverages may have reduced sperm function and that their children may have a greater risk of
fetal alcohol syndrome.
Prescription and recreational drug use can have far-reaching consequences for fetal development.
Drug interactions with individual genetic vulnerabilities are never completely predictable, and
any drug’s potential benefit must be weighed against its concomitant risks. Marijuana (THC)
use in particular can have dramatic effect on sperm counts and/or functioning. Please inform
us if you have a drug use or dependency problem.
A study published in The New England Journal of Medicine conducted by researchers at the
State University of New York at Buffalo, and presented at the annual meeting of the American
Society for Cell Biology, showed that chemicals in marijuana cannabinoids, which mimic our
bodies’ endocannabinoid compounds may interfere with the sperm’s ability to fertilize the
woman’s egg.
We advise avoidance of any drugs or medications while attempting pregnancy and
during pregnancy.
Smoking
Smoking has been proven to be a powerful vasoconstrictor, which can impair blood flow across
the placental/fetal unit. This frequently results in low-birth weight infants. Smoking also changes
cervical mucus in the female and possibly reduces sperm motility in the male, which may
contribute to infertility. We advise that both partners discontinue smoking prior to attempting
pregnancy. Smoking and the toxins in cigarettes have adverse effects on sperm quality.
In October 2000, British researchers have concluded, based on data from nearly 15,000
pregnancies, that smoking can significantly delay time to conception. Active smoking was
associated with failure to conceive within six to 12 months. Exposure to passive smoke further
increased the odds against a woman conceiving within six months.
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Environmental Exposures
Living and working in a complex urban society may present certain risks of exposure to toxic
substances. Research into the reproductive effects of exposure to pesticides, radioactive
materials and industrial solvents is just now being conducted. We recommend minimizing
these exposures until definitive research is completed.
The role of video display terminals (VDT) in affecting pregnancy is controversial and unknown.
Another risk to be concerned about is toxoplasmosis, a parasite infection transmitted through
cat feces. If you have a cat, avoid changing the litter box.
Exercise and Weight Management
For optimal fertility you should try to maintain your ideal weight. If you are significantly
overweight or underweight, you can develop ovulation problems. Exercise regularly — staying fit
will help control your weight and will keep your body strong enough to carry a pregnancy more
easily. Excessive exercise, which burns more than 2,000 to 4,000 calories per week, may impair
ovulation in some women.
Herbal Remedies
Many of these remedies have unknown effects and may interfere with your treatment. We
suggest that they not be used. A recent study has shown that sperm have difficulty attempting
to penetrate an egg with the use of some herbal medications.
Medication Use
Teratogen Registry:
1 (800) 532-3749
www.otispregnancy.org
“A community program for the elimination of preventable birth defects.” The California
Teratogen Information Service (CTIS) is a statewide program operated by the Department of
Pediatrics at the UCSD Medical Center, with satellite offices at UCLA and Stanford. They are part
of a nationwide community of Teratogen Information Services (TIS) known as the Organization of
Teratology Information Services (OTIS).
The service provides information about prescriptive and non-prescriptive drugs, street drugs,
alcohol, chemicals, infectious diseases and any other physical agents, which may be harmful to
an unborn child.
Diet and Vitamin Supplementation
A healthy balanced diet composed of fresh foods that are not processed or overcooked is one
of the best things you can do for yourselves and your future offspring. Children who start life
well nourished have a distinct advantage in their intellectual capacity and ability to fight disease.
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A multi-vitamin containing folic acid (0.4-0.8 mg/day) is a good adjunct to dietary nutrition
(please see attached list). Vitamin use should be started at least three months prior to
attempting pregnancy.
A recent study (N EngL J Med 2000; 343:1839-45) has found that the ingestion of caffeine may
increase the risk of an early spontaneous miscarriage among non-smoking women carrying
fetuses with normal karyotypes (chromosomes). Reducing caffeine intake during early pregnancy
may be prudent. The study suggests that pregnant women curtail their consumption of coffee
to two cups of American coffee per day.
Folate (Folic Acid) Sources
These fruits and vegetables are top sources of folic acid. One serving provides up to
25% of the recommended daily allowance (RDA).
Source
Serving Size
Asparagus
6 stalks
1/2
Avocado
medium
Beans*
1/2
cup cooked
Broccoli
3/4
cup cooked
Cabbage
1 cup raw
Cereals (Total, All Bran,
Grape Nuts, Product 19)
1 cup
Chicken liver
Greens**
3 ounces
3/4
Lettuce: romaine; bib
cup cooked
1 cup raw
Lentils***
1/2
cup cooked
Okra
1/2
cup cooked
Orange
1 medium
Orange Juice
Peas: green; black-eyed
6 ounces
1/2
Pineapple Juice
Spinach
Tomato Juice
*
**
***
cup cooked
6 ounces
1/2
cup cooked
8 ounces
Black, garbanzo, kidney, navy, pinto
Collard, mustard, turnip
One serving of lentils and black-eyed peas
provides 40 percent or more of the RDA.
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It is impossible to be aware of all possible factors that may cause pregnancy or fetal
complications. Nevertheless, common sense avoidance of known toxins and a healthy life-style
represent a reasonable approach while attempting pregnancy and being pregnant.
Rubella/Varicella Titre and Vaccine
Rubella (German measles or Three-day measles) is a communicable virus, which typically causes
low-grade fever, upper respiratory symptoms and a diffuse red rash. In childhood, this infection
is usually mild. However, if contracted during pregnancy, this disease can have severe effects
on the developing fetus, including blindness, heart defects, hearing defects, musculoskeletal
defects, and mental retardation. Varicella (Chickenpox) is also a communicable disease, and
now there is a vaccine available.
If you have not been tested for rubella/varicella immunity, we advise that this be done. If there
is no immunity, we recommend that you be vaccinated for rubella/varicella and then wait one
month before trying to conceive, as it is a live vaccine. (Contraception should be used during
this time).
Blood Type and Rh
You should know your blood type and Rh status. If you already know this information, please
inform us. We need documentation. If unknown, we advise a blood type and Rh be done.
Genetic Disease Prenatal Screening
It is not possible to screen patients for every known genetic disease, nor is it possible to
guarantee a healthy baby. However, it is recommended that couples consider preconception
testing for the following ethnically appropriate genetic disease screenings after consultation with
their physician. Some couples may decline testing while others may choose to proceed. Referral
to a genetic counselor for more in depth information is available if so desired. More information
is available at www.acmg.net or www.genetics.org.
Chromosomes are present in all the cells of our bodies. The normal number of chromosomes in
every cell is 46 and the chromosomes exist as 23 pairs. The first 22 pairs are numbered 1 through
22 and are called autosomes, while the final pair are the sex chromosomes, (XX designating a
female and XY designating a male). When the eggs and sperm initially form, they are known as
germ cells and have 46 chromosomes, just as in all the cells of our bodies. However, when the
germ cells mature, they undergo a division and each chromosome of each pair separates so that
each mature egg and sperm will have 23 chromosomes, one of each pair. At fertilization, when
the egg and sperm unite, the fetus then has the normal number of 46 chromosomes.
Although intrinsic fertility cannot be restored in infertile individuals with chromosome
abnormalities; there are currently several assisted reproductive techniques, particularly
intracytoplasmic sperm injection (ICSI) that allow infertile couples to have healthy babies.
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Cystic Fibrosis affects the mucus secretions from the exocrine glands such that abnormally thick
mucus secretions are produced, blocking ducts and body passages. Particularly involved are the
lungs and the intestines, which affect vital body functions such as breathing and digestion. The
disease is inherited in an autosomal recessive manner and either sex is equally affected. Because
the condition is autosomal recessive, both parents of an affected child are asymptomatic
carriers, and therefore have a one in four (or 25%) risk of recurrence in any future pregnancies.
Cystic Fibrosis occurs in about one in 3,300 Caucasian births. To be a carrier of the condition
without a family history of Cystic Fibrosis carries a population risk of one in 25.
Down Syndrome is a specific chromosome defect that occurs in about one in every 800
newborns. Although all pregnancies have a risk for chromosome abnormalities, the risk increases
as a woman gets older. The option of testing the pregnancy for chromosomal abnormalities is
generally offered to women by their obstetrician.
Sickle Cell Anemia is a hereditary chronic form of anemia in which abnormal sickle or
crescent-shaped red blood cells are present. The frequency of the gene that causes this disease
occurs almost exclusively in the African-American population.
Tay Sachs/Canavans, Gaucher (Jewish) and Tay Sachs (French Canadian/Cajun) is an inherited
disease, most common in families of Eastern European Jewish origin and in French Canadian
ancestry. No specific therapy is known. Symptoms are very early onset with progression and
death usually occurring by age three or four.
a Thalassemia and ß- Thalassemia is a group of chronic, hereditary anemias, particularly
common in persons of Mediterranean, African and Southeast Asian ancestry. Clinical features
are similar but vary in severity. The younger the child when the disease appears, the more
unfavorable the outcome.
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Relaxation Techniques
Music Therapy
Slow quiet music can decrease your heart rate, lower your blood pressure, reduce symptoms
of stress and help to put a smile on your face! Bring an MP3 player to the office on procedure
day. Sometimes your favorite music can help you relax during an uncomfortable procedure.
Meditation
There are many forms of meditation. One technique is to repeat a “mantra,” a specific word
or words, throughout the meditation session.
A second is to close your eyes, picture a flowing river and each time a thought enters your
mind, toss it into that river and let it flow away. Meditation requires a certain amount of
instruction and guidance. Performed properly and regularly, it is known to be relaxing
and revitalizing.
Aromatherapy
Try a bubble bath with special aromatherapy oils! People have used warm water to relieve
tension for centuries! If you have had an embryo transfer, water should be no warmer
than body temperature.
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Resources
Egg Donation
Alternative Conceptions
17835 Ventura Blvd.
Suite 307
Encino, CA 91316
The Center for Egg Options
222 N. Sepulveda Blvd.
20th Floor
El Segundo, CA 90245
Creative Conception
23832 Rockfield Blvd.
Suite 255
Lake Forest, CA 92630
The Donor Source
2151 Michelson Dr.
Suite 164
Irvine, CA 92612
Egg Donation, Inc
15821 Ventura Blvd.
Suite 675
Encino, CA 91436
Phone (818) 609-1455
Toll Free (888) 554-GIFT
(888-554-4438)
Fax
(818) 609-1513
Website
E-mail
www.alternativeconceptions.com
[email protected]
Tel
Fax
Website
www.eggoption.com
Phone (949) 597-3191
Toll free (888) 411-EGGS
(888-411-3447)
Fax
(949) 597-3199
Website
E-mail
www.CreativeConceptionInc.com
[email protected]
Phone
(877) 375-8888
Website
E-mail
www.thedonorsource.com
[email protected]
Phone
Fax
(818) 385-0950
(818) 385-0951
Website
E-mail
www.eggdonor.com
[email protected]
Website
E-mail
www.eggdonation.com
[email protected]
Website
E-mail
https://secure.extraconceptions.com
[email protected]
(310) 726-9600
(310) 726-9603
The Egg Donor Program
4184 Colfax Ave.
Studio City, CA 91604
Extraordinary Conceptions
1225 San Elijo Rd.
San Marcos, CA 92078
Phone
Fax
(760) 798-2265
(760) 798-4255
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Egg Donation (continued)
The Genesis Group
9025 Wilshire Blvd.
Suite 215
Beverly Hills, CA 90212
Website:
E-mail
www.genesiseggdonation.com
[email protected]
(for general information)
Fax
(310) 550-6889
(310) 978-7666
(after hours)
(310) 550-6968
Phone
Fax
(818) 505-3026
(818) 505-3028
Website
E-mail
www.giftedjourneys.com
[email protected]
Growing Generations
5757 Wilshire Blvd.
Suite 601
Los Angeles, CA 90036
Phone
Fax
(323) 965-7500
(323) 965-0900
Website
E-mail
www.GrowingGenerations.com
[email protected]
Reproductive Solutions
18686 Cumnock Pl.
Porter Ranch, CA 91326
Phone
(818) 832-1494
Website
E-mail
www.eggreproductive.com
[email protected]
Beverly Hills Egg Donation
468 N. Camden Dr.
Suite 200
Phone
Fax
(310) 601-3132
(310) 694-9063
Website
E-mail
www.bhed.com
[email protected]
Phone
Fax
(323) 965-7500
(323) 965-0900
Website
E-mail
www.growinggenerations.com/
sperm-donor-program/
program-overview
[email protected]
Website
E-mail
www.agency4solutions.com
[email protected]
Gifted Journeys
11122 Landale St.
Phone
Phone
Sperm Donation
Fertility Cryobank
5757 Wilshire Blvd.
Suite 601
Surrogacy
Agency For Surrogacy Solutions, Inc.
16954 Strawberry Dr.
Phone
Encino, CA 91436
Fax
(818) 386-0800
(818) 386-0660
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Surrogacy (continued)
Center for Surrogate Parenting
West Coast Office
Phone
15821 Ventura Blvd.
Fax
Suite 675
Encino, CA 91436
Creative Conception
23832 Rockfield Blvd.
Suite 255
Lake Forest, CA 92630
(818) 788-8288
(818) 981-8287
Phone (949) 597-3191
Toll free (888) 411-EGGS
(888-411-3447)
Fax
(949) 597-3199
Website
www.creatingfamilies.com
Website
E-mail
www.creativeconceptioninc.com
[email protected]
Egg Donor & Surrogacy Institute
10866 Wilshire Blvd.
Phone (310) 209-1898
Website
4th Floor
Toll Free (866) Eggdonation E-mail
(866-344-3662)
Fax
(323) 903-0331
1225 San Elijo Rd.
Growing Generations
5757 Wilshire Blvd.
Suite 601
The Surrogacy Program
4184 Colfax Ave.
www.eggdonoronline.com
[email protected]
Phone
Fax
(760) 798-2265
(760) 798-4255
Website
E-mail
[email protected]
Phone
Fax
(323) 965-7500
(323) 965-0900
Website
E-mail
www.GrowingGenerations.com
[email protected]
Phone
Fax
(818) 506-9300
(818) 506-9763
Website
E-mail
www.surrogacyprogram.com
[email protected]
Phone
(619) 397-0757
Ext 128
(619) 397-0736
Website
E-mail
www.surrogatealternatives.com
[email protected]
Surrogate Alternatives
Office
876 Jetty Ln.
Chula Vista, CA 91914
Fax
Mailing Address
P.O. Box 210368
Chula Vista, CA 91921
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Surrogacy (continued)
Surrogate Parenting Services
P.O. Box 7461
Laguna Niguel, CA 92607
Phone
Fax
(949) 363-9525
(949) 315-3046
Website
E-mail
www.surrogateparenting.com
[email protected]
Phone
(888) 917-3777
Support Line
Website
E-mail
www.theafa.org
[email protected]
Phone
Fax
(703) 379-9178
(703) 379-1593
Website
E-mail
www.inciid.org
[email protected]
(703) 556-7172
(703) 506-3266
Website
E-mail
www.resolve.org
[email protected]
(877) 203-7771
HelpLine
Website
www.southwest.resolve.org
Website
E-mail
www.sidelines.org
[email protected]
Website
E-mail
www.singlemothersbychoice.com
[email protected]
Support Programs
American Fertility Association
305 Madison Ave.
Suite 449
New York, NY 10165
INCIID
P.O. Box 6836
Arlington, VA 22206
RESOLVE - National Headquarters
RESOLVE: The National
Phone
Infertility Association
Fax
1760 Old Meadow Rd.
Suite 500
McLean, VA 22102
RESOLVE - Southwest Region
Phone
Sidelines National High-Risk/Pregnancy Support Network
P. O. Box 1808
Toll Free (888) 447-4754
Laguna Beach, CA 92652
(888-HI-RISK4)
Fax
(949) 497-5598
Single Mothers by Choice (SMC)
P.O. Box 1642
Phone
New York, NY 10028
(212) 988-0993
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Embryo Adoption
Nightlight Christian Adoptions
4430 E. Miraloma Ave.
Phone
Suite B
Fax
Anaheim Hills, CA 92807
(714) 693-5437
(714) 693-5438
Website
E-mail
www.nightlight.org
[email protected]
Website
E-mail
www.ivpcare.com
[email protected]
Toll Free (800) 515-DRUG
(800-515-3784)
Website
E-mail
www.mdrusa.com
[email protected]
Phone
Website
E-mail
http://roxsan.com
[email protected]
Website
E-mail
www.ferring.com
See website
Pharmaceutical Resources
Freedom Fertility Pharmacy
12 Kent Wy.
Byfield, MA 01922
ivpcare
7164 Technology Dr.
Suite 100
Frisco, TX 75034
MDR Pharmaceutical Care
16500 Ventura Blvd.
Encino, CA 91436-2011
Phone
Fax
(800) 660-4283
(888) 660-4283
Phone
Fax
(214) 387-3500
(800) 874-9179
10921 Wilshire Blvd.
Los Angeles, CA 90024-3906
Rox San Pharmacy
465 North Roxbury Dr.
(310) 273-1644
(310) 713-1177
24/7 Pharmacy
Support
Toll Free (888) 371-9919
Fax
(310) 276-4152
Fertility Drug Manufactureres
Ferring Pharmaceuticals
4 Gatehall Dr.
Third Floor
Parsippany, NJ 07054
Phone
Fax
(973) 796-1600
(973) 796-1660
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Fertility Drug Manufactureres (continued)
Schering-Plough
Global Headquarters
2000 Galloping Hill Rd.
Kenilworth, NJ 07033-0530
EMD Serono, Inc.
One Technology Place
Rockland, MA 02370
Phone
(908) 298-4000
Toll Free (800) 283-8088
Medical
Information
Responses
(all hours)
Phone (888) 275-7376
(during normal
business hours)
Fax
(781) 681-2907
Website
www.schering-plough.com
Website
www.emdserono.com
E-mail
[email protected]
Mental Health Professionals
Debbie Freeman, MFT
Licensed Marriage and Family Therapist
1925 Westwood Blvd.
Phone
West Los Angeles, CA 90025
Fax
Richard Reimer, PhD
Licensed Psychologist
3625 E. Thousand Oaks Blvd.
Suite 175
Westlake Village, CA 91362
Ellen Speyer, MFCC
4590 Macarthur Blvd.
Suite 660
Newport Beach, CA 92660
(310) 498-8229
(310) 475-2266
Phone
Fax
(805) 379-5154
(805) 497-0553
Phone
Fax
(949) 252-1525
(949) 851-4347
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Mental Health Professionals (continued)
Carole Lieber Wilkins, MA
Licensed Marriage and Family Therapist
Los Angeles Office
Phone
1460 Westwood Blvd., Suite 204
(310) 470-9049
Website
E-mail
http://lafamilybuilding.com
[email protected]
Calabasas Office
4505 Las Virgenes Rd.
Suite 217
Calabasas, CA 91302
(310) 470-9049
(818) 788-8288
(818) 981-8287
Website
www.creatingfamilies.com
Phone
Fax
(760) 798-2265
(760) 798-4255
Website
E-mail
[email protected]
Phone
Fax
(323) 965-7500
(323) 965-0900
Website
E-mail
www.growinggenerations.com
[email protected]
Phone
(213) 688-6119
Website
E-mail
www.mindbodyinfertility.com
[email protected]
Phone
(949) 412-2466
Phone
Programs for the Gay Community
Center for Surrogate Parenting
Phone
West Coast Office
Center for Surrogate
Fax
Parenting, Inc.
15821 Ventura Blvd. Suite 675
Encino, CA 91436
1225 San Elijo Rd.
Growing Generations
5757 Wilshire Blvd.
Suite 601
Fertility Wellness
The Mind Body Institute
Los Angeles Clinic
UCLA Medical Plaza
Orange County Clinic
5000 Birch St.
West Tower, Suite 3000
Newport Beach, CA92660
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Miscellaneous
American College of Obstetricians & Gynecologists
P.O. Box 96920
Phone (202) 638-5577
Washington, D.C. 20090-6920
Website
E-mail
www.acog.org
[email protected]
Website
E-mail
www.osteopathic.org
[email protected]
(972) 550-0140
(972) 550-0800
Website
E-mail
www.americanpregnancy.org
[email protected]
American Society of Reproductive Medicine
1209 Montgomery Hwy.
Phone (205) 978-5000
Birmingham, AL 35216-2809
Fax
(205) 978-5005
Website
E-mail
www.asrm.org
[email protected]
Website
www.fertilehope.org
www.livestrong.org/survivorcare
Website
E-mail
www.pcosupport.org
[email protected]
Website
E-mail
www.reproductivegenetics.com
online web form
Website
E-mail
www.sart.org
[email protected]
American Osteopathic Association
Chicago Office
Main Headquarters
142 East Ontario St.
Chicago, IL 60611
Phone (312) 202-8000
Toll-free (800) 621-1773
Fax
(312) 202-8200
American Pregnancy Association
1431 Greenway Dr.
Phone
Suite 800
Fax
Irving, TX 75038
Fertile Hope
Phone
(866) 965-7205
Polycystic Ovarian Syndrome Association, Inc.
P.O. Box 3403
Englewood, CO 80111
Reproductive Genetics Institute
Phone
Chicago Office:
2825 North Halsted
Fax
Chicago, Il 60657
(773) 472-4900
(773) 871-5221
Society for Assisted Reproductive Technology
Brooke Denham-Gomez, B.S.
Affiliate Society Manager, Membership
1209 Montgomery Hwy.
Phone (205) 978-5000
Birmingham, AL 35216-2809
Ext 109
Fax
(205) 978-5018.
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Suggested Reading
Potter MD, Daniel A. and Hanin MA, Jennifer S.
What to Do When You Can’t Get Pregnant: The Complete Guide to All the
Technologies for Couples Facing Fertility Problems
Da Capo Press, 2005
Having a baby is the most natural thing we do in life, but that doesn’t mean it’s easy. So where
do you turn when, after months or even years of trying, you just can’t get pregnant? In What to
Do When You Can’t Get Pregnant, world-renowned fertility expert Dr. Daniel A. Potter and
Jennifer S. Hanin, both fertility patients themselves, offer a step-by-step guide to the intricate
process of having a baby using the latest in reproductive technologies.
Rosenthal, M. Sara
The Fertility Sourcebook, Third Edition
McGraw - Hill, 2002
Rosenthal emphasizes the importance of self-education for the infertile couple. She has written
a step-by-step guide to infertility treatment including how to choose the right specialist and
evaluate treatment options. Her approach is comprehensive, yet refreshing. Chapter titles
include “Seven Habits of Highly Infertile People,” “Zen and the Art of Menstrual Cycle
Maintenance” and “What’s the Problem and How Do We Fix It?”
Carter, Jean W. and Carter, Michael
Sweet Grapes: How to Stop Being Infertile and Start Living Again,
Expanded Edition
Perspectives Press, 1998
Simons, Harriet Fishman
Wanting Another Child: Coping with Secondary Infertility, Second Edition
Jossey - Bass, Incorporated Publishers, 2007
American Society of Reproductive Medicine
Various patient information guides available on-line at ASRM.org
Domar, Alice D., PhD and Dreher, Henry
Healing Mind, Healthy Woman: Using the Mind-Body Connection to Manage Stress
and Take Control of Your Life
Delta, 1997
This book offers a new repertoire of therapeutic methods to two broad groups of women: those
who wish to protect and enhance their health, and those who are suffering with specific health
problems. Techniques for stress management and wellness for women defines programs tailored
for women. Their success stories inspire readers with the message that they can use the
mind-body connection to seize control of their health and well-being.
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Thoughts and Considerations
My sister is expecting again! I think she gets pregnant just rubbing up against her husband.
I am so jealous and resentful. I hate myself for feeling this way. Why can’t I be happy for her?
Your feelings are normal and valid. Explore resources such as written material, support
groups or counseling for help.
I know our friends feel uncomfortable around us. They are reluctant to announce their
pregnancies or talk about their kids. We feel like we don’t belong anywhere.
Friends may not know how to react to your infertility. Tell them how they can help you.
Spend time with friends with whom you feel comfortable and retreat when you need
quiet time for yourselves.
It hurts so much when our parents ask about grandchildren. We feel like we are letting
them down.
You are not to blame for your infertility. When you feel ready, let your family and close friends
know that you having trouble getting pregnant. Their support and encouragement can be
extremely helpful.
We have one child but are struggling to conceive our second. People remind us all the time how
lucky we are to have our son. They can’t imagine the pain we feel when he asks why he doesn’t
have a little brother or sister.
Secondary infertility raises new issues. Why don’t you feel satisfied with one child? How
do you explain your frequent physician visits to your curious child? Would you consider
adoption? What was previously a couple’s problem is now a family’s problem. Take care that
you do not deplete your energies and miss the experience of parenting the child you have.
I was the only childless woman at the baby shower. All they talked about was natural childbirth
and pediatricians. Was I supposed to chat about my Pergonal injections? And all those little
baby clothes! I felt like I was going to cry.
Take control of your social life. Decline invitations to functions you think might upset you. If
you decide to attend, plan your exit in advance. Leave early if the situation becomes intolerable. No explanations are required!
If one more person tells me I’ll get pregnant if I just relax, I’m going to scream!
Well-intentioned people have an endless supply of fertility advice. You maintain some
control by choosing with whom to share this very personal part of your life. For example, it
might be helpful for your mother to know that relaxation will not open blocked fallopian
tubes. On the other hand, there may be no benefit to discussing your fertility problems
with the receptionist at your office.
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I’ve been offered a promotion at work, but what if I get pregnant next month?
Do not let your “maybe baby” run your life. Putting key decisions on hold will only intensify
the disappointment and frustration you will experience if months pass and you are still
not pregnant.
My prayers go unanswered. I feel abandoned by God.
Religious faith will be tested by infertility. God is not punishing you for sins, real or imagined.
Sometimes bad things just happen. Instead of asking God for a baby, try praying for
patience, strength and hope. Pastoral counseling can be helpful in these situations.
My wife is obsessed with trying to get pregnant. I want to look into adoption, but she insists
on trying IVF for a third time. I dread the thought of going through another cycle.
Modern technology is a mixed blessing. It can give you your miracle baby, but it can also
make the decision to stop treatment very difficult. One partner may be ready to explore
alternatives before the other. Making a treatment plan with your physician with an agreedupon end point can help. A counselor can help identify options acceptable to both of you.
HRC HOPE 08/03/11
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You and Your Partner
I
nfertility may be the first life crisis you face together. Your shared dream of starting a family
now includes your physician, insurance company and an assortment of invasive tests and
medications. You find yourself planning your life around your treatment cycles and having
sex by prescription only. It is no wonder that infertility can put a terrible strain on even the
best of relationships.
Intimacy
Remind each other that infertility won’t last forever. Accept that sex for procreation can be
mechanical and not very satisfying at times. How about making love on a “non-fertile” day?
Spend a night in a hotel. Experiment with new and different sexual techniques. You may need to
take a break from sexual activity and maintain closeness in other ways. Most importantly, don’t
forget why you chose to spend your lives together. Make time for the things you enjoy doing as
a couple. Express your love, and work together to support and understand each other through
this difficult time.
Communication
Good communication can help you better manage all aspects of infertility and treatment, but it
is essential between partners. You may not share the same feelings, opinions and perceptions
about infertility. Remember that all feelings are valid. Avoid the tendency to think that you
are right; try and view infertility issues from your partner’s perspective. Don’t blame or pass
judgment. Accept differences and talk about them.
The fact that most couples say they talk to each other does not mean they know how to
communicate effectively. There are skills you can learn to help you express your true thoughts
and feelings in positive ways that are not perceived as criticisms or attacks. Sometimes good
communication involves “just” listening; being able to really hear what is being said without
interrupting, passing judgment or giving advice.
Many current publications focus on gender differences in the ways men and women relate to
each other. Recognizing and accepting these differences can be helpful, particularly during
stressful times. Try to see the different styles as complementary, not adversarial. Combine the
best of both stereotypical gender traits — the sensitive, understanding female and the logical,
problem-solving male — to strengthen your relationship.
Try non-verbal techniques when words aren’t working. Touching, quiet holding, snuggling and
massage can all convey feelings when words cannot.
Consider counseling if either you or your partner is having difficulty expressing or handling
feelings, or if communication between the two of you is very difficult or non-existent. The
objectivity of a trained professional can be extremely helpful in these situations.
HRC HOPE 08/03/11
99

HRC Fertility`s Guide To

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