Introduction

2. Introduction Class 8-10:15 Social Worker 10:15-10:30 To CRM after class Brief meeting with a nurse Go over your cycle instructions and injection teaching

3. Introduction Red Folder Individual order sheet Lab slip, U/S requisitions, stickers IVF Booklet Consent forms Pharmacy flyers Miscellaneous information

4. Treatment Overview Don�t compare cycles Different Meds Different Monitoring Different Protocols

5. Treatment Overview What is IVF Starts the month prior to the stimulation Lasts 8 weeks Medication for 6 weeks

6. Treatment Overview What is IVF Stimulate the ovaries to mature many eggs at once Remove eggs Mix with sperm Incubate fertilized eggs Return to the uterus

7. Medications Suppression Therapy OCP Start d1-3 Inhibits LH & FSH Regulate cycles, active pills only Side effects Early pregnancy symptoms Breakthrough bleeding

8. Medications Suppression Therapy Lupron Suppress LH, FSH, estrogen, and progesterone Better quality eggs Stop ovulation

9. Medications

10. Medications Suppression Therapy Ganarelix/Cetrotide Stop LH immediately Once a day injection Fewer shots Side Effects: headache, nausea

11. Medications Stimulation Therapy Gonal-F, Follistim, Bravelle, Repronex Creation of many follicles Once or twice a day injection Side Effects: Mood swings Ovarian Hyperstimulation Syndrome (OHSS)

12. Medications Preparation for Retrieval HCG, Pregnyl, Novarel Final maturing of eggs Given: 36 hours before egg retrieval Estradiol level is at least 600 4 follicles (2 follicles 18mm) Risk: early ovulation, OHSS

13. Medications Post Retrieval Therapy Progesterone Supports the lining of the uterus Injectable May delay period Continue even if bleeding starts Mixed in peanut or sesame oil - be aware of allergies Side effects similar to pregnancy

14. Medications Post Retrieval Therapy Doxycycline - antibiotic All patients Pills Medrol - anti-inflammatory ICSI, AH, PGD patients Pills

15. Monitoring Instructions U/S and Blood work Vaginal probe U/S to check size and number of follicles Blood test for estradiol and/or progesterone

16. Monitoring Instructions Where/when Weekdays 7-8a in U/S L-1 for U/S and bloods 7-9a 3rd floor for bloods only Weekends 7:30-8:30a in U/S L-1 for U/S and bloods

17. Monitoring Instructions Satellites 850 Boylston (weekdays only) North Shore Women�s Health Center Exeter, NH Newton Wellesley Hospital Must do all testing Tell your nurse Register at satellite Call satellite the day before each test

18. Monitoring Instructions

19. Monitoring Instructions �Rounds� with doctors by 2p Call with new orders by 5:30p If there is no call by 5:30p, call the IVF doctor on call

20. Pre-Operative Appointment During the stimulation Meet with MD and anesthesiologist to sign surgical consents On a testing day if BWH patient On a nontesting day if testing at a satellite

21. Day of Egg Retrieval Admission to 5C NPO after midnight the night before Hospital blue card Arrive 5C 1 hr before ER Admit to pre-op/recovery area Change into a hospital gown IV started Couple together pre/post op

22. Day of Egg Retrieval By stretcher to the operating room Anesthesia: general or spinal Feet in stirrups U/S guidance Needle inserted into each follicle, fluid removed by suction Fluid passed to embryologists who remove eggs from the fluid By stretcher to the recovery room

23. Day of Egg Retrieval Sperm collection Ejaculation within 1 week before the egg retrieval Abstain after HCG shot Bring hospital blue card and a picture ID

24. Day of Egg Retrieval Sperm collection Produce specimen During egg retrieval Private room on 5C Fill out paperwork and label specimen container No lubricants

25. Day of Egg Retrieval Sperm collection If you need to be together or produce at home notify your nurse If you anticipate a problem with production, consider freezing specimens before the cycle starts

26. Day of Egg Retrieval Post op recovery 1-2 hours Need a ride home May feel groggy, sore, backache Pain medication prescription Start antibiotics; also medrol if ICSI, PGD, AH

27. Day of Egg Retrieval Post op recovery Fertilization call the next day Start progesterone Take it easy for 48 hours

28. Day of Embryo Transfer You will get a call the afternoon before with the transfer time Eat lightly Arrive 1 hour before transfer time Do not empty your bladder

29. Day of Embryo Transfer

30. Day of Embryo Transfer Day 5 transfer It is not for everyone Age <40 No egg or sperm manipulation Initial fertilization > 8 Day 3: > 3 growing well

31. Day of Embryo Transfer

32. Post Embryo Transfer Instructions Pregnancy Test Approximately 18 days after egg retrieval If you have bleeding, do not stop progesterone Cycle review after negative test or +FH

33. Additional Information Consents Multiple consent forms Some consents need a witness or a notary Cannot start cycle without consents SIGN TODAY � if possible

34. Additional Information Embryo freezing Sign consents Freeze good quality embryos Notification if you have frozen embryos Cryo embryo transfer cycle (CET) Insurance company may require it

35. Additional Information Emergencies If an emergency arises Call the office at 617-732-4222 Press #1 and ask for �F & E fellow on call� Stay on the line or leave a call back number and the physician will return your call

36. Additional Information Cancellation Poor response to medication Estrogen level and follicle number don�t match Missed testing or medication Ovulation before egg retrieval No fertilization Arrested development of embryos

37. Possible Complications of ART Multiple pregnancy OHSS Infection at injection or operation site Ectopic (tubal) pregnancy Ovarian torsion (twisting) Medication side effects Surgical risks

38. Pharmacy Information We will fax/call orders to pharmacy Insurance company requirements Prior authorization Discuss pharmacy with RN

39. Typical Cycle Call with your period Suppression therapy Baseline U/S and/or blood Start stimulation 7-14 days later HCG 36 hours later ER 3-5 days later ET 16 days later pregnancy test