Treatment Plan Page1 TREATMENT PLAN TREATMENT PLAN TYPE TREATMENT PLANNED. New Update Management Review Committee
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1 Treatment Plan Page1 TREATMENT PLAN TREATMENT PLAN TYPE New Update Management Review Committee TREATMENT PLANNED Diagnostic Cycle Natural Cycle CCT Ovulation Induction CC Gonadotropins Letrozole Metformin Metformin plus Other: IUI Natural Cycles CCT CC COH Gonadotropins COH Letrozole Metformin Metformin plus Other: Donor Insemination Natural Cycles CC COH Gonadotropin COH Letrozole Metformin Metformin plus Other: IVF Conventional insemination ICSI NSA Testicular biopsy Split ICSI/Conventional Insemination PGD Aneuploidy Single Gene Defect Translocation Family Balancing with PGD & MicroSort X for female with PGD & MicroSort Y for male with PGD only for female with PGD only for male Donor Egg Family Balancing MicroSort X (desires female)
2 Treatment Plan Page2 Y (desires male) PGD and MicroSort X (desires female) Y (desires male) PGD only X (desires female) Y (desires male) ICSI NSA Testicular biopsy Split ICSI/Conventional Insemination Donor Sperm Gestational Surrogacy Egg donor anonymous designated (known) Surgery Surgery Gestational surrogacy with IVF Conventional insemination ICSI NSA Testicular biopsy Split ICSI/Conventional Insemination with Donor Egg Conventional insemination ICSI NSA Testicular biopsy Split ICSI/Conventional Insemination True Surrogacy IUI IVF Conventional insemination ICSI NSA Testicular biopsy Split ICSI/Conventional Insemination Expectant Management CYCLE DAY 2-5 LABS CCT (FSH, LH, E2, Baseline US) FSH LH E2 P4 Baseline Ultrasound (AFC & Ovarian Volume) CYCLE DAY 7-12 LABS CCT (d10 FSH) HSG Hx of PID or Hydrosalpinx Recommend Doxycycline prophylaxis
3 Treatment Plan Page3 SHG beginning the day before HSG and for 5 days day of procedure Hx of PID or Hydrosalpinx Recommend Doxycycline prophylaxis beginning the day before SHG and for 5 days day of procedure CYCLE DAY Trial Transfer Cervical Cultures Gonorrhea/Chlamydia General Genital LABS ANY DAY HIV 1&2 Hep BsAg Hep C Ab RPR for female for male for both partners for female for male for both partners for female for male for both partners for female for male for both partners CBC TSH Prolactin BASELINE LABS ONLY ONCE Rubella titer Varicella titer Blood type and Rh MOCK CYCLE for donor egg recipient for gestational surrogate LABS (MALE) SA with strict morphology AR Test 24 hour motility test Semen Cultures Neisseria gonorrhea Chlamydia Aerobic bacteria Hormone Profile Testosterone FSH LH
4 Treatment Plan Page4 E2 Prolactin Karyotype Y-micro deletion assay LABS (REPRO ENDO) Day 3 FSH CCT E2 P4 LH Prolactin hcg TSH T4 TFT panel Testosterone DHEAS SHBG hgh 17OH-P4 ACTH Stim test CAH Stim Test LABS (AUTOIMMUNE) ACL ANA LAC APA Thyroid Antibodies LABS (ID) HIV 1&2 Both partners Female partner Male partner Hep B sag Both partners Female partner Male partner Hep C Antibody Both partners Female partner Male partner VDRL Both partners Female partner Male partner CMV Chlamydia IgG Chlamydia IgM Syphyllis (RPR) Female partner Male partner
5 Treatment Plan Page5 LABS (METABOLIC) Fasting Glucose and Insulin AM Cortisol Lipid Profile ACTH Stim Test CAH Stim Test LABS (RPL) CD 3 FSH CCT LH E2 PRL TSH T4 ACA APA LAC MTHFR mutation Protein S Protein C Factor V Leiden Karotype Female Karyotype Male HSG SHG LABS (PG & PRENATAL) Serial HCG levels (every 3 days) Ectopic screen (serum HCG & pelvic US) hcg Type and Screen CBC Rubella RPR Hep B sag Hep C Ab HIV Varicella LABS (GENETIC) Karyotype Female Karyotype Male Y-del Assay CF Tay Sachs Gauchers Canavans Hgb Electrophoresis LABS (PRE-OP) CBC PT PTT Blood Type & Screen
6 Treatment Plan Page6 HSG DIAGNOSTIC PROCEDURES (FEMALE) Basic Ultrasound Baseline (CD 2-4) Antral Follicle Count Diagnostic pelvic scan Rule out SHG Hx of PID or Hydrosalpinx Recommend Doxycycline prophylaxis beginning the day before SHG and for 5 days day of procedure HSG Hx of PID or Hydrosalpinx Recommend Doxycycline prophylaxis beginning the day before SHG and for 5 days day of procedure Endometrial Biopsy call and schedule 7-8 days after LH surge (OPK) call and schedule on CD 21 with Integrin assay DEXA scan Mammogram SEMEN CRYOPRESERVATION LABS HIV 1&2 HTLV Hep B sag Hep C Ab RPR Semen Culture for GC & Chlamydia EXPECTANT MANAGEMENT Recommend expectant management for: Patient requests expectant managment for: PSYCHOLOGICAL EVAL & SERVICES Schedule psychological evaluation Obtain psych medical records SUPPORT SERVICES Refer for the Mind-Body Relaxation class Informed of 10 week class Separate fee charged by class instructor Refer for Acupuncture services ART CLASS & TRAINING Schedule orientation class with nursing staff Schedule injection training class with nursing staff SMOKING CESSATION RECOMMENDED Patient Partner Both partners CONSULTS
7 Treatment Plan Page7 Primary care Routine gynecology for annual exam and/or pap smear Andrology - Dr Opsahl Andrology - Urologist Andrology - Endocrinologist Maternal Fetal Medicine consult for High-Risk pregnancy Maternal Fetal Medicine consult for preconception counseling Genetics counseling before PGD for genetic diseases Gynecologic Oncology consult indication: Pelvic surgery consult indication: Other consult: indication: FOLLOW-UP APPOINTMENTS Complete recommended tests then return to discuss Fillin specific recommendations: Next cycle after andrology consultation after surgery to complete conversation (inadequate time to answer all questions) after psychological counseling Patient will return as needed Financial Counseling Medical Assistant/Nursing Consult
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Patient Price List. t: e: w:
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Cycle Plan Page1 CYCLE PLAN TYPE CYCLE TYPE: Initial Plan Updated Plan Management Team Review Monitoring Review
Cycle Plan Page1 CYCLE PLAN TYPE Initial Plan Updated Plan Management Team Review Monitoring Review CYCLE TYPE: Undecided - diagnostic testing only Natural Cycle Coitus with IUI Ovulation Induction CC
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