ANTAGONIST INJECTION PROTOCOL

Transcription

1 ANTAGONIST INJECTION PROTOCOL

2 DO s and DON Ts DO Avoid high impact exercise (spinning, running, Zumba etc.) Low impact exercise okay (swimming, walking, etc.) Okay to have sex while on stimulation medications, based upon comfort level. Unless one of our MDs states otherwise, DO avoid Motrin, Advil, Aleve, Aspirin products while on stim meds. Tylenol and Tylenol cold products are okay.

3 Protocols Protocols are determined by physician, based on a patient s ovarian reserve testing, antral follicle count, age and/or previous IVF history.

4 Contents of Packets Calendar Medication/Injection instruction sheets (Gonal-f or Follistim, Menopur, Ganirelix or Cetrotide) Night of HCG Instruction/Preparation sheets (purple and blue) Leuprolide yellow instruction sheet and salmon color night of leuprolide instruction sheet Post Egg Retrieval and Post Embryo Transfer sheets (no post transfer sheet if doing PGS) Crinone instruction sheet if not doing PGS Medication List Original rx for Tylenol #3 (taken as needed for post retrieval pain) and Valium (for immediate pre transfer relaxation of anxiety and muscles) unless contraindicated due to allergy

5 Calendar Calendar is your bible during an IVF cycle Make copies to keep at work, in your purse, and a copy with your partner. During IVF cycle, you must be available to receive instructions from IVF nurse by 4 p.m. every time you come in for a monitoring appointment.

6 Calendar If Oral Contraceptive Pills are in the protocol, you will call IVF coordinator line on cycle day 1 (day one is full flow before noon), to report the start of your menses. (813) Option #2. You will begin Oral Contraceptive Pills the evening of the second day.

7 Calendar If Oral Contraceptive Pills (birth control pills) are not in the protocol: You will call IVF coordinator at (813) Option #2 on cycle day 1 (full flow by noon) to schedule baseline ultrasound/lab work appointment on cycle day 2 or 3.

8 . EXAMPLE OF PROTOCOL CALENDAR USF IVF Start Birth Control Pill in pm Ultrasound and Bloodwork monitoring locations SC-South Campus USF Health South Tampa 2 Tampa General Circle, 4th floor (open weekends and holidays) SAR- Sarasota PCCR 1617 South Tuttle Ave suite 2B (M-Th) LAK- Lakeland Lakeland OB-GYN 1733 Lakeland Hills Blvd (M-F) DMP- St.Pete Doctors Medical Plaza th Ave North suite 200 (M F) WC Windguard Circle Unit 101(M-F) Sunday Monday Tuesday Wednesday Thursday Friday Saturday Ultrasound and blood work am Nurse will call with results? Stop Birth Control Pill Please call and leave message with cycle day 1 of your next menses option #2. PM PM PM PM Ultrasound and blood work am Nurse will call with results PM? Ganirelix AM Ganirelix PM AM Ganirelix PM? Start Crinone vaginally in the morning. continue each day as directed AM Ganirelix PM? Diazepam one hour before transfer with 32 oz. of fluids??embryo TGH Take another Crinone after the transfer for an additional dose today. Then continue once daily. AM Ganirelix PM AM Ganirelix PM? Start Doxycycline twice a day x7 days?stop? Diazepam one hour before transfer with 32 oz. of fluids??embryo TGH Take another Crinone after the transfer for an additional dose today. Then continue once daily.? Egg TGH? Collection? Lab will call with Fertilization results.

9 Calendar Monitoring locations/addresses are on top of your calendar. You can usually monitor at location of choice during the week, as long as there are open appointments. All weekend/holiday appointments are only at SC (South Campus).

10 MONITORING LOCATIONS USF IVF Ultrasound and Bloodwork monitoring locations SC-South Campus USF Health South Tampa 2 Tampa General Circle, 4th floor (open weekends and holidays) SAR- Sarasota PCCR 1617 South Tuttle Ave suite 2B (M-Th) LAK- Lakeland Lakeland OB-GYN 1733 Lakeland Hills Blvd (M-F) DMP- St.Pete Doctors Medical Plaza th Ave North suite 200 (M F) WC- Wesley Chapel 2718 Windguard Circle Unit 101(M-F)

11 Calendar Once treatment begins, you MUST be available at all times! No traveling out of local area while on stimulation medications.

12 Calendar Once treatment begins: All communication must be done through the IVF coordinators line (813) , Option 2. This line is checked weekdays until 4 p.m. and weekends or holidays until 2 p.m. Any urgent matters after these hours are to be addressed by calling the same main number and choosing option to page physician on call. This number is (813) , option 6 and is located on your calendar.

13 Calendar All follicle monitoring appointments are scheduled in the morning to allow for processing of ultrasound and lab results to be reviewed by physician for cycle management instructions. Each visit you come in, you will receive a call from the IVF coordinators in the early afternoon to go over your medication dosages and your next appointment date and time. **It is important that you are easily reachable on these days**

14 Calendar The first two ultrasound and lab appointments are predictable and are set on your calendar. The following appointments are determined by individual follicular development and physician orders. There is no set number of appointments, but you can anticipate an additional 6 7 lab and ultrasound appointments prior to retrieval. It is individualized to how each patient responds to their protocol. Your ovaries are the boss!

15 Calendar It is important to know that this calendar is only a tool to plan your IVF cycle. Dates are tentative! This means any blanks or question marks on your calendar will be advised after each appointment. It is not known when your egg retrieval will be until 2 days prior.

16 Stimulation Medications These are the gas that drive ovaries to produce eggs (Gonal F or Follistim and Menopur) *Administered at night (between 7-10pm). *You select the time, but need to be consistent (30-60 min window on either side of time. i.e. if you choose 7:00, you can administer as early as 6:00 or as late as 8:00) *Administered in subcutaneous tissue of abdomen (two fingers below navel down to top of pubic bone, and hip to hip)

17 Gonal F: Store medication in refrigerator Stimulation Medications Use a new needle for each injection Please review instructional video below; to view video, hover over white box below Check dosage window before and after administration to make sure it reads 0. If it does NOT after injection, check to see if pen is empty. If it is, you must dial number remaining in window on new pen and administer another injection.

18 Stimulation Medications Follistim: Store medication in refrigerator Use a new needle for each injection Check dosage window before and after administration, to make sure it reads 0. If it does NOT after injection, check to see if pen is empty. If it is, you must insert new cartridge in pen device and administer injection. This pen remembers the dose that still needs to be given with the new cartridge inserted. *Please review instructional video: to view, hover over black box to the right.

19 Menopur: Stimulation Medications Regardless of dose, you will only mix with 1ml/cc of liquid (sodium chloride provided) PLEASE NOTE THIS VIAL HAS 2 ML/CC OF LIQUID. YOU ARE ONLY TO USE 1 ML/CC TO MIX INTO YOUR POWDER Use Q cap attached to 3cc/ml syringe to mix, and short 27g ½ needle to inject. Please view the training video on Menopur administration at:

20 Antagonist Medications These are the brakes that temper speed of production, in order to prevent premature ovulation. (Ganirelix OR Cetrotide)

21 Antagonist Medications DO NOT START THIS MEDICATION UNTIL INSTRUCTED BY OUR OFFICE Administered in subcutaneous tissue of abdomen. First injection you may be instructed to administer at night, as directed by the IVF coordinator. Otherwise it will be given daily in the morning (between 7-10am). You can select the time, but need to be consistent. You have a minute window before/after the time you have chosen to give medication. For example, if you pick 7:00 am, you can give it as early as 6:00 or as late as 8:00.

22 Antagonist Medications After your monitoring appointment (ultrasound and bloodwork), the physician will review results, and advise if ovarian development is sufficient to begin antagonist medication. The coordinator will call that afternoon and advise you on when to begin medications. Once initiated, you will take this medication every morning, until told to stop by the coordinator!

23 Antagonist Medications Ganirelix Pull off the rubber top. Slowly and carefully push plunger of syringe up to advance air to top of syringe. Continue pushing up until you see tiny drop of medication at top of needle then stop. Prepare injection site on lower abdomen (2 fingers below umbilicus, hip bone to hip bone). Inject medication as directed.

24 Ganirelix Please review the instructional video on Ganirelix administration; to view hover over the black box to the right

25 Antagonist Medications Cetrotide: Prefilled syringe of diluent Attach the long needle to the syringe Insert needle into vial with powder Mix/swirl gently until mixture is clear Remove long needle from syringe Attach short needle to syringe Gently and carefully push up on plunger of syringe until small bead of medication appears at the tip Inject in abdomen with short needle. Please review instructional video; to view hover over black box on right

26 Ready to go to the show! Once the physician doing cycle management has determined that maximum follicular development has been achieved: An order will be given to initiate the ovulation process with a trigger shot(s) For most patients this will be done with a medication called HCG (chorionic gonadotropin) Ovulation occurs 40 hours after HCG injection The egg retrieval will be scheduled exactly 36 hours after the injection of HCG.

27 Trigger shot At times, based on estrogen levels, another medication called Leuprolide may be used instead of HCG for your trigger. If Leuprolide is used, it is a two part injection: You will be instructed to draw up 80 units into a syringe, administer exactly 36 hours prior to retrieval. Then you will be instructed to administer a second 80 units (12 hours later) which will be exactly 24 hours prior to retrieval. **Leuprolide is already mixed and you will draw-up using a 100 unit insulin syringe

28 HCG or Leuprolide This is the trigger shot that signals to body to initiate ovulation process. (HCG, Novarel, Pregnyl, Ovidrel) or Leuprolide based on stimulation and MD decision. ***These are timed injections*** The coordinator will tell you the exact time to administer. Medication is administered in subcutaneous tissue of abdomen (same place as other injections).

29 HCG or Leuprolide HCG you will mix with 1 cc/ml of liquid provided with long needle Prime air out of syringe to top of needle Inject with short needle Please review the instructional videos below; to view hover over black boxes below. Video 1 Video 2

30 Ovidrel trigger shot In certain circumstances, your trigger shot may be Ovidrel, a form of HCG. Medication is administered in subcutaneous tissue of abdomen (same place as other injections). The IVF coordinator will instruct you on when to administer the injection. Please review the instructional video on the right. To view, hover over the black box.

31 Retrieval Scheduled exactly 36 hours after HCG or first Leuprolide injection and is done under IV sedation using ultrasound guidance. Takes about 30 minutes. You and your spouse/significant other are required to be at TGH 1 ½ hours prior to procedure. You will receive detailed instructions from the IVF coordinator regarding the retrieval when you are triggered.

32 Retrieval You will be taken back to pre op area; during this time, our embryologist will, if applicable, take your spouse/significant other to collection room to obtain sample. You must have known family member or significant other to transport you to/from hospital.

33 Retrieval After retrieval, you will be sent home to rest the remainder of day, and are to follow instructions on Post Egg Retrieval sheet. Take Tylenol #3 as needed for discomfort/pain. You will receive a call from the embryologist and IVF coordinator the day after retrieval. Embryologist will advise you of number of eggs that normally fertilized. You will also receive a call from the embryology lab 6 7 days after retrieval advising how many embryos will be frozen. If doing PGS/PGD testing, IVF Coordinator will advise of next steps.

34 Retrieval without PGS/PGD testing Based upon fertilization results, IVF coordinator will: Call and advise you of whether transfer will be scheduled for day 3 or day 5 post retrieval (if doing fresh transfer). Give hospital information for transfer Discuss timing of initiation of Crinone/progesterone (your purple sheet)

35 Retrieval with PGS/PGD testing If you are having PGS testing done on embryo(s), you will be advised regarding instructions for setting up future frozen embryo transfer cycle. If PGS is being done, you will receive a call from embryology lab 6 days post retrieval to advise how many embryos reached blastocyst stage, were able to be biopsied, and frozen.

36 If a fresh transfer has occurred: Transfer a BHCG (blood pregnancy test) will be scheduled for approximately 15 days after the retrieval. This will be scheduled by IVF coordinator. If doing frozen embryo transfer at a future date, BHCG (blood pregnancy test) timing will be discussed during cycle management by IVF Coordinator.

37 Medication List Included in the packet, you have a list of medications and where they were sent to: If you are using TGH pharmacy: You are to make sure when you pick up medications at TGH pharmacy you are to tell pharmacy staff that they are to use TGH special pricing Point of contact at TGH pharmacy is Helen (813) Option 2, Option 0 We strongly advise you to use the list as an inventory tool to be sure all medications/syringes/needles are included to reduce number of trips to pharmacy for forgotten items. Please call pharmacy 2 3 days ahead of pick up to ensure they have your items ready when you arrive. If you have a mail order pharmacy: Please be sure you have received all necessary medications in a timely manner to begin your cycle Please check to be sure syringes/needles have been included

38 Original Written Prescriptions Included in your packet may be written prescriptions for: Tylenol #3 for post retrieval pain as needed unless noted allergy to medication Valium for pre transfer relaxation of muscles and anxiety unless noted allergy to medication These prescriptions can be dropped off at your local pharmacy as they are not part of the TGH special pricing grant.

39 While in cycle (on IVF medications), any questions can be directed to IVF Coordinator of the day at: Main IVF number (813) Option 2 Questions during work-up phase need to be directed to your individual IVF Coordinator: Dr. Plosker and Dr. Mayer patients: Joy Taylor (813) Dr. Imudia and Dr. Henne patients: Kristin LaMar (813) Questions???