Microdose Flare Protocol

Microdose Flare Protocol

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 stimulation meds. Tylenol and Tylenol cold products are okay to take.

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

Contents of Packets Calendar Medication/Injection instruction sheets (Gonal-f or Follistim) Night of HCG Instruction/Preparation sheets (purple and blue) Lupron/Leuprolide hot pink 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

Calendar Calendar is your bible during an IVF cycle Make copies to keep at work, in 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.

Calendar If Oral Contraceptive Pills are in 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) 259-0692 Option #2. You will begin Oral Contraceptive Pills the evening of the second day.

Calendar If Oral Contraceptive Pills (birth control pills) are not in protocol: You will call IVF coordinator at (813) 259-0692 Option #2 on cycle day 1 (full flow by noon) to schedule baseline ultrasound/lab work appointment on cycle day 2 or 3.

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 (Tuesday- Friday) LAK- Lakeland Lakeland OB-GYN 1733 Lakeland Hills Blvd (M-F) DMP- Doctors Medical Plaza 6450 38 th Ave North suite 200 (M-F) WC- 2718 Windguard Circle, Suite 101 Wesley Chapel, FL 33544 (M-F) Sunday Monday Tuesday Wednesday Thursday Friday Saturday Ultrasound and blood work at @ am Nurse will call with results? Stop Birth Control Pill Please call and leave message with cycle day 1 of your next menses 813-259-0692 option #2 AM PM AM PM 300 AM PM 300 AM PM 300 AM PM AM Ultrasound and blood work at @ am Nurse will call with results PM AM PM AM PM AM PM AM PM Call with onset of withdrawal bleed to arrange frozen embryo transfer which will occur 1-2 months later AM PM AM PM? HCG @? Start Doxycycline twice a day x7 days?stop? Egg Retrieval @ TGH? Collection? fertilization results 5 to 6 days after retrieval embryology lab will call with freezing results

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).

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 6450 38th Ave North suite 200 (M F) WC- Wesley Chapel 2718 Windguard Circle Unit 101(M-F)

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

Calendar Once treatment begins: All communication must be done through the IVF coordinators line (813)259-0692, 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)259-0692, option 6 and is located on your calendar.

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**

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 6 7 lab and ultrasound appointments before retrieval. It is individualized to how each patient responds to their protocol. Your ovaries are the boss!

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.

Lupron/Leuprolide: Regular dose Lupron is used initially to quiet down the ovaries, prior to beginning stimulation medications. However, with a microdose flare protocol, Lupron works with fertility medications to stimulate ovaries. After stimulation medications are initiated, Lupron changes action to inhibit premature ovulation. These are the brakes that temper the speed of follicle production.

Lupron/Leuprolide Store medication in refrigerator Administered in subcutaneous tissue of abdomen (two fingers below navel down to top of pubic bone, and hip to hip) You will be instructed when to begin medication, and will administer it in the morning (between 7-10 am) AND evening (between 7-10 pm). You select the time, but need to be consistent. You have a 30-60 minute window before and after your selected time to administer (ie if you choose to administer at 7:00, you can give it as early at 6:00 or as late as 8:00) DO NOT START THIS MEDICATION UNTIL INSTRUCTED BY OUR OFFICE! Once initiated, you will take this medication EVERY morning and EVERY evening until instructed to stop by the IVF Coordinator. Please review the instructional video; to view, hover over the black box below

Stimulation Medication Gonal-F OR Follistim and Menopur These are the gas that drive ovaries to produce eggs *Administered in the evening (between 7-10 pm). *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)

Stimulation Medication Gonal F: 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 dial number remaining in window on new pen and administer another injection. Please review instructional video below; to view video, hover over white box below

Stimulation Medication Follistim: (if you are NOT using Gonal-F) 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.

Stimulation Medications Menopur: 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.

Stimulation Medications Menopur: Please use the link below to view instructional video on Menopur https://www.ferringfertility.com/products/menopur/

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.

HCG This is the trigger shot that signals to body to initiate ovulation process. (HCG, Novarel, Pregnyl) ***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)

HCG trigger shot Please review the instructional videos below; to view hover over black boxes below Video 1 Video 2

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.

Retrieval Scheduled exactly 36 hours after HCG and is done under IV sedation using ultrasound guidance. Takes about 30 minutes You and your significant other 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.

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

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)

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 receive a call 6 7 days post retrieval as well to advise you of how many embryos are being frozen. If doing PGS/PGD testing, IVF Coordinator will advise of next steps.

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, and were able to be biopsied, and frozen.

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

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) 844 7688 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

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.

Questions?? While in cycle (on IVF medications), any questions can be directed to IVF Coordinator of the day at: Main IVF number (813) 259-0692 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) 259-0924 Dr. Imudia and Dr. Henne patients: Kristin LaMar (813) 259-0973