1. Instructions for Ovulation Induction Center for Infertility and Reproductive Surgery

2. Table of contents Click on an item below to go directly to that page. Once there, hit the arrow on the page to get back to the table of contents. 1.What is Ovulation Induction……….3What is Ovulation Induction 2.Ovulation Induction and IUI……….4Ovulation Induction and IUI 3.Medications – Stimulation……...….7Medications – Stimulation 4.Medications – Prepare for IUI..……8Medications – Prepare for IUI 5.Medication Administration…...……9Medication Administration 6.Monitoring…………………………11Monitoring 7.Daily Cycle Instructions…………...16Daily Cycle Instructions 8.Complications …………………..…17Complications 9.Cycle Cancellation ……...…………18Cycle Cancellation 10.Emergencies………………………..19Emergencies 11.Nurse Appointment………………...20Nurse Appointment 12.Other Medications………………….21Other Medications

3. What is Ovulation Induction?  Injectable medicine to stimulate a woman’s ovaries to mature more than one egg in a month  Monitoring with blood tests and ultrasound  A different injectable medicine to mature the egg(s) and cause ovulation  Sperm insemination (IUI) or timely intercourse

4. Ovulation Induction and IUI  Start instructions Call with your period day 1 Have an ultrasound on day 2 or 3 Start stimulation medicine after instructed to - day 3 between 6-9pm Day 7 or 8 have an estradiol blood test and an ultrasound More testing based on the response to the stimulation medicine

5. Ovulation Induction and IUI  Ready for Ovulation MD orders trigger shot – HCG medicine  HCG shot at midnight  Partner in to the Reproductive Endocrinology Lab 2 days later between 8-9a to produce a sperm specimen  IUI at noon the same day  (For example: HCG midnight Monday, IUI Wednesday)

6. Ovulation Induction and IUI  What’s next? If you have:  No period 2 weeks after the IUI, call your nurse to schedule a pregnancy test  An abnormal period, call your nurse  A normal period, call your nurse and begin the next cycle with an ultrasound on day 2 or 3

7. Medications  Stimulation Therapy Gonal-F, Follistim, Bravelle Repronex, Menopur  Maturing of many eggs  Once or twice a day injection  Side Effects/risks:  Mood swings  Bloating  Ovarian hyperstimulation

8. Medications  Preparation for IUI – trigger shot HCG, Pregnyl, Novarel  Final maturing of eggs in preparation for ovulation  Given: at midnight  Risks:  Early ovulation  Ovarian hyperstimulation

9. Subcutaneous (small needle) injection Clean the injection site with an alcohol wipe by rubbing in a circular motion. Remove the needle cap. Pinch the injection site with one hand. Using the other hand, quickly insert the needle straight in as far as it will go. Inject the medication by pushing the plunger down to empty the syringe. Remove the needle. Rub the area in a circular motion to massage the medication. Dispose of the syringe in a “sharps” container. If you see blood or a small amount of fluid at the injection site, simply wipe the site with the alcohol wipe and apply light pressure. Medication Administration

10. Intramuscular (big needle) injection Clean the injection site with an alcohol wipe by rubbing in a circular motion. Remove the needle cap. Stretch the injection site with one hand and using the other hand, quickly insert the needle straight in as far as it will go. Release the skin. With that hand draw back very gently on plunger; if no blood flows into the syringe, inject the medication. If blood is seen, the needle is probably in a vein - remove the needle and apply pressure to the needle site. Repeat the injection at another site after putting on a new needle. Remove the needle. Rub the area in a circular motion to massage the medication. Dispose of the syringe in a “sharps” container. If you see blood or a small amount of fluid at the injection site, simply wipe the site with the alcohol wipe and apply light pressure. Medication Administration

11. Monitoring Instructions  U/S and Blood work Vaginal probe U/S to check size and number of follicles (fluid sacs in the ovary containing the eggs) Male and female U/S technicians Blood test for estradiol and/or progesterone

12. Monitoring Instructions  Where/when Weekdays  6:45-7:30a in Ultrasound Department L-1: for ultrasound and blood  7-9a 3 rd floor: for blood only Weekends/Holidays  7-7:30a in Ultrasound Department L-1: for ultrasound and blood

13. Monitoring Instructions  Standing order lab slip Do not write on it Filed in lab for 1 year Tell lab tech what test you need  Ultrasound slips Given to you in ultrasound

14. Monitoring Instructions  Fill out a call back sheet each time you test Name and phone numbers Voice messages: Y N Have identifiers on your answering machines Leave room on the answering machine for the longest incoming message available

15. Monitoring Instructions  Satellites 850 Boylston (weekdays only)  Use BWH testing slips (see Instruction booklet for times) Patriot’s Place, Foxboro (weekdays only)  Use BWH testing slips (see Instruction booklet for times)

16. Daily Cycle Instructions  Daily orders are done by the doctors by 2p Nurses call with new instructions by 5p If there is no call by 5p, page the F&E Fellow on call 617-732-6660

17. Possible Complications Click on a complication below to go directly to an explanation. Once there, hit the arrow on the page to get back to this page.  Multiple pregnancyMultiple pregnancy  Ovarian Hyperstimulation SyndromeOvarian Hyperstimulation Syndrome  Infection at injection siteInfection at injection site  Ectopic (tubal) pregnancyEctopic (tubal) pregnancy  Ovarian torsion (twisting)Ovarian torsion (twisting)  Medication side effectsMedication side effects

18. Cycle Cancellation  Why? Poor response to medicine  Few or no follicles; low estradiol Estrogen level and follicle number not similar Missed testing or medicine error Ovulation before IUI Over response to medicine (cancel vs. change to IVF)  Too many follicles; high estradiol

19.  If an emergency arises If you have an emergency Call 617-732-6660 Ask for the F & E fellow on call Stay on the line or leave a call back number and the physician will return your call

20. Nurse Appointment  If you need more assistance, call your secretary to make an appointment with your nurse to: Review your individual protocol Discuss medications and pharmacies Learn how to do injections

21. Other Medication - sometimes in OI  After the IUIs Progesterone vaginal suppository or Crinone vaginal gel  Supports the lining of the uterus  May delay period  Continue even if bleeding starts  Side effects similar to pregnancy  Breast tenderness  Nausea

22. Multiple pregnancy - Because several follicles containing eggs can mature and ovulate at the same time, it can result in a multiple pregnancy. Thus multiple implantation of embryo can occur. Usually, the number of fetuses can be determined by ultrasound at 6-7 weeks gestation (4 -5 weeks after the IUI). Fetal reduction may be possible in high order multiple gestation pregnancies. Complications

23. Ovarian Hyperstimulation Syndrome (OHSS) - After ovulation, the follicles fill up with fluid and form cysts. This can lead to lower abdominal discomfort and bloating. Symptoms of OHSS may include: nausea and vomiting, shortness of breath, weight increase 2-3 pounds a day, low urine output. These can happen within 2 weeks after the HCG injection. The symptoms usually resolve within 1-2 weeks without treatment. Pregnancy can make it worse and last longer. Treatment may include cancelling the cycle before the HCG and in severe cases hospitalization for fluid management. Complications

24. Infection at the injection site - Symptoms of injection site infection can include redness and/or extreme tenderness at the site and fever (rare). You may be instructed to apply warm soaks to the site and/or be given antibiotic treatment. Ectopic pregnancy (tubal pregnancy) - You will have an early ultrasound to rule out ectopic pregnancy. Approximately 5% of Assisted Reproduction pregnancies become ectopic and resolve on their own or are treated with medication or surgery. Symptoms may include abdominal pain and/or irregular bleeding. Complications

25. Ovarian torsion (twisting) - In less than 1% of cases, the enlarged ovary can twist on itself. This can decrease the blood supply to the ovary and result in significant lower abdominal pain. Surgery may be required to untwist or possibly remove the ovary. Medication side effects - Read the package inserts of your medications and discuss any possible side effects with your physician. Complications