Instructions forOvulation Induction

Center for Infertilityand Reproductive Surgery

Table of contentsClick 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……….3 2. Ovulation Induction and IUI……….43. Medications – Stimulation……...….74. Medications – Prepare for IUI..……85. Medication Administration…...……96. Monitoring…………………………117. Daily Cycle Instructions…………...168. Complications …………………..…179. Cycle Cancellation ……...…………1810. Emergencies………………………..1911. Nurse Appointment………………...2012. Other Medications………………….21

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

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

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)

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

Medications

Stimulation Therapy• Gonal-F, Follistim, Bravelle

Repronex, Menopur Maturing of many eggs Once or twice a day injection Side Effects/risks:

Mood swingsBloatingOvarian hyperstimulation

Medications

Preparation for IUI – trigger shot• HCG, Pregnyl, Novarel

Final maturing of eggs in preparation for ovulation

Given: at midnight Risks:

Early ovulationOvarian hyperstimulation

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

Intramuscular (big needle) injectionClean 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

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

Monitoring Instructions

Where/when• Weekdays

6:45-7:30a in Ultrasound Department L-1: for ultrasound and blood

7-9a 3rd floor: for blood only

• Weekends/Holidays 7-7:30a in Ultrasound Department L-1:

for ultrasound and blood

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

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

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)

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

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 pregnancy Ovarian Hyperstimulation S

yndrome Infection at injection site Ectopic (tubal) pregnancy Ovarian torsion (twisting) Medication side effects

Cycle CancellationWhy?

• 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

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

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

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

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

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

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

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