CRH IVF & Egg Cryo

Medication Overview &

Injection Demonstration

UCSF Center for Reproductive Health

Kathryn deVera, RN, Deidre Koeb, RN, Katrina Cruz, NP; Liz Silloway, RN, Natalie Wallace, RN, Briauna Johnson, RN, Raebern Belen-Carmody, LVN, Sandra Rosas, LVN

Class Outline

▪ Clinic Information

▪ Cycle and Appointments Overview

▪ Oral Medications

▪ Subcutaneous (SQ) Injection Instruction

▪ Progesterone Intramuscular (IM) injection and Vaginal Forms

- for patients doing an embryo transfer

Clinic Information

▪ Hours: 7:00am to 4:30pm, Monday through Friday

▪ Saturday, Sunday, and Holiday mornings for patients who are going through treatment

▪ Main Line: 415-353-7475

▪ On-call / After-hours Line: 415-353-7475

- IMPORTANT: please reserve after-hours calls for urgent matters/emergencies, ONLY.

- For example – urgent HCG Trigger questions; and not for general medication questions or Cycle Day 1 reporting.

4

IVF / EGG CRYO TREATMENT CYCLE MEDICATION TIMELINE

Pre-Cycle

Tasks

Finalize plan

with MD

Blood work

Consents

Genetics

consult if

desired

Receive

calendar from

RN

coordinator

Order

medications

Attend

injection class

Finalize billing

for cycle

Call to

report your

period

CYCLE DAY 1

Baseline

ultrasound

(and

bloodwork)

SCHEDULED

PER

PROTOCOL

If cleared:

Start

stimulation

medications.

Inject in PM

Most patients may be on:

Lupron injections,

Estrace patches OR pills,

or birth control pills

for pre-cycle suppression

More

monitoring

appointments

EVERY

1-3 DAYS

First

monitoring

appointment E

G

G

R

E

T

R

I

E

V

A

L

HCG “Trigger”

injection when

instructed;

give in PM at

designated

time

Monitoring

appointment

indicates

follicle

maturity, ready

for trigger

36 hours

later

Continue medication

injections every night

Adjustments may be made to

your medications / dosages

Care team will contact you to

confirm your dose that

afternoon

P

R

E

T

R

E

A

T

M

E

N

T

Baseline Stim Day 5 Stim Day 9

*Ultrasound images are for example only. Individual responses vary.

Follicles

Cycle Tracking Example for Dosing

• Small circles represent follicles growing within right and left ovaries

• Follicles that make it over the 13 mm line are expected to contain mature egg

Individual response

determines # of days of

stimulation

Average # of stimulation

days: 10-12

AM monitoring

appointments

(ultrasound and/or

blood draw);

every 1-3 days

As trigger day

approaches, expect to

return to clinic daily

Oral Medications

Some protocols involve oral medications to induce ovulation (egg

development & release)

May be prescribed along with injectable Gonadotopins

- Causes the body to believe estrogen is low in order to produce more

follicle stimulating hormones

- Clomid (Clomiphene Citrate) induces ovulation by blocking estrogen receptors

- Femara (Letrozole) induces ovulation by blocking estrogen production

If indicated, your physician determines which is appropriate for you

Subcutaneous Injections for Your Cycle

SQ (Subcutaneous)—

fatty layer under skin

Needles

• Mixing Needle

– 18 or 20 gauge; 1.5 inches

• Subcutaneous Needle

For Injection

– 27 gauge; 0.5 inches

Syringes

• 3 ml (cc) syringe

• Insulin Syringe (see next slide)

Needles and Syringes

1 ml/cc

3 ml (cc)

syringe

9

Agonist

Lupron

(leuprolide acetate)

• Temporarily prevents ovulation from

occurring prior to egg retrieval

• Lupron is often the first injection

medication used in the cycle

• Generally started one week before

next expected period and continued

until just prior to egg retrieval.

• Already in liquid form

Subcutaneous (SQ) Injections

Gonadotropins

Gonal-f, Follistim, Menopur

• Stimulates multiple ovarian follicles to grow at the same time so that multiple eggs can be retrieved from the ovaries

• Can consist of just FSH (follicle stimulating hormone) or in combination with LH (lutenizinghormone)

• Can come in liquid form in pens (Gonal-f, Follistim) or in powder form (Menopur) - which will need to be mixed with liquid

• Injections given at approximately the same time each evening

75 IU

= 1 vial

FreedomMedTeach.com

Wash hands well before

beginning

Set up in a clean, quiet area; free

of distractions

Lay out all of your supplies ahead

of time

Larger needle used to draw up

and mix; smaller needle is for

injecting

Clean top of vials and abdomen

with alcohol swab

If needle touches a surface other

than the clean top of a vial, it is

contaminated. Twist off and

replace with a sterile needle

Needles and syringes are one-

time use only

75 IU = 1 powder vial

+ 1 ml sodium chloride

150 IU = 2 powder vials

+ 1 ml sodium chloride

Injection Tips and Technique

Make sure needle tip is

always in liquid

- NOT in air space above

Pull back and forth on

plunger until large air

space is filled.

Small bubbles are OK

Injection Tips and Technique

Follistim and Gonal F: Parts

Medication overfill:

Excess medication in cartridge,

more than what is specified on

label

If needed, able to use for

injections, do not throw away;

keep in fridge

May require multiple injections

from partial cartridges to get full

dose

Antagonist

Ganirelix, Cetrotide

▪ Prevents premature ovulation

▪ Generally not started until the largest follicle is 12-14 mm

▪ In certain protocols, used instead of Lupron

▪ Generally continue taking in the AM –same time each day

▪ May be instructed to bring to appointment in case need to start right away

HCG “Trigger”

Novarel, Pregnyl, Human Chorionic

Gonadotropin

Induces final egg maturation

Given when the estradiol level and the

follicle measurements look best for

successful outcome

Retrieval is ~ 36 hours later

Lupron if not used during stimulation, may also

be used as a trigger or co-trigger

per MD discretion

Ovarian Hyperstimulation Syndrome

(OHSS) precaution

Common dose: 80 units = 0.8 mL

**THIS IS THE ONLY INJECTION THAT NEEDS TO BE GIVEN

AT A SPECIFIC ASSIGNED TIME**

5,000 USP= 2 boxes

Common Side Effects

▪ Lupron / Ganirelix / Cetrotide:

- Hot flashes, Night sweats, Insomnia, Vaginal dryness

- Mood swings, Occasional headaches

- Symptoms typically last only a few days, tend to disappear shortly after

discontinuing

▪ Follistim / Gonal F / Menopur:

- Bloating, abdominal distension/discomfort, feeling of fullness

- Cramping similar to menstrual pain

- Discomfort or pressure around the ovaries

- Nausea, breast tenderness, fatigue

HCG “Trigger"

• Novarel

• Pregnyl

• Human Chorionic

Gonadotropin

(HCG)

“Co-trigger"

▪ Lupron (leuprolide

acetate)

▪ Gonal-f **

▪ Follistim **

Agonist

▪ Lupron (leuprolide

acetate) *

Gonadotropins

▪ Gonal-f **

▪ Follistim **

▪ Menopur

Antagonists

▪ Cetrotide**

▪ Ganirelix

Injectable Medication Summary*For all medication storage details, refer to manufacturer and pharmacist instruction– use this only as a guide

Progesterone

(for embryo transfer)

• Intramuscular

Progesterone - sesame oil

or synthetic (ethyl oleate)

- room temp is fine

*refrigerate multi-use vial after first use

**refrigerate after receiving from pharmacy

Important Medication Reminders

▪ Alternate the site of injections

▪ Injections should be given at

approximately the same time each day

▪ Check medication inventory once received

from pharmacy

▪ Keep track of inventory and call the

pharmacy directly to order refills, if

needed

▪ Some local pharmacies accept sharps

containers with used needles and

syringes (Walgreen’s, Mission Hall)

After Egg Retrieval, if planning embryo transfer

Progesterone

▪ Acts upon the lining of the uterus(endometrium) to make it receptive for embryo implantation

▪ Intramuscular (IM)

▪ Vaginal: Prometrium suppository, Endometrin tablet, Crinone gel

▪ Common side effects can include:➢ Breast Tenderness➢ Cramping➢ Nausea➢ Fatigue➢ Headache➢ Constipation➢ Muscle soreness or lumps at

injection site

20

Other Medications Will be reviewed during pre-op before your procedure

In preparation for FRESH embryo transfer

• started after Egg Retrieval procedure

– methylprednisolone (Medrol) tablets

– diazepam (Valium) tablet

In preparation for FROZEN embryo transfers (FET) –

• Lupron (leuprolide acetate) injections (for suppression)

• In addition to the above medications

21

IM (intramuscular)—

upper outer quadrant of

buttocks

Intramuscular (IM) Injection: Progesterone

23

Use larger, thicker needle for drawing up

medication

Switch to thinner needle for IM injection

(22g)

Remove air bubbles

Spread skin taut (do NOT pinch)

90 degree angle, insert needle quickly

Aspirate (pull back plunger) slightly to

make sure in muscle

Inject slowly

Tips for Easing Discomfort and Positioning

• Warm the progesterone to either a comfortable room or body

temperature

• Ice down the injection site for 10-20 seconds

• Relax the muscles

• Wait for the alcohol to dry completely

• Massage injection site after completion

• Apply heating pad for a few minutes (medium heat)

Helpful ResourcesClass Handouts: crh.ucsf.edu/orientation-seminars

Freedom Fertility Pharmacy* videos for injection instruction: Freedommedteach.com

UCSF Medication Injection Videos: crh.ucsf.edu/medication-videos

Home Injection Services*:

- Concierge-ivf.com (650) 946-3370

- Gentletouchfertility.com (415) 295-6461

Medical Transport Service*:

- SilverRide.com (415) 861-RIDE (7433)

Walgreens UCSF Mission Hall, 550 16th St, SF, (415) 365–0512

Monday - Friday 9am - 6pmSaturday – Sunday 9am - 3pm

Team Psychologists: Lauri Pasch, Ph.D., Sarah Holley, Ph.D

* Unless specified, these businesses or services are not affiliated with UCSF or the Center for Reproductive Health.

Best of luck to all of you in this process!