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
Class Outline
▪ Clinic & Appointments Overview
▪ Oral Medications for IVF
▪ Subcutaneous (SQ) Injection Instruction
- Watch instructional video from Freedommedteach.com
▪ Hands-on Practice on injection model
▪ Intramuscular (IM) injection instruction
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 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
Start
stimulation
medications
if cleared;
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.
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
Care team will confirm in
PM if any adjustments to
medications necessary
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
150 IU = 2 vials
75 IU
= 1 vial
Make sure needle tip is
seen in liquid BELOW and
NOT in air space above
Pull back and forth on
plunger until large air
space is filled.
Small bubbles are OK
Antagonist
Ganirelix, Cetrotide
▪ Prevents premature ovulation
▪ In certain protocols, used instead of Lupron
▪ Generally not started until the largest follicle is 12-14 mm
▪ 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
Injectable Medication Summary*For all medication storage details, refer to manufacturer and pharmacist instruction– use this only as a guide
Agonist
▪ Lupron (leuprolide
acetate) *
Gonadotropins
▪ Gonal-f **
▪ Follistim **
▪ Menopur
Antagonists
▪ Cetrotide**
▪ Ganirelix
Progesterone
(for embryo transfer)
• Intramuscular
Progesterone - sesame oil
or synthetic (ethyl oleate)
- room temp is fine
HCG “Trigger"
• Novarel
• Pregnyl
• Human Chorionic
Gonadotropin
(HCG)
“Co-trigger"
▪ Lupron (leuprolide
acetate)
▪ Gonal-f **
▪ Follistim **
*refrigerate multi-use vial after first use
**refrigerate after receiving from pharmacy
Important Medication Tips
▪ Injections should be given at approximately the same time each day
▪ Wash hands well before beginning
▪ Use larger needle to mix and draw up medication
▪ Use smaller needle for injection
▪ Clean site well with alcohol swab
▪ Alternate the site of injections
▪ Medication overfill in Follistim cartridges
▪ 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
– estradiol (Vivelle patches or Estrace 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 Resources
Class 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!