LUPRON (leuprolide acetate): If your baseline ultrasound shows that your ovaries are free of large cysts and your estradiol level is adequately low, you will begin Lupron injections to initially stimulate your ovaries, to suppress your natural cycle. (The use of generic Lupron is acceptable.) Use a 50-unit insulin syringe to draw up your twice daily (every 12 hours) dose of Lupron units. Administer in thighs or abdomen subcutaneously (sub-q).

STIMULATION AGENTS, HUMAN MENOPAUSAL GONADOTROPINS (Follistim, Gonal F, Bravelle, Pergonal, Repronex): After your second baseline ultrasound shows your ovaries to be free of large cysts and your blood estradiol is adequately low, you will be instructed to begin injections to stimulate your ovaries. Each time you have monitoring with ultrasound and/or blood work, we will call you in the afternoon to review the dose of medication that you will be taking until we see you next. You may be asked to take a single agent or a combination of agents. Your starting dose will be ampules/vials (Follistim, Bravelle, Gonal F, Fertinex) daily and _____ ampules/vials (Repronex, Pergonal). Using a 3 cc syringe and a large (18-21) gauge 1½-inch needle, mix the ampules/vials of 75 IU powder in just 1 ml (1 cc) of sterile water (diluent). Do this by mixing the 1 ml water in the first ampule of powder and drawing it back into the syringe, then placing that mixture in the second ampule and drawing it back into the syringe, and so on until all _____ ampules of powder are in solution in the 1 ml water.

For the subcutaneoususe of Follistim, Bravelle, Gonal F, or Repronex:Replace the large needle with a small (25-30) gauge ½-inch needle and inject subcutaneously (sub-q) in thighs or abdomen at a 90º angle. GIVE THIS INJECTION IN THE EVENING within two hours of previous day's dose.

For the intramuscular use of Pergonal: Replace the large needle with a small (25-27) gauge 1½ -inch needle and inject in upper outer quadrant of buttock intramuscularly (IM) at a 90º angle. GIVE THIS INJECTION IN THE EVENING within two hours of previous day's dose.

HCG (chorionic gonadotropin, Profasi, Pregnyl, Novarel): After approximately 10 to 14 days of stimulation medication, when follicle sizes and estradiol levels are appropriate, you will be instructed to take no more Lupron or stimulation medication and to inject hCG at a specific time in the evening. This is in preparation for the oocyte retrieval. You will be instructed on the day you are ready for hCG to take either 10,000 units or 5,000 units of hCG.

• For 10,000 units: Using a 3 cc (ml) syringe and a large (18-21) gauge 1½-inch needle, draw up just 1 cc (ml) of sterile water (diluent). Inject the water into the large needle with a smaller (25-27) gauge 1½-inch needle. After pulling back slightly on the plunger to check for blood, inject the medication in the upper outer quadrant of the buttock intramuscularly (IM) at a 90º angle.

• If your dose is 5,000 units, inject 2 cc (ml) of water into the 10,000 units of hCG powder and withdraw just 1 cc (ml). Replace the large needle with a small (25-27) gauge 1½-inch needle. After pulling back slightly on the plunger to check for blood, inject the medication in the upper outer quadrant of the buttock intramuscularly (IM) at a 90º angle.

If blood is seen in the syringe after pulling back the plunger, remove the needle, replace it with a sterile 1½-inch needle, and inject at another site.

PROGESTERONE-IN-OIL: Progesterone is used to supplement your ovarian production of progesterone to ensure adequate hormonal support of an early pregnancy. Using a 3-cc syringe and a large (18-21) gauge 1½-inch needle, draw up 1 ml (cc), which is 50 mg. Replace the large needle with a small (22-25) gauge 1½-inch needle and inject intramuscularly (IM) in the upper outer quadrant of the buttock after pulling back on the plunger to check for blood. If blood is seen in the syringe after pulling back the plunger, remove the needle, replace it with a sterile 1½-inch needle, and inject at another IM site. Give in the evening within one hour of previous day's dose. Use of daily heating pad or hot moist towels 15 minutes daily on injection sites, and/or massage of the sites, helps absorption of the medication and helps to prevent soreness.

ABBREVIATIONS:
ml = cc
sub-q = SQ = subcutaneously
IM = intramuscular
10 units = .1 cc
5 units = .05 cc
ampule = all glass container scored to facilitate breaking off the top
vial = container with a rubber top through which a sterile needle is inserted to mix and withdraw meds



MEDICATIONS BY MOUTH

ORAL CONTRACEPTIVE PILLS (OCP's, birth control pills, BCP's): OCP's are used to suppress your ovulation and induce a resting state in your ovaries. Beginning with the onset of your period when you are ready to proceed with IVF, take one active pill every day without interruption. DO NOT take the inactive sugar pills of which there are 7 of a different color in 28-day packs only. Discard the inactive pills as soon as you open a 28-day pill pack. You will be told on what day you should stop your pills in your cycle schedule. If you have smoked within the past two years, advise your physician of this prior to taking your OCP's. If you have an autoimmune disease (i.e. lupus) or clotting disorder, discuss the use of pills prior to use with your physician.

PRENATAL VITAMINS CONTAINING 400-1000 mcg (.4 to 1 mg) FOLIC ACID (folate): Take one tablet daily when trying to conceive and throughout pregnancy.

LOW DOSE ASPIRIN 81 mg TABS: Aspirin thins your blood, which is expected to improve blood flow to ovaries and uterine lining. Begin taking one daily at or before the time you begin leuprolide. You will stop for a few days before and after the egg retrieval to prevent increased bleeding with the oocyte retrieval. If you are allergic to aspirin or have a bleeding disorder, discuss this with you physician prior to taking the aspirin.

DOXYCYCLINE: Doxycycline is an antibiotic given to prevent infection in your ovaries as a result of oocyte retrieval. If you are not allergic to doxycycline, you will be instructed to take 1 capsule twice daily starting the day after egg retrieval. Always take with food in your stomach and with lots of water to avoid irritation to your stomach and bowel. Doxycycline can cause hypersensitivity to the sun, so protect your skin with sunscreen, hats, and long sleeves when exposed to direct sun.

MEDROL: Medrol is a steroid which is given to women whose embryos undergo assisted hatching. The purpose of medrol is to decrease the risk of rejection and invasion of embryos whose outer shell has been thinned. You will be instructed to take 8 mg twice daily following egg retrieval and continuing for four days.

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