Transcript Multiple pregnancy - Brigham and Women`s Hospital

Table of Contents
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Page
What is IVF
Medication
Suppression
Stimulation
Prepare for Retrieval
Post operative
Administration
SC injections
IM injections
Monitoring
Daily Cycle Instructions
Preoperative appointment
3
5
10
11
12
14
15
16
21
22
Page
Day of egg retrieval
Sperm collection
Day after egg retrieval
Day of embryo transfer
Cycle Cancellation
Complications
Embryo Freezing
Pregnancy test
Emergencies
Typical Cycle
Consents
Nurse Appointment
23
25
28
29
31
32
33
34
35
36
37
38
What is IVF?
Stimulate the ovaries to
mature many eggs
Surgically remove eggs
Mix with sperm
Incubate fertilized eggs
Return a few to the uterus
What is IVF?
Starts the month before the
stimulation
Lasts approximately 8 weeks
Medication for about 6 weeks
To start, call your nurse with
your period
Medications
Suppression Medicines
• Begin the month before the
stimulation
 Birth Control pills
 Lupron
 Ganirelix
 Cetrotide
 Climera patch
Medications
Suppression Medicine
• Birth control pills
 Start d1-3
 Suppress LH & FSH hormones
 Regulate cycles, active pills only
 Side effects
Early pregnancy symptoms
Breakthrough bleeding
Medications
Suppression Medicine
• Lupron
Suppress LH, FSH, estrogen, and
progesterone
Better quality eggs
Stops ovulation
Once or twice a day injection
Side effects: hot flashes, insomnia,
headache
Use condoms
Allergy: local redness
Medications
Suppression Medicine
• Ganarelix/Cetrotide
 Suppress LH immediately
 Once a day injection
 Fewer shots
 Side Effects: headache, nausea
Medications
Suppression Medicine
• Climera patch
 Stabilizes and thickens the uterine
lining
 Skin patch placed anywhere except
the chest
 Changed every other day
 Side effects: headaches, breast
tenderness, uterine cramping and
bloating. Rare: blood clots
Medications
Stimulation Medicine
• Gonal-F, Follistim, Bravelle
Repronex, Menopur
 Mature many eggs at once
 Once or twice a day injection
 Side Effects/risks:
Mood swings
Bloating
Ovarian hyperstimulation
Medications
Preparation for Retrieval
• HCG, Pregnyl, Novarel
 Final maturing of eggs
 Given:
follicles (2 follicles with mean ≥1718mm)
 Estradiol level is at least 600
 36 hours before egg retrieval Risk: early
ovulation, OHSS
4
Medications
Post Retrieval Medicine
•Progesterone
 Supports the lining of the uterus
 Injectable, vaginal suppository,
vaginal gel
 May delay period
 Continue even if bleeding starts
 Side effects similar to pregnancy
Medications
Post Retrieval Medicine
Doxycycline - antibiotic
 All patients
 Pills
• Estrace – Estrogen
 ICSI, AH, PGD patients
 Pills
• Medrol- anti-inflammatory
 ICSI, AH, PGD patients
 Pills
Medication
Administration
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) 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.
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
 7-8a in U/S L-1 for U/S and bloods
 7-9a 3rd floor for bloods only
• Weekends
 7:30-8:30a in U/S L-1 for U/S and
bloods
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: Yes or No
• Have identifiers on your
answering machines
• Leave room on the answering
machine for the longest
incoming message available
Monitoring Instructions
Satellite testing centers
• 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 617-7326660
Pre-Operative Appointment
During the stimulation
Meet with MD and
anesthesiologist to sign surgical
consents
On a testing day if BWH patient
If testing at a satellite, test at
BWH on the day of the pre-op
appointment
Day of Egg Retrieval (ER)
Admission to 5C
• No eating/drinking after midnight
the night before
• Bring hospital blue card
• Arrive 5C 1 hr before ER
• Admit to pre-op/recovery area
• Change into a hospital gown
• IV started
• Couple together pre/post op
Day of Egg Retrieval
Operating room
• Feet in stirrups
• Anesthesia
• U/S guidance,
needle inserted into each follicle,
fluid removed by suction
• Fluid passed to embryologists
who remove eggs from the fluid
• By stretcher to the recovery room
Sperm collection
In advance
• If you need to be together or produce
at home notify your nurse
• If you anticipate a problem with
production, consider freezing
specimens before the cycle starts
Day of HCG shot
• Ejaculation within 5 days before the
egg retrieval
• Abstain after HCG shot
Sperm collection
Day of Egg Retrieval
• Bring hospital blue card and a
picture ID
• Produce specimen
 Day of egg retrieval
 Private room on 5C
 Fill out paperwork and label
specimen container
 No lubricants
Day of Egg Retrieval
Post op recovery
•
•
•
•
•
1 - 1 1/2 hours
Need a ride home
May feel groggy, sore, backache
Pain medication prescription
Start antibiotics; also medrol if
ICSI, PGD, AH
Day after Egg Retrieval
Post op recovery
• Fertilization call
• Start progesterone (if Crinone
start tomorrow); also Estrace if
ICSI, PGD, AH
• Take it easy for 48 hours
Day of Embryo Transfer (ET)
You will get a call the afternoon
before the ET with the transfer
time
Arrive 1 hour before transfer
time
Do not empty your bladder
Day of Embryo Transfer
 MD will discuss the
embryos with you
 Couple can be together
for the ET
 10 minutes to recover
 Take it easy for 24
hours
Cancellation
Poor response to medication
• Few or no follicles; low estradiol
 Estrogen level and follicle
number don’t match
 Missed testing or medication
 Ovulation before egg retrieval
 No fertilization
 Arrested development of
embryos
Possible Complications of ART
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Multiple pregnancy
OHSS
 Infection at injection or
operation site
 Ectopic (tubal) pregnancy
 Ovarian torsion (twisting)
 Medication side effects
 Surgical risks
Embryo Freezing
Sign consent and NECC
contract
Freeze good quality embryos
Notification if you have frozen
embryos
Cryo embryo transfer cycle (CET)
Insurance company may require
it
Liquid Nitrogen embryo storage tank
Pregnancy Test
Approximately 18 days after
the egg retrieval
If you have bleeding, do not
stop progesterone
Cycle review after negative
test or +FH
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
Typical IVF Cycle
Call with your period
 Suppression therapy 7-21 days
 Baseline U/S and/or blood
 Start the stimulation
 7-14 days later HCG
 36 hours later egg retrieval
 3-5 days later embryo transfer
 16 days later pregnancy test
Consents
Consent booklet
Multiple consent
forms
Cannot start cycle without
signed consents
Arrange to give them to your
nurse
Nurse Appointment
If you need more assistance,
call to make an appointment
with your nurse to:
• Review your individual protocol
• Discuss medications and
pharmacies
• Learn how to do injections
Complications
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
Surgical risks
Infection: Bacteria may be
transferred into the abdominal
cavity by the retrieval needle.
Bleeding: The retrieval needle
goes through the vaginal wall and
into the ovary. These have blood
vessels and there are other blood
vessels nearby.
Trauma: It is possible to damage
nearby abdominal or pelvic organs.
Anesthesia: Complications such as:
allergic reaction, low blood
pressure, nausea or vomiting.
Failure: The egg retrieval could
fail to get any eggs or the eggs
may be abnormal or of poor quality