CVS Caremark Specialty Pharmacy Fertility Medication Guidebook Dear Patient

CVS Caremark Specialty Pharmacy Fertility Medication Guidebook Dear Patient:

Thank you for choosing CVS Caremark Specialty Pharmacy for your fertility medication needs. To assist you with managing your treatment cycle and administering medications, we are happy to offer you this Fertility Medication Guidebook. This medication guidebook is for informational and educational purposes only. Your doctor will determine what medication treatment is appropriate for you. Included, you will find calendars for cycle planning, a log to record lab results, medication storage information, and a guide to needles and syringes. Fertility Care Program

The medication instruction section was created to provide clear and concise To learn more about the instruction for administering the most commonly prescribed medications. For Fertility Care Program, please call toll-free medication descriptions, indications and side effects, please refer to the patient 1-800-793-2637, education material included with each medication. Please remember, it is important Monday through Friday, to pay close attention to your nurse and doctor’s instructions. Each patient is 9 a.m. to 6 p.m. CT. different, and your personal instructions may vary from this guidebook. Always follow your clinician’s instructions.

We know you have a choice in pharmacies, and we appreciate the opportunity to serve you. Our team is available to assist you with questions on drug coverage benefits, medication questions and delivery status. In addition, our pharmacists and nurses are available 24 hours a day, 365 days a year for emergency consultations by calling toll-free at 1-800-793-2637. We wish you the best in your fertility journey, and we appreciate you asking for CVS Caremark Specialty Pharmacy at your doctor’s office.

Sincerely,

CVS Caremark Specialty Pharmacy CVS Caremark Specialty Pharmacy

Supporting you every step of the way CVS Caremark Specialty Pharmacy is a leading fertility specialty pharmacy that offers much more than medication. Serving patients with specialized needs for 30 years, we understand the support and personalized care you may require when undergoing fertility treatment.

You can count on us to take an active role in your care by working directly with you, your doctor and your insurance company. From reviewing insurance coverage to delivering medications to your door, we are here to serve and support you through every step of your fertility treatment.

Dedicated Fertility CareTeam When you enroll in the CVS Caremark Fertility Care Program, a pharmacist-led CareTeam is assigned to you. This dedicated group of clinical experts provides you with comprehensive support and education on appropriate use of the prescribed medication, administration and storage, potential adverse reactions/side effects, and injection-related issues. You have access to our on-call pharmacists, 24 hours a day, 365 days a year for emergency consultations.

Fertility Drug Coverage Pre-Verification Program By participating in our complimentary Fertility Drug Coverage Pre-Verification Program, you will receive a comprehensive overview of your fertility drug coverage before the prescription is written. These results include fertility medication copayments* for all major fertility agents. Understanding the fertility drug coverage in advance can help you and your doctor make important financial decisions about your fertility treatment.

Prompt delivery of your fertility medications By having your doctor fax or call in your prescription to CVS Caremark Specialty Pharmacy, you can expect prompt intake and discreet, timely delivery of your medications and supplies. We ship anywhere in the United States and offer complimentary next day delivery. In certain markets, we can provide same day delivery.

*Copayment means the amount a plan participant is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan. 1 Complete offering of medications and supplies CVS Caremark Specialty Pharmacy has a broad product offering, including all medications and supplies required for a typical treatment cycle. Your medication will arrive in a temperature-controlled, secure package.

Education based on your needs We provide education specific to your condition and prescribed treatment. In addition to the materials you receive in your Welcome Packet, you also have access to our online Fertility Resource Center on Caremark.com. Here you will find a wealth of information on the diagnosis and treatment of infertility and links to helpful resources.

Competitive pricing CVS Caremark is one of the largest purchasers of prescription medications in the nation and can offer competitive pricing. If you do not have fertility medication benefits, you may be eligible to receive immediate savings on certain medications for the treatment of infertility. Contact the CVS Caremark Fertility Managed Plan toll-free at 1-888-826-5632 or visit Caremark.com/fertility for more information.

Reimbursement services As part of our patient-centric approach to care, CVS Caremark has reimbursement specialists who will help you maximize your fertility coverage while minimizing out-of-pocket expenses by offering a comprehensive analysis of your benefits. This team of experts will also ensure that your claims are completed and filed in a timely manner.

Egg donor medication services CVS Caremark Specialty Pharmacy specializes in the coordination of egg donor medications. A dedicated pharmacist is in charge to ensure confidentiality and smooth coordination of all donor cycles. Billing is direct and anonymous, and medications may be sent directly to the clinic or to you.

2 3 Contents

Patient Prescripion

Medication Prescription 5-21

Medication Descriptions 22-23

Needles and Syringes Prescription 24-25

Cycle Planning

Understanding Infertility Treatment 27

Cycle Tracking Calendars 28-32

Preparation Facts and Instructions

Ordering, Monitoring and Storing Medications 33

Medication Storage Chart 34

Needles and Syringes (size, disposal and travel) 35-36

Preparing for Injections 37-38

Medication Instructions

Lupron® (Leuprolide Acetate Injection) 39-40

Ganirelix® Acetate Injection 41-42

Cetrotide® 43

Follistim® AQ Cartridge 44-45

Follistim® AQ Vial 46-47

Gonal-f ® Multi-Dose Vial 48

Gonal-f ® RFF Pen 49

Bravelle®/Menopur®/Repronex®Vial (Subcutaneous) 50-51

Bravelle®/Repronex®/Novarel® (Intramuscular) 52-53

Luveris® Vial 54-55

This booklet contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with CVS Caremark. 2 3 Medication Instructions - continued

hCG (Generic) 56

Pregnyl® 57

Ovidrel® 58-59

Crinone® 60

Endometrin® 61

Progesterone in Oil 62

Glossary of Terms 63-67

Additional Resources

Resources 69-70

Fertility Manufacturer Sponsored Web Sites 71

Questions for My Next Visit 72

4 5 Prescription Patient Patient Prescription Medication Prescription GnRH Agonist GnRH (gonadotropin releasing hormone) agonists are prescribed to inhibit an LH surge. The GnRH agonist prevents ovulation from occurring while follicles mature to the appropriate stage.

Lupron® Injection*

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: subcutaneous subcutaneous subcutaneous Special Instructions: ______ ______

Leuprolide Acetate Injection* (Generic)

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: subcutaneous subcutaneous subcutaneous Special Instructions: ______ ______

*This medication is not indicated for fertility treatment. Please speak with your clinician for an explanation of its use. 4 5 Medication Prescription

GnRH Antagonists GnRH (gonadotropin releasing hormone) antagonists are prescribed to inhibit an LH surge. GnRH antagonists prevent ovulation from occurring while follicles mature to the appropriate stage.

Ganirelix Acetate Injection (formerly known as Antagon)

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: subcutaneous subcutaneous subcutaneous Special Instructions: ______ ______

Cetrotide® 0.25 mg/Cetrotide 3 mg

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: subcutaneous subcutaneous subcutaneous Special Instructions: ______ ______

6 7 Medication Prescription

Gonadotropins Gonadotropins are prescribed to promote ovarian stimulation and the development of egg-containing follicles. Bravelle, Follistim and Gonal-f predominantly contain the hormone FSH (follicle-stimulating hormone) while Menopur and Repronex contain both of the hormones FSH and LH (luteinizing hormone). Luveris only contains the hormone LH.

Follistim® AQ Cartridge 300 IU**

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: subcutaneous subcutaneous subcutaneous Special Instructions: ______ ______

Follistim® AQ Cartridge 600 IU**

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: subcutaneous subcutaneous subcutaneous Special Instructions: ______ ______

**This medication is to be used with the Follistim pen. 6 7 Medication Prescription

Follistim® AQ Cartridge 900 IU**

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: subcutaneous subcutaneous subcutaneous Special Instructions: ______ ______

Follistim® AQ Vial 75 IU

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: SC or IM SC or IM SC or IM Special Instructions: ______ ______

Follistim® AQ Vial 150 IU

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: SC or IM SC or IM SC or IM Special Instructions: ______ ______

**This medication is to be used with the Follistim pen. | SC – subcutaneous • IM – intramuscular 8 9 Medication Prescription

Gonal-f® Multi-Dose 1050 IU Vial

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: subcutaneous subcutaneous subcutaneous Special Instructions: ______ ______

Gonal-f® Multi-Dose 450 IU Vial

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: subcutaneous subcutaneous subcutaneous Special Instructions: ______ ______

Gonal-f® RFF Pen 300 IU

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: subcutaneous subcutaneous subcutaneous Special Instructions: ______ ______

8 9 Medication Prescription

Gonal-f® RFF Pen 450 IU

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: subcutaneous subcutaneous subcutaneous Special Instructions: ______ ______

Gonal-f® RFF Pen 900 IU

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: subcutaneous subcutaneous subcutaneous Special Instructions: ______ ______

Bravelle® 75 IU Vial

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: SC or IM SC or IM SC or IM Special Instructions: ______ ______

SC – subcutaneous • IM – intramuscular 10 11 Medication Prescription

Menopur® 75 IU Vial

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: subcutaneous subcutaneous subcutaneous Special Instructions: ______ ______

Repronex® 75 IU Vial

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: SC or IM SC or IM SC or IM Special Instructions: ______ ______

Luveris® 75 IU Vial

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: subcutaneous subcutaneous subcutaneous Special Instructions: ______ ______

SC – subcutaneous • IM – intramuscular 10 11 Medication Prescription Human Chorionic Gonadotropins (hCGs) hCGs are prescribed to simulate an LH surge. hCG will promote the final maturation of eggs and induce ovulation. Administer medication at the exact time that is instructed.

hCG 10,000 IU (Generic)

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Exact Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: intramuscular intramuscular intramuscular Special Instructions: ______ ______

Novarel® 10,000 IU

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Exact Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: intramuscular intramuscular intramuscular Special Instructions: ______ ______

Pregnyl® 10,000 IU

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Exact Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: intramuscular intramuscular intramuscular Special Instructions: ______ ______

12 13 Medication Prescription

Ovidrel® 250 mcg Syringe

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Exact Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: subcutaneous subcutaneous subcutaneous Special Instructions: ______ ______

Progesterones Progesterone is prescribed to assist in nourishing the lining of the uterus. Progesterone is needed to increase the chances of embryo implantation and to help support a pregnancy.

Crinone® 8%

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: vaginal vaginal vaginal Special Instructions: ______ ______

Endometrin®

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: X/day X/day X/day Dosage: Admin.: vaginal vaginal vaginal Special Instructions: ______ ______

12 13 Medication Prescription

Progesterone in Oil 50 mg/ml* (Brand)

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: intramuscular intramuscular intramuscular Special Instructions: ______ ______

Progesterone in Oil 50 mg/cc* (Compound) q Cottonseed q Olive Oil q Ethyl Oleate

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: intramuscular intramuscular intramuscular Special Instructions: ______ ______

Prometrium®______mg Capsules*

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: Dosage: Admin.: oral or vaginal oral or vaginal oral or vaginal Special Instructions: ______ ______

*This medication is not indicated for fertility treatment. Please speak with your clinician for an explanation of its use. 14 15 Medication Prescription

Progesterone ______mg Capsule* (Compound)

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: Dosage: Admin.: oral oral oral Special Instructions: ______ ______

Progesterone ______mg Suppository* (Compound)

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: Dosage: Admin.: vaginal vaginal vaginal Special Instructions: ______ ______

Estrogens Estrogen is prescribed to help thicken the uterine lining in preparation for embryo transfer.

Delestrogen®* q 10 mg/ml q 20 mg/ml q 40 mg/ml

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: intramuscular intramuscular intramuscular Special Instructions: ______ ______

*This medication is not indicated for fertility treatment. Please speak with your clinician for an explanation of its use. 14 15 Medication Prescription

Estraderm® ______mg Patch*

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: transdermal transdermal transdermal Special Instructions: ______ ______

Vivelle Dot® ______mg Patch*

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: transdermal transdermal transdermal Special Instructions: ______ ______

Climara ______mg Patch*

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: transdermal transdermal transdermal Special Instructions: ______ ______

*This medication is not indicated for fertility treatment. Please speak with your clinician for an explanation of its use. 16 17 Medication Prescription

Estradiol ______mg Tablet* q Estrace® (Brand)

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: X/day X/day X/day Dosage: Admin.: oral or vaginal oral or vaginal oral or vaginal Special Instructions: ______ ______

Femtrace® ______mg Tablet*

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: X/day X/day X/day Dosage: Admin.: oral oral oral Special Instructions: ______ ______

Other Commonly Prescribed Medications

Clomiphene Citrate Tablet q 50 mg q 100 mg

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: oral oral oral Special Instructions: ______ ______

*This medication is not indicated for fertility treatment. Please speak with your clinician for an explanation of its use. 16 17 Medication Prescription

Doxycycline

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: oral oral oral Special Instructions: ______ ______

Medrol®______mg Tablet

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: X/day X/day X/day Dosage: Admin.: oral oral oral Special Instructions: ______ ______

Dexamethasone ______mg Tablet

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: oral oral oral Special Instructions: ______ ______

18 19 Medication Prescription

Birth Control:______q Oral Contraceptive q Vaginal Ring q Patch

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: Special Instructions: ______ ______

Prenatal Vitamins:______

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: oral oral oral Special Instructions: ______ ______

Baby Aspirin 81 mg Tablet

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: oral oral oral Special Instructions: ______ ______

18 19 Medication Prescription

Metformin (Glucophage) ______mg Tablet

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: oral oral oral Special Instructions: ______ ______

Heparin ______u/ml Vial

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: subcutaneous subcutaneous subcutaneous Special Instructions: ______ ______

Lovenox® ______mg Syringe

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: subcutaneous subcutaneous subcutaneous Special Instructions: ______ ______

20 21 Medication Prescription

Viagra® 25 mg Suppository (Compound)

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: q a.m. q p.m. q a.m. q p.m. q a.m. q p.m. Dosage: Admin.: vaginal vaginal vaginal Special Instructions: ______ ______

______

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: Dosage: Admin.: Special Instructions: ______ ______

______

q CYCLE 1 q CYCLE 2 q CYCLE 3 Begin On: Time: Dosage: Admin.: Special Instructions: ______ ______

20 21 Medication Descriptions Baby Aspirin 81 mg* Baby aspirin acts to thin the blood. This may increase blood flow to the uterus, creating a better uterine lining for implantation.

Birth Control* Birth control are typically prescribed before fertility patients undergo IVF treatment. The pill helps prepare the ovaries and the uterus to achieve an optimal starting point before hormone treatment. The pills are also prescribed to help IVF centers coordinate start dates for IVF treatment.

Clomiphene Citrate Clomiphene citrate acts on the hypothalamus to make the brain think there are low levels of estrogen in the blood. This action will stimulate the pituitary to produce the hormones FSH and LH. Both FSH and LH cause the ovaries to start producing eggs.

Dexamethasone* Dexamethasone is a corticosteroid and is prescribed to reduce the production of male hormones (androgens) by the adrenal gland. Reducing male hormones may help treat extra hair growth or irregular periods. Decreasing androgens may also increase ovarian receptivity during ovarian stimulation.

Doxycycline* Doxycycline is an antibiotic prescribed to prevent infection after egg retrieval and embryo transfer. Egg retrievals and embryo transfers are procedures that occur during in vitro fertilization. This antibiotic may also be prescribed to the male partner to reduce the levels of bacteria that may be found in the semen.

Heparin* Heparin is an anticoagulant often prescribed in combination with baby aspirin to combat antiphospholipid antibodies. Antiphospholipid antibodies are believed to cause an imbalance in prostaglandins, which may contribute to recurrent miscarriage.

Low Dose hCG Low dose hCG is a dilution of regular chorionic gonadotropin and is usually prepared at the pharmacy. This compounded agent is typically prescribed in conjunction with FSH to assist in stimulating the ovaries to produce eggs.

*This medication is not indicated for fertility treatment. Please speak with your clinician for an explanation of its use. 22 23 Medication Descriptions Medrol (Methylprednisolone)* Medrol is a glucocorticoid. This steroid is prescribed to prevent inflammation of the uterine lining to assist with pre-embryo implantation. It may also suppress the immune function up to the time of implantation.

Metformin (Glucophage)* Metformin is often prescribed to help lower blood insulin levels in women diagnosed with insulin resistance. Lowering blood insulin levels may lead to regular menstrual cycles and a return to more normal fertility.

Microdose Lupron Microdose lupron is a dilution of regular Lupron and is usually prepared at the pharmacy. This compounded agent is typically prescribed to inhibit an LH surge in controlled ovarian hyperstimulation without over suppressing the pituitary’s ability to produce native FSH and LH.

Prenatal Vitamins* Prenatal vitamins contain folic acid to reduce the chance of neural birth defects.

Viagra Suppository Viagra suppository may increase the blood flow to the uterus helping with uterine lining growth and overall embryo implantation.

*This medication is not indicated for fertility treatment. Please speak with your clinician for an explanation of its use. 22 23 Needles and Syringes Prescription

Injection Medication Type Mixing - Syringe/Needle Injecting Needle

q Follistim SC

q Gonal-f SC RFF Pen

q Bravelle SC q Repronex q Menopur q Luveris q Follistim Vial

q Bravelle SC Q-CAP q Repronex q Menopur

q Bravelle IM q Repronex

q Bravelle IM Q-CAP q Repronex

q Leuprolide Kit SC Note: Insulin syringes have (extra syringes) fixed needles to be used q Micro-Dose for injections. Lupron q Low-Dose HCG q Heparin

SC – subcutaneous • IM – intramuscular 24 25 Needles and Syringes Prescription

Injection Medication Type Mixing - Syringe/Needle Injecting Needle

q Generic hCG IM q Novarel q Pregnyl

q Delestrogen IM

q Progesterone IM TO MIX: Switch BD 22G 11/2 needle to BD 18G 11/2 TO INJECT: After mixing, 1 in Oil needle for mixing replace 18G 1 /2 needle back to BD 22G 11/2 needle for injecting

q Progesterone IM in Oil

q ______

SC – subcutaneous • IM – intramuscular 24 25 26 27 Cycle Planning Cycle Planning Understanding Infertility Treatment

26 27 2008 Calendar

JANUARY 2008 FEBRUARY 2008 MARCH 2008

APRIL 2008 MAY 2008 JUNE 2008

JULY 2008 AUGUST 2008 SEPTEMBER 2008

OCTOBER 2008 NOVEMBER 2008 DECEMBER 2008

28 29 2009 Calendar

JANUARY 2009 FEBRUARY 2009 MARCH 2009

APRIL 2009 MAY 2009 JUNE 2009

JULY 2009 AUGUST 2009 SEPTEMBER 2009

OCTOBER 2009 NOVEMBER 2009 DECEMBER 2009

28 29 Cycle One Tracking Calendar

Cycle Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Date

Medication Dose

FSH

HMG

hCG

Blood Work

Estradiol (E2)

Progesterone

Ultrasound

L. Ovary Count

R. Ovary Count

Endo Lining

Embryology

# Eggs Retrieved

# Eggs Mature

# Eggs Fertilized

# Embryos Transferred

# Embryos Frozen

30 31 Cycle Two Tracking Calendar

Cycle Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Date

Medication Dose

FSH

HMG

hCG

Blood Work

Estradiol (E2)

Progesterone

Ultrasound

L. Ovary Count

R. Ovary Count

Endo Lining

Embryology

# Eggs Retrieved

# Eggs Mature

# Eggs Fertilized

# Embryos Transferred

# Embryos Frozen

30 31 Cycle Three Tracking Calendar

Cycle Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Date

Medication Dose

FSH

HMG

hCG

Blood Work

Estradiol (E2)

Progesterone

Ultrasound

L. Ovary Count

R. Ovary Count

Endo Lining

Embryology

# Eggs Retrieved

# Eggs Mature

# Eggs Fertilized

# Embryos Transferred

# Embryos Frozen

32 33 Preparation Facts and Instructions Preparation Facts and Instructions Ordering, Monitoring and Storing Medications

Ordering Medications Your medications will be ordered for you by your nurse or doctor. CVS Caremark Specialty Pharmacy will have fertility medications in stock, an experienced staff to answer prescription-related questions, and offer a solid understanding of your infertility drug coverage benefits (if applicable).

Discounted Fertility Medications for Cash Paying Patients If you do not have fertility medication benefits or if you have exhausted your benefit for fertility medications, you may be eligible to receive immediate savings on certain medications for the treatment of infertility. Contact the CVS Caremark Fertility Managed Plan toll-free at 1-888-826-5632 for more information. Fertility Online Resource Center Receiving and Storing Medications www.caremark.com/ When you receive your shipment of medications, the first thing you should do is fertility review its contents. Verify that you received all of the medications you may require, is a great resource including the needles and syringes. for information regarding the Each medication has specific storage requirements. To ensure the integrity of your diagnosis, treatment medications, please follow the recommended manufacturer storage conditions. and prevention of Please see the medication storage chart on the following page. Additional infertility. information can be found in the patient information booklet included with each medication. All medications that require refrigeration should be placed in a clean area, away from moisture. Medications stored at room temperature should be placed in a clean, dry area, away from sunlight.

Monitoring Medications Throughout the course of your cycle, it is recommended that you monitor the amount of medications used. In the event you need a refill, you should allow ample time to receive the medications. Typically, prescriptions can be sent via overnight delivery, with the exception of Sundays and holidays. You may also need to take into consideration delivery service restrictions in rural areas.

32 33 Medication Storage Chart

Medication Name Storage Bravelle 75 IU Vial Room temperature or refrigerated

Cetrotide 3.0 mg Room temperature

Cetrotide 0.25 mg Refrigerated

Crinone 8% Vaginal Gel Room temperature

Endometrin Room temperature

Ganirelix Acetate 250 mcg/0.5 ml Room temperature

Follistim AQ Vial Store refrigerated until expiration date or at room temperature for three (75 IU, 150 IU) months or until expiration date (whichever occurs first).

Follistim AQ Cartridge Before first use – store refrigerated until expiration date, at room temperature (300 IU, 600 IU, 900 IU) for three months, or until expiration date (whichever occurs first). After first use – you have up to 28 days at either room temperature or refrigerated to use the remaining medication.

Gonal-f 75 IU Vial Room temperature or refrigerated

Gonal-f RFF Pen Before first use – store up to one month at room temperature or until (300 IU, 450 IU, 900 IU) expiration date (whichever occurs first), or refrigerate until expiration date. After first use – you have up to 28 days at either room temperature or refrigerated to use the remaining medication.

Gonal-f Multi-Dose Vial Before first use – store at room temperature or refrigerated until expiration date. (450 IU, 1050 IU) After first use – store up to 28 days either at room temperature or refrigerated.

hCG 10,000 Units Room temperature

Leuprolide Acetate 2-Week Kit Before first use – store at room temperature. After first use – refrigerate up to 30 days.

Lupron 2-Week Kit Before first use – store at room temperature. After first use – refrigerate up to 30 days.

hCG Low-Dose Refrigerated

Micro Dose Lupron/Leuprolide Refrigerated

Luveris 75 IU Vial Room temperature or refrigerated

Menopur 75 IU Vial Room temperature or refrigerated

Novarel 10,000 Units Room temperature

Ovidrel 250 mcg/0.5 ml Room temperature or refrigerated (Do not store at room temperature for more than 30 days.)

Pregnyl 10,000 Units Room temperature

Progesterone in Oil 50 mg/ml Room temperature

Progesterone Vaginal Suppository Refrigerated

Repronex 75 IU Vial Room temperature or refrigerated

34 35 Needles and Syringes

Your nurse or doctor will prescribe needles and syringes to be used with your medications. A quick guide to the most commonly used needles and syringes is located in the patient prescription tab of this booklet. Please remember this is only a guide, your clinician may have prescribed something different. Always follow your clinician’s instructions.

Needle Size There is a chance you will be using several types of needles during your treatment. It is important that you understand the difference in needle gauges (or size). Simply put, the larger the number, the thinner the size of the needle. For example, a 30 Needle size gauge needle is very fine when compared to an 18 gauge needle which is thick. is based on:

A thick liquid (i.e., oil-based) will require a smaller gauge needle. The thick needle 1) The thickness allows the heavy liquid to be easily drawn up. A thin, water-based liquid will of the liquid to allow you to use a higher gauged (thin) needle. Subcutaneous (fatty tissue) injections be injected. only need to penetrate the skin and fatty tissue; therefore, a higher gauged (thin) 2) Injection site needle is appropriate. For intramuscular (into muscle) injections, you will require a (intramuscular or lower gauged needle that is able to penetrate the muscle. subcutaneous).

Mixing Needle You may need to reconstitute (or mix) a medication prior to injection. When this occurs, you will need two needles: a mixing needle (typically lower gauged) for the reconstitution and a second finer needle for injection. It is important to keep both needles sterile during the reconstitution process. Do not let either needle touch any surface prior to its use.

34 35 Needles and Syringes

Disposing of Used Needles and Syringes After each injection, be sure to properly dispose of used needles and syringes in a sharps container (usually red). If you do not have a sharps container, you may use a rigid puncture-resistant container with a secure lid or cap such as a heavy plastic detergent or bleach bottle. Do not use any container that can be easily punctured with a needle. This could cause injury or spread infection to others. Be sure to safely For more information dispose of needles at all times, especially when you are not at home. Never place on sharps disposal in used needles and syringes in a trash can or recycle bin. Each state has specific your state, visit: requirements on needle disposal. • www.epa.gov Traveling with Needles and Medications • www.safeneedle Before traveling, check with the Transportation Security Administration (www.tsa.gov) disposal.org for up-to-date rules and advice for traveling with medications and needles. Make sure your medications are properly labeled (keep the pharmacy label on the You may also contact medication). You may also need a letter from your doctor. It is recommended that your local government medications, needles and syringes be packed in carry on luggage, so they are not lost for further direction. when traveling.

CVS Caremark does not operate the Web sites/organizations listed here, nor is it responsible for the availability or reliability of their content. These listing do not imply or constitute an endorsement, sponsorship or recommendation by CVS Caremark. 36 37 Preparing for Injections

Doctor and Nurse Instructions • Pay close attention to clinician instructions for the correct dosage and time of day to take medications. Some medications may be taken in the morning, while others may need to be taken in the evening. • You may have some restrictions, including exercise, food or beverage.

Clean Work Space • Select a hard, sturdy surface to prepare your medications. Before starting, always clean the surface with alcohol or disinfectant. • Before each injection, assemble all of your supplies. This will include medications, needles and syringes, adhesive bandages and alcohol swabs. • Always wash your hands with soap and water or antibacterial soap. • When working with vials of powder and diluent, always wipe the rubber stopper with an alcohol swab. Do not touch rubber stopper after sterilization.

To Minimize Discomfort of Injection Site • Rub ice on site prior to injection for one minute. • Allow medication to reach room temperature before injecting. • Change your injection site slightly every day to reduce skin irritations. • Keep muscles in injection area relaxed. • Insert and remove needle at the same angle. • Massage muscle site after IM injection. • Use warm compress, towel or heating pad on site after IM injection.

36 37 Preparing for Injections

Injection Sites • The most common sites for injections are the abdomen, thigh and buttocks. • SC Injections – Common sites for self administration include the abdomen or upper outer thigh. • IM Injections – Upper quadrant of buttocks. It is recommended a friend or spouse assist you with an IM injection.

After the Injection In the event there is bleeding at the injection site, apply slight pressure with a cotton ball or gauze for one minute. After bleeding is minimized, cover with gauze or bandage.

38 39 Medication Instructions

The following pages contain administration instructions for commonly prescribed fertility medications. For indication and adverse events information, refer to the patient information literature included with each medication. Instructions Medication Lupron® (Leuprolide Acetate Injection) Please note: This medication is not indicated for fertility treatment. Please speak with your clinician for an explanation of its use.

38 39 Lupron® (Leuprolide Acetate Injection) - continued Please note: This medication is not indicated for fertility treatment. Please speak with your clinician for an explanation of its use.

40 41 Ganirelix Acetate Injection Please note: This medication is not indicated for fertility treatment. Please speak with your clinician for an explanation of its use.

40 41 Ganirelix Acetate Injection - continued

42 43 Cetrotide®

42 43 Follistim AQ Cartridge

44 45 Follistim AQ Cartridge - continued

44 45 Follistim® AQ Vial

46 47 Follistim® AQ Vial - continued

46 47 Gonal-f® Multi-Dose 450 IU Vial

48 49 Gonal-f® RFF Pen

48 49 Bravelle®, Menopur® and Repronex®

50 51 Bravelle®, Menopur® and Repronex® - continued

50 51 Bravelle®, Repronex® and Novarel®

52 53 Bravelle®, Repronex® and Novarel® - continued

52 53 Luveris®

54 55 Luveris® - continued

54 55 Instructions to Inject Generic hCG

1) Gather medications and supplies including syringes, vial of sterile water and vial of powder.

2) Thoroughly wash hands with soap and water.

3) Cleanse the injection site and surrounding two inches of skin with an alcohol swab. Allow to dry.

4) Remove the caps of the vials and swab the top of the vials with alcohol.

5) Insert mixing needle into vial of sterile water. Turn the vial upside down and draw 1 cc of sterile water. Withdraw the needle and pierce it through the vial of the hCG powder. Inject sterile water into the vial of hCG powder.

6) Slowly mix (swirl) the hCG powder vial until all of the powder is dissolved. Do not shake. Keep needle and syringe in vial.

7) Turn the vial of mixed medication upside down, making sure the tip of the needle is below the liquid level. Slowly pull the plunger back to draw medication into the syringe.

8) Withdraw the needle from the vial and replace the needle cap. Remove the mixing needle and replace it with a new needle (typically 25 G 11/2” needle).

9) Remove needle cover, hold the needle pointing up, and flick the side of the syringe to force air bubbles to the top of the syringe. Gently push the plunger until all of the air is removed and a drop of the liquid is seen at the needle tip.

10) Stretch the skin at the injection site. Insert the needle into the skin, and slowly and steadily inject the medication.

11) Withdraw the needle at the same angle it was inserted. Apply pressure to the site with an alcohol swab.

12) Dispose of syringe in a sharps container.

56 57 Pregnyl®

56 57 Ovidrel®

58 59 Ovidrel® - continued

58 59 Crinone®

60 61 Endometrin®

60 61 Instructions to Inject Progesterone in Oil

IM Injection – Thigh or Buttocks Injection Site

1) Gather medications and supplies.

2) Thoroughly wash hands with soap and water.

3) Cleanse the injection site and surrounding two inches of skin with an alcohol swab. Allow to dry.

4) Remove the cap of the Progesterone in Oil vial and swab the top of the vial with alcohol.

5) Prepare syringe and mixing needle by attaching mixing needle to a 3 cc syringe. (Mixing needle may vary by size depending on your prescription).

6) Insert mixing needle through the center of the vial. Turn the vial and syringe upside down and draw out prescribed amount.

7) Withdraw the needle from the vial and replace the needle cap. Remove the mixing needle and replace with a new injection needle.

8) Remove the needle cover, turn the syringe so the needle is pointing upwards and tap syringe to force any air bubbles to the top. Depress the plunger to expel any air until a drop of oil is seen on the needle tip.

9) Have your partner hold the syringe in one hand like they would a pencil or dart. With the other hand, tightly stretch the skin at the injection site.

10) With a quick motion, insert the entire needle into the skin at a 90° angle into the stretched skin.

11) Stabilize the syringe with either hand. Slightly pull back on the plunger and watch for any blood in the syringe. If blood is not seen in the syringe, the needle is inserted properly. If blood does appear, do not inject your medication. Withdraw the needle, cover the site with a gauze pad and apply pressure. Discard the syringe into the sharps container. Use a new, sterile needle and syringe to inject new medication.

12) If no blood is seen, depress the plunger slowly and steadily into the skin.

13) Withdraw the needle at the same angle it was inserted. Apply pressure to the site with an alcohol swab.

14) Dispose of syringe in a sharps container.

62 63 Glossary of Terms Glossary of TermsGlossary Glossary of Terms

Adhesion: The scar tissue that forms around reproductive organs following a previous injury, infection or surgery. Amenorrhea: The absence of menstruation. Androgen: Primarily a male sex hormone found in the ovaries. Andrologist: A highly trained sub-specialist urologist who deals with male infertility. Anovulation: The failure of an ovary to release an egg. ART: See Assisted Reproductive Technologies. Artificial Insemination (AI): The depositing of sperm in the vagina near the cervix or directly into the uterus, with the use of a catheter instead of by sexual intercourse. This technique is used to overcome sexual performance problems, to avoid sperm-mucus interaction problems, to maximize the potential of poor semen, and for using donor sperm. Assisted Hatching: A technique developed to encourage the embryo to hatch from its shell. Assisted Reproductive Technologies (ART): A procedure that involves the surgical removal of eggs from the ovary and subsequent fertilization of sperm and egg in the laboratory. The resulting embryo is then transferred into the woman’s uterus for implantation. Basal Body Temperature (BBT) Test: The temperature of a woman taken every morning during a cycle to help determine when ovulation takes place. Baseline Ultrasound: An examination conducted before starting therapy to determine the general position and condition of the ovaries. Blastocyst Transfer: Embryos develop for 5 to 6 days rather than the usual 2 to 3 days in IVF. Cervical Mucus: Mucus produced by the cervix that permits passage of sperm during ovulation. Cervix: Lower section of the uterus that protrudes into the vagina, through which the sperm must pass to reach the uterus. Chemical Pregnancy: The false appearance of pregnancy due to changes in hormonal levels. Controlled Ovarian Hyperstimulation: Stimulation of the ovaries with fertility medications aimed to develop multiple follicles and control the timing of ovulation. Corpus Luteum: A structure that forms at the site of an ovarian follicle after it releases an egg. The corpus luteum releases estrogen and progesterone, two hormones necessary for maintaining a pregnancy. Cryopreservation of Embryos: The process of freezing embryos so they may be used at a later time for embryo transfer. Donor Egg: An egg from one individual donated for another couple’s use with in vitro fertilization. Donor Sperm: Sperm from one individual donated for another couple’s use in ovulation induction or with in vitro fertilization. Down Regulation: The use of Lupron to suppress natural hormones. Dysmenorrhea: Cramping and pain around the time of menstruation. Dysmucorrhea: Poor quality or inadequate cervical mucus that can prohibit sperm passage. Ectopic Pregnancy: Implantation of an embryo in a place other than the uterus, typically the fallopian tube.

62 63 Egg Retrieval: A procedure used to obtain eggs from ovarian follicles for use in in vitro fertilization. The procedure may be performed during laparoscopy or through the vagina by using a needle and ultrasound to locate the follicle in the ovary. Embryo: A fertilized egg. Embryologist: A specialist in embryo development. Embryo Transfer: Placing an egg fertilized outside the womb into a woman’s uterus or fallopian tube. Endometrial Biopsy: The removal of a sample of the lining of the uterus for examination. Endometriosis: A condition in which the tissue that lines the uterus grows in locations outside the uterus, usually in various regions of the pelvis. Endometrium: The inner lining of the uterus, also known as uterine lining. Epididymis: The organ in a man where sperm are stored, nourished and mature after production. Estrogen: A female hormone produced by developing follicles that causes the uterine lining to thicken in preparation for pregnancy. FSH: See Follicle-stimulating Hormone. Fallopian Tubes: Ducts through which eggs travel to the uterus once released from the follicle. Sperm normally meet the egg in the fallopian tube, the site at which fertilization usually occurs. Fertility Specialist: A physician specializing in the practice of fertility. The American Board of Obstetrics and Gynecology certifies a subspecialty for OB-GYNs who receive extra training in reproductive endocrinology (the study of hormones) and infertility. Fertilization: The union of an egg and a sperm, which then develops into an embryo. Fibroid Tumor: Benign (not malignant or life-threatening) tumor of fibrous tissue that can occur in the uterine wall. May be totally without symptoms or may cause abnormal menstrual patterns or infertility. Fimbria: The finger-like extensions on the fallopian tubes that sweep the egg into the fallopian tube. Follicle: One of many fluid-filled sacs in the ovaries in which an egg develops until being released during ovulation. Follicle-stimulating Hormone (FSH): A pituitary hormone that stimulates follicular development in the ovaries. In a woman, FSH stimulates the growth of the ovarian follicle. Follicular Phase: Typically days 1 through 14 of the menstrual cycle. GIFT: See Gamete Intrafallopian Transfer. GnRH: See Gonadotropin-releasing Hormone. Gamete: A reproductive cell. Sperm in men. The egg in women. Gamete Intrafallopian Transfer (GIFT): After egg retrieval, the eggs are mixed with sperm and then placed, using a minor surgical procedure (laparoscopy), into a woman’s fallopian tubes for in vitro fertilization. GnRH Agonist: A compound that mimics native GnRH to bind with GnRH receptors, which over time leads to inhibition of secretion of FSH and LH. GnRH Antagonist: A medication that mimics native GnRH to bind with GnRH receptors and rapidly block the secretion of FSH and LH. Gonadotropin: Hormones secreted by the pituitary gland, which control reproductive function. Examples of these hormones are FSH and LH.

64 65 Gonadotropin-releasing Hormone (GnRH): A hormone secreted by the hypothalamus. This hormone enables the pituitary to secrete LH and FSH, that then stimulate the gonads. Gonads: Glands that make the gametes (testicles and ovaries). hCG: See Human Chorionic Gonadotropin Human Chorionic Gonadotropin (hCG): The hormone produced in early pregnancy, released by the placenta after implantation. hCG keeps the corpus luteum producing estradiol and progesterone and thus prevents menstruation. It is also used via injection to trigger ovulation. Hydrosalpinx: Blocked, dilated, fluid-filled fallopian tube. Hypogonadism: Inadequate ovarian or testicular function as shown by low sperm production or lack of follicle production as well as low or absent levels of FSH and LH. Hypogonadotropic Hypogonadism/Hypogonadotropic Hypogonadal (HH): A rare condition in which impaired activity of the hypothalamus or pituitary results in below-normal function of the gonads and in abnormally low FSH and LH serum levels and consequential negligible estrogen levels. Hypothalamus: The gland at the base of the brain that controls the release of hormones from the pituitary glands. Hysterosalpingogram (HSG): An X-ray and dye test to determine blockage or abnormalities in the fallopian tubes. HSG also evaluates the size and shape of the uterine cavity. Hysteroscopy: A visual examination of the uterus using an instrument called a hysteroscope, which enables the doctor to see into the organ without making a large incision. IVF: See In Vitro Fertilization. Idiopathic Infertility: The term used when the cause of infertility cannot be explained. Implantation (Embryo): The embedding of the embryo into the lining of the uterus to establish contact with the mother’s blood supply for nourishment. In Vitro Fertilization (IVF): Eggs produced by administering fertility drugs are retrieved from a woman’s body and fertilized via sperm in a laboratory. The resulting embryos are transferred by catheter into the uterus. Infertility: The inability to conceive after a year of unprotected intercourse (six months if a woman is over age 35). Intracytoplasmic Sperm Injection (ICSI): A micromanipulation procedure in which a single sperm is injected directly into the egg to enable fertilization. The resulting embryo is then transferred to the uterus. Intramuscular (IM) Injection: Administration of medication deep into the muscle. Injections of this type are usually given in the thigh or upper buttock area. Intrauterine Insemination (IUI): A procedure in which a doctor places sperm directly into the uterus through the cervix using a catheter. LH: See Luteinizing Hormone. Laparoscopy: Examination of the pelvic region by using a small telescope called a laparoscope. LH Surge: The pituitary gland releases a burst of luteinizing hormone that stimulates the final maturation of the follicle and induces ovulation. Luteal Phase: Typically days 15 through 28 of the menstrual cycle. Luteinizing Hormone (LH): A pituitary hormone that stimulates the gonads. In a woman, LH is necessary for the production of estrogen and ovulation. Menopause: Permanent cessation of menses. 64 65 Menses: The shedding of the lining of the uterus that occurs approximately every four weeks in non-pregnant women. Miscarriage: Spontaneous loss of a viable embryo or fetus in the womb. Morphology: The physical structure and configuration of sperm cells. Motility: The ability of sperm to swim. Poor motility means the sperm have a difficult time swimming toward the egg. Multiple Pregnancies: Any pregnancy in which there are two or more fetuses. OHSS: See Ovarian Hyperstimulation Syndrome. Oligomenorrhea: Irregular menstrual periods. Oligoovulation: Infrequent and irregular ovulation. Oligospermia: Low number of sperm in the ejaculate of the male. Oocyte: An egg. Ovarian Failure: The failure of the ovary to respond to FSH stimulation from the pituitary because of damage to or malformation of the ovary. Diagnosed by elevated FSH in the blood. Ovarian Hyperstimulation Syndrome (OHSS): A serious medical condition resulting from an over-stimulation of the ovaries. It can cause a rapid accumulation of fluid in the abdomen and lungs; early warning signs include severe pelvic pain, nausea, vomiting, weight gain and reduced urine production. Ovarian Stimulation: The administration of hormones to promote egg development in the ovaries. Ovaries: The two sexual glands of the female where eggs are stored. The ovaries also produce the hormones estrogen and progesterone. Ovulation: The release of a mature egg from an ovarian follicle. Ovulation Induction: A procedure in which fertility medications are used to stimulate the development of an egg in a woman’s ovary and its subsequent release. Ovulatory Dysfunction: A problem with the ovary where the egg is not matured or released properly. Ovum: A mature egg; the female sex cell penetrated by a sperm in the act of fertilization. Pelvic Inflammatory Disease (PID): Inflammatory disease of the pelvis (usually caused by infection) that can lead to scarring and infertility. Pituitary Gland: The endocrine gland at the base of the brain that secretes hormones such as FSH and LH. Polycystic Ovarian Syndrome (PCOS): A syndrome that may be diagnosed by the presence of several characteristics that may include polycystic ovaries (many small fluid filled follicles) noted on ultrasound, obesity, hirsutism, amenorrhea and anovulation. PCOS is a common cause of female infertility. Post-coital Test (PCT): A test to determine whether the sperm can move properly through the cervical mucus. Prolactin: Female hormone responsible for milk production in nursing mothers. Can be elevated for other reasons such as an underactive thyroid. Elevated prolactin can stop ovulation. Progesterone: The hormone produced by the corpus luteum during the second half of a woman’s cycle. It prepares the lining of the uterus to accept implantation of a fertilized egg. Prostate: The gland in the male that supplies some of the seminal fluid, and prepares the urethra for the passage of sperm. Reproductive Endocrinologist: An Obstetrician-Gynecologist with advanced education, research and professional skills in Reproductive Endocrinology and Infertility. 66 67 Scrotum: The pouch at the base of the penis that contains the testicles. Semen Analysis: A semen analysis measures the amount of semen a man produces and determines the number and quality of sperm in the semen sample. Seminal Vesicles: The pair of pouch-like glands around the prostate that produce the milky fluid that mixes with the sperm prior to ejaculation. Sharps Disposal Bin (Safety Container): A container used for the disposal of needles and other medical waste. Sono-Hysterogram (SHG): An ultrasound test to screen for uterine abnormalities. Sperm (spermatozoa): The microscopic cell that carries the male’s genetic information to the female’s egg; the male reproductive cell; the male gamete. Sperm Count: The number of sperm in an ejaculate. It is also called sperm concentration and given as the number of sperm per milliliter. Sperm Morphology: Size and shape of individual sperm. Normal sperm have an enzyme-coated head, middle piece and whip-like tail. Sperm Motility: The ability of sperm to swim and move progressively. Motility is one of the most important determining factors in the sperm’s ability to fertilize an egg. Spermatogenesis: The production of sperm. Sterility: An irreversible condition that prevents conception. Subcutaneous (SC) Injection: Administration of medication with a fine small needle just below the surface of the skin, into fatty tissue. TSH: Thyroid Stimulating Hormone is released by the pituitary gland to increase thyroid hormone production. TSH results can reveal whether thyroid function is normal, which is necessary for normal ovulation. Testes: The two male sexual glands that produce sperm as well as the male hormone testosterone. Testosterone: The male hormone responsible for the formation of secondary sex characteristics and for supporting the sex drive. Testosterone is also necessary for spermatogenesis (sperm development). Tubal Pregnancy: The development and attachment of a fertilized egg in a fallopian tube. Ultrasonographer: A technician qualified to perform abdominal and transvaginal ultrasounds to determine the size, shape and dimensions of pelvic organs, ovarian follicle production, and the existence of tumors, enlargements or inflammations. Ultrasound: A test used instead of X-rays to visualize the reproductive organs; for example, to monitor follicular development. Urologist: An MD specializing in male and female urinary tract problems who is particularly knowledgeable about penile and testicular function. Uterus: The female reproductive organ in which a fertilized egg is implanted and develops during the course of a pregnancy; also known as the womb. Vagina: Muscular opening in a woman extending from the vulva to the cervix of the uterus. Varicocele: Varicose veins in the testicle that can cause sperm abnormalities. Vas Deferens: The pair of tubes in the male that lead from the epididymis to the ejaculatory duct in the prostate. Womb: See Uterus. Zygote Intrafallopian Transfer (ZIFT): Zygote intrafallopian transfer involves in vitro fertilization with a transfer of the zygote into the fallopian tube. The zygote is an egg that has been fertilized but has not yet divided. 66 67 68 69 Additional Resources Additional Resources Resources

American College of Obstetricians and Gynecologists www.acog.org Clinician Web site dedicated to women’s health care and government advocacy. Excellent listing of OB/GYNs by state.

American Fertility Association www.theafa.org Patient advocacy group dedicated to fertility education, support and advocacy. The Web site includes online educational sessions, message boards and up-to-date articles on fertility treatment. Patient handbooks are available, including a comprehensive guide to state insurance mandates.

American Pregnancy Organization www.americanpregnancy.org This organization is dedicated to the promotion of reproductive and pregnancy wellness. Included are explanations of fertility treatments as well as an online ovulation predictor calendar.

American Society for Reproductive Medicine www.asrm.org The Web site is designed for both reproductive endocrinologists and patients. You will find fertility FAQs, patient information booklets, medical journal highlights and state infertility insurance laws.

Centers for Disease Control and Prevention www.cdc.gov/ART Government Web site that includes information on reproductive health. Provides annual report on ART success rates by clinic.

CVS Caremark Specialty Pharmacy www.caremark.com/fertility Find a wealth of information regarding the diagnosis, treatment and prevention of infertility.

Fertile Hope www.fertilehope.org A national, non-profit organization dedicated to providing reproductive information, support and hope to cancer patients and survivors whose medical treatments present the risk of infertility.

InterNational Council on Infertility Information Dissemination www.inciid.org A non-profit organization that helps individuals and couples explore their family-building options. The Web site provides information and support regarding the diagnosis, treatment and prevention of infertility and pregnancy loss. It also offers guidance to those considering adoption or childfree lifestyles.

Resolve: The National Infertility Association www.resolve.org Patient advocacy group providing education on fertility treatment and support services. Web site includes helpline, online chats, educational seminars and bulletin boards. RESOLVE also works with the U.S. government to promote legislative action for fertility insurance coverage.

Society for Assisted Reproductive Technology www.sart.org Professional organization that provides patients with general information on fertility, annual ART success rates by clinic, and financial information on treatment. A patient ART handbook is also available for download.

Ferring Fertility www.ferringfertility.com Sponsored by Ferring Pharmaceuticals, the Web site provides education on infertility treatment, diagnosis and medication instruction. Included is prescribing information and injection instructions for Bravelle, Menopur, Repronex and Novarel.

Fertility.com www.fertility.com Sponsored by EMD Serono, the Web site provides education on infertility treatment, diagnosis and medication instruction. Included is prescribing information and injection instructions for Citrotide, Gonal-f, Ovidrel, Luveris and Serphene.

Fertility Journey www.fertilityjourney.com or www.follistim.com Sponsored by Organon USA, the Web site provides education on infertility treatment, diagnosis and medication instruction. Included is prescribing information and injection instructions for Follistim, Ganirelix and Pregnyl.

Fertility LifeLines www.fertilitylifelines.com Sponsored by EMD Serono, the Web site provides education on infertility treatment, diagnosis and medication instruction. Included is prescribing information for Gonal-f, Ovidrel and Luveris.

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