UCSF Center for Reproductive Health CRH IVF & Egg Cryo Medication Overview & Injection Demonstration

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. IVF / EGG CRYO TREATMENT CYCLE MEDICATION TIMELINE

Call to Baseline First More Monitoring Pre-Cycle P report your ultrasound monitoring monitoring appointment Tasks period (and appointment appointments indicates E R bloodwork) follicle G  Finalize plan E EVERY maturity, ready G with MD SCHEDULED 1-3 DAYS CYCLE DAY 1 for trigger  Blood work PER  Consents T PROTOCOL  Genetics R consult if R E desired E If cleared: Continue medication HCG “Trigger” T  Receive Start injections every night injection when A 36 hours calendar from stimulation R instructed; later RN T medications. Adjustments may be made to give in PM at I coordinator M Inject in PM your medications / dosages designated E  Order time medications E Care team will contact you to V  Attend N confirm your dose that A injection class afternoon  Finalize billing T L for cycle

Follicles Most patients may be on: Lupron injections, Estrace patches OR pills, or birth control pills for pre-cycle suppression Baseline Stim Day 5 Stim Day 9

*Ultrasound images are for example only. Individual responses vary. 4 Cycle Tracking Example for Dosing

. 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

• 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 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 and Syringes

Needles

• Mixing Needle – 18 or 20 gauge; 1.5 inches

• Subcutaneous Needle For Injection – 27 gauge; 0.5 inches

1 ml/cc

Syringes

• 3 ml (cc) syringe 3 ml (cc) • Insulin Syringe (see next slide) syringe Subcutaneous (SQ) Injections 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

9 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 (lutenizing hormone)

• Can come in liquid form in pens (Gonal-f, Follistim) or in powder form (Menopur) - which will need to be mixed with liquid 75 IU = 1 vial • Injections given at approximately the same time each evening FreedomMedTeach.com Injection Tips and Technique  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 75 IU = 1 powder vial + 1 ml sodium chloride  If needle touches a surface other than the clean top of a vial, it is contaminated. Twist off and replace with a sterile needle

150 IU = 2 powder vials  Needles and syringes are one- + 1 ml sodium chloride time use only Injection Tips and Technique

Pull back and forth on Make sure needle tip is plunger until large air always in liquid space is filled. - NOT in air space above Small bubbles are OK 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” 5,000 USP Novarel, Pregnyl, Human Chorionic = 2 boxes 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** 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 HCG “Trigger" Progesterone

▪ Lupron (leuprolide • Novarel (for embryo transfer) acetate) * • Pregnyl • Intramuscular • Human Chorionic Progesterone - sesame oil Gonadotropins Gonadotropin or synthetic (ethyl oleate) (HCG) - room temp is fine ▪ Gonal-f **

▪ Follistim ** “Co-trigger" ▪ Menopur ▪ Lupron (leuprolide acetate) Antagonists ▪ Gonal-f ** ▪ Cetrotide** ▪ Follistim ** ▪ Ganirelix *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

. 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

23 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 - 6pm Saturday – 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!