FET

Question 1

Fresh definition

Answer 1

Definition: An embryo transfer done in the same cycle as the ovarian stimulation​

Timing: Between day 3-5 after egg collection (egg collection day 0), embryo still “fresh” and in culture in the incubator (i.e. NOT previously frozen)​

An embryo (s) time of growth in the lab/when to transfer should have been determined prior to the IVF cycle based on:​

Family goal​

Reason for IVF​

Diagnosis​

Previous treatment(s)​

Desire/Need for embryo testing (PGT)

Question 2

FET timing

Answer 2

Timing: Between day 3-5 after egg collection (egg collection day 0), embryo still “fresh” and in culture in the incubator (i.e. NOT previously frozen)​

Question 3

An embryo (s) time of growth in the lab/when to transfer should have been determined prior to the IVF cycle based on:​

Answer 3

Family goal​

Reason for IVF​

Diagnosis​

Previous treatment(s)​

Desire/Need for embryo testing (PGT)

Question 4

Patient Preparation

Answer 4

Arrive to clinic 30 min prior to transfer​

Take 1 tablet valium, 1 hour prior to transfer appointment.​

They cannot drive themselves…​

Drink 2-3 glasses of water, arrive with moderately full bladder​

Test transfer done in precycle testing ensures no surprises day of transfer​

Rarely done under anesthesia

Question 5

How many embryos to transfer?

Answer 5

The goal of ART/embryo transfer is a healthy a pregnancy while still allowing a good chance of pregnancy..​

Transferring more than one embryo, can increase the risk of a multiple pregnancy​

In the US, ~30% of IVF pregnancies are twin pregnancy​

3-4% result in triplet or higher order multiple (4 of more..)​

Elective Single Embryo transfer (eSET)​

If PGT done prior to transfer​

<35 years old​

First ART cycle or previous successful ART outcome​

Large number of high quality embryos​

Have embryos available (cryopreserved) for future cycle​

Decreases the chance of multiple preg (overall, twin rates after eSET ~1-2%

Question 6

Progyny Patients-Multiple Embryo Transfer (MET) policy

Answer 6

Progyny patients desiring Multiple Embryo Transfers (MET) - require pre-approval​

Progyny patients require pre-approval for multiple embryo transfers before starting the cycle, and only those that adhere to ASRM guidelines will be covered by insurance.​

If denied, the patient could still plan to proceed with plan it will just not be covered by Progyny.​

​

This process will mostly be handled by Finance Team, but will require RNs or PNs sending the Order to Finance before treatment in which a MET is desired .​

​

Utilize the @ phrase @METforProgyny in remarks of order to Finance-Progyny to generate the paragraph template, and fill in the required information (cycle type, number of embryos to transfer, stage of embryos)

Question 7

Candidate for Fresh Embryo Transfer - who is not a candidate?

Answer 7

Progesterone level at trigger <1.5​

Uterine lining must be >7mm​

IVF protocol allows for uterine conditions to be optimal for pregnancy​

Mid-luteal protocol patient is never a candidate for fresh embryo transfer​

Not at high risk of OHSS​

Not planning transfer based on PGT results

Question 8

Pictures of gametes/Embryos

Answer 8

Day of the patient’s embryo transfer a picture of the embryo(s) for transfer will be taken and provided to the patient by the MA with their embryo transfer report & discharge instructions. ​

​We do not take/provide pictures of gametes/embryos at any other time in the patient journey.

Question 9

Post Embryo Transfer Instructions

Answer 9

Embryos will not “fall out” ​

Media used to clean the cervix may appear as fluid/discharge​

Food: balanced diet is best, can follow pregnancy recommendations​

Exercise/Activity: Reduce activity/exercise first 3 days following transfer. No lifting over 30 pounds. No high impact exercise/activity due to continued risk of ovarian torsion.​

Sex: No intercourse/orgasm for at least 1 week​

Caffeine: in moderation, max ~ 2 cups daily​

Hot tubs/Saunas: Not allowed. Also, no direct heat to abdomen. ​

Medications: Continue all SPRING recommended luteal support as directed. ​

Pain: Tylenol okay, no NSAIDs ​

Common symptoms: Cramping (mild), spotting, breast tenderness​

Pregnancy test: Bloodtest ~14days post transfer

Question 10

Medications post egg retrieval
(meds as easy as pie)

Answer 10

Corpora Lutea functional?​

Required hormones for uterine lining support**:​

Estrogen​

Progesterone​

Immune suppression​

Medrol*​

​

**Generally wait to order luteal phase medications until transfer confirmed

Question 11

luteal support meds - estrogen - how long to take if concieved?

Answer 11

Estrogen: Estrace orally 2mg twice daily, continue until 8wks6 days if conceives​

Question 12

luteal support meds - progesterone -vaginal - when to start taking?
(give pro a day)

Answer 12

Progesterone: Vaginal form of progesterone is the default for Fresh ET. Vaginal begins the morning following the egg retrieval, if PIO preferred or indicated it would be started earlier and dosing dependent on E2 at time of trigger. ​

Question 13

luteal support meds - medrol - when to start and how long to take?

(retrieve the medrol)

Answer 13

Medrol (Methylprednisolone) is a low dose steroid used to suppress the immune system response and inflammation that may impact implantation. Begins day of egg retrieval and continues for 5 days. This is provider preference, in NYC likely not utilizing standard. ​

Question 14

luteal support meds - valium - when to take?

Answer 14

Valium (10mg) taken one hour prior to the transfer to help relax the uterus​

Question 15

Estrogen- when to take?

(ester is 4 days later)

Answer 15

Estrace/Estradiol tablet​

1 tablet orally twice daily ​

Begins 4 days post retrieval until pregnancy test.​

If pregnant, continues until 8w6days gestation.​

Warning label..only if you’re getting preg naturally, it’s safe bc we are monitoring your levels

Question 16

Progesterone—Vaginal options - when to start and when to stop?

Answer 16

Only one type prescribed​

Vaginal administration (Begins morning after retrieval):​

Endometrin tablet ​

100mg TID until 8w6days then decrease to BID until 11w6days​

Prometrium Capsule*​

200mg TID until 8w6days then decrease to BID until 11w6days​

*Cannot use if patient has peanut allergy (capsule contains peanut oil)​

Crinone 8% gel (90mg)​

Once daily in the AM until 11wks 6days gest

Question 17

Progesterone in oil (PIO) Intramuscular injection - when to start and when to stop?

(oil at night)

Answer 17

Oil based injectable progesterone supplement, if preferred by patient instead of vaginal product.​

50mg/ml->10ml multidose vial ​

Begins evening of Egg Retrieval, if pregnant continues until 11w6days gestation. Option to switch to vaginal at 8w5days (see SOP)​

​

Dosing depends on E2 level at time of trigger (see next slide)​

Oil suspensions that may be selected/available​

Sesame oil—standard (available multiple pharmacies)​

Ethyl oleate—thinner oil (only available via compounding pharm)​

Cottonseed, Olive oil, etc.. (compounding pharmacy only)

Question 18

“The two week wait”

Answer 18

Notoriously known in the fertility patient community, the two week wait from transfer to pregnancy test can be the most challenging time
The hormonal symptoms for the medications following the transfer will make them feel as though they are about to get their period and/or are pregnant. It is therefore important to remind them to try and not read into these symptoms
Due to false readings we do not recommend checking home urine pregnancy tests during this time!

Question 19

Fresh Transfer Medications​
(Progesterone)

Answer 19

Need ONE option, Vaginal is the standard. Only IM if specified by MD or requested by patient
All can be filled through local or specialty pharmacy
Only order transfer medications once the transfer has been confirmed at trigger
Progesterone ​

Vaginal (PV) Crinone, Endometrin, Prometrium ​

Crinone 8% vaginal gel applicator 90 mg​

Sig: 1 applicator once daily vaginally ​

Quantity: 20 applicators, 3 refills​

Endometrin 100 mg vaginal insert tablets​

Sig: 1 tablet three times daily vaginally​

Quantity: 40 tablets, 3 refills​

Prometrium 200 mg capsules​

Sig: 1 capsule three times daily vaginally​

Quantity: 40 capsules, 3 refills​

Intramuscular Injection (IM) Progesterone in Oil (Sesame, Olive or Ethyl Oleate)​

Progesterone in Oil 50 mg/mL, 10 mL vials​

Sig: Inject 1 mL (dose will titrate up per instructions) IM once daily ​

Quantity: 3 vials, 3 refills
These quantities will last until the patient gets her pregnancy results (2 weeks post transfer). ​

If pregnant she will need to continue for an extended time and will therefore need refills available

Question 20

Fresh Transfer Medications​
(continued)

Answer 20

Need to also order supplies if using IM Prog:
Syringes 3 mL syringes​

Order 30 syringes
Needle to draw up 18 OR 20 gauge 1.5 inch needles​

Order 30 needles
Injection Needles ​

For Ethyl Oleate 25 gauge 1.5 inch​

For Sesame Oil 22 gauge 1.5 inch Order 30 needles:

All can be filled through local or specialty pharmacy:

Estrogen Estrace 2 mg tablet (warning label)​

Sig: 1 pill PO twice daily until instructed otherwise​

Quantity: 30 tablets, 3 refills
Medrol (Methylprednisolone) 16 mg tablet​

Sig: 1 pill PO once daily x 5 days​

Quantity: 5 tablets, no refill

Valium (Diazepam) 10 mg tablets​

Sig: 1 pill one hour prior to procedure the second is an optional dose 6-8 hours later​

Quantity: 2 tablets, no refill

Question 21

why a full bladder?

Answer 21

it pushes the uterus down so it’s easier to insert the catheter

Question 22

prometrium cover

(prometrium - pro peanut)

Answer 22

peanut oil cover, so can’t use if pt has peanut allergy

Question 23

progesterone - vaginal options - endometrin - when to start and when to stop?

Answer 23

• (Endometrin) 100mg three times daily until 8 wks 6 days. At 9wks gestation, decrease to BID until 11wks6days. That will be last dose. (Begins day after egg retrieval)
  *

Question 24

progesterone - vaginal options - prometrium

(prometrium 2)

Answer 24

Prometrium capsule 200mg TID vaginally three times daily until 8 wks 6 days. At 9wks gestation, decrease to BID until 11wks6days. That will be last dose. (Begins day after egg
retrieval)

Question 25

progesterone - crinone - when to start?

(cringe the day after)

Answer 25

Vaginal gel (Crinone) once daily-(Begins day after egg retrieval)​

Question 26

progesterone - PIO (progesterone in oil) - when to start?

(oil in the evening)

Answer 26

If Progesterone in oil (PIO) to be utilized: Daily IM injection starts on evening of Egg Retrieval and continue every evening as indicated. ​