FET Flashcards
Fresh definition
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)
FET timing
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)
Patient Preparation
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
How many embryos to transfer?
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%
Progyny Patients-Multiple Embryo Transfer (MET) policy
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)
Candidate for Fresh Embryo Transfer - who is not a candidate?
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
Pictures of gametes/Embryos
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.
Post Embryo Transfer Instructions
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
Medications post egg retrieval
(meds as easy as pie)
Corpora Lutea functional?
Required hormones for uterine lining support**:
Estrogen
Progesterone
Immune suppression
Medrol*
**Generally wait to order luteal phase medications until transfer confirmed
luteal support meds - estrogen - how long to take if concieved?
Estrogen: Estrace orally 2mg twice daily, continue until 8wks6 days if conceives
luteal support meds - progesterone -vaginal - when to start taking?
(give pro a day)
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.
luteal support meds - medrol - when to start and how long to take?
(retrieve the medrol)
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.
luteal support meds - valium - when to take?
Valium (10mg) taken one hour prior to the transfer to help relax the uterus
Estrogen- when to take?
(ester is 4 days later)
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
Progesterone—Vaginal options - when to start and when to stop?
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
Progesterone in oil (PIO) Intramuscular injection - when to start and when to stop?
(oil at night)
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)
“The two week wait”
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!
Fresh Transfer Medications
(Progesterone)
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
Fresh Transfer Medications
(continued)
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
why a full bladder?
it pushes the uterus down so it’s easier to insert the catheter
prometrium cover
(prometrium - pro peanut)
peanut oil cover, so can’t use if pt has peanut allergy
progesterone - vaginal options - endometrin - when to start and when to stop?
- (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)
*
progesterone - vaginal options - prometrium
(prometrium 2)
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)
progesterone - crinone - when to start?
(cringe the day after)
Vaginal gel (Crinone) once daily-(Begins day after egg retrieval)
progesterone - PIO (progesterone in oil) - when to start?
(oil in the evening)
If Progesterone in oil (PIO) to be utilized: Daily IM injection starts on evening of Egg Retrieval and continue every evening as indicated.
