IVF Protocols Flashcards
priming - how long does it last?
2-4 weeks
Priming is about suppression of the follicles to ensure they are at the same small ideal size at the start of their stimulation – therefore leading to more synchronized growth
Variations in Priming Protocols:
Variations in Priming Protocols:
OCP
Aygestin
Mid Luteal
Demi-Halt
E2
EAP (E2 & Antag)
ATP (Aygestin & Testosterone)
ETP (Estrogen & Testosterone)
stimulation - 8-12 days - this is obviously just monitoring
We will monitor throughout the stimulation closely and adjust dosing throughout to encourage synchronized growth and pick the ideal time for trigger for retrieval
Variations in Stimulation Protocols:
Minimal Stimulation
Clomid/Letrozole Flare
priming and stimulation
Spring offers many different protocols for priming and stimulation that will be selected specifically for each patient based on their diagnosis and history in order to give them the ideal outcome
IVF: Intended treatment - (this is just an example of how it will look in Ideas)
All treatment plans will state “IVF” however, you will need to look at the actual intended treatment to determine what type of cycle they will be doing. See example
This is an egg freezing patient doing Aygestin priming – no fertilization will occur even though it states “IVF”
If there is a fraction in remarks, like 3/2, that’s the 2 meds - FSH and LH, or whatever the doc prescribed
Invitro Fertilization “IVF”
IVF technically refers to the fertilization of the egg with sperm outside of the body.
We will utilize the term “IVF” to refer to any treatment cycle of controlled ovarian stimulation with the intent of an egg retrieval.
Egg Cryopreservation
Embryo Cryopreservation
IVF with fresh embryo transfer
Egg donor cycle
You must look at the actual intended treatment to determine what type of cycle is planned
priming protocol - OCP (OCP is birth control) follicular - CD1 - how long to take the BC? And in the follicular phase?
Patient reports full flow period and is instructed to start oral contraceptive/birth control pills (OCP/BCP) on CD 1-3. The birth control will then be continued for 10-14 days unless otherwise specified in treatment plan.
*If started late follicular (CD4-ovulation): instruct pt to take 14-20days.
Ideal Timing: Last BCP Sat for W/Th BUS
- OCP follicular baseline - 3-5 days AFTER stopping BC - what meds?
- expected menses - After baseline appointment the patient will be instructed to start injectable stimulastion medications FSH & Menopur
OCP - Day 8-12 after menses - Monitoring - what meds? and how big should the follicle be?
stimulation meds - Once a dominate follicle(s) reaches a size of 12+ mm the provider will start antagonist medication (Ganirelix/Cetrotide/Fyremadel) (to prevent early LH surge)
OCP - monitoring - stim day 3-4 and 5-6
Monitoring:
Stim Day (stim day is the day we give the shots) 3-4 E2 only (blood test)
Stim Day 5-6 US & E2 (blood test)
Then continued per response until trigger
- OCP - trigger - what drugs? and when to retrieve?
(the OC is huggin lupe)
When cohort of follicles is at ideal range for best maturity outcome the provider will confirm trigger with HCG & Lupron. Her retrieval will be schedule 36 hours later
OCP follicular
CD1, OCP (10-16 days) baseline (3-4 days later) monitoring 8-12 days, retrieval = 36 hours later
PRIMING Protocol: OCP Luteal - CD1
and what bloodwork?
(this is when you start priming the month prior to stim)
Patient reports full flow period and is instructed to begin checking ovulation predictor kits for one week (expected ovulation date –3 & +3)
If the results are negative (for LH surge = with OPK) for the full week the patient will need to come in for bloodwork (E2 & P4) to confirm if the patient has ovulated yet or not
PRIMING Protocol: Aygestin - CD1
- and what if pt hasn’t ovulated according to OPK?
This ONLY starts in the luteal phase =
Patient reports full flow period and is instructed to begin checking ovulation predictor kits for one week (expected ovulation date –3 & +3)
If the results are negative (pt hasn’t ovulated) for the full week the patient will need to come in for bloodwork (E2 & P4) to confirm if the patient has ovulated yet or not
PRIMING Protocol: Aygestin – 5 days after +OPK
Once the patient reports a positive result 5 days after the positive OPK result patient is instructed to start Aygestin and continue for 10 days.
PRIMING Protocol: E2 (this is the least suppressive) - what day to start estrace?
(this is usually used for DOR)
(taking estrogen won’t stop period - it’s more to stop the body from releasing follicles)
This USUALLY starts in the luteal phase -
Patient reports full flow period and is instructed to begin checking ovulation predictor kits for one week (expected ovulation date –3 & +3)
Once the patient reports a positive result they are instructed to start Estrace BID 5 days (2 mg x 2/day) later and continue until menses
E2 - after baseline and menses, pt will do what?
After baseline appointment, and menses is confirmed the patient will be instructed to start injectable stimulation medications FSH & Menopur
PRIMING Protocol: E2 - stimulation meds (antagonist) - when egg is what size?
Once a dominate follicle(s) reaches a size of 12+ mm the provider will start antagonist medication (Ganirelix/Cetrotide)
PRIMING Protocol: E2 - retrieval - 36 hours - what to give for trigger?
When cohort of follicles is at ideal range for best maturity outcome the provider will confirm trigger with HCG & Lupron (prob won’t have HSSO bc they likely won’t have a lot of eggs due to DOR). Her retrieval will be schedule 36 hours later
check OPKs - OCP Luteal - when to start BC after positive OPK results? and how long to continue?
5 days after the positive OPK result, the patient is instructed to start oral contraceptive/birth control pills (OCP/BCP) and continue for 7-10 days unless otherwise specified in treatment plan.
Must confirm and document instructions for patient to abstain from unprotected intercourse.
Ideal Timing: Last dose BCP on Sat for Weds. Or Thurs. start
How these Priming MeDs work
Increases in Estrogen and Progesterone cause a decrease in FSH & LH production, therefore suppressing follicular growth (helps to quiet ovaries)
OCP is Estrogen & Progesterone
Aygestin is Progesterone
Estrace is Estrogen
PRIMING Protocol: Mid or Late Luteal - CD1***
(if it’s in luteal, then baseline is in luteal)
Priming is done naturally -
pt checks for LH surge - then will come in for baseline ultrasound (5 days later) could start FSH and LH 5 days after they’ve ovulated.
the uterus is separate from the FSH and LH - the follicle grows a little slower - allows for a little suppression in the beginning
Patient reports full flow period and is instructed to begin checking ovulation predictor kits for one week (expected ovulation date –3 & +3)
Once the patient reports a positive result the baseline will need to be scheduled (try to avoid weekend/holiday, if possible:
PRIMING Protocol: Mid or Late - monitoring - 8-12 days - after baseline, what stimulation meds?
(Mid is the same)
After baseline appointment, and ovulation is confirmed the patient will be instructed to start injectable stimulation medications FSH & Menopur
PRIMING Protocol: Mid or Late - retrieval - 36 hours later - what meds to trigger?
(the same - loop in the HCG)
When cohort of follicles is at ideal range for best maturity outcome the provider will confirm trigger with HCG & Lupron. Her retrieval will be schedule 36 hours later
How Mid & Late luteal Priming works
After natural ovulation progesterone levels will rise, causing the hypothalamus and pituitary gland to stop producing FSH & LH, therefore suppressing follicle growth
The mid & late luteal protocol relies on these natural hormones for suppression and therefore does not require additional medication
Lupron saturates GnRH receptors - over time they are over saturated, body can’t produce LH and FSH -
PRIMING Protocol: Demi Halt - CD1 - what meds to start? and on what day?
(Loop in demi)
Patient reports full flow period and is instructed to begin checking ovulation predictor kits for one week (expected ovulation date –3 & +3)
Once the patient reports a positive result they are instructed to start Lupron injections 5 days later and continue daily for 10-12 days
PRIMING Protocol: Demi Halt - monitoring = after baseline apt and menses is confirmed, what should pt do?
After baseline appointment, and menses is confirmed the patient will be instructed to stop Lupron and start injectable stimulation medications FSH (Lupron pts are one of the few that takes FSH bc we took it away from them) & Menopur
PRIMING : Demi Halt - retriveal - trigger - what meds to trigger?
(demi can’t trigger with loop)
When cohort of follicles is at ideal range for best maturity outcome the provider will confirm trigger with HCG & Lupron. Her retrieval will be schedule 36 hours later
*TRIGGER cannot be Lupron
How Lupron Priming works
Lupron (Leuprolide Acetate) when given in small doses over an extended period of time will shut down the pituitary gland, therefore stopping FSH and LH production and follicular growth
PRIMING Protocol: Follicular Testosterone Priming - when to start T?
Patient begins T on CD 1 or 2 and continues until Baseline
Patient reports full flow period and is instructed to begin checking ovulation predictor kits for one week (expected ovulation date –3 & +3)
Once the patient reports a positive result the baseline will need to be schedule 4-6 days later – avoiding weekends/holidays.
PRIMING Protocol: Follicular Testosterone - what stimulation meds?
After baseline appointment, and ovulation is confirmed the patient will be instructed to start injectable stimulation medications FSH & Menopur, stop Testosterone
PRIMING Protocol: Follicular Testosterone Priming - follicle what size? and what antagonist?
Once a dominate follicle(s) reaches a size of 12+ mm the provider will start antagonist medication (Gani relix/Cetrotide)
PRIMING Protocol: Follicular Testosterone Priming - retrieval 36 hours later - trigger w/ what med?
When cohort of follicles is at ideal range for best maturity outcome the provider will confirm trigger with HCG & Lupron. Her retrieval will be schedule 36 hours later
Protocol: Microdose Flare (MD Flare) - when to schedule BL and meds?
(flare early)
If Straight start: Patient reports full flow period:
Schedule: BL US +E2- CD 1 or 2.
Protocol: Microdose Flare (MD Flare)
(Uses Diluted Lupron (leuprolide Acetate—40mcg/0.2ml—Must be ordered to -
Microdose Lupron Injection begins evening of Baseline US and continue BID throughout stim
Protocol: Microdose Flare (MD Flare) - when to use lupron?
Lupron only 1st 2 days then on day 3 of Lupron add Stimulation Meds
If baseline appointment confirms start:
Start Lupron 40mcg that PM, then BID until trigger.
Only AM dose of MD lupron, day of trigger.
On day 3 of Lupron, start injectable stimulation medications, per provider
Likely FSH/HMG and GH if using
Monitoring:
- ~Day 7of Lupron injections/day 5 of stim US & E2
Then continued per response until trigger
Protocol: Microdose Flare (MD Flare)
trigger with what meds? and when is lupron taken?
(microdose 450)
When cohort of follicles is at ideal range for best maturity outcome the provider will confirm trigger with HCG & 450 FSH. Retrieval will be schedule 36 hours later
MD Lupron taken AM only, unless otherwise specified
Other priming Variations - additional meds to layer on the suppression - E2 and Antagonist
EAP: E2 & Antagonist (antogonists block) Priming:
The patient will follow the same E2 priming protocol but will in addition take Antagonist (Cetrotide/Ganirelix) (helps to drop E2) 10 days after the +OPK and continued for three nights only
Other Priming Variations (cont.) - straight start
The patient will call with their period and need to baseline that day. The stimulation, monitoring and retrieval will be the same as OCP/Aygestin
IVF bloodwork - progesterone
To determine ovulation it is most important to check progesterone levels.
It will rise after ovulation has occurred, peaking about one week after ovulation.
Progesterone Levels:
<1.5 = not yet ovulated
Instructed to continue checking OPKs
1.5 – 3 = likely just recently ovulated
Instructed to start meds/baseline in 3-5 days
> 3 = ovulated 5 or more days ago
Instructed to start meds/baseline in 1-2 days
Minimal Stimulation Protocol - baseline w/ menses - what protocols are usually used?
(Min stim is usually used for women with less than 5 follicles)
Will follow specific priming protocol, typically OCP, Aygestin or Straight Start
Minimal Stimulation Protocol - monitoring 3-7 days - after last dose of CC/LTZ, what meds will be started?
The patient will then return for monitoring after the last dose of CC/LTZ. Will then first start FSH at 150IU
Menopur 75 IU will be added around the time the antagonist is started
LMP is the day before CC/LTZ start
Minimal Stimulation Protocol - what meds to trigger? and when is retrieval?
(mini is different)
When cohort of follicles is at ideal range for best maturity outcome the provider will confirm trigger with HCG & Lupron. Her retrieval will be schedule 34 hours later***
Clomid/Letrozole Flare Protocol - baseline w/ menses
(this more for the DOR group)
Will following specific priming protocol, typically OCP, Aygestin or Straight Start
After the baseline the patient will first take Clomid or Letrozole for 5 days, starting CD2-4.
Again, sometimes the provider will request the FSH to start even earlier at the CC/LTZ start
Clomid/Letrozole Flare Protocol - CD 2-6
On CD4 the patient will start FSH at 225IU
LMP is the date of cycle before CC/LTZ start
Clomid/Letrozole Flare Protocol - Monitoring - 3-7 days - stimulating meds and antagonist
stim meds - Menopur 150 IU will be added CD4 or CD7, per provider preference, usually around the time the antagonist is started
Once a dominate follicle(s) reaches a size of 12+ mm will start antagonist medication (Ganirelix/Cetrotide)
Monitoring:
- Cycle Day 7 US & E2
Then continued per response until trigger
When cohort of follicles is at ideal range for best maturity outcome the provider will confirm trigger with HCG & Lupron. Her retrieval will be schedule 36 hours later
how GnRH works
Its FSH and LH - FSH and menopur (small amount of LH - that may be helpful in stimulating egg maturity) - this causes the eggs to grow
Cetrotide/Ganirelix/Fyremadel is a GnRH antagonist. GnRH antagonists compete with GnRH for receptors on gonadotroph cell membranes, inhibit GnRH-induced signal transduction and consequently gonadotrophin secretion. GnRH antagonists help delay the luteinizing hormone surge and prevent ovulation until the patient is instructed to trigger for retrieval .
Lupron - how does it work as a down regulator?
(Loop in the pituitary)
Lupron (Leuprolide Acetate)-GnRH agonist can be used as a downregulator of the pituitary gland when given in small doses(0.5mg) over several days(~12) when started prior to stimulation medication (FSH/LH)
When Lupron has been previously used for suppression…
When Lupron has been previously used for suppression (Demi-Halt) this trigger will not work. Therefore HCG & a high dose of FSH (450) will be used to induce final maturation
HCG as a trigger
HCG (Novarel/Pregnyl) “trigger” is chemically similar to LH and therefore mimics its affects and will cause final maturation and ovulation
Trigger injection(s) for IVF
The provider will determine the best dosing of HCG on day of trigger to decrease the risk of OHSS while still stimulating ovulation and final maturation of the egg (s)
Considerations: Age, Pt. History, Protocol, number/Size of follicles, E2 level
Most Common HCG Dosing at SPRING:
5,000 iu
2,500 iu (this is the common dose)
*1600 iu
*No HCG (Lupron only)
Interval between trigger & retrieval :
Traditional IVF protocols 36 hrs
Min Stim 34 hrs
Bloodwork (post-trigger) drawn prior to 10am to confirm response only required if trigger dosing was:
*1600iu HCG & Lupron-> HCG (if this was given as a trigger) & LH
*Lupron Only-> LH (possible P4)
HCG always given with a co-trigger
HCG & Lupron –or–
HCG & 450iu FSH (Demi-Halt)
Post trigger Confirmatory testing - when is it done?
(confirming 10 a.m.)
Confirmatory bloodwork testing must be completed on the day following administration of ovulation induction/trigger medications prior to 10am.
Add on procedures
IVF Nurses:
At the time of trigger, please review the treatment plan notes to confirm if any add-on procedures are requested:
This has been added to the trigger prep checklists to help ensure this is not missed.
Confirm with the patient to ensure they still desire the requested procedure
Add the procedure to the retrieval appointment remarksc
Ensure all additional items are completed for the particular procedure – i.e. IUD availability, Endo Bx requisitions, etc.
Ovarian Hyperstimulation Syndrome
Ovarian Hyperstimulation Syndrome (OHSS) in its mild form is a common side effect of IVF.
More Follicles = Greater Risk of OHSS
The cause is not fully understood however having a high level of HCG plays a role.
HCG hormone high Vascular Endothelial Growth Factor (VEGF) secretion from the follicles VEGF cause vascular permeability loss of fluid to third spacing
Ovarian Hyperstimulation Syndrome - what fluids to recommend?
No real treatment but time, instead alleviate symptoms:
Maintain proper hydration however should switch from water to electrolyte fluids (Sports drinks, coconut water, electrolyte waters, etc.)
Take Ibuprofen & Tylenol as needed for pain
NOTE Symptoms of ovarian torsion are typically quicker in onset and very intense sharp shooting, often one sided pain – this is an emergency!
Ovarian Hyperstimulation Syndrome - Mild Symptoms - what about weight gain?
Mild to moderate abdominal pain
Abdominal bloating and distention
Nausea
Diarrhea
Tenderness in the area of ovaries
Sudden weight gain (>5 lbs)
Ovarian Hyperstimulation Syndrome - severe Symptoms - when do they peak?
Severe abdominal pain
Severe bloated and enlarged abdomen
Persistent nausea with vomiting
Significantly decreased urination
Shortness of breath
Symptoms will peak typically 3-4 days after the retrieval
Ovarian Hyperstimulation Syndrome
NOTE Symptoms of ovarian torsion are typically quicker in onset and very intense sharp shooting, often one sided pain – this is an emergency!
Review Questions
OCP Priming - oral birth control - estrogen & progesterone
What hormone(s) in OCP? What does this medication do?
When can OCPs be started? What hormone is this? What dose and frequency? For how long?
E2 Priming - estrogen only
What hormone is E2? What does this medication do?
When will Estrace be started? What dose and frequency? For how long?
When will the baseline be scheduled? When will they get their period?
Review Questions
Aygestin Priming - progesterone
What hormone is Aygestin? What does this medication do?
When will the patient start Aygestin? What dose and frequency? For how long? 5 days after positive OPK, the duration is 10 days
When will the baseline be scheduled? Is bloodwork needed? day 4 after last pill (avoid holidays)
just an ultrasound
When will they get their period? within 3-5 days of last pill
When will stimulation medications start?
What is the LMP date?
Estimate which stimulation days the first two monitoring appointments will occur? What will be completed at these appointments?
When will antagonist start and why?
What do you anticipate for trigger medications? HCG and Lupron
How many hours pre RET? 36 hrs prior to retrieval
Review Questions
Midluteal Start
When will the patient start checking OPKs? ask how cycle is, subtract 14 days - 3 days before, 3 days after
When will the patient be instructed to notify you if no positive OPK yet? What will need to be done next to confirm if ovulation has in fact occurred?
When will the baseline be scheduled? Is bloodwork needed? LH surge + 5 days later, its ultrasound and bloodwork (E2 and P4)
Why is this protocol referred to as the “natural protocol”? How is the patient suppressed? There’s no priming beforehand, BC
When will they get their period? mid to end of stimulation bc the progesterone dropping
When will stimulation medications start?
What is the LMP date? 1st day of stim medications (2 we don’t - mini stim and flare)
Estimate which stimulation day the first monitoring appointment will occur?
When will antagonist start and why? to prevent early ovulation (LH surge) start when follicles are 12 mm or greater
What additional bloodwork would you expect around stimulation day 7? HCG, to make sure they aren’t pregnant
What do you anticipate for trigger medications? HCG and Lupron
How many hours pre RET? 36 hours
Review Questions
. Demi-Halt
What medication will they first take? What does this medication do? low dose lupron
When will Lupron be started? What dose and frequency? For how long? 0.5 mg about 10-12 days
When will the baseline be scheduled? Is bloodwork needed? baseline - 17 days post LH surge (when they get their period) need estrogen and ultrasound - E2 should be about less than 80, if it’s higher, could be preg
When will they get their period?
When will stimulation medications start?
What is the LMP date?
When will antagonist start and why? don’t order antagonist with other meds. if we DO need it, start at 12 days take until day of trigger.
What do you anticipate for trigger medications? HCG and 450 of FSH
How many hours pre RET? 36
Review Questions
. EAP Priming - Estrogen and Antagonist priming
What additional medication (from standard E2 priming) will they take?
When will they start this medication?
What dose & frequency? For how long?
- ATP Priming - Agestin and Testosterone priming. take testosterone for 12 hours (patch or cream)
What additional medication (from standard Aygestin priming) will they take?
When will they start this medication?
What dose & frequency? For how long?
Review Questions
Clomid/Letrozole Flare
What is the first stimulation medication to be started? When and for how long will it be continued? What is the LMP date? LMP date is 1st day of actual period or the day before starting clomid or letrozole
What will be the first estimated monitoring appointment?
When will FSH be started and at what estimated dose?
When will Menopur be started and at what estimated dose?
When will antagonist be started
What medications do you anticipate for trigger? How many hours pre RET?
Review Questions
What is the reasoning for a low dose HCG or Lupron only trigger? try to prevent OHSS if pt is already at risk
- The patient normally has a 28 day cycle and is proceeding with Aygestin priming. Per her calendar she is calling on CD18 to report she has not yet gotten a positive OPK. What are her appropriate next steps? blood work E2 and P4a. Her results come back as follows: E2 = 105 and P4 = 2.0
Has she ovulated? When will she start Aygestin? b. Her results come back as follows: E2 = 186 and P4 = 0.57 - not ovulated Has she ovulated? What will be her next steps? not ovulated, continue OPKs and she should ovulate soon (E2 is going up, so egg is growing)
- The patient is currently stimulation day 6. Her E2 results today are 458. She would like to know if this is appropriate. What is the proper interpretation of this result as well as what she can expect for future results? did she ask the doc, continuing to rise appropriately and eggs are maturing
- When is bloodwork checked the day after triggering? What hormones and why? What do you anticipate these results to be?
post trigger bloodwork is only if the pt had low dose HCG and if the pt had lupron only or 1600 HCG (this is a low dose)
if HCG and lupron - blood test would be HCG and LH
if we’re doing lupron only = test for LH and sometimes progesterone -
Review Questions
The patient is calling you three days post retrieval. She retrieved and froze 22 eggs. She is reporting extreme bloating. She states that she feels pregnant and becomes more easily short of breath upon walking up stairs. What do you think of these symptoms? What are your recommendations and instructions for this patient? OHSS - prob doesn’t need to come in urgently, she should monitor symptoms
16. The partner of a patient who just had her retrieval yesterday calls you to report the patient is experiencing horrible cramping pains that are sharp and intense. She has been vomiting but reports no fever. What do you think of these symptoms? What are your recommendations and instructions for this patient? torsion - ER visit
progesterone - what does it do?
keeps period from coming, until you take it away - rebound
estrogen helps what?
helps lining develop a little
Other Priming Variations (cont.) - straight start
The patient will call with their period and need to baseline that day. The stimulation, monitoring and retrieval will be the same as OCP/Aygestin
Other Priming Variations (cont.) - Random Start
The patient will pick a random time to baseline and randomly start at any point in their cycle. The stimulation, monitoring and retrieval will be the same as OCP/Aygestin
for Min stim - LMP date
(mini lmp period)
day before period
min stim - trigger and how many hrs between trigger and retrieval?
Lurpon and HCG, 34 hours
priming protocol- OCP - how long after stopping BC will they get their period?
3-5 days after stopping the birth control pill the patient will get their full flow period. They will need their baseline ultrasound(BUS) during this time – ideally 4 days after last dose however avoid weekend/holidays
priming protocol - OCP (OCP is birth control) follicular - CD1 - what is done at baseline? and what is the LMP?
(need to memorize this part) baseline will be US only, no bloodwork
stopping BC will give a withdrawal bleed
(need to memorize this part) LMP is the date of stim start
OCP - luteal phase - what to do at baseline? LMP?
still ultrasound only
LMP date of stimulation start
aygestin - when can it be started? and how long to continue? (think when it normally starts to go up)
NOTE: Depending on provider preferences–Aygestin (norethindrone) 5mg can be started 3-7 days post LH surge (+OPK) and continue 8-10 days.
if high responder when stopping aygestin? and what is the # for a high responder?
Ideal timing:
If high responder (i.e. AFC >10)
Stop aygestin (last pill sat) baseline Weds, E2 Friday and US Monday
when stopping aygestin - low responder?
If low responder (i.e. AFC <10)
Stop aygestin (last pill sunday) baseline Thursday. US/E2 Monday.
aygestin - if planning a fresh transfer -
If planning fresh transfer, patient needs menses prior to stim start plan at least 4 days between last pill and baseline.
aygestin - if using an egg donor
If Egg donor, plan 3 days between last pill and baseline
aygestin - in all cases, if pt starts period prior to scheduled baseline…
ensure BL moved up so they are being seen the following day (CD2)
after stopping aygestin all the same as previous slide
E2
(If Egg donor, plan 3 days between last pill and baseline)
You can schedule the baseline ultrasound for two weeks from +OPK, however the patient will not start stimulation
and will continue Estrace until menses
E2 - what to do at baseline? and LMP?
(E2 and OCP are the same)
Baseline will be US only, no bloodwork
Ensure BL on day of menses or following day
LMP is the date of
stimulation start
E2 - what tests on stim day 5?
(think, they’re taking E2, so…)
US & E2
Then continued per response until trigger
mid to late luteal - baseline? and what tests? what is the LMP?
(think, it’s luteal)
***baseline will be US, E2, and P4 (4-6 days after +OPK)
LMP is the date of stiumation start
when is baseline scheduled for mid luteal?
(Midluteal) 3-6 days later (ideally 5) after positive OPK
when is baseline scheduled for late luteal?
(Late Luteal) 10-12 days after positive OPK
mid to late luteal - monitoring - stim day 5 - what tests?
Monitoring:
- Stim Day 5 US & E2
Then continued per response until trigger
mid to late luteal - when is HGC checked?
(HGC is in the 7th inning)
NOTE: an HCG will be checked on stim day 7/8
mid to late luteal - how big is the follicle when they give the antagonist? (the same)
ANTAGONIST:
Once a dominate follicle(s) reaches a size of 12+ mm the provider will start antagonist medication (Ganirelix/Cetrotide
demi halt - when to schedule baseline ultrasound?
You can schedule the baseline ultrasound after 10-12 days of Lupron – ideally 12 days however avoid weekends/holidays. The patient will likely get her menses during this time.
demi halt - what to do at baseline?
(demi is just 2)
***baseline will be US & E2 (if E2 is elevated, make a different plan)
demi halt - how does lupron work?
LH+5 = 5 days after LH surge, you start lupron bc you want to take it when body wouldn’t normally produce FSH = keep hormones asleep w/ blanket
demi halt - antagonist - what size of follicle? and what med?
ANTAGONIST:
Once a dominate follicle(s) reaches a size of 12+ mm the provider will start antagonist medication (Ganirelix/Cetrotide)
mid or late luteal - when is menses expected during stimulation?
Late luteal and mid luteal
Menses expected during stimulation:
LL- SD 2-7
ML-SD 9-11
testosterone - when are meds started?
The medications will be started on day 5 after positive results (unless baseline on 6th day and will start that evening)t
testosterone - tests for baseline?
LMP?
(testosterone is 3)
baseline will be US, E2, P4
LMP is the date of stimulation start
microdose - what med?
(Uses Diluted Lupron (leuprolide Acetate—40mcg/0.2ml—Must be ordered to - CD1
microdose flare - if priming with OCP?
If Priming, options are:
OCPs Priming:
Follicular or Luteal phase (see prior slides).
Ideal: Last pill on Saturday for W/Th. Baseline.
microdose flare - E2 priming - how much and when to start taking?
E2 Priming:
2mg BID starting 5 days post LH surge(+OPK) and continue until Menses (see prior slides).
Plan BL US two weeks from LH Surge.
E2 not usually required, since patient is taking E2, double check with provider on their preference.
basline will be US and E2
other priming varations - ATP (Aygestin and T)
ATP: Aygestin & Testosterone Priming:
:The patient will follow the same Aygestin priming protocol but will in addition take Testosterone patches (Androderm) for as long as Aygestin also starting 5 days after the positive OPK result. They will be placed on outer thigh at 9 PM and removed the following morning at 9 AM, for 10 nights
other priming varations - random start
the patient will pick a random time to baseline and randomly start at any point in their cycle. The stimulation, monitoring and retrieval will be the same as OCP/Aygestin
IVF bloodwork - E2
Estradiol levels (E2) will be monitored throughout the stimulation cycle. As the follicles/eggs grow they will produce higher levels of E2. There is no target level that the patient needs to meet, instead it is just important that it continues to steadily rise and does not plateau or drop.
Estrogen is also checked as a second data point to determine where the patient is at in their cycle. The E2 will rise and peak with ovulation. For example, if P4 is 0.7 but the E2 is 200 the patient has not yet ovulated but will likely soon
when E2 starts to get really high, we worry about OHSS
min stim - after the baseline, what meds to take?
(mini goes back to the beginning)
After the baseline the patient will first take Clomid or Letrozole for 5 days, starting CD2-4.Sometimes the provide will request for simultaneous stimulation meaning the FSH will start earlier at the CC/LTZ start
min stim - what is the LMP?
(think, there is no stimulation)
LMP is the day before CC/LTZ start**
min stim - what size is the egg when anatagonist is given?
(same)
antagonist:
(antagonist) Once a dominate follicle(s) reaches a size of 12+ mm will start antagonist medication (Ganirelix/Cetrotide)
min stim- what day is US and E2?
(mini 7)
- Cycle Day 7 US & E2
Then continued per response until trigger
menopur has
FSH and LH
antagonist (ganirelix)
prevents premature ovulation
methods that require bloodwork with baseline
demi-halt (we need to make sure pt takes Lupron at the right time or it could have the opposite effect), mid luteal
most luteal priming meds - start on what day?
LH + 5 for most of them
which method does not have an antagonist?
Demi-halt - Lupron - bc it’s an agonist
is lupron pill or injection?
injection
clomid/letrizole flare - when using gantroline (sp) how big should the follicles be?
Started when follicles are ~12 mm (when they’re small bc once the surge starts, it’s hard to stop)
how can lupron be used as a trigger?
can be used to “Trigger” ovulation when given as a single high dose (4 mg) will work as a pulse to the pituitary gland to surge production of LH for final maturation and ovulation
is lupron an antogonist or agonist?
agonist
confirmatory testing - HCG 2,500
HCG 2,500 or greater & Lupron 4mg or FSH
No confirmatory testing required unless patient is >200lbs
If patient weighs >200lbs
HCG, LH
confirmatory testing- HCG 1,600 and lupron 4 mg or FSH
HCG 1,600 and Lupron 4mg or FSH
HCG & LH
confirmatory testing - No HCG, Lupron 4 mg only
No HCG, Lupron 4mg ONLY
LH & P4
HCG Results - >20
HCG Results
> 20, okay to proceed with retrieval as planned
HCG Results - <20
<20, nurse to alert provider to review
LH results - >12
LH Results
> 12, okay to proceed with retrieval as planned
LH results <12
<12, nurse to alert provider to review
P4 results
P4 Results: only required with Lupron (Leuprolide Acetate) trigger only
P4 results only applicable if LH <12, need to alert provider to review
day of LH surge, there is a little
FSH released
which method uses FSH with the trigger? (again with the Lupron)
demi halt and flare bc they both use Lupron
what does the antagonist do?
prevents early ovulation
how does lupron work as a trigger?
it mimicks LH surge (just by causing the eggs to mature)
clomid/letrozole flare
same as clomid/LTZ, BUT add FSH on CD4 and a little higher dose
