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XIO > IVF Protocols > Flashcards

IVF Protocols Flashcards

1
Q

priming - how long does it last?

A

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

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2
Q

Variations in Priming Protocols:

A

Variations in Priming Protocols:​

OCP​

Aygestin​

Mid Luteal​

Demi-Halt​

E2​

EAP (E2 & Antag)​

ATP (Aygestin & Testosterone)​

ETP (Estrogen & Testosterone)

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3
Q

stimulation - 8-12 days - this is obviously just monitoring

A

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

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4
Q

priming and stimulation

A

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

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5
Q

IVF: Intended treatment - (this is just an example of how it will look in Ideas)

A

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

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6
Q

Invitro Fertilization “IVF”

A

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​

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7
Q

priming protocol - OCP (OCP is birth control) follicular - CD1 - how long to take the BC? And in the follicular phase?

A

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​

​

​

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8
Q
A
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9
Q
  • OCP follicular baseline - 3-5 days AFTER stopping BC - what meds?
A
  • expected menses - After baseline appointment the patient will be instructed to start injectable stimulastion medications FSH & Menopur​
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10
Q

OCP - Day 8-12 after menses - Monitoring - what meds? and how big should the follicle be?

A

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)

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11
Q

OCP - monitoring - stim day 3-4 and 5-6

A

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

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12
Q
  • OCP - trigger - what drugs? and when to retrieve?

(the OC is huggin lupe)

A

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​

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13
Q

OCP follicular

A

CD1, OCP (10-16 days) baseline (3-4 days later) monitoring 8-12 days, retrieval = 36 hours later

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14
Q

PRIMING Protocol: OCP Luteal - CD1

and what bloodwork?

A

(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

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15
Q

PRIMING Protocol: Aygestin - CD1
- and what if pt hasn’t ovulated according to OPK?

A

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

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16
Q

PRIMING Protocol: Aygestin – 5 days after +OPK

A

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.

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17
Q

PRIMING Protocol: E2 (this is the least suppressive) - what day to start estrace?

(this is usually used for DOR)

A

(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

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18
Q

E2 - after baseline and menses, pt will do what?

A

After baseline appointment, and menses is confirmed the patient will be instructed to start injectable stimulation medications FSH & Menopur

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19
Q

PRIMING Protocol: E2 - stimulation meds (antagonist) - when egg is what size?

A

Once a dominate follicle(s) reaches a size of 12+ mm the provider will start antagonist medication (Ganirelix/Cetrotide)

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20
Q

PRIMING Protocol: E2 - retrieval - 36 hours - what to give for trigger?

A

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

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21
Q
A
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22
Q

check OPKs - OCP Luteal - when to start BC after positive OPK results? and how long to continue?

A

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

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23
Q

How these Priming MeDs work

A

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

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24
Q

PRIMING Protocol: Mid or Late Luteal - CD1***

(if it’s in luteal, then baseline is in luteal)

A

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:​

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25
Q

PRIMING Protocol: Mid or Late - monitoring - 8-12 days - after baseline, what stimulation meds?

(Mid is the same)

A

After baseline appointment, and ovulation is confirmed the patient will be instructed to start injectable stimulation medications FSH & Menopur

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26
Q

PRIMING Protocol: Mid or Late - retrieval - 36 hours later - what meds to trigger?

(the same - loop in the HCG)

A

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

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27
Q

How Mid & Late luteal Priming works

A

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 -

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28
Q

PRIMING Protocol: Demi Halt - CD1 - what meds to start? and on what day?

(Loop in demi)

A

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

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29
Q

PRIMING Protocol: Demi Halt - monitoring = after baseline apt and menses is confirmed, what should pt do?

A

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

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30
Q

PRIMING : Demi Halt - retriveal - trigger - what meds to trigger?

(demi can’t trigger with loop)

A

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

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31
Q

How Lupron Priming works

A

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

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32
Q

PRIMING Protocol: Follicular Testosterone Priming - when to start T?

A

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.

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33
Q

PRIMING Protocol: Follicular Testosterone - what stimulation meds?

A

After baseline appointment, and ovulation is confirmed the patient will be instructed to start injectable stimulation medications FSH & Menopur, stop Testosterone

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34
Q

PRIMING Protocol: Follicular Testosterone Priming - follicle what size? and what antagonist?

A

Once a dominate follicle(s) reaches a size of 12+ mm the provider will start antagonist medication (Gani relix/Cetrotide)

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35
Q

PRIMING Protocol: Follicular Testosterone Priming - retrieval 36 hours later - trigger w/ what med?

A

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

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36
Q

Protocol: Microdose Flare (MD Flare)​ - when to schedule BL and meds?

(flare early)

A

If Straight start: Patient reports full flow period:​

Schedule: BL US +E2- CD 1 or 2. ​

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37
Q

Protocol: Microdose Flare (MD Flare)​
(Uses Diluted Lupron (leuprolide Acetate—40mcg/0.2ml—Must be ordered to -

A

Microdose Lupron Injection begins evening of Baseline US and continue BID throughout stim

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38
Q

Protocol: Microdose Flare (MD Flare)​ - when to use lupron?

A

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:​

  1. ~Day 7of Lupron injections/day 5 of stim US & E2​

Then continued per response until trigger

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39
Q

Protocol: Microdose Flare (MD Flare)​
trigger with what meds? and when is lupron taken?

(microdose 450)

A

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

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40
Q

Other priming Variations - additional meds to layer on the suppression - E2 and Antagonist

A

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

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41
Q

Other Priming Variations (cont.) - straight start

A

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

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42
Q

IVF bloodwork - progesterone

A

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

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43
Q

Minimal Stimulation Protocol - baseline w/ menses - what protocols are usually used?

(Min stim is usually used for women with less than 5 follicles)

A

Will follow specific priming protocol, typically OCP, Aygestin or Straight Start

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44
Q

Minimal Stimulation Protocol - monitoring 3-7 days - after last dose of CC/LTZ, what meds will be started?

A

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

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45
Q

Minimal Stimulation Protocol - what meds to trigger? and when is retrieval?

(mini is different)

A

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***

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46
Q

Clomid/Letrozole Flare Protocol - baseline w/ menses

(this more for the DOR group)

A

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

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47
Q

Clomid/Letrozole Flare Protocol - CD 2-6

A

​​On CD4 the patient will start FSH at 225IU

LMP is the date of cycle before CC/LTZ start

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48
Q

Clomid/Letrozole Flare Protocol - Monitoring - 3-7 days - stimulating meds and antagonist

A

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:​

  1. 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

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49
Q

how GnRH works

A

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 .

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50
Q

Lupron - how does it work as a down regulator?

(Loop in the pituitary)

A

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)

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51
Q

When Lupron has been previously used for suppression…

A

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

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52
Q

HCG as a trigger

A

HCG (Novarel/Pregnyl) “trigger” is chemically similar to LH and therefore mimics its affects and will cause final maturation and ovulation

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53
Q

Trigger injection(s) for IVF

A

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)

54
Q

Post trigger Confirmatory testing - when is it done?

(confirming 10 a.m.)

A

Confirmatory bloodwork testing must be completed on the day following administration of ovulation induction/trigger medications prior to 10am.

55
Q

Add on procedures

A

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 remarks​c

Ensure all additional items are completed for the particular procedure – i.e. IUD availability, Endo Bx requisitions, etc.

56
Q

Ovarian Hyperstimulation Syndrome

A

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

57
Q

Ovarian Hyperstimulation Syndrome - what fluids to recommend?

A

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!

58
Q

Ovarian Hyperstimulation Syndrome - Mild Symptoms - what about weight gain?

A

Mild to moderate abdominal pain​

Abdominal bloating and distention ​

Nausea​

Diarrhea​

Tenderness in the area of ovaries​

Sudden weight gain (>5 lbs)

59
Q

Ovarian Hyperstimulation Syndrome - severe Symptoms - when do they peak?

A

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

60
Q

Ovarian Hyperstimulation Syndrome

A

NOTE Symptoms of ovarian torsion are typically quicker in onset and very intense sharp shooting, often one sided pain – this is an emergency!

61
Q

Review Questions

A

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?

62
Q

Review Questions

A

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

63
Q

Review Questions

A

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

64
Q

Review Questions

A

. 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

65
Q

Review Questions

A

. 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? ​

  1. 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?

66
Q

Review Questions

A

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?

67
Q

Review Questions

A

What is the reasoning for a low dose HCG or Lupron only trigger?​ try to prevent OHSS if pt is already at risk

  1. 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)
  2. 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
  3. 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 -
68
Q

Review Questions

A

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

69
Q

progesterone - what does it do?

A

keeps period from coming, until you take it away - rebound

70
Q

estrogen helps what?

A

helps lining develop a little

71
Q

Other Priming Variations (cont.) - straight start

A

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

72
Q

Other Priming Variations (cont.) - Random Start

A

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

73
Q

for Min stim - LMP date

(mini lmp period)

A

day before period

74
Q

min stim - trigger and how many hrs between trigger and retrieval?

A

Lurpon and HCG, 34 hours

75
Q

priming protocol- OCP - how long after stopping BC will they get their period?

A

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​

76
Q

priming protocol - OCP (OCP is birth control) follicular - CD1 - what is done at baseline? and what is the LMP?

A

(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

77
Q

OCP - luteal phase - what to do at baseline? LMP?

A

still ultrasound only
LMP date of stimulation start

78
Q

aygestin - when can it be started? and how long to continue? (think when it normally starts to go up)

A

NOTE: Depending on provider preferences–Aygestin (norethindrone) 5mg can be started 3-7 days post LH surge (+OPK) and continue 8-10 days. ​

79
Q

if high responder when stopping aygestin? and what is the # for a high responder?

A

Ideal timing:​

If high responder (i.e. AFC >10)​

Stop aygestin (last pill sat) baseline Weds, E2 Friday and US Monday​

80
Q

when stopping aygestin - low responder?

A

If low responder (i.e. AFC <10)​

Stop aygestin (last pill sunday) baseline Thursday. US/E2 Monday.

81
Q

aygestin - if planning a fresh transfer -

A

If planning fresh transfer, patient needs menses prior to stim start plan at least 4 days between last pill and baseline. ​

82
Q

aygestin - if using an egg donor

A

If Egg donor, plan 3 days between last pill and baseline​

83
Q

aygestin - in all cases, if pt starts period prior to scheduled baseline…

A

ensure BL moved up so they are being seen the following day (CD2)
after stopping aygestin all the same as previous slide

84
Q

E2

A

(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

85
Q

E2 - what to do at baseline? and LMP?

(E2 and OCP are the same)

A

Baseline will be US only, no bloodwork

Ensure BL on day of menses or following day

LMP is the date of
stimulation start

86
Q

E2 - what tests on stim day 5?

(think, they’re taking E2, so…)

A

US & E2

Then continued per response until trigger

87
Q

mid to late luteal - baseline? and what tests? what is the LMP?

(think, it’s luteal)

A

***baseline will be US, E2, and P4 (4-6 days after +OPK)
LMP is the date of stiumation start

88
Q

when is baseline scheduled for mid luteal?

A

(Midluteal) 3-6 days later (ideally 5)​ after positive OPK

89
Q

when is baseline scheduled for late luteal?

A

(Late Luteal) 10-12 days after positive OPK

90
Q

mid to late luteal - monitoring - stim day 5 - what tests?

A

Monitoring:​

  1. Stim Day 5 US & E2​

Then continued per response until trigger​

91
Q

mid to late luteal - when is HGC checked?

(HGC is in the 7th inning)

A

NOTE: an HCG will be checked on stim day 7/8

92
Q

mid to late luteal - how big is the follicle when they give the antagonist? (the same)

A

ANTAGONIST:
Once a dominate follicle(s) reaches a size of 12+ mm the provider will start antagonist medication (Ganirelix/Cetrotide

93
Q

demi halt - when to schedule baseline ultrasound?

A

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.

94
Q

demi halt - what to do at baseline?

(demi is just 2)

A

***baseline will be US & E2 (if E2 is elevated, make a different plan)

95
Q

demi halt - how does lupron work?

A

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

96
Q

demi halt - antagonist - what size of follicle? and what med?

A

ANTAGONIST:
Once a dominate follicle(s) reaches a size of 12+ mm the provider will start antagonist medication (Ganirelix/Cetrotide)

97
Q

mid or late luteal - when is menses expected during stimulation?

Late luteal and mid luteal

A

Menses expected during stimulation:​

LL- SD 2-7​

ML-SD 9-11

98
Q

testosterone - when are meds started?

A

The medications will be started on day 5 after positive results (unless baseline on 6th day and will start that evening)t

99
Q

testosterone - tests for baseline?
LMP?

(testosterone is 3)

A

baseline will be US, E2, P4
LMP is the date of stimulation start

100
Q

microdose - what med?

A

(Uses Diluted Lupron (leuprolide Acetate—40mcg/0.2ml—Must be ordered to - CD1

101
Q

microdose flare - if priming with OCP?

A

If Priming, options are:​

OCPs Priming:​

Follicular or Luteal phase (see prior slides).​

Ideal: Last pill on Saturday for W/Th. Baseline. ​

102
Q

microdose flare - E2 priming - how much and when to start taking?

A

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

103
Q

other priming varations - ATP (Aygestin and T)

A

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

104
Q

other priming varations - random start

A

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

105
Q

IVF bloodwork - E2

A

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

106
Q

min stim - after the baseline, what meds to take?

(mini goes back to the beginning)

A

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

107
Q

min stim - what is the LMP?

(think, there is no stimulation)

A

LMP is the day before CC/LTZ start**

108
Q

min stim - what size is the egg when anatagonist is given?

(same)

A

antagonist:
(antagonist) Once a dominate follicle(s) reaches a size of 12+ mm will start antagonist medication (Ganirelix/Cetrotide)

109
Q

min stim- what day is US and E2?

(mini 7)

A
  1. Cycle Day 7 US & E2​

Then continued per response until trigger

110
Q

menopur has

A

FSH and LH

111
Q

antagonist (ganirelix)

A

prevents premature ovulation

112
Q

methods that require bloodwork with baseline

A

demi-halt (we need to make sure pt takes Lupron at the right time or it could have the opposite effect), mid luteal

113
Q

most luteal priming meds - start on what day?

A

LH + 5 for most of them

114
Q

which method does not have an antagonist?

A

Demi-halt - Lupron - bc it’s an agonist

115
Q

is lupron pill or injection?

A

injection

116
Q

clomid/letrizole flare - when using gantroline (sp) how big should the follicles be?

A

Started when follicles are ~12 mm (when they’re small bc once the surge starts, it’s hard to stop)

117
Q

how can lupron be used as a trigger?

A

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

118
Q

is lupron an antogonist or agonist?

A

agonist

119
Q

confirmatory testing - HCG 2,500

A

HCG 2,500 or greater & Lupron 4mg or FSH​

No confirmatory testing required unless patient is >200lbs​

If patient weighs >200lbs​

HCG, LH​

120
Q

confirmatory testing- HCG 1,600 and lupron 4 mg or FSH

A

HCG 1,600 and Lupron 4mg or FSH​

HCG & LH ​

121
Q

confirmatory testing - No HCG, Lupron 4 mg only

A

No HCG, Lupron 4mg ONLY​

LH & P4

122
Q

HCG Results​ - >20

A

HCG Results​

> 20, okay to proceed with retrieval as planned ​

123
Q

HCG Results - <20

A

<20, nurse to alert provider to review​

124
Q

LH results - >12

A

LH Results​

> 12, okay to proceed with retrieval as planned ​

125
Q

LH results <12

A

<12, nurse to alert provider to review​

126
Q

P4 results

A

P4 Results: only required with Lupron (Leuprolide Acetate) trigger only​

P4 results only applicable if LH <12, need to alert provider to review

127
Q

day of LH surge, there is a little

A

FSH released

128
Q

which method uses FSH with the trigger? (again with the Lupron)

A

demi halt and flare bc they both use Lupron

129
Q

what does the antagonist do?

A

prevents early ovulation

130
Q

how does lupron work as a trigger?

A

it mimicks LH surge (just by causing the eggs to mature)

131
Q

clomid/letrozole flare

A

same as clomid/LTZ, BUT add FSH on CD4 and a little higher dose

132
Q
A

XIO (400 decks)

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