ovulation induction Flashcards
Ovulation Induction (OI)
a process in which medication is used to stimulate a woman’s ovaries to produce multiple mature follicles and ova.
Timed Intercourse (TIC)
a process in which monitoring of a women’s cycle is done to predict the most favorable time to have intercourse.
Intrauterine insemination (IUI)
A procedure that places sperm past the cervix and in a woman’s uterus around the time of ovulation.
Thawed/therapeutic donor insemination (TDI)
The IUI procedure mentioned above. The sperm sample being thawed is from a sperm donor.
OPK types - this is just clear blue
Basic test—compares darkness of lines
Clearblue easy “Digital” Ovulation test
Solid Smiley=>LH surge (this is the best/most simple one)
Advanced Ovulation test- more confusion for patients
Confusing- flashing smiley->rising estrogen
Solid Smiley=>LH surge
Thawed/therapeutic Donor Insemination (TDI)
- when do we need the donor sample by?
non-identified sperm donor (sperm bank - they do all of the FDA stuff, infectious disease screening, etc):
Psych consult required (ASRM guideline)-copy sent to clinic
Patient selects sperm donor from sperm bank (consider CR screening results)
Once approved, Tissue Bank team Coordinator/Patient schedule delivery
Donor sperm (2 vials rec.) on-site @ least 1 week prior to BL (baseline)
Consents signed prior for transport/sperm cryo
Patient charged long-term storage if sample not used within 6 months
IDEAS Workflow OI->TIC/IUI/TDI Baseline
PNs ->IUI patients(CA/OR)
RN->Order medication, give lab results
NYC-RNs manage IUI cycles
IUI/TIC patient calls to report their cycle day one :
Create a menstrual cycle note.
Document first day of full flow period
Enter LMP into Treatment Plan as CD1
Scheduled baseline ultrasound CD1-4
5. Ask if patient has meds (inc. trigger)
6. Confirm finance has been notified
For all TIC & IUI cycles the “Start of follicular phase (LMP)” is the first day of full flow (cycle day one)
IDEAS Workflow OI->TIC/IUI/TDI Trigger - when to take the trigger med?
(pull the trigger at 2200)
Trigger date/time (22:00) entered into Treatment plan
- Trigger medication confirmed in Cycle summary
IUI Scheduling
A minimum of 2 hours before the IUI the partner will be scheduled for “IUI Prep” on the Andrology schedule. In remarks specify if producing here or dropping off and when the patient is scheduled for IUI.
The patient is scheduled for “IUI” on the provider’s schedule. In remarks specify when the partner is scheduled to produce
Frozen sperm sample - if pt is sick, when do they need to notify the lab not to thaw the sample by?
If using a frozen semen sample (donor or partner) schedule as “Sperm Thaw”. if the patient does NOT want the sample thawed, they are responsible for alerting the lab via email prior to 8 am the day of their procedure.
Ovidrel Booster—Ideas documentation
If Ovidrel is used to Booster a natural LH surge, you must document in the cycle summary but you should add into the cycle summary to clarify it is used as a Booster NOT as a Trigger
Edit treatment plan:
Add drug->Booster-Ovidrel
Confirm the Ovidrel
Enter the LH surge into Treatment plan to set LD0
LD0 should be day following LH surge
timed intercourse
simplistic, advises couples on most fertile window, natural or medicated (ovulation induction-OI), may utilitize ultrasound monitoring and/or ovulation predictor kit (OPK) - assess response to medication/follicular growth, date to adminster trigger injections, if recommended
TIC timeline
Baseline Ultrasound
CD 1-4
Medications, if indicated
5 days
Monitoring (TVUS/OPK)
~ CD 9-11*
Trigger Injection
Follicle size ~18-20mm
Intercourse
Day of trigger + 2 days later
Intrauterine Insemination (IUI)
IUI -> washed sperm placed into the uterine cavity, partner or donor sperm, natural or medicated, ultrasound monitoring, determine response to meds, inform of date for trigger of ovulationu
usually 1st monitoring visit is on what day? (for TIC)
cycle day 9
when egg is mature, sac should be what size?
18-20 mm
IUI procedure - when does it occur?
2 days after a trigger, or day after an LH surge
example cycle - what are the days?
LMP
Baseline US (ultrasound)
CD (cycle day) 1-4- fine to wait until day 4 for ultrasound
Medications start
CD 2-4, taken 5 days
Follicular Development/
US Monitoring
CD 9-11
Trigger ovulation
~CD 12-14
IUI 2 days after trigger
Pregnancy Test
2 weeks from IUI
meds are usually
a tablet
initial meds are given how many times a day? and day or evening? and for how many days?
1x a day at night for 5 days
ultrasound monitoring
ovarian baseline (looking at the follicles), ovary-midcycle - looking at follicles growing - should be one bigger than the others, uterus-midcycle - checking for the thickening of the lining and the pattern of the lining - this is called a trilaminar - 3 stripes - should see this near ovulation
urine test for LH - how often to do? and what time?
1x a day - same time every day during the window of time we’ve told them. usually done between 12-3 p.m. lh surge usually happens at night.
2 weeks after IUI
pt has to do a urine test to check for preg. we make an apt to make sure the pt has reported the result.
Ovulation Predictor Kit (OPK) - when to start using the kit? and at what time of day?
Urine test to identify peak of LH (~24 hours prior to ovulation)
Begin testing 3 days prior to expected surge (12p-3pm) once daily
Continue until positive, or until 3 days following expected surge
use an ovulation kit
about 3 days before expected surge and 3 days after (unless they’ve ovulated) - once a day - 2nd urine of the day
Blood test expectations - IUI
E2 (Estradiol)-to assess ovarian activity
E2<80 at baseline
E2>100 when follicle developing/egg maturing
LH - –to assess if already starting to surge
LH <12, no ovulation
LH>12, may be surging—need to assess US, etc
Progesterone-if suspected post ovulatory
P4<1.5—no ovulation
P4>2.5- suggests ovulation
how fast does follicle grow?
2 mm `a day about
“Trigger” medication - how quickly does it induce ovulation? the hours?
injection to mimic LH surge
cause ovulation 36 hours later
when providing semen sample, how long to stay abstinent?
stay abstinent for 2-5 days prior, have sex 2 days prior
IUI
sample obtained, washed/thawed prior to procedure, 2 hours needed between thawing or receiving sample before doing the IUI
vaginismis
pain when anything goes into vagina
on day of IUI - what does the minimum sperm count need to be?
get a mini report - count, motility, need a minimum of 5 million
if using a sperm donor
you get at least 2 vials to make sure you have enough
if pt is sick on IUI,
pt needs to email andrology team before 8 a.m. to let them know not to thaw sperm
Fresh or Frozen sperm?
fresh is most common - Recommend abstain 2 days prior to sample production
Frozen- Partner or Donor - Ensure sample available and at site of procedure - prob not decreasing quality due to freezing, but we aren’t totally sure
Partner, prior to freezing - Infectious Disease testing (IDT) completed/resulted and reviewed.
Sperm Cryopreservation consent
if someone wants to freeze sperm - how long is short term storage?
have to create an order for it (infection disease testing, signed consent, etc)
short term storage consent - maybe person will be out of town - kept for less than 6 months
long term storage consent -
progress notes
what you are going to document or doc about the pt - this is where salve info is
salve messages go
automatically into IDEAS
menstrual cycle note
keep track of pt - progress on pt period
LMP
last menstrual period
in ideas - when you create a template in progress notes - nursing
you fill in the questions and then press “merge” to get the notes to copy to the bottom
in ideas - cycle summary
on the chart the dots are follicles - black is right ovary, orange is left ovary
ovadril
the trigger shot - this is HGC
on TEST - Luteal day 0
day of ovulation
***luteal day 0 - timeline
2 days after a trigger shot
1 day after an LH surge
day of the IUI
intended treatment is put in
by the doc
how to create timeline for pt treatment
under treatment options - treatment plan - add “day 1”, “day 2” etc,
time to take trigger meds
usually 10 p.m.
on date of trigger, include
the time - 2200
we can also use ovadril as a booster
and not a trigger - use as a booster if the pt is surging to help make the corpus luteum even better
if you use ovadril as a booster,
you don’t want the body to think it’s a trigger
ovadril will metabolize
in about 7 days, so don’t worry about false positive.
note that ovadril is a booster
in the cycle summary
IUI usually scheduled with
NP, not dr.
when scheduling a sperm drop off,
its andrology and you don’t need to select a staff member
when adding frozen sperm sample
add in remarks “thaw sample for IUI at 12:30” etc
1st thing to do when pt calls
document LMP, double check that everything has been done to continue cycle - consent forms, bloodwork, etc.
can you waiver an infectious disease screening?
NO
if pt asks to trigger at 2 a.m. to make it exactly 36 hours, should she do it?
no, egg is viable for 24 hours, so anytime that day is fine
before scheduling a sperm freeze,
infection screening and cryo freezing consent form
is frozen as good as fresh?
usually yes, but risk of lower count if frozen
what does high fertility indicate?
close to ovulation
peak fertility
peak of LH - ovulation is certain
flashing smiley
rising estrogen
static smiley
ovulating
OPK
ovulation predictor kit
natural cycle IUI
not taking any meds, just tracking own cycle and doing OPK
The patient is doing a natural cycle IUI with donor sperm. She is calling to report a positiveOPK reading today. What will be your/her next steps?
double check their chart, make sure they have sperm, make sure you have LMS date, schedule IUI, schedule sperm thaw 2 hours prior
trigger medication - how is it administered? and at what time?
SQ injuection given in the evening - 8-10 p.m.(self administered),
what day is a trigger med administered?
2 days prior to IUI
how long are eggs and sperm viable for?
egg viable - 24 hours, sperm viability up to 5 days in female
