(Also See Insurance FAQ)
Follistim, Bravelle, Gonal F superovulation cycles: 50 mg progesterone vaginal suppositories will be ordered to use each night at bedtime starting 4 days after trigger dose and continued until pregnancy ultrasound or until negative pregnancy test. Testing done 14 days after trigger dose
In vitro fertilization: Start injections of progesterone, Endometrin or Crinone the day after egg harvest. The progesterone injections are 50 mg daily. Endometrin is three times vaginally each day, and Crinone is once per day in the morning . The usual course is to start with progesterone injections and change to a vaginal progesterone preparation (Endometrin/Crinone) once a blood test confirms pregnancy. Progesterone needs to be continued minimally until pregnancy ultrasound.
Egg recipiency; Progesterone is started the morning after the donor’s ovulation is triggered. We recommend progesterone injections. Once the pregnancy is confirmed by ultrasound, we can switch to a vaginal progesterone preparation (Endometrin (three times per day) or Crinone (twice a day-morning and early evening). Supplementation is continued through 8 to 10 weeks gestation.
FET cycle: progesterone injections, once started continue until the confirmatory ob ultrasound. At that time you may change to a vaginal progesterone preparation . Endometrin is used three times vaginally each day, and Crinone is twice per day in the morning and early evening . Supplementation is continued thru 8 to 10 weeks gestation.
diseases such as cystic fibrosis and spinal muscular atrophy (see Counsyl pamphlet to do salivary testing, results take two weeks)
Superovulation (controlled ovarian hyperstimulation, COH) involves injections of FSH, (no chemicals) from day 3 onward, for anywhere from 5 to 10 days. When you are near the point of receiving your trigger dose to begin the process of ovulation, (OVIDREL) you will be asked to take ANTAGON (ganirelix) that will prevent you from ovulating prematurely. When triggered we ask you to have intercourse and then either repeat sex 36 to 39 hours later, or do intrauterine insemination ( IUI). What decision to I have to make?
* Intercourse versus IUI: IUI will double your chance of conception. Why? Unsure of why IUI vs. timed coitus is more effective; perhaps due to circumventing cervical barriers, placing so many motile sperm into uterus, etc. IUI only improves pregnancy rates if done in conjunction with stimulation meds (oral or injectable)
* Costs: frequently your insurance carrier will not pay for your medications or monitoring visits if you decide to have IUI done. They consider this “artificial “and hence opt out of coverage. We have argued vehemently with the carriers to cover and even allow couples to pay for IUI themselves, but we have not succeeded.
* feasibility : couples will engage in intercourse the evening the trigger dose is given, will take the next day off and then do IUI the next morning, 36 to 39 hours after the trigger dose. This means husbands will need to come to the office to give or drop off a specimen that morning. Wives will have their IUI scheduled, usually sixty or ninety minutes after drop off. DON’T WORRY SPECIMEN ONCE READY IS KEPT IN WARM INCUBATOR.
* Who does IUI? : Usually a nurse or MD. It will unlikely be YOUR doctor as percentages have it that he or she will be doing something else as their schedules are determined weeks out. If you have had a difficult IUI then a physician will do your insemination
* Costs: please determine with our financial folks. They will give you their best estimate but can only go by what your insurance carrier tells them. Plus the amount of medication and number of ultrasound visits vary person to person and cycle to cycle. The lower your ovarian reserve, (AMH low and age older) then expect to use more medication to stimulate your ovaries.
* Number of IUI’s: two IUI’s per cycle improve pregnancy rates, but not significantly. So we would rather you not pay more for little increase in success. We DO recommend that you NOT do more than three IUI cycles before considering IVF with ICSI.
It is best to start acupuncture as early as possible so that you have time for any changes to take root before starting a medicated cycle. Acupuncture treatments are usually given weekly but a specific plan is designed for each individual. The acupuncture itself is a relatively painless experience and the needles are very thin, flexible, and disposable. First-timers usually have a hard time believing it is painless, but do not be afraid! We are very gentle and interested primarily in your comfort and relaxation during treatments.
The body of research on acupuncture’s benefits during infertility treatment has expanded greatly over the past decade. We now have a meta- analysis and 2 Chochrane Reviews to help interpret all the data. While still pointing to the need to do more research, they report favorable results for acupuncture in conjunction with infertility treatments.
Effects of acupuncture on rates of pregnancy and live birth among women undergoing in vitro fertilization: systematic review and meta-analysis. Manheimer E et al, BMJ 2008;336
The British Medical Journal published a meta analysis of 7 of the acupuncture and IVF trials,
choosing only those studies which met their strict criteria. The authors concluded, “The odds
ratio of 1.65 suggests that acupuncture increased the odds of clinical pregnancy by 65%
compared with the control groups… In absolute terms 10 patients would need to be treated
with acupuncture to bring about one additional clinical pregnancy. These are clinically relevant benefits.” The accompanying editorial in the BMJ comments that adding acupuncture to IVF improved pregnancy rates more than any other recent improvement or advance in IVF technology.
Acupuncture and assisted conception. Cheong Y et al, Cochrane Database of Systematic Reviews 2008, Issue 4.
This group of researchers analyzed clinical trial data of acupuncture and IVF and concluded that acupuncture is a useful addition to IVF. This information was published as a Cochrane Review.
Acupncture and assisted conception. Cheong Y et al, Cochrane Database of Systematic
Reviews 2009 Issue 1
A more recent version of this data base by the same authors concluded that there is an increase
in live birth rate when acupuncture is performed on day of embryo transfer.
The Role of Acupuncture in the Management of Subfertility. Ng E H etal, Fertility & Sterility 2008, Jul;90(1):1-13
Another review of the literature from Hong Kong suggests that the positive effect of
acupuncture in the treatment of infertility may be related to the central sympathetic inhibition by the endorphin system, the change in uterine blood flow and motility, and stress reduction.
It is also worth noting that some research has suggested a lack of, or even negative effect for
acupuncture on pregnancy rates. (Fratterelli FL et al Fertil Steril 2008 Vol 90 Suppl 1, pg S105, Craig L.B et al, Fertil Steril 2007 Vol 88, Suppl 1, pg S40). While these and other studies are a small minority, they help us learn about which techniques work, better define who the best candidates for acupuncture are and what circumstances acupuncture positively affects the IVF process.
Most recently the research has begun to focus on acupuncture’s role in stress reduction and pregnancy outcomes. Our clinical experience has convinced us that acupuncture plays an important part in reducing the physical side effects of intense stress and anxiety. Future research will help us learn more about the mechanisms involved in this process. To see a more complete review of the literature to date, here.
To learn more about acupuncture for fertility enhancement visit, www.triangleacupunctureclinic.com or call 933-4480 to set up an appointment.
Many times your next steps will be outlined for you at this visit and if not, it will be
reviewed when we call you with your lab results. Callbacks typically will occur between
12-4 depending on your appointment time and lab turnaround time.
ultrasound allows us to check for cysts before you take medications. We can also get
an idea of the number of resting follicles or eggs (antral follicle count) to ensure that
you are starting on an appropriate dose of medication.
- Cysts are fluid filled “sacs” in your ovaries, like a follicle, only they do not have an egg inside. The majority of these cysts will be harmless functional cysts that produce estrogen, some will be harmless non-functional cysts that are not producing estrogen but are taking up space in the ovary.
- Cysts are often a “carryover” from a prior cycle of stimulation with Letrozole, Clomiphene citrate or one of the injectable FSH cycles. These are called corpus luteum cysts. After the egg is released, fluid accumulates in the follicle. In fact, a third of women will have carry over cysts.
- Cysts are more common in women with poor ovarian reserve (advanced maternal age and/or low AMH values) in a natural cycle.
The mock transfer (aka trial transfer) is a procedure where a physician will use an empty catheter to practice performing an embryo transfer. The angle and depth of the uterus is noted, along with the best catheter and speculum for the patient. When we are ready for embryo transfer, we are comfortable that the cavity can be easily navigated and there won’t be any difficulty placing the embryos in the uterus.
Most patients tolerate both of the procedures well. However, if you have had issues with procedures in the past and would like us to give you some medication to help you remain relaxed, please leave a message and pharmacy number in the nurses voicemail when scheduling your procedure so that we can call in a prescription for you.
of the bladder will actually straighten the uterus, making it easier to pass the transfer
catheter. Additionally, a full bladder aids in visualization while utilizing abdominal
shedding. When you are taking injectable medications for either Controlled Ovarian Hyperstimulation or In Vitro Fertilization, those medications or associated procedures such as egg retrieval can inhibit your body’s natural ability to produce progesterone at adequate levels. Therefore, we have you take progesterone supplements, via injections or suppositories, in order to support the lining and subsequent pregnancy until the placenta takes over the progesterone production which is at about 7-9 weeks.
Conceptions pregnancy rates are most reflective of patients that have used injectable
conditions that you may have should be well controlled. You should have had a discussion about pregnancy with your primary care physicians if you are on any long term medication. Eating a well balanced diet and taking a generic prenatal vitamin is recommended. Moderate exercise 3-4 times a week (30-45 min of brisk walking will suffice). Weight loss is recommended for those who are overweight. Drinking plenty of water is also recommended. Minimize alcohol and caffeine consumption. Keep your stress levels under control. Feel free to speak with a mental professional if you have a difficult time managing your stress.
Any recommended testing should be completed prior to starting treatment. If you are Caucasian it is recommended that you complete cystic fibrosis screening and have results prior to attempting pregnancy. If you are African American or Middle Eastern, it is recommended that you undergo hemoglobinopathy screening and have results prior to attempting pregnancy. Feel free to schedule a follow up consultation if you have any questions or concerns.
AMH is used to check for ovarian reserve. The physicians use this value, as well as age, history of current condition, and past medical history to develop a treatment plan.