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Ad Astra Per Aspera | To the Stars through Difficulties

Ad Astra Per Aspera | To the Stars through Difficulties

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IVF Patients' Instruction

IVF Cycle Overview

Before starting your IVF treatment, please make sure that you have appropriate, current means of communicating with your team. Ensure you have your nurse’s phone line and email, the after-hour emergency line phone number, and your doctor’s email. Also, ensure that you have indicated your preferred phone line contact and that we have your current e-mail. All pre-cycle investigations and checklists must be complete before starting, including completed consents, fee payments and injection teaching.

Please ensure that you had a discussion with your team regarding:

– The type of sedation of choice for egg retrieval should be discussed with your IVF team.
– The number of embryos to be transferred.
– The option of sperm freezing as a backup. This option should be discussed if your partner may have difficulty collecting sperm sample on the day of egg retrieval or he may not be available.

IVF treatments consist of two phases:

The first is superovulation where you will be taking fertility injections on a daily basis. The dose will be titrated by your doctor based on information obtained by blood work and follicular ultrasound measurements. The information will be communicated to you through your primary nurse regardless of which location you go to. You may see a different nurse after the monitoring studies in order to attend to your immediate needs. These will, of course, be communicated to your primary nurse and physician. This phase of ovarian stimulation usually requires 10 days of injections and ends with an ovulation trigger: Ovidrel or HCG.

When you start your period, please call your nurse on the first day of your menstrual bleed in order to initiate your ovarian stimulation phase (which usually takes takes10 days (9-12-day range). Again, please ensure that you have submitted all your consents and fees and have purchased your medications before your period starts to avoid unnecessary delays and stress.

The second phase is the Embryology lab phase, which starts with the egg retrieval (36 hours after ovulation trigger) and ends with the Embryo transfer 3-5 days after the egg harvest.

Instructions for fertility drugs related to dose change or triggers are through phone calls and/or emails. They will follow every clinic visit. Those communications can occasionally be as late as 8 pm. Therefore, your timing to administer your fertility drugs should be in the evening after 8 pm. Please refer to the OI section (Ovarian stimulation with injectables).

Please refrain from sexual activity by treatment day 9. No restrictions prior to that. Abstaining from intercourse, for more than 7 days, is not advisable.  Your male Partner must be available on the day of the egg retrieval to provide a sperm sample unless a sample is already frozen and there are no plans to collect a fresh sample.  If your partner has difficulty collecting a sample on demand, freezing a sperm sample as a backup is advised. Men with very low sperm counts will also be asked to freeze a sperm sample as a backup before starting the ovarian stimulation.

Instruction for IVF Patients at Ovidrel Trigger and Before Egg Collection

When your follicles are ready and look mature your ovulation will be triggered. This means you will take your Ovidrel/HCG on the evening that you are contacted (by phone or e mail).

Please take your Ovidrel at the specified time. No more fertility injections are needed after this point, since the follicle growth phase has ended. Your egg retrieval will be 35-36 hours after the Ovidrel/HCG injection. There is now no more need to come to the clinic for the pre-booked monitoring visit the day following the trigger.

Expect a phone call from your nurse to remind you of egg collection preparation instructions:

1. You will start your antibiotics (already called in to your pharmacy) the night before OPU (ovum pickup) and every 12 hours for 4 days.

2. Do not have breakfast the morning of the OPU. Do not eat after midnight. Arrive to clinic 15 minutes before your scheduled OPU.

3. Do not wear any perfume.

4. Your partner needs to be with you to drive you home after the OPU.

5. Sperm sample will be collected that morning unless we have a frozen sample to use.

6. Remember, no intercourse after the Ovidrel/HCG trigger.

Instruction to IVF Patients after Egg Collection

Before going home following your egg retrieval, you will be assessed to ensure that you are not overly uncomfortable and able to urinate clear urine. There should be no significant vaginal bleeding and all your vital signs should be stable.

Expect some discomfort, light bleeding and cramping for a few hours, but no longer than 6 hours. You can take Tylenol for pain. Call your nurse or the after-hours line if you have significant issues.

You cannot drive yourself home.

Do not drive until the following morning.

You can go back to work until the embryo transfer.

You can resume your usual daily activities.

Refrain from intercourse for 7-10 days. You may need to refrain longer if you are hyper-stimulated, with markedly enlarged ovaries.

You will start progesterone supplementation the day after the OPU and will continue until your pregnancy test unless informed otherwise. If you are pregnant, we will continue progesterone and other oral meds until 12 weeks gestation.

You will be given a tentative date for your embryo transfer. You will be contacted by the embryology team for fertilization and subsequent embryo status.

Instructions for IVF Patients after Embryo Transfer

IVF treatment ends with the embryo transfer. A pregnancy test 10 days later is scheduled. Most patients are advised to rest physically and mentally for the following 3-4 days. Once implantation is complete, you are no different than any patients who are conceiving naturally, except for the ovarian enlargement caused by fertility drugs if you had a fresh transfer. Realistically, there are no specific restrictions, however, avoiding vigorous physical activity and sexual activity leading to orgasm is advised.

Intercourse Instructions during IVF Cycle

There are usually no restrictions on sexual activities during the ovarian stimulation phase. Ovarian discomfort due to enlargement caused by fertility drugs can be a limiting factor. Most patients are generally advised to refrain from sexual activities by treatment day 9. Sexual intercourse can be resumed in the early pregnancy provided ovarian enlargement from fertility injections is not significant and there is no hyperstimulation.

Failed IVF Cycle with Negative Pregnancy Test after Embryo Transfer

A negative pregnancy test following an embryo transfer can have a significant negative emotional impact. Please do not let the negative emotion and despair take over. Your frustration and mixed emotions of anger and guilt are totally understandable; however, we have to remember that the expected pregnancy rate per embryo transfer is in the range of 60%. This means we expect 4 patients out of 10 will have a negative pregnancy test.

The most important part following a negative outcome is to analyze the previous cycle, evaluating all of the indicators available to determine areas that require attention and improvement. We will look at the stimulation protocol and your response, how many eggs were expected and how many we collected, the percentage of mature eggs, fertilization rate and cleavage/blastocyst formation rate. By performing detailed, thorough analysis and reviewing the pre-cycle work up, appropriate and objective recommendations can be made.

As long as we have a good ovarian response with good quality eggs and good fertilization rates, success will be a reality. Stay the course. The clinic will also share the financial risk with you in subsequent cycles. We believe in your ability to succeed, otherwise, we would suggest other options.

A review appointment will be booked for you by your IVF nurse to go over the treatment and future plan.

Low Ovarian Reserve/Not Meeting Criteria to Proceed with ART

Having a low ovarian reserve does not always mean you have a bad reserve, especially for younger patients and patients with endometriosis. Unfortunately, many patients are told that they have a low ovarian reserve and their only hope to have a baby is to go for donor egg IVF or donated frozen embryos. Many patients with low reserve are successful at having healthy babies from their own eggs! It just means that your response to stimulation is quantitatively limited.

However, to proceed with ART, you need to have an antral follicle count> 5 follicles on day 3 of the menstrual cycle and FSH level <12. If criteria are not met, there will be room for trial supplements including COQ10 and DHEA, in addition to acupuncture. We do not overlook cycle-to-cycle variation and sometimes, you may get a better wave of new follicles in future cycles. However, if there is no improvement, other options including donor egg IVF and frozen donated embryo transfer can be offered.  Occasionally, we may modify our criteria to start a cycle on an individual basis and after counselling with the patient.