The purpose of the stimulation phase is to stimulate multiple follicles to grow so that they are of optimum size (approximately 20mm) for retrieval. Multiple follicles are stimulated because some eggs will not fertilize or develop normally after fertilization. Once we have determined, through blood-work, that your ovaries are suppressed, you will begin stimulation medications. There are several different medication combinations and your IVF team will select the best one for your particular needs. Your calendar may or may not have your medications and dosages listed. Your Nurse Coordinator will give you the specific medication instructions throughout the monitoring process. You will need to learn about your specific medications and how they are administered by going to www.freedommedteach.com and select the specific medications that your IVF team has prescribed for you.
Your Nurse Coordinator will order all your medications for you. The amount of medications that is ordered for you is determined by your IVF team. We try to order as little medication as possible so that you don’t have an excess left over once the cycle is complete. Your left over medication cannot be returned to the pharmacy and our clinic cannot buy it from you. We encourage you to appropriately store all of your left over medication until you are completely finished with all IVF treatment. Some of your un-used medications may be used for a future treatment.
There are several different specialty pharmacies that we use in ordering your medications. Please let your Nurse Coordinator know if there is a specific pharmacy you are required to use for insurance purposes. This will save both time and money for you. Once your medications have been ordered the pharmacy will contact you to arrange payment and delivery. Your medications will be shipped overnight via FedEx, usually in an insulated box with ice packs. Many of these medications must be refrigerated. It is very important that you have your shipment delivered to an address where you will be able to sign for it and keep it cool. Once you have your box of medications, find the invoice and make sure you have all of the medications that were ordered. Your nurse will give you a copy of what medications were ordered before the shipment arrives. Compare this list to the invoice. If you have any questions about your medications, CALL YOUR NURSE and she will go through them with you.
It’s very important that you have all the medications you need BEFORE you are scheduled to take them. There will be refills on your medications so if you start to run low, call the pharmacy and they will send you a refill. The clinic has extra medications on hand and we will be happy to loan you enough to get you through the end of your cycle. Once your cycle is complete, we will order a refill in your name to be delivered to our office to replace what you have borrowed. IT IS VERY IMPORTANT THAT YOU KEEP TRACK OF HOW MUCH MEDICATION YOU HAVE AT HOME. You must let us know if you need to borrow some from our stock. YOU ARE RESPONSIBLE FOR YOUR MEDICATIONS. You cannot get these from local pharmacies, they have to come from a specialty pharmacy. If you live outside of Spokane and find yourself out of medications, you will need to drive to Spokane to get some from our clinic. It takes a minimum of 24 hours to get it from the pharmacy.
You will notice on your calendar that on the day you start your injectable medications your husband will need to begin taking his doxycycline (vibramycin). He will take this twice a day, 30 minutes after a meal. If doxycycline is taken without food it will likely cause an upset stomach. It can also increase sun sensitivity so use sunscreen if you are exposed to the sun. The purpose for this antibiotic is to ensure that the semen specimen is free of any infection on the day of your egg retrieval.
Morning clinic is when you will come to the clinic for monitoring of your stimulation cycle with blood work and ultrasounds. MORNING CLINIC IS ALWAYS AT 7:00 AM IN OUR OFFICE. It is first come, first serve so be sure to check in at the front desk. There may be 2-25 women scheduled for monitoring each day. Most patients come by themselves to morning clinic because there isn’t a lot to see during these appointments. Please try to leave children at home if at all possible. Things move very quickly. Dr. Robins is the only one doing ultrasounds and he often has many to do in a very short amount of time. You will have your blood drawn first (these are not fasting labs). Please drink plenty of fluids during the stimulation process. Staying well hydrated helps make the blood draw easier. After your blood draw you will return to the waiting room before your scan. The ultrasounds are always vaginal. Make sure you have emptied your bladder before you are called back for your scan. You will go in to an exam room and undress from the waist down. There will be a paper drape on the table to wrap around your waist. The assistant will then call you in to the adjoining exam room through a connecting door to have your scan done by Dr. Robins. He measures your follicles and looks at your endometrial lining. He won’t measure or count every single follicle, just the biggest ones. The scan will take 2-3 minutes at most. Again, he’s moving very quickly. This is not a good time to ask him questions as you will not get the attention you deserve during this appointment. His role during morning clinic is that of an ultrasound tech as opposed to your treatment advisor. His aim is to get all of the scans completed and get you on your way to work, school, family, etc. Once your scan is complete you will return to the exam room you changed in, get dressed and be on your way to the rest of your day!
If you need to borrow medication from the clinic, this is the time to ask. A Nurse Coordinator is available at morning clinic to help you with questions that cannot wait until the afternoon. Your Nurse Coordinator will contact you later in the day once all of your lab results are back and we have consulted Dr. Robins about any changes to your treatment. This is the best time to ask questions. We want to make sure your questions answered and you feel comfortable with the process. Please have a pen and note pad ready to take down instructions when we call you. Some patients prefer to have their instructions emailed to them, just let your Nurse Coordinator know what works best for you. Check your email and voicemail regularly throughout the day for your instructions. If you have questions about them, contact your nurse immediately so she can clarify things for you. If you don’t reach your nurse and the office is closed, call the on-call nurse and she will help you, (509) 462-7070.
You will likely have a morning clinic appointment on a weekend. Yes, we work weekends! The main doors to the building are locked on weekends so you will need to use the side door. This is located to the left of the main entrance directly in front of the handicapped parking area. That door is locked as well, but there is an intercom on the wall. Push the button and we will buzz you in. The main phone line is directed to the answering service on the weekends. If you have an urgent question that cannot wait until the following Monday, call the main number (509) 462-7070 and ask to speak to the on-call nurse. You can also leave a message on your nurse coordinator’s voicemail over the weekend and it will be checked on Sunday afternoons by the on-call nurse.
You will see several dates with appointments for scans and labs throughout your stimulation cycle. These dates are only an estimate and will likely change. You may have more monitoring if your stimulation takes longer than expected, or you may have less. Your retrieval date may be different than the date that is listed on your calendar. Your husband/partner will need to be in our office on the day of retrieval for a semen collection. If this is not possible, you will need to make arrangements with your Nurse Coordinator prior to starting your stimulation medications. If you will be using donor sperm, arrange to have the specimen to our office at least 3 days prior to your scheduled retrieval.
Toward the end of the stimulation process Dr. Robins will determine that your follicles are ready for egg retrieval. He may say during your scan that you are ‘ready for your trigger shot, or hit shot.’ This means that you will be taking a medication that will finish the maturation process of the eggs and initiate the ovulation process. You will either take hCG (human chorionic gonadotropin) or Lupron (leuprolide acetate). Dr. Robins will determine which of these medications you will need on the day of your trigger shot. Your nurse may order both of these medications for you, depending on your treatment protocol. You should review the hCG mixing and injection instructions on www.freedommedteach.com. The hCG is an intramuscular injection given in the hip so you will need someone to help you with this. The Lupron trigger shot is a subcutaneous injection given in your stomach, like your other injectable medications. Lupron is given in 2 separate doses, 12 hours apart. Your nurse will give you very specific instructions as to when your trigger shot should be given. It is very important that you are on time for this injection! Your egg retrieval will be 35 hours after your trigger shot. Trigger injections will be given anywhere from 10:00pm to 1:00am. You may need someone to give you this injection so plan accordingly. You will notice on your calendar that is says to have protected intercourse on the same night as your trigger shot. If intercourse is not possible, your husband/partner needs to have an ejaculation. The purpose of this is to ensure the best possible semen sample on retrieval day. Do not have intercourse/ejaculation again until after the retrieval process is over. Once you are instructed to take your trigger shot, you will be done with your stimulation medications. Again, be sure so save any unused medications in case you need them at a later date.
The stimulation and monitoring phase of IVF can be a very stressful time. There are a lot of things to remember, lots of early mornings and lots of injections. We encourage you to keep your schedules as light as possible so as not to add any additional stress during this time. Try not to plan trips, schedule extra projects, or commit to additional responsibilities. Your number one responsibility is to take care of yourself, try to relax and follow your nurse’s instructions. All of this helps to ensure a smooth stimulation cycle.