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Patient Information

ORIENTATION

Welcome to the Assisted Reproductive Technologies and In Vitro Fertilization Program. To ensure that you have the opportunity to make informed choices regarding your reproductive potential, you will need to attend an IVF Orientation Class.

Please speak with one of our fertility nursing staff to arrange for a class. The class is a 1 1/2 -- 2 hour meeting designed to explain each step of the IVF process in detail. Informed consent regarding all medications used during the cycle is given. We will also cover information about clinic and the practical day-to-day aspects of undergoing an IVF cycle.

Please note: these are group classes and as a courtesy to all, begin promptly at the appointed time. If you are late, you will need to reschedule your orientation class, which may mean a delay of one or more months to your starting a cycle.

Classes are held in our office, NYS Empire Plan routinely is the only insurance company that covers nursing education classes, for all other patients this fee will be included in the contracted IVF fee.

If I’ve done IVF elsewhere, do I still need to attend an orientation?

Regardless of whether you’ve done IVF elsewhere, you are still expected to attend an orientation class. The information covered is vital to your cycle and to orient you to any nuances of care in our practice.

PRE-CYCLE TESTING

Before your expected IVF cycle, you will need to complete pre-cycle testing your physician has ordered. These tests usually include baseline hormonal testing (generally performed on menstrual cycle day (CD) 3), and an evaluation of your uterine cavity by sonohysterography or hysteroscopy. Information about these procedures will be available to you depending on your case.

Also, a semen analysis and sperm-wash will be required for your male partner in our lab. These tests must all be done within 3 months of the start of your IVF cycle. Other tests may be ordered. You can arrange testing by calling our IVF coordinator.

Most blood tests are done in our office during clinic hours. To ensure coverage by your insurance carrier, you will need to find out which laboratory you may use for these tests (see "checking insurance coverage" below).

CHECKING INSURANCE COVERAGE

In New York State services such as IVF are often uncovered. Pre-cycle evaluation (see above) may be covered, however. Also, various insurance carriers offer different coverages for services depending on your employer’s contract with the insurance carrier. Educate yourself regarding your coverage before you begin therapy. Our Operations Administrator, Renee Bessette, can help you with this process.

Will my plan cover fertility medications?

This depends on your contract, and sometimes on whether you have a drug rider in your plan. Having a prescription card with your insurance package does not guarantee that you have coverage for fertility medications. Many insurers exclude these drugs or cover them at a larger co-payment for the patient.

HMOs generally require prior approval to determine your coverage. The member services department at your insurance company can tell you if this is the case. If your insurance covers IVF and requires prior authorization for medication, notify your nurse coordinator well before the start of your IVF cycle. Be prepared to give details such as phone/fax numbers and what is required (a letter, phone call, insurance form, etc.).

WHAT MEDICATIONS ARE USED?

Gonadotrophins (menotropins) are injectable fertility medications containing the hormone FSH (follicle stimulating hormone), or FSH and LH (luteinizing hormone) in combination. FSH is the hormone responsible for stimulating the growth of a follicle (ovarian cyst which contains an egg) during the first half of your menstrual cycle. Brand names include Gonal-F and Follistim (FSH products), Bravelle and Menopur (FSH and LH combination products). These medications are given subcutaneously or intramuscularly.

Will I use any other medications during my treatment cycle?

Yes. Besides the stimulating medications described above, you will need to take an injection of human chorionic gonadotropin (hCG-Ovidrel) to help your eggs mature. hCG will be taken at precisely 36 hours before egg retrieval. Some patients will also need to take leuprolide acetate (Lupron) before beginning stimulating medications. Lupron prevents ovulation from occurring before egg retrieval. You may also need to take oral antibiotics and progesterone supplements after retrieval.

Side Effects of Medications

There are common and potentially serious side effects of IVF medications. The following information is meant to be an overview of these side effects. We will review detailed information t the IVF Orientation Class. If you have any questions, please call your Nurse Coordinator.

Common side effects may include but are not limited to pregnancy symptoms, breast tenderness, bloating, headache, mild nausea, lethargy, mood swings and hot flashes. Many women have some or all of these symptoms at some point during therapy. These side effects are normal and do not mean anything is wrong or you are having an adverse reaction to your medication.

The combination of fertility drugs and hCG can lengthen your cycle, making it seem your period is a few days late. Many women also complain of heavier than usual periods after a therapy cycle. How much a woman bleeds during her menses is related to how thickened her uterine lining becomes during the cycle. Since fertility medications will potentially thicken the lining, it makes sense that the menses may be heavier than usual.

Another side effect are residual "functional" ovarian cysts that occur as a result of the stimulation during a therapy cycle. If you have a residual cyst on cycle day 3 ,you will be instructed to take a "rest" cycle. Usually these residual cysts clear up on their own with no medical intervention.

Serious side effects occur rarely, but due to their serious nature you should be aware of them. These too will be discussed in depth at the Orientation Class. The most common serious side effect is ovarian hyperstimulation syndrome (OHSS), which happens when your ovaries stimulate excessively in response to fertility medications. This follicular growth can cause the ovaries to enlarge, leading to pain, bloating, fluid within the pelvis and potential damage to your ovaries. Women who become hyperstimulated will be put on complete bed rest to manage these symptoms. Rarely, hospitalization is required in severe cases.

WILL I HAVE TO GIVE MY OWN SHOTS?

Since these injections are administered in the evening, you will need to learn to give your own injections or have someone give you the injection. Subcutaneous injections are often self-administered; intramuscular injections are usually administered by a partner or friend. All patients will receive educational material regarding reconstitution of medications if reconstitution is necessary and proper technique for administering medications.

Giving Your Injections

Detailed instruction on the reconstitution and administration of all injectable fertility medications will be covered in the educational video/DVD you receive and on our web site.

WHEN AND HOW OFTEN WILL I NEED TO COME TO THE OFFICE?

Each patient's cycle is individualized, and therefore it is impossible to give an exact schedule of appointments. However, a typical cycle for IVF will usually include about 6 visits for blood and ultrasound. These tests are performed during designated appointment times for your convenience. If it is necessary to do testing on Sundays or Holidays, a specific time will be arranged. It is imperative that these blood tests be completed within the hours of clinic in order obtain results that are available to the doctor in the afternoon. You will receive a call in the afternoon with further directions therefore we must have a number to contact you where a detailed message may be left unless we are able to speak with you directly.

DESCRIPTION OF A TYPICAL IVF CYCLE

PRE-CYCLE PHASE

1 to 3 months before your first IVF cycle, arrange for:

An IVF Orientation Class with our IVF Coordinator
An appointment for Financial Counseling with Renee Bessette (See pages on Insurance Coverage).
Completion of preliminary testing ordered by your physician. Testing may include cycle day 3 bloodwork, evaluation of your uterus and a semen analysis. These diagnostic tests are usually covered by insurance. Our coordinator can help you arrange your testing and will let you know when they are completed.

Purchase your medications. Be aware that your insurance company may require prior approval and our Nurse Coordinator will need several days to complete this for you before your cycle. Insurance company response to prior approval requests can take up to four weeks.

You must sign the consent forms for IVF, cryopreservation and micromanipulation during a scheduled appointment with your physician or our physician assistant. This appointment can be scheduled with your Nurse coordinator. Both partners must read the consent before the appointment and both partners must be present for the appointment.

Please note: once you are cleared from a medical perspective, you will also need financial clearance from our Operations Administrator, Renee Bessette (please refer to "Financial Information" section above and the "Financial Information for In-Vitro Fertilization Services" handout).

IVF CYCLE PHASE

Overview of a typical cycle:

Cycle Day 1: This is the first day you need to use a tampon or pad for menstrual flow. Call to leave a message to schedule your cycle day 3 (2/4) clinic appointment on the clinic scheduling line at 434-9759 ext. 401. You must do this regardless of what day you will be in. Please specify the preferred appointment time should one be desired.
Remember: If cycle day 1 is a Friday and your menstrual flow begins after 4pm, call to schedule clinic for Monday, cycle day 4.
Cycle Day 3: Report to the office at your designated appointment time for a blood test and transvaginal ultrasound. For an IVF cycle the beginning of your menses may indicate the need to start the birth control pill or stimulation medications depending on your specific protocol. You will be given additional instructions during the clinic visit.
Stimulation Days: Report to the office at your designated appointment time for repeat blood test and ultrasound to determine response to the medication and assess potential need for further medication during this cycle. Repeat visits to clinic will be scheduled based upon this assessment.
When it is determined that you are ready for egg retrieval, you will be given written instructions and told to take hCG at an EXACT TIME. This will trigger the maturation process of the eggs. You will also be given a time to report to the office for retrieval. It is important to allow enough time for travel and weather conditions so that you arrive on time. Following retrieval you will begin medications to support the uterine lining in the event that pregnancy occurs.
You will be notified of fertilization outcomes the next day. You will also be notified of when to return for embryo transfer. Once transfer is complete, you will arrange for pregnancy testing. It is strongly recommended that you make a post IVF appointment with the physician following your pregnancy testing if you do not achieve pregnancy. Typically these appointments are made 3 or more weeks after you get your menses.
On the requested Cycle Day (2,3 or 21), schedule clinic for blood draw and possible ultrasound. A tentative plan will be given to you that morning, and you will only receive a call back in the afternoon if there are any changes recommended. You may be asked to begin leuprolide acetate (Lupron) or stimulating drugs. You will be given the dosage dependent on protocol and told when to return to our office.
On your next scheduled clinic appointment, and on each successive one, you will need a blood draw and ultrasound. You will meet briefly with a staff member after your ultrasound. In the afternoon, when blood levels are available, your results will be reviewed by your physician and you will receive a call in the afternoon with further instructions.

For this reason you must have an answering machine. You should plan to take stimulating medications between 7 and 9 PM each evening. If your physician has recommended you also take a morning dose of medication. this should be administered between 7 and 9 AM (the two doses do not need to be 12 hours apart). Lupron is usually taken in the evening.

When you are ready for egg retrieval, you will be given written instructions and told to take hCG at an EXACT TIME. This will trigger the maturation process of the eggs. You will also be given a time to report to our office for retrieval. Please allow enough time for travel and weather conditions so you arrive on time. After retrieval you will begin medications to support your uterine lining if pregnancy occurs.

You will be notified of fertilization outcomes the next day. You will also be notified when to return for embryo transfer. Once transfer is complete, you will arrange for pregnancy testing. We strongly recommend that you make a post IVF appointment with your physician after your pregnancy testing if you do not achieve pregnancy. Typically these appointments are made three or more weeks after you get your menses.

HELPFUL HINTS DURING THERAPY

Keep track of medication and supplies, and ask for new prescriptions as needed. Please note that prescriptions are generally written with refills, so check your medication packaging for refill information. Syringes, needles, and HCG CANNOT be called in to a pharmacy, so make sure you have enough of these on hand.

During winter months, we suggest you have an extra day’s worth of medication on hand. If bad weather or other unforeseen events keep you from coming to clinic, contact your Coordinator for instructions. We usually will have you return the next day and give you a medication dose that evening.

MULTIPLE BIRTHS

IVF is associated with an increase in the number of twin, triplet, or even higher-order pregnancies. All multiple pregnancies are "high-risk" by definition, although perinatology (high-risk obstetrics) consultation is usually not necessary for twins.

Twinning occurs in about 15-20% of pregnancy cycles. Triplet pregnancies occur in about 1-2% of pregnancy cycles, and more than triplets is rare.

In the case of triplet pregnancy, there is no need for invasive intervention. Although this is an extremely high risk situation regarding the potential for premature labor and premature birth, with proper obstetric and prenatal care, the infants are typically born late enough to do wonderfully well if delivered in a high-risk obstetrical unit. The decision to perform selective fetal-reduction (see below) in the case of triplet pregnancy is primarily on a social, not a medical, basis.

Couples conceiving a grand multiple (three or more) pregnancy are urged to seek consultation with a high risk obstetrician (perinatologist). The decision to intervene with selective fetal reduction (selective abortion) is perhaps the most difficult decision an infertility couple has to face.

We refer patients to the Mount Sinai Medical Center on Fifth Avenue in Manhattan for this procedure. The procedure is typically done at about nine weeks gestation (seven weeks after embryo transfer / five weeks after news of the positive pregnancy test). Medical, psychological and spiritual counseling are all critical to successful decision-making. While these decisions need to be made rarely, you should discuss how you would proceed with a grand multiple pregnancy early in treatment.

WHAT ARE SATELLITE SERVICES?

Of course, we hope you choose Albany IVF for your assisted reproduction and fertility services. However, if you choose to have your IVF and assisted reproduction services at another center far from the Capital Region, we would be happy to assist the process in any way that we can. Many IVF centers allow patients traveling a great distance to have blood work and ultrasound studies performed at a location closer to their home until they near their egg retrieval or embryo transfer procedure. However, not all programs allow satellite relationships.

You must ask your primary IVF Program Coordinator if they would be willing to participate in a satellite relationship with Albany IVF. If they will, have them contact our IVF Coordinator. You will be responsible for bringing a prescription with specific orders to the office each day testing is requested – usually blood work and ultrasounds. We perform the tests on the ordered days and immediately fax results to your primary center. Your primary center then communicates further instructions about your cycle to you. A separate fee schedule is available for these services. For more information on satellite services, contact our Operations Administrator, Renee Bessette, at ext. 222 or at rbessette@albanyivf.com.