The Sher Institutes for Reproductive Medicine
Medication Administration Guidelines
________________________________________________________________
Tips:
- An ml = cc
- Needles are STERILE, do not touch them before using them to inject and only use them ONCE
- Rotate injection sites from one side of the abdomen to the other, and from one thigh to the other
- With a multi-dose medication vial, swab the top of the medication vial with an alcohol swab before each use
- When in doubt about medication dosage or injection, PLEASE call the office for clarification. DO NOT GUESS!
- There is a nurse on call through the service after office hours. Please call 702-892-9696 before 11pm and the service will promptly page the nurse on call
- Read all of the medication labels before taking the medication to ensure that you are taking the correct medication
- Report all medication errors and unusual reactions to your coordinator as soon as possible
Dexamethasone 0.75 mg Tablet or Prednisone 10 mg
- This is a steroid tablet
- This is given to decrease inflammation and reduce the inflammatory response of your body to foreign bodies (your embryo) before embryo transfer
- Take once a day in the morning with your breakfast to decrease GI upset and other potential side effects
- Potential side effects are insomnia, increase in appetite and bloating.
Lupron (Leuprolide Acetate)
- Lupron is taken to suppress your hormones at the pituitary level, it does NOT suppress your ovaries
- Injection to be given subcutaneous in either the upper thigh (up by panty line) or in the abdomen (stay 1 inch away from belly button) in the AM (between breakfast and lunch) with a few hour flexibility between days (See diagram on page 5)
- The medication comes in a multi-dose vial
- Use the insulin syringes with the orange cap to draw up dose and inject
- Refer to your calendar for dosage and measure units (U) on the syringe
- The most common side effect is hot flashes, this will be relieved by the start of your hormone medication (i.e., E2V or Gonal-F or Follistim
Ganirelix/Cetrotide
- To be taken like Lupron, subcutaneous in AM
- Also like Lupron, it is being taken to suppress your own hormones and has a better long term effect with fewer side effects
- Given at ½ dose (125 mcg) rather than prepackaged dose of 250 mcg (same as 0.25 mg)
- Ganirelix:
- To split Ganirelix (prefilled in a syringe) use a 1 cc syringe that does not have a needle and pull down plunger to 0.25 cc.
- Then inject 0.25cc from the prefilled Ganirelix syringe into the 1 cc syringe you have just prepared.
- Place a 27 gauge ½ inch needle on the 1 cc syringe to inject.
- Save the remaining 0.25 cc in prefilled syringe for next morning’s shot.
- Keep refrigerated.
- Cetrotide:
- To split Cetrotide fill the vial of powder with the prefilled water (1 cc) in kit.
- Now you will have 2 doses in vial.
- Use same orange cap syringe that you used for the Lupron and withdrawal 50 Units (½ cc) of Cetrotide for first morning’s injection.
- Save the remaining 50 Units (½ cc) in vial for next day’s injection.
- Keep refrigerated.
- Second dose may only measure up to 35 or 40 Units. This is normal, do not mix up another vial just inject whatever is left for the second dose.
E2V = Estradiol Valerate = Delestrogen
- Not all protocols involve E2V, so if this is not on your calendar then omit instructions.
- This is given to “prime” the receptors on the ovaries to improve response the following week to the stimulation medications.
- This is an IM (intramuscular) injection given in the PM (between dinner and bedtime) in the upper outer quadrant of the buttock (See diagram on page 5)
- Give while lying down to relax the muscle
- Verify that your Delestrogen concentration is 20 mg/ml
- Use a 1 cc syringe without a needle (NOT a Lupron syringe) and attach a 18 gauge 1 ½” needle to draw out the medication to 0.2 cc or the dosage in which you have been instructed to take. Switch needle to a 22 gauge 1 ½” to then inject intramuscularly.
E2V 2 mg suppositories
- Not all protocols use the Estradiol Valerate vaginal suppositories
- These are given to ensure that the uterus is being supplied with enough estrogen
- Insert vaginally at bedtime
- These may or may not be continued after CD9.
- Make sure you are inserting the E2V 2mg (Estradiol Valerate) suppositories NOT the suppositories used after embryo transfer which are Estradiol Valerate 1 mg/ Progesterone 50 mg suppositories (or E2V/ P4). If you use the latter in error your cycle will be immediately cancelled.
- Keep refrigerated
Folic Acid 1mg tablet
- Prescription strength folic acid dose (over-the-counter dose is only 400 mcg).
- These tablets are taken to prevent Spina Bifida-type problems in fetus.
- No side effects and can be taken anytime.
- You may opt to take a Prenatal Vitamin instead of straight Folic Acid, this is fine as long as it is prescription strength
SDF (Viagra) Suppositories
- Given to increase blood flow to endometrial lining
- Take vaginally 4 times daily
- No side effects, except possible vaginal irritation from so many suppositories.
- Place the suppositories over the course of a day (with the last at bedtime, unless you are taking E2V suppositories as well) and that it doesn’t have to be exactly a certain amount of hours apart.
- You may wish to wear a panty liner since not all of the wax absorbs and you may experience slight oozing.
- You should try to at least be sitting for 15 minutes after each insertion.
- Keep refrigerated
Terbutaline 5 mg Tablets
- Given to relax the uterine muscle which will allow more blood flow through the uterine vessels
- Starts with SDF suppositories.
- One tablet three times a day
- You will experience the side effects of nervousness, shakiness and a racing heart! If your heart rate is over 120 beats per minute, please skip a dose
- Your body will adjust to the Terbutaline in 2-5 days and you will no longer experience the side effects
Heparin 5,000 IU / Lovenox 30 mg
- Only use if indicated on your calendar
- Twice a day injections, to be given in the AM with Lupron/Cetrotide and in the PM with stimulation medications/hormone injections
- Subcutaneous injection given with a ½ cc or 1 cc insulin (Lupron) syringe
- Verify the concentration of your Heparin. If 10,000 units/ml then your dose twice a day is 5000 units or ½ ml (which is equivalent to 50 units on the insulin syringe).
- You may also use Lovenox 30 mg one a day subcutaneously anytime in the day in lieu of heparin.
- You may experience some bruising at injection site, do not rub vigorously
Gonal F / Follistim
- This is FSH (Follicle Stimulation Hormone) or stimulation medication
- This is given subcutaneously anytime in the evening anytime between dinner time and bed time
- Please refer to packet instructions for reconstitution as can come in multidose vial, single dose vial and Pen form
- Your coordinator will go over instructions with you or you may contact Fertility Lifelines (1-866-538-7879) for Gonal-F product support 24 hours a day
Luveris
- This is pure Luteinizing Hormone (LH)
- To be given as a separate injection in the PM with your stimulation medication
- This is given subcutaneously
- The dose is always 1/2 vial (37.5 IU) as indicated on your calendar
- Use the 3ml syringe with 22 gauge 1 ½” needle to draw up 1 cc of diluent
- Inject full 1 cc into vial of powder (this is now 2 doses)
- With same syringe/needle, withdrawal only ½ cc (0.5 ml) and refrigerate remaining ½ cc for next evening’s dose
- Change needle to the 27 gauge ½ “ to inject subcutaneously.
Progesterone in oil
- This medication will be given in one of two dosage amounts, 50 mg (1cc) or 100 mg (2cc). See your calendar for your dosage.
- This is an IM (intramuscular) injection given in the PM (between dinner and bedtime) in the upper outer quadrant of the buttock (See diagram on page 5)
- Give while lying down to relax the muscle.
- Use a 3 cc syringe with an attached 18 gauge 1 ½” needle (or 20 gauge) to draw out the medication to the dosage in which you have been instructed to take. Switch needle to a 22 gauge 1 ½” (or 25 gauge 1 ½” needle if your product is made in ethyl oleate oil) to then inject intramuscularly.
Final Comments
- On CD9 (cycle day 9 when monitoring in our office begins) you will be given a new calendar and instructions once we have determined how you are progressing
- There will be medications you have received that are not on your calendar at this point (i.e., Cipro, hCG 10,000 units, progesterone in oil, Clindamycin suppositories, E2V/ Progesterone suppositories). These will be used post CD9.
______________________________________________________________________
Injections sites
Intramuscular injection sites
Subcutaneous Injection Site (use upper thigh or lower abdomen)
I WILL DISCUSS HOW I FEEL ABOUT EACH OF THESE AND THE OUTRAGEOUS COST IN MY NEXT BLOG......I THINK I'VE SHARED ENOUGH FOR ONE BLOG POST :)
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